MATERNAL AND CHILD SURVIVAL PROGRAM (MCSP) BURKINA …

MATERNAL AND CHILD SURVIVAL PROGRAM (MCSP) – BURKINA FASO

Preventing epidemics through surveillance and vaccination in Burkina Faso

Intervention District Rapid Assessment Report

MCSP – BF Team Dr. Abdoul Aziz Gbaya Mr. Souleymane Sakande Mr. Gaoussou Nabaloum Mr. Lazare Bouda Ms. Asseta Ouedraogo

Ministry of Health Mr. Moumouni Nikiema (DPV) Mr. Denis Ouedraogo (DPSP)

September 2018

1 Maternal and Child Survival Program (MCSP) – Burkina Faso, Rapid Assessment Report – September 2018

Table of contents

Table of contents

Table of contents .......................................................................................................................................... 1

Abbreviations ................................................................................................................................................ 3

Tables and figures ......................................................................................................................................... 4

Executive summary ....................................................................................................................................... 6

Introduction .................................................................................................................................................. 8

Context ...................................................................................................................................................... 8

MCSP's scope of work ............................................................................................................................... 8

I-Rapid assessment objectives ...................................................................................................................... 9

1.1 General objective ................................................................................................................................ 9

1.1 Specific objectives ............................................................................................................................... 9

II-Methodology ............................................................................................................................................. 9

2.1 Assessment design .............................................................................................................................. 9

2.2 Assessment sites ................................................................................................................................. 9

2.3 Data collection ................................................................................................................................... 13

2.4 Data management and analysis ......................................................................................................... 13

2.5 Ethical considerations........................................................................................................................ 13

III-Survey organization ................................................................................................................................ 13

3.1 Survey coordination .......................................................................................................................... 13

3.2 Constitution of teams ........................................................................................................................ 14

3.1 Surveyor training ............................................................................................................................... 14

3.4 Schedule ............................................................................................................................................ 14

IV Main findings .......................................................................................................................................... 15

4.1 Health district profiles ....................................................................................................................... 15

4.1.1 Basic information on all districts .................................................................................................... 15

4.1.2 Availability of tools, guidelines, and databases for surveillance and EPI ........................................ 16

4.1.3 Expanded Program on Immunization (EPI) status in health districts .............................................. 18

4.1.3.1 Evaluation of the Reaching Every District / Reaching Every Child in the Community (RED/REC)

approach ................................................................................................................................................. 18

4.1.3.2 Service delivery, onsite/outreach/mobile sessions and EPI performance ................................... 22


4.1.3.3 Supply and quality of vaccines ..................................................................................................... 22

4.1.4 Epidemiologic surveillance system status in health districts .......................................................... 24

4.1.4.1 Integrated Disease Surveillance and Response (IDSR) / Case-Based Surveillance of Meningitis

(CBSM) ..................................................................................................................................................... 24

4.1.4.2 Community-based surveillance of meningitis .............................................................................. 27

4.2 Health facility profiles ........................................................................................................................ 28

4.2.1 Basic information on all health facilities ......................................................................................... 28

4.2.2 Availability of EPI and surveillance tools and guidelines ................................................................. 28

4.2.3 EPI status in health facilities ........................................................................................................... 30

4.2.3.1 Evaluation of the Reaching Every District / Reaching Every Child in the Community (RED/REC)

approach ................................................................................................................................................. 30

4.2.3.2 Service delivery, onsite/outreach/mobile sessions and EPI performance ................................... 35

4.2.3.3 Supply and quality of vaccines ..................................................................................................... 36

4.2.4 Epidemiologic surveillance system status in health facilities .......................................................... 38

4.2.4.1 Integrated Disease Surveillance and Response (IDSR) / Case-Based Surveillance of Meningitis

(CBSM) ..................................................................................................................................................... 38

4.2.4.2 Community-based surveillance of meningitis .............................................................................. 38

4.3 Challenges and difficulties reported by health district and health facility officials............................ 40

4.4 Observation of immunization sessions .............................................................................................. 41

4.4.1 Organization of vaccination sites .................................................................................................... 41

4.4.2 Cold chain condition and status of vaccines and consumables ...................................................... 42

4.4.3 Vaccine administration and injection safety ................................................................................... 43

4.4.4 Communication .............................................................................................................................. 44

4.5 Interviews with caregivers accompanying vaccinated children ......................................................... 46

4.6 Community support for immunization and disease surveillance....................................................... 48

4.6.1 Community health worker activities ............................................................................................... 48

4.6.2 Interviews with community health workers and community leaders ............................................ 54

Conclusion ................................................................................................................................................... 55


Abbreviations

CBSM: Case-Based Surveillance of Meningitis

CHW: Community Health Worker

CISSE: Health Information and Epidemiologic Surveillance Center

CMA: Medical Center with Surgical Services

CMU: Urban Medical Center

COGES: management committee

CSPS: Health and Social Promotion Center

DHIS: District Health Information Software

DPSP: Division for the Protection of Population Health

DPV: Division for Prevention through Vaccinations

DRS: Regional Health Division

DVDMT: District Vaccine Data Management Tool

EPI: Expanded Program on Immunization

ICP: Head-Nurse

IDSR: Integrated Disease Surveillance and Response

INSD: National Institute of Statistics and Demography

MCD: District Chief Medical Officer

MCSP: Maternal and Child Survival Program

RED/REC: Reaching Every District / Reaching Every Child in the Community

TLOH: Telegram Weekly Official Letter

WHO: World Health Organization


Tables and figures

Tables

Table 1: List of sites visited during the rapid assessment

Table 2: Basic health district information

Table 3: Availability of vaccination tools and guidelines, health districts

Table 4: Availability of epidemiologic surveillance tools and guidelines, health districts

Table 5: Availability of databases, health districts

Table 6: Planning of the RED/REC approach, health districts

Table 7: Reaching of target populations, health districts

Table 8: Monitoring and use of data for action, health districts

Table 9: Formative supervision, health districts

Table 10: Connections with the community, health districts

Table 11: Service delivery, onsite/outreach/mobile sessions and performance, health districts

Table 12: Supply and quality of vaccines, health districts

Table 13: Integrated Disease Surveillance and Response (IDSR) / Case-Based Surveillance of Meningitis (CBSM),

health districts

Table 14: Community-based surveillance of meningitis, health districts

Table 15: Basic health facility information

Table 16: Availability of vaccination tools and guidelines, health facilities

Table 17: Availability of epidemiologic surveillance tools and guidelines, health facilities

Table 18: Planning of the RED/REC approach, health facilities

Table 19: Reaching of target populations, health facilities

Table 20: Monitoring and use of data for action, health facilities

Table 21: Formative supervision, health facilities

Table 22: Connections with the community, health facilities

Table 23: Service delivery, onsite/outreach/mobile sessions and performance, health facilities

Table 24: Supply and quality of vaccines, health facilities

Table 25: Integrated Disease Surveillance and Response (IDSR) / Case-Based Surveillance of Meningitis (CBSM),

health facilities

Table 26: Community-based surveillance of meningitis, health facilities

Table 27: Organization of vaccination sites

Table 28: Cold chain condition and status of vaccines and consumables

Table 29: Vaccine administration and injection safety

Table 30: Communication

Table 31: Communication on vaccinations and EPI diseases

Table 32: Communication on vaccine side effects

Table 33: Communication on follow-up immunization visits

Table 34: Basic village/neighborhood information

Table 35: Availability of community health worker documents and tools

Table 36: Evaluation of the RED/REC approach

Table 37: Surveillance of EPI diseases


Figures

Figure 1. Immunization coverage by antigen in poorly performing districts, January-December 2017

Figure 2. Immunization coverage by antigen in high-performing districts, January-December 2017

Figure 3. Immunization coverage by antigen in health facilities in Center region districts, January-June 2018

Figure 4. Immunization coverage by antigen in health facilities in Center-East region districts, January-June 2018

Figure 5. Immunization coverage by antigen in health facilities in East region districts, January-June 2018


Executive summary

The Maternal and Child Survival Program (MCSP) is a USAID-funded project in Burkina Faso that aims to

prevent epidemics through vaccination and surveillance, with a focus on preventing meningitis

outbreaks. Before starting its activities, the project team, accompanied by ministerial counterparts,

visited the field to assess and understand the current status of the health system, particularly

epidemiological surveillance and routine immunization.

The rapid assessment was carried out in the three regions of Burkina Faso (Center, Center-East, and

East) proposed by the Ministry of Health to receive the interventions of the MCSP project. In each of

these regions, two health districts were included (Baskuy and Sig-Noghin for the Center, Pouytenga and

Zabré for the Center-East, and Pama and Manni for the East).

Questionnaires and structured interview guides were administered to district authorities (Chief Medical

Officers, immunization officers, and surveillance officers), health professionals (Head-Nurses and

immunization officers), community health workers, and community leaders. A direct observation grid

was used to follow the process of immunization sessions. In addition, a questionnaire was administered

to caregivers to assess their interaction with providers and their level of awareness of the services

offered to their children.

Using these tools, investigators collected key information on the availability of management tools,

guidelines, and materials on immunization and epidemiological surveillance, on the socio-demographic

characteristics of the areas visited, on the status of implementation of the Reaching Every District /

Reaching Every Child in the Community (RED / REC) components, on providing immunization services in

fixed and outreach strategies, on immunization coverage performance, on the availability of cold chain

equipment, the supply process, the quality of vaccines, and the epidemiological surveillance system.

The results of the rapid assessment show that:

• EPI tools, guidelines, and reference documents and epidemiological surveillance are not

available throughout the project intervention areas.

• Some health facilities have not developed a micro-plan for their health area this year.

• The identification of particular at-risk and/or hard-to-reach populations is not

systematically performed to help reach all targeted children who need to be vaccinated.

• Program performance is not routinely monitored to guide decision-making in some

health facilities.

• Supervision visits to health facilities programmed by the districts are not all carried out.

• Close relationships are forged with community representatives who are involved in

immunization activities, both for raising awareness among the population and for

searching for unvaccinated children.

Health facility managers face other immunization challenges. These include, among others:

• The irregularity of outreach strategy visits observed in some health facilities

• Data quality issues


• The unavailability of functional cold chain equipment in some places

• Quality issues in interpersonal communication between providers and caregivers.

For surveillance of epidemic-prone diseases, the lack of training for both health staff and community

health workers was emphasized at all levels.

The rapid assessment enabled the MCSP project team to better understand the gaps and challenges that

each level of the health system faces in routine immunization and epidemiological surveillance. In

addition, the results served to prioritize the interventions to be implemented to meet the needs

expressed by the Ministry of Health.


Introduction

Context The Maternal and Child Survival Program (MCSP) is a global, USAID Cooperative Agreement to introduce

and support high-impact health interventions with a focus on 25 high-priority countries with the

ultimate goal of ending preventable child and maternal deaths. The program aims to ensure that all

women, newborns, and children with the greatest need have equal access to quality health services in

order to save lives. The MCSP supports programming in maternal, neonatal, and children's health,

immunization, family planning and reproductive health, nutrition, health systems strengthening,

water/sanitation/hygiene, malaria, the prevention of mother-to-child transmission of HIV, and pediatric

HIV care and treatment.

Burkina Faso is part of the 'meningitis belt' and is constantly exposed to a high risk of meningitis

outbreak. While the number of cases of meningitis A fell as a result of the vast immunization campaign

conducted in 2010, cases of meningitis continue to arise due to the presence of other strains of

meningococcal bacteria (X, W, C), pneumococcal infections, and Haemophilus influenzae type b. Burkina

Faso's routine immunization system shows very high immunization coverage. However, the quality of

this data is questionable, as this year the country had a measles epidemic that led to the organization of

an immunization response campaign in 26 health districts in 12 regions. The program faces major

challenges related to vaccine transport and distribution, cold chain equipment, vaccine storage capacity,

formative supervision, routine immunization communication strategies, community participation in

immunization, management and elimination of waste from immunization, data management, data

quality, and regional disparities in immunization coverage.

Even though Burkina Faso's meningitis surveillance system is effective and serves as a model for neighboring countries, data quality, laboratory sample transport, and community-based surveillance are all areas that are currently being improved and require more support. Surveillance systems for diseases other than meningitis should also be improved.

MCSP's action plan in Burkina Faso proposes interventions to prevent epidemics through immunization

and surveillance, with a focus on preventing meningitis outbreaks. The project, which USAID has funded

for one year, proposes interventions in line with the 'One Health' approach and the Global Health

Security Agenda (GHSA) package of activities for immunization, real-time surveillance, and reporting.

MCSP has the following objectives:

Scaling up and strengthening case-based and community-based surveillance to improve

meningitis detection and confirmation

Improving preparedness and response mechanisms for future meningitis outbreaks

Increasing meningitis A, PCV3, and Penta3 immunization coverage by strengthening the overall

routine immunization system in low-performing districts and maintaining high coverage in well-

performing districts.

MCSP's scope of work In collaboration with other partners, MCSP works at the central level to help strengthen the

government's view of surveillance and support strategic coordination of the Expanded Program on


Immunization (EPI). At the decentralized level, MCSP supports the strengthening of routine

immunization and community-based surveillance of epidemic-prone diseases in six health districts

within three regions.

I-Rapid assessment objectives

1.1 General objective In order to understand the baseline situation, MCSP conducted a two-week visit of its intervention sites.

The aim of the visit was to meet with regional health authorities, health districts, health facilities, and

communities, present the project's objectives and priorities, identify key partners, and collect baseline

data in order to adapt interventions.

1.1 Specific objectives - Assess and understand the current status of the health system and particularly community-based

epidemiologic surveillance to detect suspected cases of meningitis and confirm meningitis

outbreaks.

- Understand the gaps and challenges that each level of the health system faces in routine

immunization, particularly during the second year of life, and meningitis surveillance.

- Assess the current status of the health system in providing routine immunization services.

- Establish benchmarks related to key elements of the Reaching Every District / Reaching Every Child

in the Community (RED/REC) approach for routine immunization.

II-Methodology

2.1 Assessment design The rapid assessment was conducted through a descriptive, cross-sectional survey to collect key

information from health districts, health facilities, and communities.

2.2 Assessment sites The rapid assessment was carried out in the three regions of Burkina Faso (Center, Center-East, and

East) proposed by the Ministry of Health to receive the interventions of the MCSP project. Two target

districts were chosen in each region (Baskuy and Sig Noghin in the Center, Pouytenga and Zabré in the

Center-East, and Pama and Manni in the East) based on their performance according to 2017 data on

administrative immunization coverage for certain antigen tracers (meningitis A, measles and rubella 2,

Penta3, and PCV3).

The figures below show the administrative immunization coverage performance of the selected districts

in 2017.


Figure 1. Immunization coverage by antigen in poorly-performing districts, January-December 2017

Figure 2. Immunization coverage by antigen in high-performing districts, January-December 2017

Taking into account the immunization coverage data for certain antigens (BCG, Penta1, Penta3, RR1,

RR2, and meningitis A) reported in the first half of 2018 (see figures below), two health facilities were

selected in each district, for a total of 12 out of the approximately 100 health facilities in the six districts.

In each district, a reasoned choice was made between poorly-performing and high-performing health

facilities in order to capture information on the overall situation in the district. This choice was discussed

with district authorities in order to confirm, for example, accessibility during the rainy season.


Figure 3. Immunization coverage by antigen in health facilities in Center region districts, January-June

2018

Figure 4. Immunization coverage by antigen in health facilities in Center-East region districts, January-

June 2018

0%

20%

40%

60%

80%

100%

120%

140%

Secteur 12 Secteur 6 Pabré Bissighin

BCG 0% 63% 15% 328%

Penta 1 16% 80% 13% 343%

Penta 3 19% 89% 15% 325%

RR 1 15% 73% 16% 322%

RR 2 14% 48% 12% 183%

Men A 12% 49% 12% 185%

Couv

ertu

re (%

)

0%

20%

40%

60%

80%

100%

120%

140%

Pouytenga Kodemende Zabré Diarra-Betongo

BCG 67% 106% 65% 256%

Penta 1 68% 133% 86% 268%

Penta 3 59% 148% 87% 267%

RR 1 52% 159% 69% 258%

RR 2 31% 136% 49% 169%

Men A 31% 136% 55% 169%

Couv

ertu

re (

%)


Figure 5. Immunization coverage by antigen in health facilities in East region districts, January-June

2018

In each health facility's area of responsibility, a neighborhood/village was chosen for holding discussions

with community members (community leaders, community health workers). Table 1 shows a list of

health facilities and villages visited during the rapid assessment.

Table 1: List of sites visited during the rapid assessment

Region District 2017 performance Health facility Village

Center

Sig-Noghin Good CSPS Bissighin Zone 4 / Zone 5

CSPS Pabré Pabré

Baskuy Poor

CMU Sector 6 (formerly Sector 8)

Gounghin

CSPS Sector 12 (formerly Sector 11)

Dapoya

Center-East

Zabré Good CSPS Zabré Zabré

CSPS Diarra-Betongo Banse

Pouytenga Poor CMA Pouytenga Sector 3

CSPS Kodemende Kodemende

East

Manni Good CSPS Bourgou Bourgou

CSPS Dakiri Dakiri

Pama Poor Urban CSPS Pama Pama Center

CSPS Kompienga Kompienga

3 6 12 12

0%

20%

40%

60%

80%

100%

120%

140%

Pama Kompienga Dakiri Bourgou

BCG 39% 55% 92% 126%

Penta 1 44% 54% 86% 148%

Penta 3 43% 54% 94% 147%

RR 1 51% 56% 100% 172%

RR 2 41% 49% 107% 89%

Men A 41% 49% 107% 103%

Couv

ertu

re (

%)


2.3 Data collection Data were collected from the project's six target health districts and the 12 health facilities selected in

these districts. Questionnaires and structured interview guides were administered to district authorities

(Chief Medical Officers, EPI officers, and Health Information and Epidemiologic Surveillance Center

(CISSE) officers), health professionals (head-nurses and EPI officers), community health workers, and

community leaders. A direct observation grid was used to follow the process of immunization sessions.

In addition, a questionnaire was administered to caregivers to assess their interaction with providers

and their level of awareness of the services offered to their children.

Using these tools, investigators collected key information on the availability of management tools,

guidelines, and materials on EPI and epidemiologic surveillance, on the socio-demographic

characteristics of the areas visited, on the status of implementation of RED/REC components, on onsite

and outreach immunization service delivery strategies, on immunization coverage performance, on the

availability of cold chain equipment, the supply process, the quality of vaccines, and the epidemiologic

surveillance system.

2.4 Data management and analysis The data collected during the interviews were written down on paper and then entered by MCSP staff

into Epi Info data entry screens. Once data was entered for all health districts and health facilities, MCSP

staff verified data quality. Errors and inconsistencies in the database were verified and corrected by

cross-checking with data recorded on the original data collection forms.

All of the data collected was then processed and analyzed on STATA according to the analysis plan in

order to understand the current status of the immunization and surveillance system in the project's

target areas as well as immunization and epidemiologic surveillance practices.

2.5 Ethical considerations The rapid assessment was conducted in accordance with national guidelines on human research. An

ethics committee's approval was not necessary given that this was a program evaluation that will only

be used to improve the program and not for publication. However, informed verbal consent was

obtained from each participant before they were interviewed. In addition, participant confidentiality

and anonymity were ensured in the processing and analysis of all data.

III-Survey organization

3.1 Survey coordination The rapid field assessment was prepared and led by MCSP staff using a participative approach in

collaboration with colleagues at the Ministry of Health. MCSP staff coordinated all activities in

partnership with the Division for Prevention through Vaccinations (DPV), the Division for the Protection

of Population Health (DPSP), Regional Health Divisions (DRS), and health districts, where appropriate.

During planning meetings, they discussed the assessment methodology, approved survey tools, and

prepared the operational organization of the field survey.


3.2 Constitution of teams The survey team was composed of two MCSP staff members and two national project focal points

appointed by the central technical divisions of the Ministry of Health, the DPV and DPSP. A facilitator

was appointed by the authority in each region and health district visited to assist with the assessment in

health facilities.

3.1 Surveyor training Surveyors were trained on the methodology and instructions for completing data collection tools in

Ouagadougou on July 30, 2018. The training consisted of a guided reading of all of the tools followed by

explanations to ensure common understanding.

3.4 Schedule The rapid assessment was conducted in all six of the project's health districts from July 30 to August 15,

2018 according to the schedule below.

Ministry of Health authorization July 23, 2018

Finalization of data collection tools July 30, 2018

Surveyor training July 30, 2018

Data collection in the field July 31 – August 15, 2018

Creation of data entry forms August 16 – 20, 2018

Data entry and processing August 20 – 24, 2018

Data analysis August 27 – 31, 2018

Descriptive report draft September 8, 2018

Rapid assessment final report September 18, 2018


IV Main findings

4.1 Health district profiles

4.1.1 Basic information on all districts

The six health districts have a total of 153 health facilities, of which only around 100 offer immunization

services to citizens. Ouagadougou, in the Sig-Noghin health district, has the largest number of health

facilities (44 private facilities) that do not offer immunization services.

Demographic data on immunization targets were available in all of the districts visited. The source of

this data most commonly reported by those surveyed was the National Institute of Statistics and

Demography (INSD). However, three out of the six districts (Baskuy, Sig-Noghin, and Pama) believe that

the population data attributed to them by the central authorities are incorrect. Among the reasons to

explain shortfalls, they mentioned "difficulties meeting certain target populations" in successive

immunization campaigns and added that they have "a problem managing the aging population" in their

area of responsibility. Others argued that their "population is underestimated in certain urban areas and

overestimated in rural areas."

An updated health district map showing health facilities was available in almost all of the health districts

visited, except Sig-Noghin.

Table 2: Basic health district information

Region

Center Center-East East

District Baskuy Sig-Noghin Pouytenga Zabré Manni Pama

Basic information

Total number of health facilities in the district

17 66 25 17 15 13

Total number of health facilities administering vaccines in the district

17 22 18 14 14 12

Total district population in 2018 323,646 348,338 216,281 160,010 190,251 125,961

Target population for immunization aged 0-11 months in the district in 2018

7,244 10,912 9,426 6,229 8,466 5,561

INSD is the source of population data

Do you think this population data is correct?

Do you have an up-to-date map of the district with its health facilities?

Is the district map posted?

The following legend applies to all tables throughout this report:

the answer to the question is YES

the question does not apply or was omitted

the answer to the question is NO

the answer to the question is YES, PARTIALLY


4.1.2 Availability of tools, guidelines, and databases for surveillance and EPI

All immunization and disease surveillance tools and guidelines were available in health districts except

for the Health Worker Immunization Guide, the revised epidemic-prone disease fact sheet, and

notebooks with descriptive listings of cases of epidemic-prone diseases. In addition, no EPI performance

review had been conducted for the first half of 2018 due to a "lack of resources," according to those

surveyed in two health districts (Baskuy and Pama).

Compared to health districts in the Center region, those in the outlying East and Center-East regions had

fewer available immunization and surveillance tools and guidelines. However, the Integrated Disease

Surveillance and Response (IDSR) Technical Guide (2016 version) was available in all health districts.

Actual occurrence

Table 3: Availability of vaccination tools and guidelines, health districts

Region



Immunization tools and guidelines

National EPI policy documents (National

Immunization Policy, Health Worker Immunization

Guide) available in the district

Immunization coverage monitoring curve posted in the district

Latest EPI activity report(s)

EPI guidelines

EPI performance review for the first half of 2018

Summary of 2017 budget and expenses for immunization activities

Health district map with

health facilities


Table 4: Availability of epidemiologic surveillance tools and guidelines, health districts

Region



Epidemiologic surveillance tools and guidelines

Revised definitions of cases of epidemic-prone diseases

Revised epidemic-prone disease data sheet

Descriptive list of epidemic-prone disease cases

Descriptive list notebook

Epidemic-prone disease notification form (June 2017 version)

Telegram Weekly Official Letter (TLOH) collection form

TLOH notebook

Weekly summary sheet of laboratory data

Standard operating procedures for meningitis control

2016 Integrated Disease Surveillance and Response (IDSR) Technical Guide

All EPI and epidemiologic surveillance databases were available in all target MCSP health districts.

Table 5: Availability of databases, health districts

Region



Databases

Harmonized TLOH data entry form

Harmonized IDSR descriptive list database

MenAfriNet database

DHIS2

DVDMT

Other (specify): for example, Household Excel file


4.1.3 Expanded Program on Immunization (EPI) status in health districts

4.1.3.1 Evaluation of the Reaching Every District / Reaching Every Child in the Community

(RED/REC) approach

The Reaching Every District / Reaching Every Child in the Community (RED/REC) strategy was proposed

by the World Health Organization (WHO) in the early 2000s to strengthen immunization systems in

Africa and create a lasting and equitable rise in immunization coverage rates. It promotes five

operational components of programs: 1) planning and management of resources; 2) re-establishing

outreach services; 3) monitoring and use of data for action; 4) supportive supervision; 5) linking services

with communities.

Planning: All health districts developed an annual health action plan for 2018. They all included EPI

activities except for Pama, where "funding for EPI activities is uncertain." All districts except Sig-Noghin

had a breakdown of their target population by health facility. In Pouytenga and Manni, no health

facilities had sent their micro-plan to the district for approval and modification before requesting

funding from local authorities. Health facilities in the districts of Baskuy and Zabré received funding for

their activities, including those related to immunization.

Table 6: Planning of the RED/REC approach, health districts

Reaching of target populations: All health districts, including those in urban and peri-urban areas of the

capital, said 8% to 75% of their target population lives in areas that can only be covered by the outreach

strategy, i.e., that lives more than five kilometers from a health facility. In addition, everyone surveyed

said there were high-risk and/or hard-to-reach populations in their district. These include citizens in the

Pama health district, who live in "areas bordering neighboring countries, unsafe areas in the Kabonga

forest, or areas that are inaccessible during the rainy season." However, officials added that measures

are being taken to reach all target populations. Elsewhere, like in Baskuy, these populations include

Districts Baskuy Sig-Noghin Pouytenga Zabré Manni Pama

PLANIFICATION

Avez-vous un PLAN d’action annuel de santé de

votre District ?

Les activités du PEV sont-elles incluses dans ce

plan d’action?

Existe-t-il une répartition de la population cible du

District par formation sanitaire ?

Combien de formations sanitaires (CSPS) ont

envoyé des microplans à l’Equipe Cadre de District

pour financement cette année ?

17 22 0 10 0 12

Combien de ces microplans sont financés ? 10 0 10 0 0

Combien de microplans des FS sont financés pour

les activités du PEV de routine cette année ?10 0 10 0 0

Régions

Centre Centre-Est Est


those living in "unplanned settlements around the dam" who do not systematically use the health

system and whom the district has not yet found the means to reach.

Table 7: Reaching of target populations, health districts

Region



REACHING OF TARGET POPULATIONS

What proportion of the population is covered by

the onsite strategy?

91%

91%

92%

51%

29%

25%


the outreach strategy?

9%

9%

8%

49%

71%

75%

Are there any high-risk and/or hard-to-access populations in your district?

Have steps been taken to reach these populations?

Monitoring and use of data for action: Except for Manni, all of the health districts visited have EPI data

collection tools (tally sheets, immunization records, health facility data reporting forms, etc.). The health

districts of Baskuy, Sig-Noghin, and Pouytenga also had completed and up-to-date self-monitoring

curves of immunization coverage and dropouts. In Zabré and Manni, these curves were available but not

kept up-to-date. In Pama, EPI performance indicators were not tracked.

When surveyed, almost all EPI officials were able to interpret EPI monitoring curves, except for the

official in Pouytenga, who was only appointed two weeks prior to the survey.

During the survey, only the Zabré health district did not have updated routine immunization

performance data for its health facilities for the last quarter (April, May, and June 2018), which it said it

was "currently processing."

Districts do not share feedback and data with health facilities systematically and regularly but rather

occasionally at District Health Council meetings. Occasionally, shared health facility performance data is

used to take action, for example, to "call for improved recruitment of target populations."


Table 8: Monitoring and use of data for action, health districts

Region



MONITORING AND USE OF DATA FOR ACTION

Are data collection tools available at every level?

Is there an up-to-date immunization coverage and

dropout monitoring curve for the district?

Is the immunization coverage and dropout

monitoring curve for the district posted?

Does the health official know how to interpret the curve?

Does the district have up-to-date routine

immunization performance data for its health

facilities for the last quarter (April, May, and June 2018)?

Is this data shared with health facilities?

Is this data used for action?

Formative supervision: All health districts have a checklist or integrated supervision template including

aspects of EPI that is used during health facility visits. Even though norms and guidelines state that

health districts should supervise health facilities every three months, in every district except Pouytenga,

supervisory visits are only conducted twice a year due to a lack of resources. The latest supervisory

reports from the first half of 2018 were only available in Baskuy and Sig-Noghin and did not include

aspects of EPI. In addition, the Baskuy health district only conducted one of two scheduled supervisory

visits during the last quarter (April, May, and June 2018), while the districts of Sig-Noghin, Pouytenga,

Zabré, and Pama conducted all scheduled visits. The Manni health district did not conduct any of the

three scheduled supervisory visits during the last quarter.


Table 9: Formative supervision, health districts

Region



FORMATIVE SUPERVISION

Do you have a validated EPI (or integrated) supervision checklist/template?

Is this checklist/template used?

Do health facilities receive EPI (or integrated) supervisory visits every three months?

Are EPI (or integrated) supervision reports available?

During the last quarter (April, May, and June 2018),

what proportion of scheduled EPI (or integrated)

supervisory visits of health facilities were conducted by the district?

50%

100%

100%

100%

0%

100%

Connections with the community: Health district officials surveyed during the rapid assessment said that

community members were involved in planning immunization services and participated in EPI activity

review and monitoring meetings in every district except Zabré. However, no districts hold meetings to

manage their activities in communities except for Sig-Noghin. But all of those surveyed said

communities were engaged in raising citizen awareness about immunization, organizing health district

outreach activities, and looking for patients who had not been immunized or those lost to follow-up.

Table 10: Connections with the community, health districts

Region



CONNECTIONS WITH THE COMMUNITY

Are community members involved in planning

immunization services?

Are they involved in monitoring and review meetings?

Do you hold health facility activity management meetings in the community?

Do you think the community is engaged in raising awareness in favor of immunization?

Is it involved in organizing outreach activities?

Is it involved in looking for immunization dropouts?


4.1.3.2 Service delivery, onsite/outreach/mobile sessions and EPI performance

During the last quarter (April, May, and June 2018), only the Baskuy health district conducted all

scheduled onsite immunization sessions. This information was not available in Sig-Noghin, Pouytenga, or

Pama, where those surveyed admitted not having compiled any district data on the number of sessions

conducted by health facilities.

No health district conducted all of the outreach sessions scheduled this quarter. The health districts of

Pama, Pouytenga, and Manni had the lowest outreach session completion rates.

On the whole, the three health districts of Baskuy, Sig-Noghin, and Zabré administered many more

Penta3 vaccines than Penta1 vaccines to children during the last quarter (April, May, and June 2018),

resulting in negative Penta1/ Penta3 dropout rates. On the other hand, Manni, Pouytenga, and Pama

administered more Penta1 vaccines than Penta3 vaccines to children, even though Pouytenga and Pama

had Penta1/ Penta3 dropout rates above the acceptable standard of 5% or less.

When asked to comment on this indicator, certain EPI officials admitted that the negative

Penta1/ Penta3 dropout rate was not satisfactory. However, they explained that it was a result of

"population changes, Penta3 immunization of children outside the area of responsibility," etc.

Table 11: Service delivery, onsite/outreach/mobile sessions and performance, health districts

Region



Immunization service delivery by strategy and performance

How many total onsite immunization sessions were

organized in the district during the last quarter

(April, May, and June 2018)?

340/340

378/410

486/526

How many total outreach immunization sessions

were organized in the district during the last quarter

(April, May, and June 2018)?

61/65

119/328

212/244

265/398

138/312

How many doses of Penta1 were administered in

your health district during the last quarter (April, May, and June 2018)?

1,420

3,526

2,026

1,681

2,486

1,544


your health district during the last quarter (April, May, and June 2018)?

1,709

3,706

1,744

1,792

2,445

1,450

Calculate the Penta1/Penta3 dropout rate for the period

-20% -5% 14% -7% 2% 24%

Is the rate acceptable (≤ 5%)?

4.1.3.3 Supply and quality of vaccines

All health districts have cold chain equipment to store vaccines, including refrigerators and freezers.

Most of this equipment functions properly and uses electricity as its primary energy source. This


sometimes poses a problem because in every district except Zabré, there is no generator to take over in

the event of a power outage. Pouytenga and Manni use gas as a source of energy for cold chain

equipment.

Cold chain temperature monitoring forms were available and up to date with twice-daily readings in all

health districts except Zabré. Thermometers in refrigerators displayed temperatures ranging from 2 to 8

degrees Celsius, which corresponded to monitoring records. Surveyors could not verify this in Manni,

which was experiencing a power outage during their visit.

Health district vaccine inventory records were available and up to date in four of the six districts visited.

In Zabré, the records were available but not up to date. In addition, the health districts of Sig-Noghin,

Pouytenga, Zabré, and Pama experienced vaccine stockouts (rotavirus, pneumococcal, yellow fever) or

other supply shortages (BCG injections) during the last quarter (April, May, and June 2018).

However, staff surveyed knew the technique for estimating vaccine needs based on targets and said that

districts were restocked twice a month.


Table 12: Supply and quality of vaccines, health districts

Region



Supply and quality of vaccines

Is there cold chain equipment

in the district (central office)?

How many pieces of equipment (refrigerators) are

functioning/non-functioning? 2/0 4/0 2/0 2/1 2/1 2/0

How many pieces of equipment (freezers) are

functioning/non-functioning? 1/0 1/0 3/2 1/0 0/3 0/2

Is electricity the source of energy used

for the cold chain?

Is gas also used as a source

of energy for the cold chain?

Does the district have a generator for

the cold chain?

Is the source of energy a problem for

the cold chain at this level?

Are cold chain temperature monitoring forms

available and up-to-date with twice-daily

readings?

Check the refrigerator thermometer(s)

and ensure the temperature ranges from 2 to 8

degrees Celsius and corresponds to monitoring

records

Is a vaccine inventory/individual inventory record

available and up-to-date?

Have you experienced vaccine stockouts or other

supply shortages during the last quarter (April, May,

and June 2018)?

How would you describe your vaccination needs

and supply levels?

4.1.4 Epidemiologic surveillance system status in health districts

4.1.4.1 Integrated Disease Surveillance and Response (IDSR) / Case-Based Surveillance of

Meningitis (CBSM)

Many people are involved in epidemiologic surveillance among health district management teams but

also among hospital and laboratory staff. Some of them have been trained in IDSR. The most recent

training was conducted in Manni in 2016, while in the Zabré health district, for example, the last IDSR

training was conducted in 2010. The Sig-Noghin health district had the largest number of health workers

trained in CBSM and held its last training in 2016. In every other health district, one or zero staff

members had been trained in CBSM.


During the last quarter (April, May, and June 2018), health districts on the whole reported complete and

timely epidemiologic surveillance data. All weekly reports (TLOH) from all health facilities were received

on time, except for those in the Pouytenga health district.

In addition, epidemiologic surveillance curves for EPI diseases under surveillance (acute flaccid paralysis,

yellow fever, neonatal tetanus, cerebrospinal meningitis, and measles) were tracked, up-to-date, and

posted in nearly all health districts except Sig-Noghin.

The systems most commonly used by health districts to transport biological samples and tests are public

transportation and workers traveling on assignment. When surveyed, officials responsible for

surveillance in every district other than Zabré and Pama said their system was "effective" and that

samples arrived at laboratories in a timely manner.

The health districts of Baskuy, Sig-Noghin, and Zabré have functioning Epidemic Management

Committees which last met during the first quarter of 2018 or the end of 2017. Finally, all health districts

except Baskuy have a meningitis outbreak response plan.


Table 13: Integrated Disease Surveillance and Response (IDSR) / Case-Based Surveillance of Meningitis

(CBSM), health districts

Region



Integrated Disease Surveillance and Response

(IDSR) / Case-Based Surveillance

of Meningitis (CBSM)

How many workers are involved in

epidemiologic surveillance in your district? 5 6 6 1 3 7

How many are trained in IDSR? 11 0 0 1 1 0

When were workers in the health facility

last trained in IDSR? 2,014 2,015

2,010 2,016

How many are trained in CBSM? 1 25 1 0 0 1

When were workers in the district

last trained in CBSM? 2017 2016 2016

2015

Were epidemiologic surveillance data/weekly

reports (TLOH) received from all health facilities

during the last quarter?

Number of epidemiologic surveillance weekly

reports (TLOH) expected from health facilities

during the last quarter

156

286

72

221

179

39


reports (TLOH) received from health facilities during

the last quarter

156

286

71

221

179

39


reports (TLOH) received on time from health

facilities during the last quarter

156

286

62

221

179

39

Is the epidemiologic surveillance curve tracked for

all EPI diseases under surveillance?

Is public transportation used as a means of

transporting biological samples (tests)

in your district?

Is a worker on assignment used as a means

of transporting biological samples (tests) in your

district?

Is a messenger used as a means

of transporting biological samples (tests) in your

district?

Is this system effective?

Do samples arrive within

the required timeframe?

Is there a functioning epidemic management committee in the district?

Does the district have

a meningitis epidemic response plan?


4.1.4.2 Community-based surveillance of meningitis

Community health workers are involved in community-based surveillance in all health districts. Those in

the city (Ouagadougou) work on a voluntary basis and do not receive any formal remuneration.

Elsewhere, they are officially recruited and paid by the government and given the status of Agent de

Santé à Base Communautaire (ASBC). Most of them, except for those in Baskuy and Pouytenga, received

basic training in community-based surveillance when they were recruited in 2016 or 2017.

During the last quarter (April, May, and June 2018), only five suspected cases of meningitis were

detected in the Pouytenga district. None were referred to a health facility for investigation. However,

officials in the districts surveyed said that community health workers raise awareness to refer any

suspected cases of meningitis to health facilities.

Table 14: Community-based surveillance of meningitis, health districts

Region



Community-based surveillance of meningitis

Are there community health workers involved in

community-based surveillance in the district?

How many community health workers are involved

in community-based surveillance in the district?

35

44

129

177

342

80

How many are trained in community-based surveillance in the district?

0 44 0 177 342 80

When were community health workers in the

district last trained in community-based

surveillance?

2016

2017

2017

2017

Is there a definition of community cases (in local languages) of meningitis in the district?

Have identified community health workers been trained in using this definition?

During the last quarter (April, May, and June

2018), how many suspected cases of meningitis

were detected in the district?

0

5

0

0

0

How many were referred? 0 0 0 0 0

How many were investigated? 0

0 0 0 0

What approaches do community health workers use

to refer a suspected case of meningitis to a health facility?


4.2 Health facility profiles

4.2.1 Basic information on all health facilities

All health facilities have health areas with two or more villages or neighborhoods except for the Baskuy Sector 12 Centre de Santé et de

Promotion Sociale (CSPS), which has only one. When surveyors visited in August 2018, four out of the 12 health facilities visited (Sector 12,

Pouytenga, Zabré, and Kompienga) had not developed and posted their monthly plan for community immunization sessions.

Demographic data on immunization targets were available in all of the health facilities visited. The source of this data most commonly reported

by those surveyed was the health district, which obtains it from the National Institute of Statistics and Demography (INSD). The majority of those

surveyed believe that the population data attributed to them is incorrect, containing either overestimations (Sector 12, Pabré, Pama) or

underestimations (Kompienga, Diarra-Betongo, Pouytenga, Sector 6). However, in Bourgou and Dakiri, there "seems to be trust in the health

district," "estimates are equal to data from the local census conducted by community health workers, and indicators do not exceed 100%."

Nearly half of all health facilities have no up-to-date map of their health area indicating villages and neighborhoods.

Table 15: Basic health facility information

District

Baskuy Sig-Noghin Pouytenga Zabré Manni Pama

Health facility Sector 12 Sector 6 Pabré Bissighin Kodemende Pouytenga Diarra-

Betongo Zabré Bourgou Dakiri Kompienga Pama

Basic information

Total number of villages/neighborhoods in the health area

1 6 3 2 6 9 4 15 10 16 3 5

Does your health facility have an immunization session plan for the current month?

Is your immunization session plan for the current month posted?

Total health area population in 2018 31,812 25,051 17,729 14,466 3,946 81,316 3,945 40,728 11,912 19,350 18,311 20,116

Target population for immunization aged 0-11 months in the health area in 2018

712 560 555 453 172 3,544 154 1,586 530 905 808 888

INSD is the source of population data

Do you think this population data is correct?

Do you have an up-to-date map of the health area with its villages/neighborhoods?

Is the health area map posted?


4.2.2 Availability of EPI and surveillance tools and guidelines

The Health Worker Immunization Guide was only available in two health facilities (Pabré and Bissighin). Most health facility officials surveyed did

not even know this EPI reference document existed. However, EPI guidelines and reference guides in the form of small policy reminders were

available and posted on the walls of nearly all health facilities, except for Sector 6, Pouytenga, and Pama. A self-monitoring curve of

immunization coverage was posted in all health facilities except Pabré (recently renovated EPI room) and Pouytenga (unsuitable and barely

functional EPI room).

The surveillance tool missing from most health facilities was the revised epidemic-prone disease fact sheet, even though descriptive listings of

suspected cases of epidemic-prone diseases were available everywhere. Only Diarra-Betongo did not have the latest version (June 2017) of

epidemic-prone disease reporting forms.

Compared to all other health facilities, Pouytenga had the fewest available EPI and surveillance tools and guidelines.

Table 16: Availability of vaccination tools and guidelines, health facilities

District


Health facility Sector 12 Sector 6 Pabré Bissighin Kodemende Pouytenga Diarra


Immunization tools and guidelines

National EPI policy documents (Health

Worker Immunization Guide) available in the

health facility

Immunization coverage monitoring curve posted

in the health facility

Latest EPI activity report(s)

EPI guidelines

Map of the health facility's area of responsibility

Immunization session plan by strategy


Table 17: Availability of epidemiologic surveillance tools and guidelines, health facilities

District




Epidemiologic surveillance tools and guidelines / National Health Information System (SNIS) routine materials

Revised definitions of suspected cases of epidemic-prone diseases

Revised epidemic-prone disease data sheet

Descriptive list of epidemic-prone disease cases

Epidemic-prone disease notification form (June 2017 version)

Monthly Activity Reports (RMAs) CSPS_CM_CMA

OBC form

4.2.3 EPI status in health facilities

4.2.3.1 Evaluation of the Reaching Every District / Reaching Every Child in the Community (RED/REC) approach

Planning: Some health facilities did not develop a micro-plan for their health area in 2018 (two health facilities in the districts of Baskuy,

Pouytenga, Zabré, Bourgou). Health facilities that did have a 2018 micro-plan included the community in the development process and

programmed EPI activities. In addition, nearly all health facilities had a breakdown of the target population in their health area by

village/neighborhood and strategy.

Four health facilities (Pabré, Diarra-Betongo, Kompienga, and Pama) shared their micro-plan with their health districts for approval and

modification before requesting funding from local authorities. However, only Diarra-Betongo and Kompienga said their micro-plans were

funded, even though officials from other health facilities said that their management committees (COGES) and municipalities generally helped

fund certain micro-plan activities (supervision, outreach).


Table 18: Planning of the RED/REC approach, health facilities

District




PLANNING

Do you have a micro-plan for your health area?

Was this micro-plan developed with the community?

Are EPI activities included in the health area micro-

plan?

Is there a breakdown of the health area's target population by village and strategy?

Did you send your micro-plan to the district

management team for funding this year?

Was the micro-plan funded?

Does the management committee contribute to funding the micro-plan (supervision, outreach activities)?

Does the municipality contribute to funding the micro-plan (supervision, outreach activities)?

Reaching target populations: Three health facilities (Sector 6, Sector 12, and Pouytenga) said that their entire target population is located within

the 'onsite' area, i.e., within five kilometers from a health facility. At other health facilities, such as Zabré, Dakiri, and Bourgou, over 50% of the

target population lives more than five kilometers from the health facility and therefore requires health services to come to them through

outreach activities.

Many health facilities have high-risk and/or hard-to-reach populations in their health area, often due to geographic, physical, or natural barriers

(isolation during the rainy season) but also due to cultural barriers and those linked to certain beliefs, such as "certain populations that observe

directional prohibitions and refuse to allow their children to move toward the east." Health facilities are taking steps, however, to reach all

target populations, no matter where they are located, for example by working with community leaders to raise awareness and organizing

ramping up and/or catchup days after the rainy season.


Table 19: Reaching of target populations, health facilities

District






the onsite strategy?

100%

100%

69%

100%

60%

46%

29%

41%

75%

70%


the outreach strategy?

0%

0%

31%

0%

40%

54%

71%

59%

25%

30%

Are there any high-risk and/or hard-to-access populations in your health area?

Have steps been taken to reach these populations?

Monitoring and use of data for action: All of the health facilities visited had EPI data collection tools (tally sheets, immunization records, health

facility data reporting forms, etc.). Bissighin, Diarra-Betongo, Zabré, Bourgou, and Dakiri also had completed and up-to-date self-monitoring

curves of immunization coverage and dropouts. Five other health facilities (Sector 12, Sector 6, Kodemende, Kompienga, and Pama) had self-

monitoring curves but they were not up to date. Only Pouytenga had no EPI performance monitoring curve.

When surveyed, EPI officials were able to interpret EPI monitoring curves, except for those in Kompienga.

The two health facilities of Pouytenga and Bourgou did not have up-to-date routine immunization performance data for the last quarter (April,

May, and June 2018).

All health facilities reported receiving feedback and data on their performance from their health district. Where appropriate, they use this data

to guide their actions and improve their performance.


Table 20: Monitoring and use of data for action, health facilities

District




MONITORING AND USE OF DATA FOR ACTION

Are data collection tools available?

Is there an up-to-date immunization coverage

and dropout monitoring curve for the health

facility?

Is the immunization coverage and dropout

monitoring curve for the health facility posted?

Does the health official know how to interpret the curve?

Does the health facility have up-to-date routine

immunization performance data for the last

quarter (April, May, and June 2018)?

Is this data shared or provided by the health district?

Is this data used for action?

Formative supervision: According to program guidelines, all health facilities' EPI activities must be supervised each quarter by their health district

management teams. Due to a lack of financial resources, supervisory visits have been tacitly rescheduled for once every six months in the

majority of health facilities visited. Half of health facilities reported having been supervised during the previous quarter (April, May, and June

2018), even though some of those 'integrated' supervisory visits did not include aspects of EPI.

In addition, many supervisory visits scheduled during the last quarter (April, May, and June 2018) were not conducted, as was the case in Pabré,

Kodemende, Pouytenga, Diarra-Betongo, Zabré, Bourgou, and Dakiri.


Table 21: Formative supervision, health facilities

District




FORMATIVE SUPERVISION

Does the district conduct an EPI (or integrated) supervisory visit of your health facility every quarter?

Does the district conduct an EPI (or integrated) supervisory visit of your health facility every six months?

Did your health facility receive an EPI (or integrated) supervisory visit

during the last quarter (April, May, and June 2018)?

Does your health facility have a supervisory notebook with feedback from past visits?

Have the EPI recommendations in the notebook been implemented?

During the last quarter (April, May, and June 2018),

what proportion of scheduled EPI (or integrated)

supervisory visits of your health facility were conducted by the district?

100%

100%

0%

100%

0%

0%

0%

0%

0%

0%

100%

100%

Connections with the community: Everywhere except for Sector 12 in Baskuy, community members were involved in planning immunization

services and participated in EPI activity review and monitoring meetings. Decentralized meetings outside the health facility framework were held

in certain communities to discuss the management of the health facility's activities.

Except for in Pouytenga, all of those surveyed in the rapid assessment said communities were engaged in raising citizen awareness about

immunization, organizing health facility outreach activities, and looking for unvaccinated patients or those lost to follow-up.


Table 22: Connections with the community, health facilities

District




CONNECTIONS WITH THE COMMUNITY

Are community members involved in planning

immunization services?

Are they involved in monitoring and review meetings?

Do you hold health facility activity management meetings in the community?

Do you think the community is engaged in raising awareness in favor of immunization?

Is it involved in organizing outreach activities?

Is it involved in looking for immunization dropouts?

4.2.3.2 Service delivery, onsite/outreach/mobile sessions and EPI performance

Except in certain places (Sector 12, Kodemende, Diarra-Betongo, and Dakiri), the majority of health facilities conducted scheduled, onsite

immunization sessions during the last quarter (April, May, and June 2018).

Diarra-Betongo and Dakiri did not conduct all of the outreach sessions scheduled this quarter. Compared to other health facilities, they had the

lowest outreach session completion rates.

On the whole, the three health facilities of Bissighin, Bourgou, and Kompienga had acceptable Penta1/Penta3 dropout rates (below 5%).

Several health facilities had negative Penta1/Penta3 dropout rates. Reasons they gave included administering more Penta3 vaccines to children outside their area of responsibility. Kodemende, for example, stated that it "vaccinates in villages outside its outreach zone."


Table 23: Service delivery, onsite/outreach/mobile sessions and performance, health facilities

District




Immunization service delivery by strategy and performance

How many total onsite immunization sessions

were organized by the health facility during the

last quarter (April, May, and June 2018)?

31/60

60/60

60/60

60/60

40/60

7/12

64/70

62/65

19/24

28/28

24/24

How many total outreach immunization sessions

were organized by the health facility during the last

quarter (April, May, and June 2018)?

0/0

0/0

15/15

9/9

18/18

0/0

0/6

18/18

36/36

7/36

15/15

33/33


your health facility during the last quarter (April, May, and June 2018)?

44

184

33

739

57

509

84

288

168

106

210

199


your health facility during the last quarter (April, May, and June 2018)?

58

202

37

727

65

452

92

321

160

122

200

178

Calculate the Penta1/Penta3 dropout rate for the period

-32% -10% -12% 2% -14% 11% -10% -11% 5% -15% 5% 11%

Is the rate acceptable (≤ 5%)?

4.2.3.3 Supply and quality of vaccines

Only the two health facilities in the Sig-Noghin health district did not have cold chain equipment in good working order. All other health facilities

had cold chain equipment to store vaccines, including refrigerators, freezers, vaccine carriers, and coolers.

Electricity was only used at the three health facilities of Zabré, Kompienga, and Pama, which means the most common source of energy for cold

chain equipment in health facilities is gas, except for in Pama. Very few health facilities (Sector 6, Pabré, Kodemende, and Pama) reported having

problems with a lack of gas as their main source of energy.

Cold chain temperature monitoring forms were available and up-to-date with twice-daily readings in all health facilities. Everywhere except

Pouytenga and Pama, thermometers in refrigerators displayed temperatures ranging from 2 to 8 degrees Celsius, which corresponded to

monitoring records.


Vaccine inventory records were available and up to date in all health facilities. However, several health facilities (Pabré, Bissighin, Pouytenga,

Diarra-Betongo, Zabré, Kompienga, and Pama) experienced vaccine and consumable stockouts (rotavirus, pneumococcal, and yellow fever) at

several points during the last quarter (April, May, and June 2018).

Table 24: Supply and quality of vaccines, health facilities

District




Supply and quality of vaccines

Is there cold chain equipment in your health facility?

How many pieces of equipment (refrigerators) are functioning/non-functioning?

1/0 1/0 0/1 0/1 1/0 1/2 1/0 1/0 1/0 1/0 2/0 2/0

How many pieces of equipment (freezers) are functioning/non-functioning?

0/0 0/0 0/0 0/0 0/0 0/1 0/0 1/0 0/0 0/0 0/0 0/0

How many pieces of equipment (vaccine carriers) does the health facility have?

10 10

8 2 10 7 7 8 13

13

How many pieces of equipment (coolers) does the health facility have?

0 1

0 0 0 0 0 1

1

Is electricity the source of energy used for the cold chain?

Is gas the source of energy used

for the cold chain?

Is the source of energy a problem for the cold chain at this level?

Are cold chain temperature monitoring forms

available and up-to-date with twice-daily readings?

Check the refrigerator thermometer(s) and ensure

the temperature ranges from 2 to 8 degrees

Celsius and corresponds to monitoring records

Is a vaccine inventory/individual

inventory record available and up-to-date?

Have you experienced vaccine stockouts or other

supply shortages during the last quarter (April, May,

and June 2018)?

How would you describe your vaccination needs

and supply levels?


4.2.4 Epidemiologic surveillance system status in health facilities

4.2.4.1 Integrated Disease Surveillance and Response (IDSR) / Case-Based Surveillance of Meningitis (CBSM)

Many people were involved in epidemiologic surveillance in the health facilities visited. However, few reported having received training in IDSR.

Some were trained nearly a decade ago (in Zabré), while the most recent training was held this year (in Diarra-Betongo) or in 2017 (Dakiri). Many

health facilities had no workers trained in Case-Based Surveillance of Meningitis (CBSM), as was the case at Sector 6, Pouytenga, Bourgou, and

Pama. Epidemiologic surveillance materials were available everywhere except Pabré. Two health facilities (Diarra-Betongo and Dakiri) said they

did not receive feedback on their data and weekly reports from their health district.

Table 25: Integrated Disease Surveillance and Response (IDSR) / Case-Based Surveillance of Meningitis (CBSM), health facilities

District




Integrated Disease Surveillance and Response

(IDSR) / Case-Based Surveillance of Meningitis

(CBSM)

How many workers are involved in epidemiologic surveillance in your health facility?

11 1 13 45 3 8 3 16 3 5 18 16

How many are trained in IDSR? 0 0 0 2 0 1 1 2 1 2 1 0

When were community health workers last trained in IDSR?

2015

2015 2018 2009 2015 2017 2011

How many are trained in CBSM? 1 0 1 1 1 0 1 1 0 1 1 0

When were community health workers last trained in CBSM?

2015 2013 2012

2018 2010

2016 2016

Are there epidemiologic surveillance materials in this health facility (CSPS)?

Does the district provide your health facility with

feedback on your epidemiologic surveillance

data/weekly reports (TLOH)?

4.2.4.2 Community-based surveillance of meningitis

On the whole, few health facility workers had been trained in community-based surveillance of meningitis. Community health workers involved

in community-based surveillance are present in all health facilities but have little training, which does not help the situation. Only three health

facilities reported having a definition of cases of meningitis in the community. During the last quarter (April, May, and June 2018), only three

suspected cases of meningitis detected in Kompienga were referred to and investigated by the health facility.


Table 26: Community-based surveillance of meningitis, health facilities

District




Community-based surveillance of meningitis

How many workers are trained in community-based surveillance in your health facility?

0 0 8 0 0 0 3 0 0 2 1 0

When were health workers in your health facility

last trained in community-based surveillance?

2015

2018

2017

2016

Are there community health workers

involved in community-based surveillance in your

health area?

How many community health workers are

involved in community-based surveillance in your health area?

0

6

8

10

6

8

8

16

34

32

32

10

How many ASBCs and other community health

workers are trained in community-based

surveillance?

0

0

8

0

6

0

8

8

0

32

6

10

When were community health workers

in the health area last trained in community-based

surveillance?

2015

2018

2018

2014

2017

2016

2016

Is there a definition of community cases (in local

languages) of meningitis in the health facility?

Have identified community health workers been trained in using this definition?

During the last quarter (April, May, and June

2018), how many suspected cases of meningitis

were detected in your health area?

0

0

0

0

0

3

0

0

0

3

3

0

How many were referred by community health workers?

0 0 0 0 0 0 0 0 0 0 3 0

How many were investigated by the health facility? 0 0 0 0 0 0 0 0 0 0 3 0

What approaches do community health workers use to refer a suspected case of meningitis to health facilities?


The major challenge reported by nearly all health district and health

facility officials remains the lack of training for staff and community

health workers on EPI and surveillance (IDSR, CBSM, community-

based surveillance), which they say is a pressing need that must be

addressed.

4.3 Challenges and difficulties reported by health district and health facility officials

After answering the questionnaires, health district and health facility officials agreed to summarize their

assessment of the challenges, difficulties, and problems they face in implementing routine immunization

and epidemiologic surveillance activities in their area of responsibility. Full transcriptions of their

interviews are included in the annex, but the box below summarizes their assessment.

On the whole, the other problems they mentioned were related to the geographic inaccessibility of

certain areas during the rainy season, insufficient EPI-specific formative supervision, insufficient

outreach to hard-to-access target populations, and the lack of financial, logistical, and communications

resources (motorbikes, fuel, phone and Internet credits).

Some of those surveyed also mentioned problems with the cold chain (insufficient and/or non-

functioning refrigerators, lack of vaccine carriers) and data quality.


4.4 Observation of immunization sessions Direct observation of immunization sessions allowed surveyors to see how immunization services are delivered to beneficiaries. They observed

the organization of the immunization site, the condition of the cold chain and status of vaccines and consumables, the vaccine administration

procedure, injection safety, and communication. Survey teams observed eight immunization sessions, with at least one session in each of the

project's target districts.

4.4.1 Organization of vaccination sites

On the whole, immunization sessions were conducted in properly-equipped, clean spaces allowing for proper management of patients,

everywhere except Bissighin and Kompienga. The number of vaccinators and volunteers assigned to the immunization site was deemed

sufficient for handling the number of beneficiaries everywhere except Kompienga, where a large crowd came in for immunization after two days

of rain but only two staff members were available to provide immunizations.

Program management tools (vaccination records, tally sheets, and vaccination summary sheets) were also available and properly completed at

all of the sites visited.


Table 27: Organization of vaccination sites

District


Health facility Sector 12 Sector 6 Bissighin Bougretenga Pouytenga Zabré Bourgou Kompienga

Immunization sites

Is the immunization site well-organized (clean, in

the shade, with chairs, logical circulation of

people)?

Does the organization of the immunization site

allow for satisfactory management of patients?

Are there enough vaccinators and volunteers

assigned to the immunization site?

Are members of the immunization team properly

identified (uniforms, coats, etc.)?

Does a community health worker/mobilizer work

with the immunization team at the site?

Are management tools available at

the site (immunization records, tally sheets, and

immunization summary sheets)?

Are management tools fully and correctly

completed (immunization records, tally sheets, and

immunization summary sheets)?

Are clean water, cotton, and antiseptic hand

solution available at the site?

4.4.2 Cold chain condition and status of vaccines and consumables

At all of the sites visited, vaccines were properly stored in vaccine carriers and proper storage conditions were observed. All consumables

(vaccines, auto-disable syringes, dilution syringes, and solvents) were also available in sufficient quantities.


Table 28: Cold chain condition and status of vaccines and consumables

District



Cold chain condition and status of vaccines and consumables

Does the team use a vaccine carrier to store vaccines and diluents?

Are vaccines available in sufficient quantities?

Are auto-disable syringes available in sufficient quantities?

Are dilution syringes available in sufficient quantities?

Are solvents available in sufficient quantities?

Are vaccine storage conditions satisfactory

(vaccine vial monitors (VVMs) intact, sealed ice packs, bottles not submerged in water, etc.)?

Are consumables available at

the site (vaccines, cards, auto-disable syringes, dilution syringes, safety boxes, etc.)?

4.4.3 Vaccine administration and injection safety

Surveyors observed proper knowledge of vaccination administration procedures by workers administering vaccines. While no pre-filled syringes

were found at vaccination sites, for vaccines reconstituted from antigens, the date and time that bottles were opened were only systematically

recorded at Sector 6, in Baskuy, and Zabré. Auto-disable syringes were disposed of in safety boxes immediately after vaccines were

administered.


Table 29: Vaccine administration and injection safety

District



Vaccine administration and injection safety

Are vaccines administered using the proper technique?

Are syringes pre-filled before vaccination ?

Are the date and time of reconstitution written on vaccine bottles?

Are bottles of reconstituted vaccines disposed of

at the end of the session or six hours after

reconstitution?

Are the auto-disable syringes used immediately

placed in safety boxes without recapping?

Are trash bags available for collecting other

waste (bottles, syringe packaging, cotton, etc.)?

Are safety boxes identified and closed?

4.4.4 Communication

EPI communication activities during group discussions were organized at some health facilities (Sector 12, Sector 8, Bougretenga, Zabré, and

Kompienga) at the start of immunization sessions. Topics addressed included vaccine-preventable diseases, the immunization schedule, types of

vaccines, and adverse events following immunization.

EPI promotional materials (brochures, signs, posters) were not available and visible at many immunization sites. The only facilities where they

were seen were Sector 6, Bissighin, and Zabré.

Interpersonal communication between health providers and caregivers accompanying children was not common at certain sites visited, such as

Kompienga, Bourgou, and Bissighin. Vaccinators communicated very little with parents about the types of vaccines being administered to their

children and the importance of following the routine immunization schedule. They did, however, indicate the next appointment date, the

possibility of adverse events following immunization, and what to do if such events occur.


Table 30: Communication

District



Group communication

Are immunization communication materials

(posters) visible at the immunization site?

Are communication activities (talks) conducted ahead of immunization sessions?

Do topics addressed in talks include vaccine-

preventable diseases, the immunization

schedule, types of vaccines, and adverse events following immunization?

Interpersonal communication

Do vaccinators communicate with parents about

the types of vaccines being administered to their

children (and the diseases they protect against)?

Does the immunization team communicate with

parents about vaccine side effects and what to do if

they occur?

Does a member of the immunization team

communicate with parents about the importance of

adhering to the routine immunization schedule?

Does a member of the immunization team tell

parents when their child's follow-up immunization appointment is scheduled?


4.5 Interviews with caregivers accompanying vaccinated children

After vaccine administration, several caregivers accompanying children who had just been vaccinated

were asked to answer a few questions about the service delivered to their child. All of the questions

were related to communication and their interaction with vaccinators.

In each of the eight health facilities visited, five caregivers answered the survey, except for Sector 6 in

Baskuy, where the session was nearly complete and only one mother was surveyed, bringing the total

number of caregivers surveyed to 36.

The results show that over half of caregivers reported that the vaccinator did not indicate the type of

vaccine being administered to their child (56%) or the diseases the vaccine would protect against (61%).

Only at Bougretenga and Zabré was this information shared with caregivers.

Table 31: Communication on vaccinations and EPI diseases

Did the vaccinator tell you which vaccine(s) they

administered to your child today? (n= 36)

Did the vaccinator tell you against which disease(s)

the vaccine(s) they administered to your child

today protect? (n= 36)

District Health facility No Yes No Yes

Baskuy Sector 12 2 3 2 3

Sector 6 1 1

Sig-Noghin Bissighin 5 5

Pouytenga Bougretenga 5 5

Pouytenga 4 1 5

Zabré Zabré 5 1 4

Manni Bourgou 5 5

Pama Kompienga 4 1 4 1

Total (56%) 20 (44%) 16 (61%) 22 (39%) 14

An average of approximately 70% of caregivers reported that vaccinators had indicated possible side

effects of the vaccines administered to their child and what to do if their child experienced any of those

effects. At Kompienga, a much lower proportion of caregivers reported having been informed by

vaccinators of vaccine side effects.

Table 32: Communication on vaccine side effects

Did the immunization team tell you about the

possible side effects of the vaccine(s) they

administered to your child today? (n= 36)

Did the immunization team tell you what to do

if your child experiences any side effects?

(n= 35)

District Health facility No Yes No Yes

Baskuy Sector 12 2 3 2 3

Sector 6 1 1

Sig-Noghin Bissighin 1 4 1 4

Pouytenga Bougretenga 2 3 2 3

Pouytenga 1 4 1 4

Zabré Zabré 5 5

Manni Bourgou 1 4 4

Pama Kompienga 4 1 4 1

Total (31%) 11 (69%) 25 (29%) 10 (71%) 25


More than eight out of ten caregivers reported having been informed of their child's next immunization

appointment by a member of the immunization team.

Table 33: Communication on follow-up immunization visits

Did a team member tell you

when your child's follow-up immunization visit is

scheduled? (n= 36)

District Health facility No Yes

Baskuy Sector 12 2 3

Sector 6 1

Sig-Noghin Bissighin 1 4

Pouytenga Bougretenga 5

Pouytenga 2 3

Zabré Zabré 5

Manni Bourgou 5

Pama Kompienga 1 4

Total (17%) 6 (83%) 30


4.6 Community support for immunization and disease surveillance Community members are actively involved in the organization, management, and delivery of health services, including immunization and disease

surveillance in their municipality. Some are volunteers who are referred to generically as community health workers (Agents de Santé

Communautaire, or ASC). Others in neighborhoods and villages of Burkina Faso, except for those in Ouagadougou, are recruited and receive a

salary from the government. They are referred to as Agents de Santé à Base Communautaire (ASBC).

4.6.1 Community health worker activities

The table below shows a breakdown of the number of community health workers attached to the health facilities visited according to their

status, i.e., whether they are recruited by the government (ASBC) or not (other community health workers). On the whole, all of the community

health workers surveyed admitted not knowing the number of households living in their target village or neighborhood. Only two of them (at

Sector 6 and Diarra-Betongo) knew the size of the total population and target immunization population in their village or neighborhood. All of

them identified recognized traditional healers in their municipality to whom the community turns when needed.

Table 34: Basic village/neighborhood information

District




Basic information

Do you know the total number of households in the village/neighborhood?

Total village/neighborhood population in 2018

25,504

883

Target population for immunization aged 0-11 months in the village/neighborhood in 2018

560

20 34

Number of ASBCs in the village/neighborhood 0 2 8 0 2 2 2 16 2 2 6 2

Number of community health workers

(other than ASBCs) in the village/neighborhood 12 0 0 15 0 0 1 25 0 1 0 10

Number of traditional healers in the village/neighborhood

3 5 4 10 2 2 2 6 4 10 1 9

Documents and tools to facilitate the work of community health workers were lacking in practically all of the health facilities visited. Only the

community health workers at Zabré, Bourgou, and Dakiri were fortunate enough to have a community-based surveillance record, image boxes to


educate the community, forms for reporting suspected cases of meningitis, case referral forms, and a community-based surveillance training

module. Community health workers at Sector 12 in Baskuy, Kompienga, Bissighin, and Pouytenga had the fewest tools. No community health

worker surveyed had population counting forms.

Table 35: Availability of community health worker documents and tools

District




Community health worker documents and tools

Population counting forms

Community-based surveillance records

Image boxes for educating citizens in the

village/neighborhood

Suspected meningitis case reporting forms

Suspected meningitis case referral forms

Community-based surveillance training

module

The involvement of community health workers in organizing immunization activities conducted by health facilities could improve the

community's acceptance and use of the services offered to them. At all of the health facilities visited except Pouytenga and Kompienga, the

community health workers surveyed reported having participated in micro-planning meetings with health facility officials. Some participated in

population counting, while others helped develop a map of the health area or identify new population groupings in their area of responsibility.

However, few of them (only in Kodemende, Kompienga, and Pama) reported having been involved in determining the target population in their

health area.

Of all the community health workers surveyed, only those in Bissighin reported that citizens in their target village or neighborhood did not take

their children to be vaccinated at the health facility but have their children vaccinated when health facility staff come to their village or

neighborhood.


All community health workers, except those in Pouytenga, support health facilities in reaching target populations by helping to look for

unvaccinated patients or those lost to follow-up. In addition, the majority of them had participated in immunization activity review and

monitoring meetings at their health facility.

In the area of communication, community health workers had conducted awareness-raising activities in their communities, either to pass on

messages to announce immunization sessions, go door-to-door in their village or neighborhood, or identify unvaccinated patients or those lost

to follow-up to refer them to the health facility for immunization. Only the community health workers at health facilities in the Baskuy health

district reported not having conducted awareness-raising activities.


Table 36: Evaluation of the RED/REC approach

District




PLANNING

Are you involved in micro-planning meetings

with health facility officials?

Did you play a role in

population counting?

Did you play a role in developing the health area

map?

Did you play a role in identifying new population

groupings?

Were you involved in determining the target population in the health area?


To vaccinate children, residents of the

village/neighborhood bring them to the health

facility.

To vaccinate children, health facility staff go to

the village/neighborhood.

Do you help look for children who are unvaccinated

or lost to follow-up?

Do you participate in meetings to monitor

immunization activities at the health facility?

Were you at the last monthly meeting to monitor

immunization activities at the health facility?

COMMUNICATION

To raise awareness in the

village/neighborhood, do you issue a message

to announce immunization sessions?

To raise awareness in the

village/neighborhood, do you raise awareness

by going door-to-door?

To raise awareness in the village/neighborhood, do

you identify unvaccinated children or dropouts and

refer them for immunization?


Because they are close to and live within the community, community health workers are expected to help monitor events, including diseases,

that could constitute a threat to the population. On the whole, community health workers at all health facilities except those in the Center

region reported being involved in surveillance of EPI diseases (like meningitis) and having been recently trained in surveillance, in 2016 or 2017,

when they were recruited.

During the last quarter (April, May, and June 2018), only community health workers at Dakiri, in the Manni health district, detected a suspected

case of meningitis and referred it to the health facility for confirmation and treatment.

Most community health workers surveyed have a register or notebook for documenting any cases of meningitis (or other disease under

surveillance) they detect. They added that if they detected a case, they would report or refer it to the health facility. None of them would

consider referring a case to a traditional healer.


Table 37: Surveillance of EPI diseases

District




Surveillance of EPI diseases

Are you involved in EPI disease surveillance (such

as meningitis) in the village/neighborhood?

Have you been trained in surveillance of EPI diseases?

When were you trained in surveillance of EPI diseases?

2016

2017 2016 2017 2015 2016 2017

2017

Did you detect any suspected cases of meningitis

during the last quarter (April, May, and June 2018)

in the village/neighborhood?

How many cases did you detect? 0 0 0 0 0 0 0 0 0 1 0 0

Do you have a record/notebook where you

document cases you detect?

If you detect a case, do you report it to the health facility?

If you detect a case, do you refer it to the health facility?

If you detect a case, do you refer it to a traditional

healer?

How many suspected cases of meningitis were

referred to the health facility during the last

quarter (April, May, and June 2018) in this village/neighborhood?

0

0

0

0

0

0

0

0

0

1

0

0

Do you have a definition of cases of meningitis (in local languages) that you use?


4.6.2 Interviews with community health workers and community leaders

In interviews, community health workers attached to the health facilities selected for the rapid field

assessment specified the role they play in ensuring that children in their municipality are vaccinated.

They also shared the challenges and problems they face and proposed solutions.

Community health workers

help raise awareness about

immunization, inform citizens

of immunization dates, look for

immunization dropouts, and

mobilize the community during

mass immunization campaigns.

Among those surveyed, some

reported not having any case

referral forms or any local definition of cases of diseases under surveillance.

Solutions they recommended including training community health workers and providing them with

communication tools and materials and means of transportation. They also asked to receive regular

wages.

The community leaders surveyed during the rapid assessment also agreed to answer questions related

to their involvement in health facility activities in their municipality and the role they could play in

ensuring children are immunized. They were also asked to name the challenges and problems related to

immunization and vaccine-preventable disease surveillance and propose possible solutions to these

problems.

On the whole, they are all involved in activities at their health facility, such as participating in review and

performance presentation meetings. They play a role in social mobilization in favor of immunization and

in raising citizen awareness during talks, sermons, or home visits. Some of them support health facilities

in looking for unvaccinated patients or those lost to follow-up and intervene in cases of patients in their

community who are hesitant or refuse to be vaccinated.

Several reported facing challenges in traveling to reach the entire population or spreading messages due

to some people's lack of receptiveness. They suggested stepping up awareness-raising of EPI and disease

surveillance and said health workers should do the same. They also asked to be provided with means of

transportation and fuel in order to do their jobs.

The problems community health workers face in their

work are related to a lack of training in EPI and

epidemiologic surveillance and a lack of working tools

(megaphones), EPI communication materials (image

boxes, brochures, posters), and means of transportation

(bicycles). They also reported irregular and delayed salary

payments.


Conclusion

The rapid assessment provided the MCSP team with an opportunity to visit the field along with

ministerial counterparts (DPV and DPSP). Together they met with officials from all of the target regions

and districts and a few health facilities, as well as community representatives, and presented the project

to them. It also provided an opportunity to collect and analyze baseline data and understand the current

status of immunization and epidemiologic surveillance systems in the project's areas of intervention.

In summary, the team found the following:

EPI and epidemiological surveillance tools, guidelines, and reference documents are not available

throughout the project intervention areas.

Some health facilities have not developed a micro-plan for their health area this year. The identification

of particular at-risk and/or hard-to-reach populations is not systematically performed to help reach all

targeted children who need to be vaccinated. Program performance is not routinely monitored to guide

decision-making in some health facilities. EPI-specific supervision visits to health facilities scheduled by

the districts are not all carried out. Close relationships are forged with community representatives who

are involved in immunization activities, both for raising awareness among the population and for

searching for unvaccinated children.

Health facility managers face other immunization challenges. These include, among others: the

irregularity of outreach strategy visits observed in some health facilities, data quality issues, the

unavailability of functional cold chain equipment in some places, and quality issues in interpersonal

communication between providers and caregivers.

For surveillance of epidemic-prone diseases, the lack of training was emphasized at all levels for both

health staff and community health workers.

The MCSP project is committed to working with the Ministry of Health to prevent epidemic outbreaks,

particularly of meningitis, by focusing on the following strategies:

Strengthening the community-based surveillance system in target areas

Strengthening the routine immunization system

Preparing and responding to outbreaks

Contributing to a 'One Health' approach.

Based on the findings of the rapid field assessment and the needs expressed by the officials and actors

surveyed, while respecting the action plan approved and accepted by its donor, USAID, MCSP proposes

implementing the following priority interventions:

Surveillance of epidemic-prone diseases and exceptional events

Train health workers on revised IDSR and Case-Based Surveillance guides in the six target districts

Conduct a training of trainers on the revised IDSR guides at the region and district levels


Support the cascade training of health and surveillance workers at the health facility and

community levels

Conduct post-training follow up and formative supervision activities

Extend community-based surveillance/surveillance of exceptional events to three new districts

(Baskuy, Pouytenga, and Pama)

Adapt training tools (Davycas-CDC) to the surveillance of exceptional events

Train and involve community health workers in community-based surveillance/surveillance of

exceptional events

Improve communication strategies for surveillance

Support the revision of existing communication tools and design new tools

Routine immunization

Train health workers in EPI in the six target districts

Conduct a training of trainers on EPI at the region and district levels

Support the cascade training of health and immunization workers at the health facility level

Conduct post-training follow up and formative supervision activities

Strengthen the RED/REC approach in the six target districts

Conduct a Reaching Every District / Reaching Every Child in the Community (RED/REC) approach

training at the district and health facility levels

Provide technical support to implement the RED/REC approach at the district and health facility

levels

Improve data quality and the use of data for decision-making

Strengthen mechanisms for quality data collection (data collection and reporting tools, data

validation meetings, data completeness, etc.)

Promote data review and validation

Promote community engagement in routine immunization

Build the capacity of community health workers in actively looking for children using the 'My

Village My Home' (MVMH) approach

Support community health workers and community leaders in raising community awareness and

enhancing knowledge and demand for immunization by fighting rumors

Enhance knowledge, raise awareness, and communicate about routine immunization

Improve provider-patient communication during routine immunization sessions

Use multimedia approaches to enhance knowledge and change behavior in terms of routine

immunization.

All of these interventions will be included in a detailed implementation plan that will guide the MCSP

project's activities in its target areas.

MATERNAL AND CHILD SURVIVAL PROGRAM (MCSP) BURKINA …

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