Strengthening District Support to the Micronutrient Program in a Low Income Setting: Rural Mali (West Africa).

Objectives: Since 2003, the Malian Ministry of Health (MoH) and its partners have adopted and scaled up a national program to deliver Vitamin A Supplementation (VAS) to children 6-59 months and post-partum women. The programme has achieved consistently high coverage of over 90%, however the majority of funding for implementation is provided by partners. The MoH has identified the need to increase country ownership of the VAS programme to increase programme sustainability. Methods: District level advocacy workshops were held in two regions with district health teams, local administration and civil society participants. The workshops, facilitated by the National Division of Nutrition and HKI Mali, provided information to participants to increase their awareness of VAS and encourage the mobilization of local resources to support VAS programme activities. Seven workshops were held one month before the most recent national Child Health Days (CHDs) with a total of 455 participants. Results: 178 district stakeholders committed to allocate additional resources to VAS distribution events, including allowances for distributers, fuel for supervision vehicles, transport for social mobilizers, and health supplies for VAS distribution. Decision makers also initiated local solutions for service delivery of VAS distribution, including covering the fuel cost for vaccinators, increasing local social mobilization efforts and adding a budget line for VAS activities in the community development plan. Conclusions: Advocacy efforts were effective in increasing resources allocated to VAS distribution and demonstrated an increase in local engagement at the district level.

Factors Affecting the Performance of Community Volunteers during Child Health Days in Douala, Cameroon.

Objectives: In the Littoral region of Cameroon, targeted awareness and social mobilization has increased coverage of vitamin A supplementation (VAS) during Child Health Days (CHDs) from 52.9%% in 2011 to 71.6% in 2012. Following this increase, coverage stagnated for the 2nd round of 2012 (71.0%) and the first round in 2013 (71.4%) thus falling short of the national target of 90% coverage of children 6-59 months. Methods: To determine barriers to high VAS coverage, targeted interviews were conducted with community volunteers participating in CHDs to identify factors contributing to CHD performance. Community volunteers were categorized as having "acceptable performance" or "poor performance" based whether their team met the daily target of reaching at least 120 children per day. Results: Interviews were conducted with 61 community volunteers with poor performance and 39 with acceptable performance from 6 health districts. The main factors found to influence performance were caretakers' awareness of the event and age of the volunteer (p<0.10). When asked how the campaign could be improved to reach all children, the most common response among both groups was better sensitization of parents (57%), ensuring stock (14%) and increasing the volunteer's allowance (12%). 37% of volunteers cited resistance by parents as the barrier that prevented teams from achieving universal coverage. Conclusions: Although door-to-door distribution is used to deliver services during CHDs to facilitate delivery, interviews with community volunteers indicate that better sensitization of caretakers prior to CHDs is still critical to achieving high coverage.

Validation of Vitamin A Supplementation Coverage Using Post-event Coverage Surveys in 11 Sub- Saharan African Countries.

Objectives: Twice-yearly child health days (CHDs) have had remarkable success reaching children twice-yearly with life-saving interventions, including vitamin A supplementation (VAS). In 2012, over 80% of targeted children in Sub-Saharan Africa received VAS according to tally-sheet data. All countries implementing CHDs use tally-sheet data to measure coverage; however, coverage measured from tally-sheets is prone to errors due to inaccurate census data, incorrect tallying and mathematical errors totaling coverage across districts and regions. Methods: To validate coverage reported by tally-sheets, Helen Keller International implemented Post-Event Coverage Surveys (PECS) using a 30x30 cluster design and standard WHO EPI cluster sampling methodology in 11 countries in sub-Saharan Africa. For each survey, 900 caretakers of children 6-59 months were interviewed within six weeks of CHDs to reduce recall bias. Results: Thirty-five post event coverage surveys were conducted between January 2010 and July 2013. PECS coverage was lower than administrative coverage in 33/35 (94%) of cases. PECS and administrative coverage data were within a 5% margin of difference in 5 cases (14%), and within >5-10% in 8 cases (23%). However, in 11 cases (31%), results differed by >10-20%, and in 11 cases (31%), results differed by 21-82%. Conclusions: PEC surveys indicate considerable over-reporting of coverage by tally-sheets and provide critical data that is essential to evaluate and improve VAS distribution during CHDs. The continued use of PEC surveys is recommended in areas where tally-sheet data has not been confirmed or has been shown to be unreliable.