How did Senegal implement?

Collaborated to implement effective programs

Close collaboration within Senegal and with external partners and donors has facilitated the design, development, and implementation of policies and programs. The MSAS maintains a strong focus on incorporating international guidelines and technical advice from external partners. Informants at national and lower levels reported referring to international guidelines during coordination meetings, discussing them as a team, and then determining how they might be implemented in Senegal.

As in many other countries, an Interagency Coordinating Committee (ICC) at the national level supports collaboration, coordination, resource allocation, and evidence-based decision making among the MSAS and external partners. ICC members include officials from MSAS and the Ministry of Economy, Finance, and Planning as well as external partners, community representatives, and technical experts.

Partner engagement is not limited to the national level. Partners also provide funding and technical assistance at health district, health post, and community levels. MSAS and external partners such as UNICEF, WHO, and PATH collaborate closely, each one playing clearly defined, complementary roles.

In 2012 Senegal established a national immunization technical advisory group, referred to as the Comité Consultatif pour la Vaccination au Sénégal, or CCVS. The CCVS advises the MSAS on immunization policies and provides technical and scientific expertise.

Within the MSAS, coordination meetings and supportive supervision were seen by almost all interviewees as vital to improving accountability, transparency, and support. Each year the national coordination meeting is chaired by the Minister of Health and Social Action. This session brings together regional and district-level management teams and external partners to review immunization performance indicators, follow up on recommendations from the previous year, discuss lessons learned, identify solutions to frontline challenges, and determine next steps.

Coordination meetings and supportive supervision have increased in frequency (see table below)—a tribute to their effectiveness and to the value that system participants have come to attach to them.

Coordination and supervision cadence^1,2

Subnational coordination meetings are opportunities to increase transparency, study performance, provide feedback, and promote accountability for coverage improvement. Through these meetings, coverage data, lessons learned, and best practices flow from health posts up to the regional and national levels. During these meetings, those who have the best coverage are celebrated, and those who are having difficulties work through problems with managers. Specific strategies are developed to address challenges and improve coverage.

However, management teams at the regional and district levels were noted to be “lacking capacity,” in terms of planning and supervision, and did not have enough control over resources and decision making due to centralized management of health activities. This may be a consequence of decentralization, as discussed in the Challenges section.

Improved disease surveillance and coverage monitoring, using data for performance improvement

Senegal adopted an integrated disease surveillance and response system in 1998, building on prior disease-specific and sentinel surveillance systems.³ Additional indicators have been added over time, and now the system conducts surveillance on 44 high-priority diseases and conditions, as well as on adverse events following immunization. Surveillance data are reported daily using mobile devices, and clinical samples are shipped to Dakar for analysis. Confirmed cases are investigated and district officials coordinate any necessary responses.

In addition to providing valuable epidemiological data, disease surveillance can reveal gaps in immunization coverage.

To improve monitoring of vaccine coverage, Senegal implemented the District Health Information Software 2 (DHIS2) health information management system in 2013. DHIS2 is used to aggregate and analyze data across the health system and to discover immunization coverage gaps, decrease stock waste, monitor cold-chain performance, and follow up on facility reports.⁴ This system reflects WHO recommendations to enhance national health information management systems by combining vaccination, health care delivery, and other program data.⁵

Starting in 2014, DHIS2 was implemented in health posts, complementing paper-based recordkeeping. DHIS2 use in health posts enabled reliable and timely coverage monitoring. Nurses-in-charge at health posts submit weekly data monitoring reports through DHIS2, and district-level staff aggregate and validate vaccination data from the health posts. The district health office provides feedback to the health facilities through DHIS2 and helps develop tailored strategies to reach missed children and improve coverage. When coverage decreases, the health post staff also work with community leaders to discuss the challenge and brainstorm solutions that are specific to the community.

Many interviewees discussed the value that surveillance and coverage monitoring have for increasing coverage. Timely monitoring reveals coverage gaps, showing where routine services need to be strengthened and where supplemental vaccination campaigns may be needed to improve population immunity.

Data system challenges include inadequate staffing, poor connectivity, and unpredictable energy supplies. Senegal also lacks sufficient resources for critical activities such as data quality assessments, training, and maintenance of data hardware and software. In addition, health worker strikes have interrupted data collection, although service provision has not always been affected.

Adapted services to mobile populations

Mobile people in Senegal include nomadic pastoralists of the Fulani ethnic group and fishing communities on Senegal’s coastal islands. Nomadic families are not always present in a community on outreach days, or for communication about immunization. As a result, children of nomadic families tend to have lower immunization coverage than settled families.^6,7

In addition, nomadic families may be more difficult for health care workers to reach:

To improve coverage for mobile populations, some health posts have increased the frequency of facility-based vaccination. As one head nurse noted, “We have set up a fixed [post] strategy that is held every Monday, because in general for health posts, the fixed [post] strategies apply once a month. We changed and we told ourselves that . . . we will make fixed [post] strategies every Monday.”

Since vaccination registries are managed locally by health post staff, tracking coverage and reducing dropouts among mobile families is especially challenging. Coordination meetings between community members and health post staff help in locating migrant families. Some health workers have also taken the initiative to communicate with colleagues to find children who have missed vaccinations, and to ensure they get the doses they need. Health workers have also adapted their messaging to family needs, recommending that they access vaccinations wherever they can.