#1NIGER Health Sectoral and Thematic Report January - December 2018 Prepared by UNICEF Niger March 2019 unicef for every child#2Cover Photo Credit: ©UNICEF/ Niger 2018/ Vincent Trémeau Table of Contents I. Abbreviations and Acronyms... II. Executive Summary. III. Strategic Context of 2018... IV. Results Achieved in the Sector V. Financial analysis.... VI. Future Work Plan... VII. Expression of Thanks Annex: Donor Feedback Form .... ANC ARI CHW I. Abbreviations and Acronyms DHIS-2 Antenatal consultation Acute respiratory infection Community health worker District Health Information System Demographic and Health Survey Diphtheria/pertussis/tetanus Emergency obstetric care Human immunodeficiency virus Integrated community case management Integrated management of childhood illness Multi-year plan DHS DPT3 EMOC HIV HMIS Health Information Management System iCCM IMNCI MYP NGO ORS PMTCT PSM SDG Sustainable Development Goal SMC Seasonal malaria chemoprevention UNFPA United Nations Population Fund UNICEF WHO Non-governmental organization Oral rehydration salt Prevention of mother-to-child transmission of HIV Procurement and Supply Management 19 20 22355812 United Nations Children's Fund World Health Organization II. Executive Summary This report presents the activities and results achieved by UNICEF in collaboration with its partners in the health sector in 2018. 2018 marked the final year of the 2014-2018 UNICEF Niger programmatic cycle, as well as the development of the new country programme for 2019-2021, aligned with the Government's Economic and Social Development Plan 2017-2021 and the United Nations Development Assistance Framework 2019-2021. In 2018, UNICEF continued to support the development of accessible, quality healthcare in Niger through the implementation of high-impact preventive, promotional and curative interventions, at scale or in priority sites such as emergency areas or regions affected by epidemics. Interventions such as kangaroo mother care, or the management of potentially 2#3severe bacterial infection in young infants less than two months showed positive results. The piloting of those interventions is still ongoing, mainly in Maradi region. This year again, seasonal malaria chemoprevention saved the lives of many children with an incidence of malaria decreasing by 13,608 cases compared to 2017. In addition, the development of the Community Health Strategic Plan 2019-2023 was one of the main priorities, as well as the scaling up of Integrated Community Case Management of childhood illnesses, which reached 86 municipalities in 6 regions in 2018. By the end of the year, 100,445 children had been treated for pneumonia, 101,704 for diarrhea and 97,092 for malaria. Good progress was achieved with the Enlarged Programme on Immunization. This was achieved through cold chain optimization including effective vaccine management, and the development of national guidelines for Reaching Every Child with Equity. According to WHO and UNICEF estimates of National Immunization Coverage, the Penta-3 coverage rate increased from 68% in 2014 to 81% in 2017, allowing the protection of increased numbers of children against vaccine-preventable diseases. UNICEF also supported heath system strengthening and improved data collection and analysis. In 2018, the scaling up of the District Health Information System platform progressed, as well as the strengthening of the capacities of the national procurement institution. In 2018, UNICEF contributed to strengthening emergency preparedness and response activities through active participation in national coordination mechanisms including the National Health Cluster and the National Committee for Outbreak Control. UNICEF also supported the implementation of "The New Way of Working" by strengthening coordination between humanitarian and development-oriented stakeholders and embedding health system strengthening interventions as part of emergency preparedness and response programmes. As in previous years, Niger experienced several outbreaks in 2018, including measles. UNICEF supported the Government-run vaccination response for measles, reaching 158,285 children aged 9 months to 14 years throughout the country, representing twice the number of children who were targeted (71,732). UNICEF support included vaccine pre-positioning and operational support. Moreover, UNICEF provided emergency assistance to Diffa and Tillabery regions, where health service delivery was disrupted due to security issues and population movements. Initiatives included support to mobile clinics (reaching 6,788 children) and iCCM in emergencies (reaching 1,288 children). Finally, UNICEF supported the implementation of the HIV scale-up plan to accelerate screening, antiretroviral treatment and prevention of mother-to-child transmission of HIV led to increased coverage. In 2018, 96% of health facilities including referral hospitals were providing HIV testing services; however, only 10% of HIV-exposed infants were tested within 2 months of birth, pointing to the need for further work. III. Strategic Context of 2018 Niger context Niger is a landlocked Sahelian country of 21.5 million people, most of whom live in rural areas (84%). The population is young, with 58% of Nigeriens being under 18, and nearly half of the population is poor, despite reductions in the poverty rate over the past decade. The country, which ranks last on the 2018 Human Development Index, sees its development constrained by several factors: climatic conditions that hinder rural development, vulnerability due to the absence of economic diversification, high population growth, gender equality issues, low 3#4levels of literacy and education, and the size and landlocked nature of the country, which obstruct the provision of essential goods and services to the population. In addition, Niger is confronted with recurrent crises. For many years, the country has suffered from chronic food insecurity, and faced food and nutrition crises in 2010 and 2012. It also regularly experiences epidemics, including cholera, as well as floods. Moreover, instability in the Sahel region has in recent years led to insecurity and population displacement, especially in the eastern part of the country affected by the armed conflict with Boko Haram and in the western areas bordering with Mali. The growth rate in Niger has experienced significant fluctuations in recent years and dropped from 3.5% in 2015 to 5.2% in 2017. Niger relies strongly on external support provided by technical and financial partners, such as non-refundable aid, budget support, and loans. Except for the education sector, budgetary allocations to social sectors remain far below international recommendations or national commitments. Allocations to the education sector were 15-20% in recent years, compared with a national commitment to increase the education budget to at least 25% of the national budget by 2020. However, the share of health in the national budget was 7% on average between 2010 and 2017, while the World Health Organization recommends at least 13%. Niger's health sector Over the past 20 year, the under-five mortality rate decreased substantially, allowing Niger to be one of the countries that reached Millennium Development Goal 4 related to the reduction of under-five mortality. The maternal mortality rate slightly declined and went from 535 per 100,000 live births in 2012 to 520 per 100,000 live births, according to the most recent statics of 2015. However, many challenges impeded the health sector efforts to maintain achievements, including the low national health coverage at 48.4%, as well as the fragile governance and limited leadership of the sector. A study on the multidimensional deprivation of children in Niger conducted in 2016 indicates that deprivation in health affects 68% of children under 2 years, of which 76% live in rural areas. The incidence of the number of multidimensional deprivations is 2.74 times greater in rural areas than in urban areas in the age group of 2 to 4 years old. Three main challenges could explain such a situation: i) the rapid growth of the population in link with child marriage and the high fertility rate (7.6 children per woman), ii) the poverty level: the number of people in need of humanitarian assistance represents more than 10% of the population in Niger iii) the weak level of education. In 2018, the country continued its modernization efforts, with wide-ranging initiatives to address systemic issues, particularly in the health sector. The reform of the national procurement and supply management system is moving forward with strategic planning for strengthening governance, distribution, and storage capacity, with a focus on the "last mile" (for example, the distribution of medical supplies up to the last sites of health service such as health huts), which is critical for delivering quality services to the most vulnerable children. The health information system also kept evolving with the introduction and gradual scale-up of the District Health Information System platform (DHIS-2). However, in 2018 Niger was still confronted with data quality issues which pose a challenge to achieving results for children in Niger, with serious consequences on national policy planning and decision-making. The 2017 Demographic and Health Survey could not be published in 2018 due to severe quality issues, resulting in the lack of updated baseline data to monitor progress in the implementation of the country national and international development commitments. 4#5A positive feature in 2018 was the spirit of partnership that prevailed among technical and financial partners in some key sectors. With the common goal to strengthen government ownership and capacities, and ensure efficient use of funds, donors continued to support sector-wide approaches. The Health Basket Fund is well-established and recognized as the preferred financing mechanism for several bilateral and multilateral entities, including the United Nations, and other sectors, and provides an avenue for UNICEF to advocate on strategic issues. This basket fund helps to strengthen equity in access to services, as the fund cover all the country, compared with donor-supported programmes that tend to target specific geographic areas. Nonetheless, the health sector remains under-funded with only 5.58% allocated to the total national budget in 2018. Aiming at greater budget effectiveness and efficiency, the financial reform initiated by the Ministry of Finance in 2017 foresaw the creation of a centralized bank account for all public institutions, including the Ministry of Health. However, this reform entailed the sudden closure of Government entities commercial bank accounts, without transition measures in place, which severely hindered implementation. The current decentralization process, with health one of the four initial sectors to be transferred to decentralized levels, offers important opportunities. Decentralization in the health sector focuses on improving physical assets management, human resources management, and access to healthcare. However, the reform is at an early stage of implementation, with capacity building and resource transfer as key pre-requisites. In 2018, Niger faced health epidemics including a large-scale cholera outbreak (3,822 cases and 78 deaths in 4 regions), measles (4,607 cases and 20 deaths nationwide), meningitis (1,496 cases and 115 deaths nationwide), and a circulating vaccine-derived poliovirus (13 cases and 1 death in 2 regions). In addition, floods affected over 200,000 people nationwide, among them over 120,000 people living in Dosso and Agadez regions. In addition, armed conflict and population movements affected three of Niger's eight regions (Diffa, Tillabery and Tahoua regions), disrupting access to essential health services. Several constraints continued to impact activities in the health sector in 2018, including: • • Inadequate neonatal services (insufficient human resources, underfunding, inadequate service delivery conditions); Failure to pay incentive fees for community volunteers on time, therefore threatening the sustainability of interventions; Insufficient funding and delay in disbursement of State funds for the purchase of vaccines; Shortage of vaccines for the response to measles outbreaks; • The existence of several parallel supply chains; • Weak management of the Free Health Care Policy; • Insufficient early diagnosis of HIV in young infants. IV. Results Achieved in the Sector In 2018, UNICEF continued to support Government efforts to reduce maternal and child mortality, in alignment with the Health Sector Development Plan (2017-2021) and with outcome 3 of the United Nations Development Framework for 2014-2018. UNICEF worked with several partners for maternal, neonatal and child health interventions: other UN agencies, the Global Fund, the President Malaria Initiative, the World Bank, the mechanism of the French Muskoka Fund, GAVI, John Snow International (JSI), the Bill and Melinda Gate Foundation, and Rotary International. Various funding sources were used to implement the UNICEF/Government of Niger cooperation programme, including health 5#6thematic funds. The health thematic funds were optimally used toward priorities to cover funding gaps for high-impact interventions for children Table 1: Health Indicators Health 2018 Results Health Indicators Baseline 2013 (% and/or #) Target Progress 2018 (% and/or #) 2018 (% and/or #) Children <1 year receiving DTP- containing vaccine at national level Children <1 year receiving measles- containing vaccine at national level Children 0-59 months vaccinated with polio through a UNICEF-supported programme during campaigns 75% Health Outcome 1: Children under 5 years of age and pregnant women, particularly the most vulnerable, increasingly benefit from quality high-impact interventions for the prevention and management of maternal and childhood illnesses, including in emergency situations. 68% 85% 99% (Health Information Management System - HIMS data 2018) 101% (HIMS data 2018) 85% 100% 100% 103% Women attended at least four times during their pregnancy by any provider (skilled or unskilled) for reasons related to the pregnancy 33% 60% Children aged 0-59 months with 58% 80% symptoms of pneumonia taken to an appropriate health provider National budget allocated for health 6% 10% 38.8% ((Ministry of Health Statistics Yearbook 2017, issued in December 2018) Data not available (Demographic and Health Survey 2018) 5.58% (Target: 15% as per Abuja Declaration) Number of cases of polio 0 % of children aged 12-23 months 75% 85% Data not available vaccinated against measles % of children under 5 years of age with 39% 80% Data not available malaria treated % of children under 5 years with 55% 75-80% Data not available diarrhoea who sought treatment from a health facility Proportion of births assisted by qualified personnel 29% 60% 36.3% (Ministry of Health Statistics Yearbook 2017, issued in December 2018) Output 1.1: By 2018, targeted health facilities offer a comprehensive evidence-based package of high impact quality preventive, promotional and curative interventions for maternal, neonatal, child and adolescent health and support improved demand for services Policy on focused antenatal care has No Yes Yes been developed, adopted and implemented Primary health care facilities providing 30% 80% 100% clinical care to children under five using the IMNCI approach Health workers in UNICEF supported 20% 100% 100% programmes trained in rapid diagnostic testing for malaria in children 6#7% of children under 5 years of age who benefited from a 3rd dose of seasonal malaria chemoprophylaxis in the 35 convergence municipalities (Comdeco) % of pregnant women benefitting from IPT2 as part of ANC in districts containing convergence municipalities (with particular attention on adolescents) 80% 96.15% 35% 60% 58.23% (Ministry of Health Statistics Yearbook 2017, issued in December 2018) Output 1.2: By 2018, targeted community health workers (male and female) offer a simplified package of evidence-based quality, high impact preventive, promotional and curative interventions for maternal, neonatal, child and adolescent health and support improved demand for services. Existence of Policy for Community Health Workers to provide antibiotics for No Yes Yes pneumonia Community Health workers in UNICEF supported programmes trained in Rapid Diagnostic Testing for malaria in children 0 100% 100% Months country had full stock access to OORS at the national level Data not 12 12 available Investment case in health initiated/ No Yes Yes finalized with focus on iCCM Accountability framework on iCCM No Yes Yes developed and validated (between Ministry of Health, Ministry of Community Development, Municipalities, NGOs) Strategic community health plan No Yes Yes available 1,951 1,857 Number of community health workers offering the full package of high-impact interventions to the populations living more than 5 km from CSI/health posts in convergence municipalities Percentage of under-five children affected with ARI for whom treatment is Data not 70% available 41% sought from CHW according to the protocol in convergence municipalities Output 1.3: By 2018, health facilities offer effective vaccination services using fixed (<5km), outreach (between 5 and 15 km) and mobile (>15 km) strategies to reach all children, including the hardest to reach as a result of geographical, cultural or other reasons. Equity-based approaches will be adopted Existence of a Multi-Year Plan (MYP) for Yes Immunization Yes Data not available 0 Months with stock out of measles vaccine at the national level (Target: 0 month) Planned supplemental implementation activities that were cancelled, postponed or reduced in size, during the previous 6 months due to gaps in vaccine supply Number of weeks of stock out of any vaccine at health district level in convergence municipalities 7 Yes 0 0#8% of activities in the Effective Vaccine Management (EVM) improvement plan implemented % of health districts in convergence municipalities having less than three confirmed cases of measles Data not 90% 89% available 5.5% 90% 90% Analysis of "Equity in Immunization" has been conducted and corrective actions No Yes No are identified Output 1.4 By 2018, all levels of the health system, community structures and local authorities have strengthened capacities in planning and monitoring in accordance with equity- and gender-based approaches, in supply management (including supplies aimed at the prevention, detection and case management of HIV) and in logistics HMIS generates annual reports of health facility and HRH distribution according to national guidelines Yes Yes No Health Management Information System generates periodic reports with data disaggregated by age and sex (for Yes Yes No relevant indicators) at national and sub- national level Relevant essential commodities No Yes No registered with the relevant regulation authority and guidelines for use in facilities available An analysis of sex-disaggregated infant and child mortality estimates is produced Number of health districts with convergence municipalities with at least 30% of their micro-plans funded, having improved their performance from one monitoring to the next Yes Yes Yes 0 30 7 An analysis of the essential health commodities conducted at national level (2016) No Yes Yes The supply system for essential No Yes No medicines and other health commodities optimized (2017-2018) % of health districts in convergence municipalities that submit their Notifiable Diseases report timely and with 100% completeness Data not available 50% 33% % of districts in convergence municipalities having an operational and functional cold-chain and oxygen concentrator maintenance/repair system 50% 38% Output 1.5: By 2018, health facilities and community structures have strengthened capacities to prepare for and respond to epidemics, natural disasters and population displacement Comprehensive multi-sectoral cholera Yes Yes Yes preparedness plan available Number of children aged 9 months to 14 years vaccinated against measles in Data not available 300,000 89,740 Diffa region 8#9Number of children (malaria) and women (ANC) who have access to lifesaving interventions through outreach on mobile strategies 32,015 210,000 6,788 1 (2015) Number of children (malaria) and women (ANC) who have access to high impact interventions in supported health districts 65,030 (2015) 120,000 18,4972 HIV and AIDS Outcome: Pregnant women, adolescents and children have access to and make greater use of quality preventive and curative care services for an AIDS-free generation. % of children born to seropositive 21% 60% mothers benefiting from ARV prophylaxis 58.6% (HMIS data - first semester 2018) and cotrimoxazole Percentage and number of pregnant 0% 20% women living with HIV with lifelong 35.5% (HMIS data - first semester 2018) access to ART for PMTCT and for their own health Percentage of HIV exposed infants 0% 50% receiving a virological test for HIV within 2 months of birth 10%, (HMIS data - first semester 2018) Output 2.1: By 2018, health facilities offer adequate, integrated services to adolescents at risk of HIV infection; PMTCT for pregnant women and exposed newborns; and case management for children and adolescents infected with HIV % of pregnant women tested for HIV during ANC in CSIs in convergence municipalities 25% 80% 72.2% (HMIS data - first semester 2018) Health Outcome: Children under 5 years of age and pregnant women, particularly the most vulnerable, increasingly benefit from quality high-impact interventions for the prevention and management of maternal and childhood illnesses, including in emergency situations. Despite a decreasing tendency, the child mortality rate is still high in Niger. Access to care remains limited to only 48.4 % of the population living at less than 5 km from a health facility; and with only 5.58% of the national budget allocated to health, the health system largely depends on external funding. Building on lessons learned, UNICEF continued to support the Government of Niger, using different sources of funding including thematic funds. Thematic funds were instrumental in achieving results in child survival, thanks to their flexibility. UNICEF continued to implement key interventions such as the seasonal malaria chemoprevention (SMC), Integrated Community Case Management (iCCM) of childhood illnesses, and neonatal care including kangaroo mother care. In 2018, SMC covered more than 96% of children aged 3 to 59 months in selected health districts, out of a target of 80%. Immunization coverage increased from 85% in 2017 to 99% and 100% for diphtheria/pertussis/tetanus (DPT3) and measles respectively. The proportion of births assisted by qualified personnel was 36.3% as per the Ministry of Health Statistics Yearbook 2017 (issued in December 2018), below expectations due to various reasons, including strong social barriers and beliefs. The proportion of women who attended at least four consultations by any provider (skilled or unskilled) during their pregnancy for reasons related to the pregnancy was 38.8% in 2018, below the expected result of 60%. 1 Number of children reached by mobile clinic services 2 Number of children treated for malaria 9#10The failure to achieve the result is partly linked to strong customs and beliefs according to which women hide their pregnancy for a long time and only start antenatal consultations at a late stage of the pregnancy, which does not allow them to complete the four recommended consultations before delivery. The health information system continued to develop with the introduction and gradual scale- up of the District Health Information System online platform (DHIS-2) to align with national and international priorities. The Demographic and Health Survey (DHS) is a key source for statistics on health indicators and was conducted in 2018, however it was not published due to severe quality constraints. This situation led to a lack of data on several outcome indicators. Output 1.1: By 2018, targeted health facilities offer a comprehensive evidence-based package of high impact quality preventive, promotional and curative interventions for maternal, neonatal, child and adolescent health and support improved demand for services Progress was recorded on maternal and neonatal health. The coverage of basic emergency obstetric and neonatal care facilities (basic emergency obstetric care) increased from 21% in 2014 to 44% in 2017. Among the facilities, 66% provided essential newborn care and resuscitation in 2018, compared with 19% in 2014 (United Nations Population Fund - UNFPA Emergency Obstetric Care Survey 2014 and 2018). In 2018, emphasis continued to be on newborn care with increased availability of newborn care practices such as kangaroo mother care and the management of potential severe bacterial infections in young infants aged less than two months. In Maradi and Zinder regions, UNICEF built the capacity of 120 health workers on newborn resuscitation, through low dose high-frequency training approach, and supported the kangaroo mother care method. Table.2: Kangaroo mother care Indicators From January to September 2018 in TOTAL From January to September 2018 in Maradi neonatology Zinder neonatology Total live births Newborn admission in neonatal unit unit 3, 336 unit 2,533 5,869 2,375 2,006 4,381 Preterm newborn or newborn 452 424 876 with low weight at birth Preterm newborn or newborn 211 75 286 with low weight at birth treated through the kangaroo mother care method Death 243 283 526 In 2018, following the evaluation of the former Reproductive Health Road Map, the Ministry of Health, supported by UNICEF and other partners, developed a new Reproductive, Maternal, Neonatal, Child and Adolescent Health Strategic Plan. This document, which adopts an integrated, life-cycle approach, was being budgeted at the end of 2018. When completed, this strategic plan will be a key tool for future resource mobilization initiatives for the sector. 10#11As a result of advocacy by UNICEF and other development partners, the Ministry of Health built and equipped a newborn resuscitation block in the maternal and child centres of three regions where partners, including UNICEF, provide technical and financial support for the reduction of neonatal mortality. In addition, to improve the management of young infant infections, Niger started piloting a new World Health Organization (WHO) directive on the management of possible serious bacterial infection (PSBI), in the framework of a UNICEF and Bill and Melinda Gates Foundation partnership. Through this approach, trained health workers in primary care facilities use simplified antibiotic regimens to treat sick newborns and young infants on an outpatient basis. This approach was integrated into the new National Strategic Plan on Maternal, Newborn, Child and Adolescent health, and started to be implemented in April 2018 in four pilot health districts in the region of Maradi. For the third consecutive year, large-scale seasonal malaria chemoprevention campaigns coupled with malnutrition screening took place, covering 61 out of 72 districts in 2018. This was done with funding from several partners, mainly UNICEF, the Global Fund, the World Bank, the President Malaria Initiative, Fonds Français Muskoka (FFM) and Catholic Relief Services. Out of a target of 4 million children aged 3-59 months, 3.9 million received the first dose of seasonal malaria chemoprophylaxis and a total of 3.6 million children received the medicines during the four consecutive rounds, contributing to the reduction of 13,608 malaria cases compared with 2017. Over 3.5 million children were screened for malnutrition monthly during the lean season (July – October). During each round, 30,000 to 35,000 children were found to suffer from severe acute malnutrition and were referred to a health facility for treatment. Table.3: Number of cases of malaria and number of deaths from malaria in 2017 versus 2018 Regions Number of cases Number of deaths Average cases/100,000 2017 2018 2017 2018 people 2017 2018 Agadez 23,480 26,334 14 53 602.05 675.23 Diffa 33,642 42,172 15 16 862.62 1,081.33 Dosso 237,771 226,361 381 256 6,096.69 5,804.13 Maradi 354,552 276,105 397 581 9,091.08 7,079.62 Niamey 141,854 150,555 76 93 3,637.28 3,860.38 Tahoua 300,957 334,574 321 547 7,716.85 8,578.82 Tillabéry 256,765 267,352 321 419 6,583.72 6,855.18 Zinder 416,588 428,548 491 350 10,681.74 10,988.41 Total 1,765,609 1,752,001 2,016 2,315 45,272.03 44,923.10 Source: Ministry of Health weekly report on diseases surveillance, September 2018 Output 1.2: By 2018, targeted community health workers (male and female) offer a simplified package of evidence-based quality, high impact preventive, promotional and curative interventions for maternal, neonatal, child and adolescent health and support improved demand for services Key milestones were reached to institutionalize community health and consolidate achievements for the integrated community case management (iCCM) of childhood illnesses. With USAID and UNICEF support, the Niger's roadmap to accelerate community health institutionalization was launched at the Global Conference on Primary Health Care in October 2018. UNICEF facilitated the National Coordination Committee which was set up in 2017 and became functional in 2018, thus improving synergy among community health interventions. A 11#12community health situational analysis was conducted to collect evidence that has supported the development of the National Community Health Strategic Plan, with UNICEF support. The plan will be validated in 2019 and will guide the implementation of community interventions from 2019 to 2023. Through a partnership between UNICEF and the Agence nigérienne de volontariat pour le développement (ANVD)", a reference guidance on the development of community health workers was shared with all the stakeholders. A roadmap has been developed to operationalize this document. A joint supervision mission conducted by the Ministry of Health with UNICEF in the Maradi and Tahoua regions and including 20 volunteers from ANVD allowed the coaching of 420 community health workers in 4 districts of Maradi region. The integrated community case management (iCCM) comprehensive package was scaled up with varying coverage in 27 out of the country's 72 districts, with significant technical and financial support from UNICEF, the Global Fund to Fight AIDS, Tuberculosis, and Malaria and other partners. As of late 2018, 5,252 community volunteers had provided a set of curative, preventive and promotional health services to 590,380 children in villages located at more than 5 km away from a health facility. Moreover, in 2018, community health workers ensured the management of 97,092 cases of malaria, 101,704 cases of diarrhoea and 100,445 cases of pneumonia as well as the screening of 34,446 cases of malnourished children. However, sustainability remains a challenge as the provision of financial incentives to community health workers is currently done by donors. Output 1.3: By 2018, health facilities offer effective vaccination services using fixed (<5km), outreach (between 5 and 15 km) and mobile (>15 km) strategies to reach all children, including the hardest to reach as a result of geographical, cultural or other reasons. Equity-based approaches will be adopted UNICEF continued to support immunization, which was repositioned as a key result for children (KRC) and integrated with other essential services as part of the "Immunization-Plus" platform. While Niger was certified in 2016 as having stopped the transmission of Wild Poliovirus, in 2018, circulation of vaccine-derived poliovirus type 2 was confirmed in Zinder and Diffa regions, indicating low individual and herd immunity. An outbreak response was undertaken in 30 districts across 4 at-risk regions, with UNICEF support on both health and social mobilization aspects. Niger maintained the certification for maternal and neonatal tetanus elimination, and a plan to sustain this status is being finalized with technical support from UNICEF. According to WHO/UNICEF estimates, Penta-3 vaccination coverage rates increased from 68% in 2014 to 81% in 2017. UNICEF support included vaccine and procurement of consumable worth US$ 2,929,261 purchased by the Government of Niger (not including GAVI funds). UNICEF contributed to the funding of the health sector through the Health Basket Fund with an amount of US$1,400,000 in 2018 and is planning to increase its contribution up to US$2,000,000 starting from 2019, with stronger investments in nutrition and health. Participation in the Basket Fund provides key opportunities to UNICEF for discussing strategic matters with the Ministry of Health and other key partners, and for advocating for maternal and child health. Output 1.4: By 2018, all levels of the health system, community structures and local authorities have strengthened capacities in planning and monitoring in accordance with equity- and gender-based approaches, in supply management (including supplies aimed at the prevention, detection and case management of HIV) and in logistics In 2018, UNICEF conducted an evaluation of its support to the implementation of the Free Health Care policy, focusing on medicines supply and distribution through a parallel chain. 12#13Results pointed out the limited effectiveness and missed opportunities for health system strengthening. As a result, in 2018 UNICEF shifted its focus from medical drugs procurement and distribution to supporting the ongoing procurement and supply chain reform for national supply chain strengthening, as well as joining a national partnership for free health care management by establishing a dedicated management entity and decentralizing the reimbursement system. The procurement and supply chain system in place since 2016 received increasing support through strategy formulation and action planning as part of the ongoing reform in partnership with the World Bank, the Global Fund, and the President's Malaria Initiative. Emphasis was placed on modeling for "the Last Mile" distribution and integrating community supply chain. Building upon 2017 results, additional milestones were completed in 2018: baseline assessments, including a diagnostic study on the national Procurement Supply Management (PSM) system; an organizational and institutional audit of the national procurement authority; a human resources assessment; a storage capacity assessment; a logistic management information system assessment; a strategic guidance on priority support areas to the reform; policy framework components including governance bodies decrees (steering group and technical working group); a manual on roles and responsibilities; an operational guidance and planning including a list of tracer commodities for DHIS2 integration, and finally, activity plans with budgets were developed for implementation as of 2019. The national framework components will be captured in a national strategy currently under development with the support of the Global Fund, and based on the PSM system design, which is also ongoing. Strengthening health information systems was also accelerated by facilitating DHIS2 scale-up coordination and partnerships. As a result, the Roadmap for DHIS2 Scale-up (2019-2021) was successfully developed in 2018 in partnership with the Global Fund and disseminated for resource mobilization. Community health systems were included, by conducting a self- evaluation that generated key insights for strengthening and training on community DHIS2, including roadmap development for community integration that was successfully embedded in the Roadmap for DHIS2 Scale-up 2019-2021. Decentralized monitoring to improve and sustain monitoring and quality was conducted in 5 out of the 16 target districts. With UNICEF support, the training manual was revised focusing on improving periodic data collection in primary health care facilities and integrating community-based interventions, feedback at improvement planning at district and town levels. A lesson learned module was produced to strengthen the results in view of its implementation at scale. This progress was linked to UNICEF and other partners' successful advocacy through the national Health Basket Fund. Output 1.5: By 2018, health facilities and community structures have strengthened capacities to prepare for and respond to epidemics, natural disasters and population displacement In 2018, Niger continued to experience emergency upsurge, with disease outbreaks in various regions of the country, and with internally displaced people, returnees and refugees needing essential health services in Diffa, Tillbery and Tahoua regions affected by armed conflict. UNICEF contributed to strengthening emergency preparedness and response activities through active participation in national coordination mechanisms including the National Health Cluster and the National Committee for Outbreak Control. UNICEF continued to support the implementation of "The New Way of Working" by strengthening coordination between humanitarian and development-oriented stakeholders and embedding health system strengthening interventions as part of the Niger emergency preparedness and response programme. 13#14The measles outbreak response reached 158,285 children aged 9 months to 14 years nationwide, with financial and technical support from UNICEF. In addition, 52,249 people aged 2 to 29 years were vaccinated against meningitis, and UNICEF provided technical assistance by facilitation access to the International Coordination Group (ICG) support for vaccines and operational costs. Moreover, UNICEF provided emergency assistance to Diffa and Tillabery regions, where health service delivery was disrupted due to security issues and population movements. 117,110 under-five children were reached with essential health services through fixed and mobile delivery strategies. Initiatives included support to mobile clinics (reaching 6,788 children) and iCCM in emergencies (reaching 1,288 children). The major challenges hindering emergency preparedness and response activities included physical access constraints due to persisting insecurity and difficulties to access hard-to-reach communities. HIV and AIDS Outcome: Pregnant women, adolescents and children have access to and make greater use of quality preventive and curative care services for an AIDS-free generation In 2018, UNICEF continued to support Government efforts to fight HIV and AIDS. Implementing the HIV scale-up plan to accelerate screening, antiretroviral treatment and prevention of mother-to-child transmission (PMTCT) of HIV led to increased coverage. In 2018, 96% of health facilities including referral hospitals were providing PMTCT services; however, only 10% of HIV-exposed infants were tested within 2 months of birth (19 babies out of 198 born from HIV-positive women). This was due to limited access to molecular biology equipment. To address this situation, UNICEF advocated for the use of GeneXpert Point of Care machines, which were available in 12 laboratories throughout the country but not used for HIV testing. UNICEF provided reagents and training for 24 laboratory technicians, resulting in testing for HIV-exposed infants becoming available in all the regions of the country. During the first semester of the year, ³ 417,393 pregnant women had attended the first antenatal consultation and 342,820 among them (82%) received counselling on HIV prevention and were also tested for HIV. A total of 600 seropositive pregnant women were recorded, when they did their first antenatal consultation or were about to deliver (some pregnant women never attend any antenatal consultation before delivery). Among the 600 seropositive women, 387 discovered their HIV status when they underwent testing during ANC or delivery, and the remaining 213 were already aware of the fact that they were HIV-positive. 536 among them received antiretroviral treatment or prophylaxis for the treatment and prevention of mother-to-child transmission of HIV; reaching 89.33% coverage. However, out of the 600 seropositive women, only 213 were receiving long-lasting antiretroviral treatment. Also during the first semester of 2018 in Niger, 116 out of 198 newborns at risk of contracting HIV received antiretroviral prophylaxis in accordance to PMTCT guidelines, representing a 58.6% coverage. Output 2.1: By 2018, health facilities offer adequate, integrated services to adolescents at risk of HIV infection; PMTCT for pregnant women and exposed newborns; and case management for children and adolescents infected with HIV. In the health districts located in convergence municipalities, 81,453 (72%) pregnant women have been tested during the first ANC (with a seroprevalence of 0,13%) out of the 112,840 3 Latest data available from the Ministry of Health 14#15attendants counselled during the first semester of the year. Among the ones who have been tested, 20% were below 19 years old and 52.45% below 25 years. Out of 108 women who had been tested HIV positive, 40,7% were less than 25 years old, and 69.4% of them were receiving antiretroviral treatment. In order to accelerate the prevention of HIV among the youth and adolescent groups, UNICEF supported sensitization, counselling and testing campaigns in Zinder, Maradi, and Dosso regions and during a festival of pastoralists (Cure Salée) in Agadez region. More than 20,000 teenagers and young people were targeted in each region. V. Financial analysis Table 1: 2018 planned budget by thematic sector (in USD) Intermediate Results 1. Health facilities integrated package Funding Type 1 RR Planned Budget 2 336,407 ORR RR 1,729,441 484,479 2. Community integrated package ORR 616,205 RR 75,046 3. Emergency Health ORR 858 ORE 1,576,407 RR 1,203,097 4. Health System Strengthening ORR 50,157 RR 117,572 5. Immunization ORR 1,798,298 RR 6. PMTCT Paediatric and adolescent care ORR Total Budget 391,190 480,682 8,859,840 1 RR: Regular Resources, ORR: Other Resources Emergency Regular, ORE: Other Resources - 2 Planned budget for ORR does not include estimated recovery cost. The total budget planned for 2018 was US$8,9 million, with ORR accounting for 53%, RR for 29% and ORE for 18%. Table 2: Country-level thematic contributions to thematic pool received in 2018 (in USD) Donor Denmark Total Grant Number Contribution Amount SC1899010010 1,325,601 1,325,601 Programmable Amount 1,238,879 1,238,879 Table 3: Expenditures in the Thematic Sector (in USD) Expenditure Amount* Other Organizational Targets Resources Other Regular All Resources Resources Emergency - Regular 15 Programme Accounts (USD)#1621-01 Maternal and Newborn health 21-02 Immunization 447,411 134,839 582,250 1,594,861 123,603 1,718,464 21-03 Child health 601,254 1,632,241 3,615,248 5,848,743 21-06 HIV treatment and care 30,312 128,040 158,352 of children living with HIV 21-07 HIV prevention Total 601,254 12,639 3,717,464 42,287 4,044,017 54,926 8,362,735 In 2018, RR represented the major source of funding for health intervention, representing 48% of total expenditure, followed by ORR with 44%. Child health accounted for the greatest share of expenditure (70%), followed by immunization (21%). HIV/PMTCT interventions consumed only 3% of the budget in 2018. Table 4: Thematic expenses by Results area (in USD) Organizational Targets Expenditure Amount* Other Resources Other Resources - All Programme Accounts Emergency Regular (USD) 21-01 Maternal and newborn health 1,078 1,078 21-02 Immunization 1,208 67,670 68,878 21-03 Child Health 17,540 699,990 717,530 Total 18,748 768,738 787,486 Table 5: Expenses by Specific Intervention Codes (in USD) Row Labels Expense (USD) 3180/A0/881/001/1 HEALTH FACILITIES INTEGRATED PACKAGE 21-01-02 Facility-based maternal and newborn care (including emergency obstetric and newborn care, quality improvement) 21-01-05 Maternal and newborn care policy advocacy 1,428,292 315,840 266,409 21-02-10 Polio vaccines and devices 311,787 21-03-02 IMNCI - facilities 520,774 21-03-11 HSS - Health sector policy, planning and governance at national or sub-national levels 13,481 3180/A0/881/001/2 COMMUNITY INTEGRATED PACKAGE 21-03-01 IMNCI Integrated Community Case Management (iCCM) 3180/A0/881/001/3 HEALTH SYSTEM STRENGHTENING 21-03-10 HSS- Health system procurement and supplies management 21-03-11 HSS- Health sector policy, planning and governance at national or subnational levels 891,342 891,342 1,258,780 19,783 1,231,662 21-03-16 HSS- Management Information System 7,334 3180/A0/881/001/4 HEALTH EMERGENCY 559,248 21-03-18 Public health emergencies, including diseases outbreaks 559,248 3180/A0/881/001/5 PROGRAMME MANAGEMENT - CSD 2,605,117 21-03-99 Technical assistance- child health 2,605,117 3180/A0/881/001/7 IMMUNIZATION 1,406,678 21-02-02 Immunization supply chain, including cold chain 230,284 16#1721-02-05 Polio operations 21-02-10 Polio vaccines and devices 21-02-14 Polio operations cost 3180/A0/882/002 HIV/AIDS 21-06-01 Infant and child HIV diagnosis 21-06-02 Paediatric ART 21-07-01 ART for PMTCT 21-07-08 Maternal HIV testing and counseling 21-07-12 HIV testing including self-testing and counseling in adolescent Grand Total Table 6: Planned budget for 2019 (in USD) 149,912 740,834 285,648 213,279 126,849 31,503 30,535 18,844 5,549 8,362,736 Funding Planned Funded Intermediate Result Shortfall 2 Type Budget 1 Budget 1 RR 1,500,000 1,500,000 0 Maternal and child health ORR 8,308,628 287,161 8,021,467 system strengthening ORE 1,057,341 350,000 707,341 RR 400,000 400,000 0 Integrated immunization ORR 626,200 1,564,528 -938,328 services ORE 394,670 394,670 RR 1,200,000 1,200,000 0 Community health ORR 3,444,223 325,213 3,119,010 outreach ORE 195,989 195,989 RR 800,000 800,000 0 Health programme support ORR 769,369 462,501 306,868 Sub-total Regular 3,900,000 3,900,000 0 Resources Sub-total Other Resources - Regular Subtotal ORE 13,148,420 2,639,403 10,509,017 1,648,000 18,696,420 350,000 1,298,000 6,889,403 11,807,017 Total for 2019 Planned and Funded budget for ORR and ORE excludes recovery cost. RR plan is based on total RR approved for the Country Programme duration Other Resources shortfall represents ORR and ORE funding required for the achievements of results in 2019. 17#18The planned budget to carry out activities for 2019 is US$18.7 million but only US$6.9 million are available. To implement all the health programme activities planned in Niger in 2019, UNICEF faces a funding shortfall of US$11.8 million. VI. Future Work Plan In cooperation with the Government and in consultation with United Nations country team and partners, UNICEF has developed a new country programme to align with the Government's Economic and Social Development Plan 2017-2021 and the United Nations Development Assistance Framework 2019-2021. To maximize impact, the programme will begin a strategic shift from a predominantly service-delivery mode to more-important investments in systems strengthening and capacity-building. This spirit will also permeate UNICEF humanitarian response interventions, with sustainable solutions pursued to maximize contributions to national and local development plans. The vision for the new country programme is to support the Government towards ensuring that all children, especially the most vulnerable, enjoy their rights; adolescents and youth are empowered; communities and systems are strengthened and resilient; and humanitarian assistance and development address the structural causes of fragility and vulnerability. As per its 2019-2021 Country Programme Document, UNICEF plans to contribute to the following health outcome: by the end of 2021, women and children, including those who are marginalized and those living in humanitarian emergencies, have access to and use high- impact health and HIV interventions, pregnancy during teenagerhood. UNICEF will focus its efforts on three outputs: i) facility-based maternal and child health extended to PMTCT/HIV, health system strengthening, and emergency; ii) immunization, and iii) community health. To sustain child survival gains and close quality and equity gaps, the programme will support the Government to: (a) increase the coverage and quality of maternal, newborn, child and adolescent health services, particularly in the most deprived, underserved areas, including those affected by emergencies; (b) strengthen routine immunization nationwide, with renewed emphasis on urban areas; and (c) expand community health services, including through demand creation and the empowerment of caretakers and communities through social and behavioural change communication. Efforts will continue towards the prevention of mother-to- child transmission of HIV and the treatment of paediatric HIV, to maintain and reduce the already low prevalence of HIV/AIDS (0.4 per cent). At the national level, UNICEF will support strengthened political commitment, accountability and capacities to expand health interventions through increased government budgets in support of universal health coverage. Efforts will focus on leveraging government resources and partnerships for sustainable health systems through the Health Basket Fund, with the Global Fund to Fight AIDS, Tuberculosis and Malaria and the World Bank on supply chain management and with Gavi, the Vaccine Alliance, on immunization. UNICEF will advocate for a multi-stakeholder platform for community health and the integration of community-based data and supplies into the health system. Critical to success will be the national roll-out of the integrated community case management programme, along with the community health worker programme and the implementation of the sustainable incentives mechanism. In areas affected by emergencies, UNICEF will provide technical assistance and capacity-building to support the continuity of health services and preparedness and response to disease outbreaks. 18#19VII. Expression of Thanks On behalf of the children and women of this country, UNICEF Niger would like to thank the donors who have supported its health programme in 2018. No development is possible without ensuring the survival of the most vulnerable people, especially women and children, and equal access to good health. This can only be done with the support of resource partners committed to achieving meaningful results for the children and the women of Niger. We would also like to thank the Government of Niger and other major partners; whose collaboration was instrumental in achieving these results. O UNICEF Niger 2018/ I. Abdou 19#20Annex: Donor Feedback Form UNICEF is working to improve the quality of its reports and would highly appreciate your feedback. 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