[]{#InterventionsCaseManagement .anchor}

**PRESIDENT'S MALARIA INITIATIVE**

**Malaria Operational Plan**

**Year Three -- Fiscal Year 2009**

**SENEGAL**

**TABLE OF CONTENTS**

Abbreviations and Acronyms
................................................................................3

Executive
Summary............................................................................................5

[President's Malaria Initiative
..............................................................................](#OLE_LINK6).10

[Malaria Situation in Senegal
...............................................................................11](#MalariaSituationinAngola)

[National Malaria Control
Plan..............................................................................](#NAtionalMalariaControlProgramActivities)13

Major Partners in Malaria Control
........................................................................14

[Current Status of Malaria Indicators
.....................................................................](#currentstatusofmalindicators)..17

[Goals and Targets of President's Malaria Initiative
....................................................](#Goal).18

Expected Results -- Year
Three.............................................................................19

[Interventions -- Prevention](#InterventionsPrevention)

[Insecticide-treated nets (ITNs)
..................................................................](#itns)\...19

[Indoor residual spraying (IRS)
...............................................................\...](#IRS)\...25

Malaria in Pregnancy
..............................................................................28

[Interventions -- Case Management](#InterventionsCaseManagement)

[Malaria
diagnosis.................................................................................](#MalariaDiagnosisandTreatment)\....31

Treatment.............................................................................................34

Pharmaceutical management and drug
quality..................................................36

Community-Based Interventions
\..........................................................................39

HIV/AIDS and malaria
.....................................................................................43

Communication and
coordination..........................................................................45

[Capacity Building
.........................................................................................](#Communication)\...46

[Monitoring and Evaluation
..............................................................................](#MandEPlan)\...47

[Staffing and Administration
...........................................................................\...](#Staffing)..50

Annex 1:

Table 1
...............................................................................................52

Table 2
...............................................................................................53

Table
3.............................................................................................\...60

Table
4.............................................................................................\...61

**ABBREVIATIONS and ACRONYMS**

ABCD *Atteindre les Bénéficiaires Communautaires à travers les
Districts* (Reaching community beneficiaries via the health districts)

ACT artemisinin-based combination therapy

AIDS Acquired Immunodeficiency Syndrome

ANC antenatal care

AL artemether-lumefantrine

ART anti-retroviral therapy

AS--AQ artesunate-amodiaquine combination therapy

BCC behavior change communication

CBO community-based organization

CCF Christian Children's Fund

CCM Country Coordinating Mechanism

CDC Centers for Disease Control and Prevention

CESAG *Centre Africain des Etudes Supérieures en Gestion* (African
Center for Advanced

> Management Studies)

CTO Cognizant Technical Officer

CMS Central Medical Stores

DHS Demographic and Health Survey

DPL Directorate of Pharmacies and Laboratories

DRH Division of Reproductive Health

Fr CFA West African Financial Community Franc (USD \$1 = Fr CFA 420)

FY fiscal year

GIS geographic information systems

GOS Government of Senegal

HIV human immunodeficiency virus

HMIS health management information system

IDB Islamic Development Bank

IEC information, education, communication

IMCI integrated management of childhood illnesses

IP *Institut Pasteur du Sénégal*

IPTp intermittent preventive treatment in pregnant women

IRD *Institute pour le Recherche et Développement*

IRS indoor residual spraying

ITN insecticide-treated bednet

LLIN long-lasting insecticide-treated bednet

M&E monitoring and evaluation

MIP Malaria in pregnancy

MIS Malaria Indicator Survey

MOH Ministry of Health

MOP Malaria Operational Plan

MSH Management Sciences for Health

NGO non-governmental organization

NMCP National Malaria Control Program

PGIRE Integrated Water Resources Management Program (World Bank/OMVS
funded)

PLWHA people living with HIV/AIDS

PMI President's Malaria Initiative

PMTCT prevention of mother to child transmission (of HIV)

PRN Nutrition Enhancement Project (World Bank funded)

QAMSA Quality of Antimalarials in Sub-Saharan Africa study

RBM Roll Back Malaria

RDT rapid diagnostic test

RTI Research Triangle Institute

SLAP *Service de Lutte Antiparasitaire* (Parasite Control Service)

SP sulfadoxine-pyrimethamine

SPS Strengthening Pharmaceutical Systems Project

SRCS Senegalese Red Cross Society

UCAD University Cheikh Anta Diop

UNICEF United Nations Children's Fund

USAID United States Agency for International Development

USG United States Government

WHO World Health Organization

[]{#OLE_LINK6 .anchor}**EXECUTIVE SUMMARY**

In June 2006, the United States Government announced that Senegal was
selected to be included in a five-year, \$1.2 billion initiative to
rapidly scale up malaria prevention and treatment interventions in
high-burden countries in sub-Saharan Africa.

Senegal has a population estimated at 11.6 million, with approximately
2.2 million children under five, 417,600 pregnant women and 61,000
children and adults living with HIV/AIDS. Malaria is a major cause of
morbidity and mortality in Senegal and a high priority for the
government. Between 1-1.5 million cases of malaria are reported each
year, over one-quarter of which are in children less than five years of
age. Malaria is responsible for about one-third of all outpatient
consultations and 27% of deaths reported in health facilities.

![](media/image1.jpeg){width="5.009027777777778in"
height="3.6458333333333335in"}

**Map of Senegal showing the current 11 Regions**

The most recent information on nationwide coverage of key malaria
prevention and control measures in Senegal comes from a Malaria
Indicator Survey (MIS) conducted from November to December 2006. Since
artemisinin-based combination therapies (ACTs) had only been introduced
into the health system in Senegal earlier that year, only 3% of children
under five with fever were reported to have taken an ACT within 24 hours
of the onset of their symptoms. Approximately 49% of pregnant women
reported receiving two doses of intermittent preventive treatment for
malaria in pregnancy (IPTp). Approximately 36% of households possessed
at least one insecticide-treated mosquito net (ITN), with greater
ownership in rural compared to urban areas and in the poorer as opposed
to the richer quintiles. Seventeen percent of pregnant women and 16% of
children under five had slept under an ITN the night before the survey.

In Round 4, the Global Fund to Fight AIDS, TB, and Malaria (Global Fund)
awarded a \$33.3 million grant to Senegal covering activities through
2010, the principal recipient of which was the National Malaria Control
Program (NMCP). Senegal was also awarded a \$67 million grant under the
Global Fund's Round 7 competition, with \$29.8 million approved for
phase one in March 2008. With additional support from the President's
Malaria Initiative (PMI), World Health Organization (WHO), the United
Nations Children's Fund (UNICEF), the World Bank, the United States
Peace Corps, and other national and international partners, the
Government of Senegal has made significant progress in the scale-up of
malaria prevention and control interventions.

The following table shows the proposed Year 2 targets and the activities
supported by PMI and partners during year 2:

+------------------------------+---------------------------------------+
| **Proposed Year 2 Targets**  | **Expected Results after 2 Years of   |
|                              | Implementation**                      |
| (PMI and partners)           |                                       |
|                              | (March 2009\*)                        |
+------------------------------+---------------------------------------+
| 1 million ITNs distributed   | As of September 2008, 1,010,522 ITNs  |
|                              | had been distributed or marketed      |
|                              | through the private sector with       |
|                              | direct PMI support                    |
+------------------------------+---------------------------------------+
| 680,000 residents living in  | In Year 2 a second round of spraying  |
| 76,000 houses protected by   | was carried out in Richard Toll       |
| IRS in three districts       | District because of the second peak   |
|                              | of transmission in April.             |
|                              |                                       |
|                              | In Year 2, another round of spraying  |
|                              | in three districts covered 153,942    |
|                              | houses and protected 645,346 people.  |
|                              | \*\*                                  |
+------------------------------+---------------------------------------+
| ACTs will be implemented in  | To date, PMI has directly supported   |
| all MOH health facilities in | training and supervision of over 920  |
| 100% of MOH districts        | health workers at health centers and  |
| nationwide                   | posts and 236 management staff,       |
|                              | representing 100% of health           |
|                              | districts.                            |
+------------------------------+---------------------------------------+
| Community-based treatment of | To date, 3,299 community health       |
| malaria with ACTs            | workers have been trained by PMI to   |
| implemented in 100% of       | diagnose and treat cases of           |
| functional health huts       | uncomplicated malaria using ACTs at   |
| nationwide                   | health huts, representing 100% of     |
|                              | functional health huts nationwide.    |
|                              | From October 2006-September 2008,     |
|                              | 67,028 cases of suspected malaria/in  |
|                              | children under 5 were treated with    |
|                              | ACTs at these community sites.        |
+------------------------------+---------------------------------------+
| IPTp will be fully           | In Year 2, PMI supported refresher    |
| implemented in all MOH       | training and supportive supervision   |
| districts                    | of 1,156 health care workers          |
|                              | including regional and district       |
|                              | health care teams in MIP              |
|                              | interventions (100% of staff in all   |
|                              | districts).                           |
+------------------------------+---------------------------------------+

\*Year 2 implementation ends March 31^st^, 2009

\*\* A review of data collection procedures found that in Year 1
**households** were counted, not **houses**. The Year 2 target was set
based on Year 1 results and thus refers to the number of households, not
houses. In Year 2 the NMCP and partners requested that only houses be
counted by spray teams.

This PMI Year 3 Malaria Operational Plan (MOP) is based on progress in
Years 1 and 2 and a planning exercise carried out in May-June 2008. The
MOP was developed with the participation of the NMCP and nearly all
national and international partners involved with malaria prevention and
control in the country. The activities that PMI is proposing to support
fit well with the Ministry of Health (MOH) 2006-2010 Strategic Plan for
Malaria Control.

The following paragraphs briefly describe the progress to date and Year
3 plans for each of the major interventions. Further detail can be found
in the body of the MOP document technical interventions sections that
follow.

**[Insecticide-treated nets (ITNs)]{.underline}**: A key NMCP strategy
for malaria prevention is the distribution of ITNs, especially LLINs, to
pregnant women and children under five years of age. During its first
two years of implementation, PMI has supported a comprehensive,
three-pronged strategy to increase household ownership and use of ITNs,
especially LLINs and especially among vulnerable populations: 1) **free
distributions** of approximately 872,000 LLINs to young children
participating in the MOH's local supplementation days 4,121 LLINs to
people living with HIV/AIDS (PLWHA); and 900 LLINs to cover 100% of
pregnant women and children on an island in the Fatick region; 2)
**subsidized distribution** of approximately 158,000 LLINs to pregnant
women and children under five through a voucher program in 550
facilities in 37 of the country's 63 districts; and 3) **social
marketing**, resulting in retail sales of 126,930 ITNs and LLINs. In
addition, PMI and partners supported the retreatment of 125,632 nets
with insecticide. To ensure high rates of LLIN demand and use, PMI has
invested in information, education, and communication (IEC) and behavior
change communication (BCC) activities.

In Year 3, the PMI will continue to complement and coordinate with the
NMCP to maximize LLIN distribution using the "catch-up" and "keep-up"
strategies endorsed by RBM. In June 2009 the NMCP plans to hold a free
distribution campaign targeting all children under five nationwide,
using its Global Fund Round 7 grant to purchase 1.3 million of the 2.5
million LLINs needed. PMI will contribute 200,000 LLINs, \$500,000 in
logistics and operational support, and assistance to the NMCP to secure
additional donors and partners to fill the remaining LLIN and budget
gaps. At the NMCP's request, PMI will complement the campaign by
focusing its support for LLIN distribution during Year 3 on expanding
the "keep-up" strategy: a routine system of subsidized LLIN vouchers for
pregnant women and children under five to all districts nationwide. PMI
will also continue to support social marketing activities to stimulate
the commercial market for LLINs and increase LLIN use.

An estimated 5.95 million LLINs are needed to cover all sleeping spaces
in Senegal, based on an average of 2 people per LLIN.  Through the NMCP,
PMI, and partners, approximately 1,578,000 LLINs have been distributed
in Senegal since 2005, with 1,452,000 estimated to be still effective,
leaving a gap of 4.5 million LLINs.  The 3.9 million LLINs expected to
be distributed in 2009 will fill 88% of the estimated gap and ensure
high rates of household possession by the end of FY09.

**[Indoor residual spraying (IRS)]{.underline}**: During Year 1, PMI
strengthened vector control capabilities by supporting spraying with a
synthetic pyrethroid insecticide in three districts, one in each of the
three ecological zones, covering a total population of over 675,000.
More than 98% of households found by spray teams were actually sprayed.
PMI also collaborated with entomologists at the Université Cheikh Anta
Diop (UCAD) and the Institut Pasteur (IP) to develop a detailed IRS
entomological monitoring and evaluation plan. Based on results obtained
through the entomological monitoring, observations made during program
monitoring missions, and a programmatic evaluation, the training,
organization and supervision of spray teams was improved for Year 2
activities. PMI supported a second round of spraying in Richard Toll in
March 2008 and in summer 2008 completed another spray round in all three
original districts, covering a population of 645,346. In Year 3, PMI
will support IRS and entomological monitoring in the same districts as
in Year 1 and 2, and will continue to support entomological monitoring
in a fourth district, as planned with Year 2 funds. A plan for
developing capacities in the MOH to conduct IRS operations is being
developed, building on the lead role the NMCP, UCAD, the Parasite
Control Service (*Service de lutte anti-parasitaire* or SLAP) and the
Hygiene Service have in training and supervision.

**[Intermittent preventive treatment in pregnant women
(IPTp)]{.underline}**: With the efforts of PMI and other partners, IPTp
implementation is underway in all MOH antenatal care service delivery
sites nationwide. With Year 1 funds, PMI supported the production and
use of new ANC registers and ANC cards that allow for accurate recording
of two IPT treatments, as well as job aids to promote the correct
management of malaria in pregnancy. In Year 2, PMI supported refresher
training and supportive supervision of 1,156 health care workers in MIP
interventions including regional and district health care teams from all
eleven regions. PMI funds have also been used to support health care
workers providing MIP services, including IPTp, during their regular
outreach visits to health huts. Finally, PMI supported the purchase and
dissemination of water filters and reusable cups to facilitate
directly-observed SP treatment for IPTp. In Year 3, PMI will strengthen
MIP interventions nationwide through training, monitoring, and
supportive supervision of health care workers in MIP service delivery.
As infrequent and late ANC attendance is a limiting factor to reaching
IPTp coverage goals, PMI will also support mass media and community
IEC/BCC activities to increase ANC attendance early in pregnancy and
ensure completion of all recommended visits.

**[Case management:]{.underline}** *Diagnosis:* During Year 1, PMI
worked closely with the NMCP and other partners to assess existing
laboratory capacity, equipment, and needs for the microscopic diagnosis
of malaria. Based on this assessment, PMI purchased 84 clinical
microscopes, 3 teaching microscopes, laboratory equipment and supplies
and developed a plan for training and increased supervision of
laboratory workers. During Year 2, PMI supported development of a new
curriculum for the microscopic diagnosis of malaria and a revised system
of supervision, quality assurance and quality control. To date, 12
regional and national staff and 70 laboratory technicians from the
district level have been trained, with 21 district-level staff having
received post-training follow-up visits. In Year 3, PMI will support
training in parasitological diagnosis of malaria and strengthen the
quality assurance and supervision of health facility laboratories in
microscopy and extend this system to include RDTs and an operations
research project will examine the predictive values of the diagnostic
and treatment algorithm. Technical assistance will also be provided to
support the extension of the quality assurance/quality control system
and the diagnostic and treatment algorithm operations research project

*Treatment:* Through its Round 4 and 7 Global Fund grants, the NMCP is
able to meet all public sector needs for ACTs through 2012. During its
first two years, PMI supported refresher training in case management and
supportive supervision at health center and health post levels in all
regions for 1,156 clinical-level providers and management staff. In Year
3, PMI will continue to strengthen case management of malaria with ACTs
through supportive supervision and monitoring, training of new health
care workers, and preparation for the transition from AS-AQ to AL in
2010. PMI will also purchase medications and equipment for treatment of
severe malaria.

**[Pharmaceutical Management and Drug Quality:]{.underline}** In March
2007, PMI supported refresher training for three MOH program staff in
ACT quantification. In 2008, PMI implementers field tested and finalized
a pharmaceutical management procedures manual and supervision guide, and
conducted training for health facility pharmacy managers and health
system supervisors. PMI has collaborated with UCAD in monitoring
antimalarial drug quality and in producing evidence-based data on drug
quality. Results of drug quality monitoring at five sites around the
country showed that nearly 30% of antimalarial drugs did not conform to
one or more quality standards. Most of the non-conforming drugs were in
the informal sector and were expired. PMI coordination also resulted in
the establishment of a National Pharmacovigilance Committee. In Year 3,
PMI will continue to support the strengthening of pharmaceutical
management systems for ACTs and the monitoring of drug efficacy for
first and second-line antimalarials.

**[Community Interventions:]{.underline}** In Years 1 and 2, PMI has
supported malaria interventions at the community level through a
consortium of international and local NGOs. With PMI support, a total of
9,568 community members have been trained in malaria prevention and
control interventions, including health hut management. Community
interventions reached national scale with FY07 funds, covering every
district in Senegal, and include two broad categories of activities: 1)
community case management of malaria, and 2) community mobilization for
malaria prevention and control. In Year 3 PMI will continue the
community case management and mobilization efforts begun in Years 1 and
2 and will support the NMCP in its plan to roll out RDTs and a planned
new treatment protocol to the community level. The NMCP has requested
that PMI and its community health partners train, assist with
supervision, and update job aids and training materials for these
activities.

**[Monitoring and Evaluation (M&E)]{.underline}:** In Year 1, PMI
provided support to build national capacity in monitoring and
evaluation, including implementation of a national Malaria Indicator
Survey (MIS) in November-December 2006 to provide baseline data for PMI,
and support to two demographic surveillance sites to obtain facility
level malaria-specific mortality data for children under five. During
Year 2, the PMI resident advisors actively participated in the quarterly
reviews and on a commission charged with following up on recommendations
stemming from the reviews, including improvements in the quality of the
data collection methods and monitoring. Year 3 PMI monitoring and
evaluation activities will be done jointly with the NMCP and other
partners, and PMI will support implementation of the NMCP M&E plan. To
measure mid-point coverage for PMI-supported interventions, PMI, the
NMCP and partners will support a nationwide MIS including anemia and
parasitemia testing, with data collection beginning in November 2008.
PMI will also provide support to the NMCP to improve systems for storage
and archiving of data stored on paper forms and an improved computer
network for the management and back up of its computerized data bases.

**[Budget:]{.underline}** The FY2009 PMI budget for Senegal is \$15.7
million. Of this amount, 42% will support household ownership and use of
LLINs, 20% IRS activities, 7% improved malaria diagnosis and treatment
at the health facility level, 3.5% malaria in pregnancy activities, and
14% community-based malaria interventions (including case management and
promotion of ITNs, IEC for IRS, and malaria in pregnancy activities). A
total of 45.5% will be spent on commodities.

**PRESIDENT'S MALARIA INITIATIVE**

On June 30, 2005, the United States Government announced a new
five-year, \$1.2 billion initiative to rapidly scale up malaria
prevention and treatment interventions in high-burden countries in
sub-Saharan Africa. The goal of this Initiative is to reduce
malaria-related mortality by 50% after three years of full
implementation in each country. This will be achieved by reaching 85%
coverage of the most vulnerable groups\-\-- especially children under
five years of age and pregnant women \-\--with proven preventive and
therapeutic interventions. These include artemisinin-based combination
therapies (ACTs), insecticide-treated nets (ITNs), intermittent
preventive treatment (IPTp) of pregnant women, and indoor residual
spraying (IRS).

The President's Malaria Initiative (PMI) began in Fiscal Year 2006 in
three countries, Angola, Tanzania, and Uganda. Senegal was added as one
of the four additional countries announced on June 8, 2006, beginning
implementation in Fiscal Year 2007. Funding for the Initiative began
with \$30 million in FY06 with three initial countries, increased to
\$135 million in FY07 with four additional for a total of seven
countries, increased further to \$300 million in FY08 and FY09 with 15
countries, and is expected to reach \$500 million in FY10.

In implementing this Initiative, the United States Government is
committed to working closely with host governments and within existing
national malaria control strategies and plans. Efforts are being
coordinated with other national and international partners, including
the Global Fund, Roll Back Malaria (RBM), the World Bank, the World
Health Organization (WHO), the United Nations Children's Fund (UNICEF),
the US Peace Corps, and the non-governmental and private sectors, to
ensure that investments are complementary and that RBM and Millennium
Development Goals can be achieved. Country Assessment and Planning
sessions for the PMI, as well as subsequent evaluations, are highly
consultative and held in collaboration with the National Malaria Control
Program (NMCP) and other partners.

This PMI Year 3 Malaria Operational Plan (MOP) for Senegal was developed
in close collaboration with the NMCP and nearly all national and
international partners involved with malaria prevention and control in
the country. The proposed PMI activities fit well with the Ministry of
Health (MOH) 2006-2010 Strategic Plan for Malaria Control. Proposed
programming also builds on investments made by the PMI in Years 1 and 2
to improve and expand malaria-related services and activities. This plan
briefly reviews the current status of malaria control policies and
interventions in Senegal, outlines progress achieved to date, identifies
persistent challenges and current unmet needs if the targets of the PMI
are to be achieved, and provides a detailed description of proposed Year
3 PMI activities.

[]{#MalariaSituationinAngola .anchor}**MALARIA SITUATION IN SENEGAL**

Senegal has a population of approximately 11.6 million[^1] with 45%
living in urban areas. The proportion of the population living below the
poverty line is 62% in rural areas, 32% in Dakar and 39% in other urban
areas[^2]. Although substantial improvements have been achieved since
the 1960s, Senegal's indicators of human development remain unacceptably
low with Senegal ranked 156 out of 177 countries worldwide on the Human
Development Index[^3]. The infant mortality rate is 61 and the under
five mortality rate is 121 per 1,000 live births. Maternal mortality is
estimated to be 401 per 100,000 live births and the mean life expectancy
is 56 years[^4]. The adult HIV prevalence rate is estimated at 0.7% for
adults 15-49 years of age, with 56,000 adults and 5,000 children
estimated to be living with HIV/AIDS[^5].

Administratively, the country is divided into 11 regions and 35
departments, with three new regions currently being established. The
health system functions at the level of the regions (each with a
Regional Chief Medical Officer) and is further decentralized into health
districts that may be all or part of an administrative department.
Health districts are led by the District Chief Medical Officer who,
together with the Health District Management Team, oversees both the
District Health Center and the staff at peripheral facilities throughout
the district. There are currently 63 health districts in Senegal, with
two more in the process of being established. Although not a formal part
of the health system, Senegal's health care pyramid rests on a
foundation of 1297 "health huts" that are established and managed by
local communities. The community health workers (CHWs) who staff the
huts are supervised by the nurse at the nearest health post and offer
preventive and curative services or referral for more complicated
medical care. Additional staff includes *matrones*, who are trained
birth attendants; and *relais*, who are health educators and
communicators.

Malaria is endemic throughout Senegal. The three ecological zones, based
on annual rainfall, are the northern Sahelian zone with \< 300 mm of
rainfall occurring between July and September, a central Sahelian zone
and 400 -- 1000 mm of rainfall occurring between July and October, and a
southern tropical zone with 1000 -- 1250 mm of rainfall and a rainy
season from June to October. The two epidemiological zones are the
Sahelian, with high transmission toward the end of and immediately after
the rainy season and little transmission during the rest of the year,
and the tropical, with year-round transmission peaking during the rainy
season. Transmission is becoming less seasonal in peri-urban areas and
in areas close to rivers or other water sources that persist through the
dry season. With the construction of a large dam at Diama and the
extension of irrigation in the Senegal River Valley a second period of
peak transmission now occurs from April to May. *Plasmodium falciparum*
is the major malaria parasite species, accounting for more than 90% of
all infections. The main vector species are *Anopheles gambiae sensu
strictu* (both M and S sub-species), *An. arabiensis*, *An. funestus,*
and *An. melas*. The species distribution depends on rainfall and the
presence of permanent sources of water.

![](media/image2.wmf){width="6.226388888888889in"
height="4.576388888888889in"}

According to routine data collected by the NMCP, from 2001 -- 2006
malaria was responsible for 33 -- 39% of all outpatient consultations.
The proportion of outpatient consultations caused by malaria dropped to
24% in 2007; however this drop is explained at least in part by the
shift in October from a purely clinical case definition to one that
relies on parasitological confirmation. After pilot testing rapid
diagnostic tests (RDTs), the NMCP distributed them to all districts,
initiated cascade training, and starting in September 2007 directed
clinicians to confirm all suspected cases of malaria before beginning
treatment. The proportion of all deaths in children under five in health
facilities that were attributed to malaria has steadily declined from
40% in 2001 to 21% in 2007. While it is believed that scale up of
malaria prevention and treatment measures is responsible for some of
this drop, it is also due, at least in part, to the change in case
definition of malaria from clinical to confirmed in late 2007. The 2006
Malaria Indicator Survey (MIS) estimated (with data collected at the end
of the rainy season), that 37% of children under five had an episode of
fever or convulsions during the two previous weeks. Only 11% of these
children received some type of antimalarial drug within the first 24
hours of symptom onset, with only three percent having received an ACT;
however, ACTs had only been introduced in Senegal earlier that year.

The vulnerable groups in Senegal comprise an estimated 2,204,000
children under five and 417,600 pregnant women.

**NATIONAL MALARIA CONTROL PLAN**

Proposed PMI activities align well with the 2006-2010 Strategic Plan for
Malaria Control, which has the overall objective of reducing morbidity
and mortality due to malaria by 50% by 2010. In addition, the following
specific objectives are identified:

-   Increase to 80% the rate of coverage and utilization of ITNs by
    2010;

-   Cover 80% of households in targeted zones with indoor residual
    spraying;

-   Treat 80% of malaria cases at all levels of the health pyramid in
    accordance with national directives;

-   Increase to 80% coverage of IPTp in accordance with national
    directives; and

-   Improve the management of the program at all levels.

In order to accomplish these objectives, the NMCP focuses on
strengthening prevention and assuring correct and timely treatment at
all levels of the healthcare system. The Strategic Plan for Malaria
Control outlines an integrated package of activities with the following
components:

-   **Malaria case management** (uncomplicated and severe): improved
    diagnosis using rapid diagnostic tests and microscopic verification,
    early and correct treatment with ACTs (uncomplicated malaria) or
    quinine (severe malaria and malaria in pregnancy), and community
    case management;

-   **Prevention of malaria in pregnant women**: intermittent preventive
    treatment with at least two doses of sulfadoxine-pyrimethamine (SP)
    using directly observed therapy during antenatal care;

-   **Vector control**: indoor residual spraying and use of ITNs,
    particularly among pregnant women and children under five (although
    the NMCP has more recently expressed a desire to obtain high LLIN
    coverage of the general population);

-   **Environmental management/hygiene**: identification and destruction
    of mosquito breeding areas through community-based interventions;
    and

-   **Epidemic prevention and control**: establishment of sentinel
    surveillance sites in high-risk districts, epidemic response
    planning, strengthening prevention measures (ITNs, IRS, etc.).

Supporting interventions include human resource management, management
and mobilization of financial resources, supply chain management,
coordination of partnerships, and community mobilization.

**MAJOR PARTNERS IN MALARIA CONTROL**

**[Multilateral and Bilateral Donors]{.underline}**

**Global Fund to Fight AIDS, Tuberculosis and Malaria**

In Round 4, the Global Fund awarded a \$33.3 million grant to Senegal
covering activities from September 2005 to August 2010, with the
agreement for the second phase of funding signed in early 2008 following
several months of negotiations. The Principal Recipient of this grant is
the NMCP. Thus far, this grant has been used to procure 6,000,000
treatment courses of artesunate-amodiaquine (AS-AQ), 340,000 doses of
SP, 746,000 ITNs, 445,000 LLINs, and 300,000 RDTs. All of these
commodities have been or are being distributed to public health
facilities and the private sector throughout the country, and
approximately 100,000 LLINs are expected during 2008. The NMCP also uses
the grant to fund community-based organizations (CBOs) working on
malaria prevention throughout the country. Most of these interventions
involve IEC/BCC and the untargeted subsidized sale of ITNs as available,
but to date do not involve case management, IPTp, or vector control
measures. PMI is planning to partner with the NMCP's CBO grantees to
include promotion and education about the subsidized voucher program and
other PMI-supported LLIN activities in the CBOs' activities.

Senegal was also awarded a \$67 million grant under the Global Fund's
Round 7 competition, with \$29.8 million approved for phase one in March
2008. With this grant the NMCP plans to expand the availability of ACTs
at the community level, including making more than 500 additional health
huts functional and providing ACTs to communities where there is no
health hut; purchase RDTs for use in all public health facilities and
community health huts; provide 1.3 million LLINs for a nationwide free
distribution campaign in 2009; and reinforce the institutional
capacities of the NMCP and the Central Medical Stores (CMS).

**World Bank**

In past years World Bank funds were used to procure ITNs and to support
IEC activities focused on malaria prevention messages. The current
country assistance strategy (2007 -- 2010) for the World Bank in Senegal
is based on three pillars, one being human development/shared growth.
Part of this pillar is improving health service delivery for women and
children, with a goal of reducing malaria mortality by one third in 2010
compared to a 2005 baseline and a target that 50% of targeted households
will use an ITN by 2009. The Bank will support the Government of Senegal
in reaching these goals and outcomes through Poverty Reduction Support
Credits and two separate Bank programs.

The first of these World Bank-funded programs is the Senegal River Basin
Project, and specifically the Integrated Water Resources Management
Program (*Projet de Gestion Integrée des Ressources en Eau-PGIRE*). This
Project plans to distribute 300,000 LLINs to children under five in
October/November 2008, with a goal of covering 80% of all households in
19 districts in the Senegal River basin (St. Louis, Matam, Tambacounda,
and Louga Regions). Procurement of a second lot of 300,000 LLINs is also
being planned. The project will work through local organizations to
manage the community-level distribution and communications activities.
In order to avoid duplication, PMI took the Project's free net
distribution into account when planning the FY08 PMI distribution. PGIRE
has expressed interest in collaborating with PMI on the MIS planned for
October in order to collect baseline data on malaria indicators in its
project areas.

The second World Bank project is the Nutrition Enhancement Project
(*Programme de Renforcement de la Nutrition -- PRN*). This
community-based project completed Phase 1 in 2005 and started phase 2 in
2006. During Phase 1, a total of 42,500 ITNs and 17,000 net re-treatment
kits were distributed to children under three. Phase 2 operates in 115
local communities in 29 districts, serving all children in rural
locations and selected children in urban areas. The project recently
completed a mass distribution of approximately 450,000 LLINs to children
under five in 96 communities in 25 districts (the four excluded
districts are those in Dakar that benefited from the mass distribution
supported by PMI in May 2007). An additional 50,000 LLINs will be
distributed to pregnant women in its intervention areas. Again, in order
to avoid duplication, PMI took the PRN's free net distribution into
account when planning the FY08 PMI distribution.

**World Health Organization (WHO)**

WHO provides technical and some financial support for the implementation
of treatment and prevention policies; planning, monitoring and
evaluation; research; surveillance and management of the NMCP.

**UNICEF**

UNICEF provides support to the health sector in Senegal primarily
through support of district level health plans. Since 2002, UNICEF has
spent \$2.1 million on malaria specific activities targeted primarily to
the Kolda and Tambacounda regions through the multi-country Accelerated
Child Survival and Development Project. These activities have included
the purchase and distribution (through subsidized sale) of ITNs, KO Tab
insecticide re-treatment kits and bottles of deltamethrin insecticide.
UNICEF plans to distribute 60,000 free LLINs in the Matam, Kolda and
Tambacounda regions (20,000 per region) in late 2008 as part of the
Child Survival Days.

**Islamic Development Bank** (IDB)

The Islamic Development Bank is planning to provide \$8 million in loans
for the procurement of LLINs and RDTs, health personnel training, and
support for supervision. Negotiations between the MOH and the IDB are
ongoing and it is unclear when funds will actually be made available.

**African Development Bank** (ADB)

The African Development Bank is financing a community project in the
Fatick and Matam regions (including IEC and net retreatment) and
supported development of the NMCP's communication plan.

**Other Bilateral Donors**

**The Belgian Cooperation** has been involved with both clinical and
community-level malaria prevention and treatment activities, primarily
in the Diourbel region. The current project has ended and the future of
Belgian cooperation has not yet been determined. The **French
Cooperation** is involved with malaria activities through French
government support to the Global Fund and staffing of a technical
advisor at the MOH. The French also contribute significantly to research
activities through the *Institute Pasteur* and IRD. The **Japanese**
(JICA) support about 10 volunteers in the health sector, with one
dedicated to malaria. JICA has submitted a request to the NMCP and
several other donors for LLINs to distribute in the area where this
volunteer works. The **Chinese Cooperation** donates ACTs (200,000 doses
in 2007 and approximately \$300,000 worth is planned for 2008), sponsors
training in malariology, and is constructing a training and research
center in cooperation with the MOH.

**The United States Peace Corps**

USAID and Peace Corps have been working collaboratively on various
programs in Senegal over the past few years, and under PMI the
relationship has been strengthened. Following the October 2007
communiqué from the US Malaria Coordinator and the Peace Corps Director
encouraging PMI to work closely with Peace Corps in all focus countries,
the Senegal PMI team and the Peace Corps Country Director met several
times and agreed on principles of collaboration and coordination. The
Peace Corps Country Director has asked all volunteers, not only those
assigned to work in health, to work on malaria, and has assigned a
third-year health volunteer in Dakar as the PMI focal person. PMI staff
and implementing partners met with all 160 serving volunteers in
Senegal, as well as the most recent group of trainees, to discuss ideas
for collaboration. The volunteers have designated a PMI/USAID
representative for each geographic zone to facilitate communication
among all volunteers with PMI staff and implementing partners. In 2008,
the PMI staff are working with Peace Corps to put a reporting mechanism
in place to track the work that volunteers do toward achieving PMI
goals.

Examples of how volunteers will contribute to reaching PMI goals
include:

-   Retreating bednets that are physically in good condition.

-   Participating in planning and implementing the mass LLIN campaign at
    their sites. The third-year volunteer is participating in planning
    at the national level.

-   Follow-up to ITN distributions (free, voucher, from other donors, or
    any other kind) to promote hang-up and use.

-   Follow-up to women/families who receive a voucher and don't exchange
    it for a net.

-   Mobilizing their communities for IRS.

-   IEC/BCC (net use, promoting ANC and IPT for pregnant women,
    treatment-seeking, sanitation and village cleanup, and IRS).

**[Non-governmental and Faith-Based Organizations]{.underline}**

**Christian Children's Fund Consortium**

PMI's community-level activities in Senegal are implemented by a
consortium of non-governmental and faith-based organizations led by
Christian Children's Fund. Members of the consortium include World
Vision, Plan, Counterpart International, Catholic Relief Services and
Africare. Among them they cover all health districts in the country with
the interventions described in the "Community" section below.
Occasionally members contract with local

organizations to help meet specific needs.

In addition, PMI's clinical and policy-level activities are managed by
several US-based organizations, including IntraHealth International, the
Academy for Educational Development, and Management Sciences for Health.

**The Senegalese Red Cross Society (SRCS)**

Though the Senegalese Red Cross Society has not been active in malaria
in recent years, they contributed significantly to the 2008 LLIN mass
distribution campaign through participation in the national planning
committee and mobilization of nearly 1000 local volunteers. With support
from the International Federation of Red Cross and Red Crescent
Societies, SRCS volunteers will continue to conduct community-based IEC
activities to promote correct LLIN use.

**Community-based Organizations**

The NMCP and health districts routinely contract with community-based
organizations for the distribution of ITNs, retreatment campaigns, and
other social mobilization activities. These are described in the
"Community" section.

**[Academic Research Partners]{.underline}**

Senegal is fortunate to have strong national capacity in epidemiology,
parasitology and entomology at the NMCP, UCAD, the Parasite Control
Service, and the Institute Pasteur. These groups have a strong
collaborative relationship and they have together published much of the
recent literature on malaria in Senegal.

**[Private Sector Donors]{.underline}**

The **Pfizer** pharmaceutical company is implementing a malaria
intervention program focused in 3 health districts in the Tambacounda
Region, with funding estimated at \$300,000 per year for five years. The
program focuses on IEC/BCC for improved care-seeking behavior, as well
as increasing access to care by making additional community health huts
functional through staff training and provision of basic equipment. This
activity is managed by one of PMI's implementing partners and
significant efforts have been made by PMI staff, Pfizer, and the project
Chief of Party to ensure that the programs are complementary rather than
duplicative.

[]{#currentstatusofmalindicators .anchor}**CURRENT STATUS OF MALARIA
INDICATORS**

The PMI funded a baseline Malaria Indicator Survey in Senegal in 2006.
According to this survey, conducted at the end of the rainy season, 57%
of households owned at least one bednet and 36% of households owned at
least one ITN. Approximately 16% of children under five had slept under
an ITN the previous night, as did 17% of pregnant women. These results
are increases over the results of the Demographic and Health Survey done
in January 2005, where only 20% of households owned at least one ITN and
7% of children under five and 9% of pregnant women slept under an ITN
the night before the survey. The 2006 MIS also showed an increase in
pregnant women receiving one dose of IPTp with SP from 21% to 69%, with
51% of women having received two or more doses of SP in 2006. As ACTs
had been introduced into the health system in Senegal in early 2006,
only 3% of children under five with fever were reported to have taken an
ACT within 24 hours of the onset of their symptoms. Except for malaria
treatment, the comparison of these surveys shows a considerable increase
in coverage and utilization of major malaria prevention and control
activities; however, it also shows that continued support is needed to
scale up interventions rapidly to reach targets established by the NMCP
and PMI.

+---------------------------------------------+----------+------------+
| **Recent Estimates of Malaria Indicators:** |          |            |
|                                             |          |            |
| **Survey Data**                             |          |            |
+---------------------------------------------+----------+------------+
| **Indicator**                               | **2005   | **2006     |
|                                             | DHS**    | MIS**      |
+---------------------------------------------+----------+------------+
| Proportion of children under five years old | \--      | 3%         |
| with fever in the last two weeks who        |          |            |
| received treatment with an ACT within 24    |          |            |
| hours of onset of fever                     |          |            |
+---------------------------------------------+----------+------------+
| Proportion of households with at least one  | 20%      | 36%        |
| ITN                                         |          |            |
+---------------------------------------------+----------+------------+
| Proportion of children under five who slept | 7%       | 16%        |
| under an ITN the previous night             |          |            |
+---------------------------------------------+----------+------------+
| Proportion of pregnant women who slept      | 9%       | 17%        |
| under an ITN the previous night             |          |            |
+---------------------------------------------+----------+------------+
| Proportion of women who received 2 or more  | 13%      | 51%        |
| doses of IPTp during their last pregnancy   |          |            |
| in the last 2 years                         |          |            |
+---------------------------------------------+----------+------------+

**GOAL AND TARGETS OF THE PRESIDENT'S MALARIA INITIATIVE**

[]{#Goal .anchor}

**Goal** 

The goal of the PMI is to reduce malaria-associated mortality by 50%
compared to pre-Initiative levels in all PMI countries.  

**Target**

By the end of 2010, PMI will assist Senegal to achieve the following
targets in populations at risk for malaria:

-   \>90% of households with a pregnant woman and/or children under five
    will own at least one ITN;

-   85% of children under five will have slept under an ITN the previous
    night;

-   85% of pregnant women will have slept under an ITN the previous
    night;

-   85% of houses in geographic areas targeted for IRS will have been
    sprayed;

-   85% of pregnant women and children under five will have slept under
    an ITN the previous night or in a house that has been sprayed with
    IRS in the last 6 months;

-   85% of women who have completed a pregnancy in the last two years
    will have received two or more doses of IPTp during that pregnancy;

-   85% of government health facilities have ACTs available for
    treatment of uncomplicated malaria; and

-   85% of children under five with suspected malaria will have received
    treatment with an ACT within 24 hours of onset of their symptoms.

**EXPECTED RESULTS -- YEAR THREE**

At the end of Year 3 of the PMI in Senegal (March 31, 2010), the
following results will have been achieved:

[Prevention]{.underline}:

-   More than 3 million LLINs will have been distributed to vulnerable
    populations by the NMCP and its partners; PMI will have procured at
    least 700,000 LLINs for routine distribution and at least 200,000
    LLINs for a nationwide campaign and provided logistical support for
    the nationwide campaign to distribute 2.5 million LLINs to children
    6-59 months (expected to increase household ownership of one or more
    ITNs to more than 85% nationwide);

-   Approximately 155,000 houses in three districts targeted for IRS
    will have been sprayed, protecting more than 675,000 residents (with
    at least 85% of targeted houses sprayed);

-   At least 85% of pregnant women will have received two or more doses
    of IPTp during ANC.

[Treatment]{.underline}:

-   80% of all suspected cases of malaria seen in health facilities will
    receive parasitological confirmation (by microscopy or RDT)

-   Rapid diagnostic tests will be implemented at 75% of functional
    health huts nationwide

-   With support from PMI to train new healthcare workers in the case
    management of malaria, and procurement of drugs for the treatment of
    severe malaria, 70% of children under five with suspected malaria
    will have received treatment with an ACT within 24 hours of onset of
    their symptoms. The Global Fund will procure all needed ACTs for the
    treatment of uncomplicated malaria.

> []{#InterventionsPrevention .anchor}

**INTERVENTIONS -- PREVENTION**

**[Insecticide-treated nets (ITNs)]{.underline}**

[]{#itns .anchor}Please refer to the "Community" and "HIV/AIDS and
Malaria" sections for additional ITN activity descriptions.

[Current Status:]{.underline}

*Data and Trends*

Comparisons between the most recent DHS, conducted in January 2005, at
the start of the dry season, and the MIS, conducted in November-December
2006, just at the end of the rainy season, show the status of indicators
for ownership and use of mosquito nets. The 2008 MIS will provide
up-to-date information on net ownership and use.

  ------------------------- --------- -------------- -------------------------
  **Indicator**             **2005    **2006 MIS     **2006 MIS Regional
                            DHS**     (national)**   Range**

  \% Households with        38.0      56.7           37 (Dakar) -- 89
  [\>]{.underline}1 net                              (Ziguinchor)
  (treated or untreated)                             

  \% Households with an     20.2      36.3           15 (Matam) -- 58 (Kolda)
  ITN\*                                              

  \% Children under five    13.9      27.9           13 (Louga) -- 67
  sleeping under a net                               (Ziguinchor)

  \% Children under five    7.1       16.4           6 (Louga) -- 41 (Kolda)
  sleeping under an ITN\*                            

  \% Pregnant women         14.4      31.8           4 (Dakar) -- 65 (Kolda)
  sleeping under a net                               

  \% Pregnant women         8.5       17.2           0 (Dakar) -- 46 (Kolda)
  sleeping under an ITN\*                            
  ------------------------- --------- -------------- -------------------------

\*An ITN in this survey is defined as a long-lasting treated net, a
treated net purchased within the past 12 months, or a net re-treated
within the past 12 months

[NMCP Policies and ITN distribution mechanisms]{.underline}

Key strategies for malaria prevention in the NMCP 2006-2010 Strategic
Plan are the distribution of LLINs[^6] to pregnant women and children
under five years of age and improving and reinforcing communication on
the use of ITNs, with a goal that 80% of each group will sleep under an
ITN by 2010. The NMCP also is following the "catch-up" and "keep-up"
strategies endorsed by the RBM partnership[^7] to rapidly increase and
maintain high coverage with LLINs. In its Strategic Plan, the NMCP
remains committed to diversifying suppliers of ITNs while providing
subsidized nets. The NMCP promotes four approaches for distribution of
ITNs: periodic mass free distribution, targeted subsidies through a
voucher program, untargeted subsidies through health facilities and
CBOs, and commercial sales. The NMCP also conducts mass campaigns to
re-impregnate existing nets just before the rainy season.

**1. Free distribution of nets to vulnerable groups**

As part of the multi-pronged strategy to deliver ITNs to vulnerable
groups, the NMCP in 2007 began to work with partners on large-scale mass
distributions of LLINs to "catch-up" net ownership among children under
five. Because the target population for Senegal's "local supplementation
days" campaign is 6-59 months, PMI LLINs are distributed to this group
in a streamlined approach. The campaign coordinating committee discussed
at length whether children under six months should be included in the
LLIN distribution and it was decided that changing the target group for
one of the campaign interventions would be too complicated for the
door-to-door teams. Children 0-5 months remain a target population for
prevention efforts under PMI, and the voucher program and other LLIN
distribution mechanisms work to support coverage of this vulnerable
group. The "catch up" strategy is complemented by ongoing routine
distribution and IEC to ensure LLINs are properly used.

**2. Nets sold at subsidized prices through the PMI voucher program
(voucher worth \$6) targeting pregnant women and children under five**

The voucher program, implemented through the NetMark agreement, ensures
that PMI's LLIN subsidies are targeted exclusively to pregnant women and
children under five. The system began as a pilot activity in six
districts in 2004 and because of its high redemption rate it was
expanded with PMI funds in 2007. Under this system, health committees at
participating facilities negotiate agreements with private sector LLIN
distributors to stock and sell nets through the health facility's
pharmacy. These agreements specify the co-payment required of the client
for each type of LLIN, and the amount of the co-payment the health
committee will retain. The distributors are then responsible for
ensuring a consistent supply of LLINs to the points of sale. At present,
committees can choose from among circular and rectangular styles of
three brands of LLINs (Olyset®, PermaNet® and Dawa Plus®), with a fourth
(IconLife®, sold in other countries as NetProtect®) joining the program
in 2008.

Health personnel at participating facilities are provided with vouchers
and are trained to counsel pregnant women attending ANC and caretakers
of children under five receiving child health services. Pregnant women
or caretakers are told about the use of LLINs to prevent malaria and
offered a personalized voucher (documenting the name, contact
information, and whether the net is for a pregnant woman or child under
five). The client presents the coupon together with the co-payment at
the health facility's pharmacy for the LLIN of his or her choice.
Currently co-payments range from 800 CFA (\$1.90) for the Olyset®
rectangular LLIN to 1500 CFA (\$3.60) for a conical LLIN; these
co-payments are in the range of the MOH policy of 1000 CFA per net.

LLIN distributors collect the redeemed vouchers and restock the nets,
and PMI's implementing partner reimburses the distributors for redeemed
vouchers. A portion of the co-payment stays with the health committee
and the rest goes to the distributor. The program is designed to best
utilize the strengths of the public and private sectors. The private
sector distributors make a profit by selling their nets and have an
interest in ensuring a constant supply of stock at all participating
facilities. They assume 100% of the cost of transport and logistics for
delivery of the nets to the distribution point, thus transferring this
burden from overtaxed MOH systems. The health committee draws a small
income from each sale, giving it an incentive to make the system work
and to promote redemption of vouchers, but also adding to its available
funds to purchase health facility equipment, maintain facilities and
support other activities as mandated by Senegal's decentralization code.
Historical data show that before the health committees were included in
the system, exchange rates were far lower. The NMCP as well as health
workers in participating districts report that this is the only routine
distribution system that does not experience stock-outs. The NMCP has
asked that this program be expanded to ensure the routine distribution
of LLINs to children born after the "catch-up" campaigns held in 2008
and 2009.

Senegal has adopted the Bamako Initiative and thus has a long tradition
of requiring co-payments for health services and products, a practice
generally well-accepted by the public. While the NMCP and partners feel
strongly that the voucher program's co-payment is not a barrier to most
people, the various free LLIN distribution campaigns planned in 2008 and
2009, involving nearly two million free LLINs, should reach families
that cannot afford the co-payment for an LLIN through routine services.

**3. Untargeted sales of subsidized bednets**

The NMCP supports untargeted bednet sales at health facility pharmacies
and through CBOs at a subsidized price of FrCFA 1000 (about \$2.40). In
the past few years, nets for this program have included ITNs as well as
untreated nets bundled with treatment kits and have come from donations
by UNICEF and the World Bank and procurement with the Global Fund Round
4 grant. Details on the distribution of bednets by CBOs are in the
"Community Interventions" section. The health districts and the CBOs
each receive a portion of the Fr CFA 1000 payment, but maintaining a
consistent supply of nets through these channels has been a challenge
for the NMCP. Funds for bednets are only periodically available and the
bednets are immediately put into distribution, with no consistent
supply. In addition, it has been difficult for districts and the NMCP to
get regular and reliable reports from some CBOs regarding their
distribution activities, posing problems for accountability.

**4. Commercial nets sold at market prices to the general public**

The elimination of national taxes and tariffs on ITNs in 2004, along
with increased availability of competing brands on the commercial
market, has brought down retail prices of ITNs over the past few years,
increasing access for the general population. Six major manufacturers
supply ITNs and LLINs in Senegal, all of whom partner with the NMCP and
NetMark. Commercial suppliers reach all 11 regions of Senegal, but do
not reach limited rural areas (specifically Kédougou). The commercial
partners project their retail and institutional sales for the 2008
calendar year to be approximately 100,000. This is a decrease from past
years but is logical given the large availability of free and subsidized
ITNs in the country. The number of retailers is estimated to be at least
525, including pharmacies, gas stations, the Pridoux chain of stores,
NGOs, CBOs, etc. These bednets are sold at FrCFA 4500 -- 7500 (\$10.70
-- 17.90). Unbranded, untreated nets are still available in some
Senegalese markets at prices comparable to the cheaper ITNs, so informed
consumers have little rationale to purchase untreated nets. However,
consumers and retailers are not always aware of the difference between
an LLIN and an ITN.

Social marketing efforts have also resulted in a consistent stock of
nets being available in-country at any time. Expanding the market here
has served to encourage net manufacturers to invest in Senegal, to
develop their own marketing plans, and to promote their products. The
in-country stocks have also served other large buyers of nets; NetMark
partners have sold over 585,000 nets as institutional sales in the past
year, 500,000 of which were distributed by the World Bank Nutritional
Enhancement Program as described below.

[Progress to Date:]{.underline}

During its first two years of implementation (FY07-FY08), PMI has
supported a comprehensive, three-pronged strategy to increase household
ownership of LLINs, especially among vulnerable populations. Equally
important are the strategies to boost LLIN use that are included in
social marketing activities and in the community interventions supported
by PMI.

1)  PMI has supported the **free distribution** of nearly 872,407 LLINs
    to children under five participating in two rounds of the MOH's
    "local supplementation days" campaign: in Dakar Region in May 2007
    and in Diourbel, Fatick, Kaolack, Thiès and Zinguinchor Regions in
    June 2008. Follow-up activities resulted in the distribution of
    69,000 LLINs to other vulnerable populations in these regions.
    Another 42,000 LLINs were contributed to the NMCP and distributed to
    children under five and pregnant women in four districts of Dakar
    region that experienced heavy flooding in September 2008. PMI also
    supported the free distribution of 4,121 LLINs to people living with
    HIV/AIDS (PLWHA) through regional PLWHA networks. Approximately 950
    LLINs were also distributed through projects managed by Peace Corps
    Volunteers, one of which helped ensure universal coverage of an
    entire rural community. Finally, PMI contributed 900 nets to another
    partner for distribution to the pregnant women and children on an
    island in the Fatick region -- bringing coverage to 100% for the
    vulnerable groups on the island.

2)  PMI supported the **subsidized distribution** of LLINs to pregnant
    women and children under five through expansion of the voucher
    program from 20 health facilities in 6 districts before the start of
    PMI activites to the current 550 facilities in 37 districts,
    covering seven of the country's 11 regions. Fatick and Dakar regions
    were added late during Year 2 of PMI. Nearly 1,000 health workers,
    members of local health committees, and local NGO representatives
    have been trained in the voucher system. During Year 1, more than
    95,000 pregnant women or parents of young children exchanged
    vouchers for LLINs (including the pre-PMI program), and as of
    September in Year 2 the program has distributed 158,000 LLINs to
    these vulnerable groups, resulting in LLINs being provided to 14% of
    the target populations in the seven regions. The voucher redemption
    rate for Year 2 was 94%.

3)  Partly as a result of PMI **social marketing** support, which funds
    such activities as billboards and TV and radio spots, 69,225
    unsubsidized ITNs were sold in retail outlets during FY07 and 57,705
    were sold in FY08. Social marketing messages strive to identify the
    advantages of LLINs over other types of bednets and strengthen the
    brand identity of suppliers in Senegal. Expanding the market here
    has served to encourage LLIN manufacturers to invest in Senegal, to
    develop their own marketing plans, and to promote their products.
    Although increasing sources of free and subsidized ITNs mean retail
    sales are lower than in previous years, there is still a market for
    the convenience and choice of a full-cost net, and PMI's small
    investment helps to promote and ensure that this demand is met.
    Furthermore, because rural and poor populations have higher net
    ownership than urban or richer quintile populations, a small
    investment to encourage LLIN demand is warranted.

+---------+-------------+-------------+---------------+--------------+
| *       | **Product** | **Retail    | **            | **Retail     |
| *Distri |             | Sales**     | Institutional | Price        |
| butor** |             |             | Sales\* Oct   | (estimate,   |
|         |             | **Oct 07 -- | 07 -- June    | FCFA)**      |
|         |             | June 08**   | 08**          |              |
+---------+-------------+-------------+---------------+--------------+
| DNS     | PermaNet    | 1,525       | 1,700         | 5,890 --     |
|         | (LLIN)      |             |               | 8,000        |
+---------+-------------+-------------+---------------+--------------+
| PaluNet | Sentinelle  | 17,614      | 10,458        | 4,000 --     |
|         | (ITN)       |             |               | 6,000        |
+---------+-------------+-------------+---------------+--------------+
| SONI    | Olyset      | 307         | 14,500        | 3,800 --     |
|         |             |             |               | 4,000        |
+---------+-------------+-------------+---------------+--------------+
| PaluNet | DawaPlus    | \-          | 2,580         | \-           |
+---------+-------------+-------------+---------------+--------------+
| CAD     | KO Net      | 1,388       | \-            | 3500         |
|         | (ITN)       |             |               |              |
+---------+-------------+-------------+---------------+--------------+
| **      |             | **20,834**  | **29,238**    |              |
| TOTAL** |             |             |               |              |
+---------+-------------+-------------+---------------+--------------+

\*Institutional sales are defined as bulk or quantity sales to groups or
institutions (i.e. not individual retail sales).

In Year 1 PMI also funded the retreatment of more than 97,200
conventional mosquito nets, and an additional 28,432 were retreated with
matching funds as part of the campaign. PMI did not support any
retreatment activities in Year 2.

In total, PMI *directly* supported distribution/re-treatment of 486,156
LLINs during Year 1 and 1,010,522 during Year 2 (as of September).

The NMCP is working with several partners to distribute approximately
1.1 million additional LLINs besides those of PMI:

-   the World Bank Nutritional Enhancement Program - 450,000 LLINs for
    children under five and 50,000 nets for pregnant women in 25
    districts in nine regions

-   the World Bank Senegal River Basin Project -- 600,000 LLINs for
    children under five in 19 districts in four regions

-   UNICEF- 60,000 LLINs for children under five in three regions

In addition, since September 2006 the NMCP distributed 791,000 Global
Fund-supported ITNs through health facility and CBO channels and
retreated nearly 94,000 nets. Combined with PMI-supported distribution
efforts, over 3.4 million ITNs were distributed during Years 1 and 2 of
PMI in Senegal.

[Proposed Year 3 Activities]{.underline}: (\$6,675,000)

In Year 3 the PMI will complement and coordinate with the NMCP to
maximize LLIN distribution. In FY09, the NMCP will focus on rapidly
increasing LLIN coverage through a nationwide mass distribution campaign
in mid-2009 targeting all children under five, integrated with other
child health interventions. The NMCP is allocating its entire 2009 LLIN
budget for the purchase of 1.3 million of the estimated 2.5 million
LLINs needed for the national campaign. PMI will complement the NMCP's
efforts with the following interventions for Year 3 that will result in
the distribution of more than 975,000 LLINs:

*1. [Subsidized distribution of LLINs to pregnant women and children
under five via the voucher system]{.underline}: (\$4,900,000)*

> As requested by the NMCP, PMI support for LLIN distribution in Year 3
> will focus on expanding the routine system of subsidized vouchers for
> pregnant women and children under five to national scale, thus
> providing a "keep-up" strategy. During FY09 an estimated 425,000 women
> will become pregnant and an estimated 275,000 children will be born
> after the cutoff date (and hence be too young) for inclusion in the
> May / June campaign. The entry of new ITN brands into the market
> should continue to give consumers more choice, and the increased
> competition is likely to further reduce co-payments. The value of the
> voucher will be maintained at \$6, and vouchers will continue to be
> valid only for LLINs. This restriction is to promote use of the more
> effective but more expensive long-lasting nets, while maintaining
> consumer choice. PMI will continue to advocate for more competition
> and lower co-payments when orienting new health committees and when
> committees are renewing their contracts with distributors. An average
> of 58,000 LLINs will be distributed per month during the high demand
> season as a result of this activity.

*2. [Distribution of free LLINs during a national campaign]{.underline}:
(\$1,500,000)*

> To reach PMI and NMCP targets, a successful campaign in June 2009 is
> essential to rapidly increase coverage. PMI will support the MOH and
> NMCP mass distribution of LLINs by purchasing 200,000 LLINs for the
> campaign, assisting the NMCP in securing other donations to meet its
> goal, and supporting part of the operational costs for net
> distribution. Several other organizations have contacted the PMI team
> to express interest in contributing to the campaign and have requested
> proposals from the NMCP. PMI will also support IEC/BCC promoting LLIN
> ownership and utilization as part of ongoing mobilization activities
> described in the Community section. *(\$500,000 of the total
> \$1,500,000 is allocated for operational costs, and the remaining
> \$1,000,000 is for procurement of nets*)

*3. [Social Marketing of retail LLINs]{.underline}: (\$200,000)*

> The PMI will continue to support efforts of private LLIN distributors
> to expand their markets and sales and promote their products to those
> consumers who prefer the choice and convenience of buying a
> full-priced retail net. These funds will be used for mass
> communication (billboards, TV and radio spots, newspaper ads, "road
> shows", and other promotional items and activities) to increase
> consumer awareness of the benefits of LLINs and their proper use, as
> well as for technical assistance in planning and marketing for local
> distributors. It is expected that sales of ITNs by private sector
> distributors will reach least 75,000 consumers in 2009.

*[Gap analysis:]{.underline}*

An estimated 5.95 million LLINs are needed to cover all sleeping spaces
in Senegal, based on an average of 2 people per LLIN.  Through the NMCP,
PMI, and partners, approximately 1,578,000 LLINs have been distributed
in Senegal since 2005, with 1,452,000 estimated to be still effective,
leaving a gap of 4.5 million LLINs.  The 3.9 million LLINs expected to
be distributed in 2009 will fill 88% of the estimated gap and ensure
high rates of household possession by the end of FY09.

**[Indoor residual spraying (IRS)]{.underline}**

This section describes IRS operations and entomological and insecticide
monitoring. All IRS-related IEC/BCC activities are described in the
"Community" section.

[Current Status]{.underline}:

The 2006-2010 Strategic Plan for Malaria Control includes IRS as a key
strategy for malaria prevention in Senegal. As the NMCP had little
experience with IRS, PMI proposed training and equipping
locally-recruited spraying agents with help from and supervision by the
Hygiene Service (the environmental public health division of the
Ministry of Health). The MOH and its partners selected synthetic
pyrethroids for use in this activity.

*Anopheles gambiae* and *An. arabiensis* are the principal vectors over
much of the country and *An. funestus* is found around permanent bodies
of water in the south. All three species feed and rest indoors to some
extent and thus are susceptible to IRS. Other vectors, such as *An.
melas,* which predominate in the mangrove swamps of coastal river
deltas, prefer to feed outdoors. Consequently, in areas where they are
the major vectors, IRS would probably have limited impact. Because
malaria transmission is seasonal in much of the country, a single round
of spraying just before the rains begin each year should be adequate in
those areas. An exception is the irrigated areas upriver from the Diama
dam on the Senegal River, where a second round is necessary before the
second peak of transmission in April and May. In Dakar, where
approximately 25% of Senegal's population resides, malaria transmission
is limited to a few peri-urban districts and these densely populated
neighborhoods would pose special challenges to IRS activities.
Therefore, vector control activities such as IRS would probably not be
cost effective in this setting.

The Australian company Mineral Deposits Limited (MDL) has carried out
two spray operations in two mining camps and 2,000-3,000 houses in eight
villages near its gold mine in Saraya District in southeastern Senegal.
The company used alpha cypermethrin (Fendona) during the first round and
an organophosphate during the second round. Company representatives
stated that the pyrethroid was greatly appreciated by the local
population but that the organophosphate's noxious fumes made it less
acceptable. MDL contacted PMI with the desire to collaborate more
closely with the NMCP and the Hygiene Service on future spray rounds;
PMI facilitated their introduction and following this MDL has brought
Hygiene Service leadership to the mining camp to asses the situation.

[Progress to Date:]{.underline}

In 2007, PMI Year 1 funds supported Senegal's first large-scale IRS
campaign in the health districts of Vélingara, Nioro and Richard Toll --
with each district representing one of the country's three ecological
zones. After completing logistics and environmental assessments and
receiving clearances from both the USG and the GOS, PMI funds supported
the training of more than 275 spray trainers, supervisors, and
operators, the purchase of all commodities and protective equipment, and
all communication, supervision, monitoring, and environmental compliance
activities. The campaign achieved high coverage rates in all three
districts, covering 76,279 households (98% of those found by the spray
teams) and protecting a population of 678,971. Earlier reports gave the
results in terms of "houses", but a review of the data and in
discussions with staff from RTI the data were actually collected in 2007
on "households. The insecticide, chosen by the NMCP and its in-country
partners, was lambda-cyhalothrin wettable powder (ICON 10-WP).

Entomologists from UCAD, the NMCP, the *Institut Pasteur* (IP), the
Anti-Parasite Service in Thiès (SLAP), and the *Institut de Recherche
pour Développement* (IRD) conducted monitoring from July to September
2007 in five villages of each of the three districts. The monitoring
included cone bioassays on walls to test for insecticidal activity,
knockdown spray catches and human landing catches. In the first month
after spraying in Vélingara and Nioro, the insecticidal activity was
very high on all wall surfaces, but decreased significantly the second
month and by the third month less than 50% of mosquitoes died in the
cone bioassays. In Richard Toll the killing effect of the walls was
always below 70% and decreased to 20% in the third month. The low
insecticidal activity of the walls was corroborated by the high parity
rates in collected anopheline females, suggesting no decrease in
longevity of females, and similar indoor and outdoor biting rates of
mosquitoes. The short duration of residual activity could have either
been due to poor quality of insecticide application or to poor quality
of the insecticide itself. Data from Richard Toll show that spray
quality was poor, with the killing effect at one month after treatment
varying considerably between walls of the same room.

The second spray round was carried out in Richard Toll during March and
April 2008, in order to prevent the second peak of malaria transmission
during April and May.  The training curriculum of spray operators was
revised by staff from the NMCP, SLAP, the Hygiene Service, UCAD and RTI
International.  Supervision was reinforced by the active participation
of regional and district Hygiene Service staff.  This round protected
over 22,070 households and 135,661 people.  The decrease in number of
households sprayed and population protected compared to the first round
were felt by staff involved in the campaign to be the result of the
following factors: the inclusion of mosques and schools in the 2007
figures and their exclusion in 2008 (these structures were counted as
households in 2007), the repatriation of Mauritanian refugees, the
seasonal migrations of Fulani herdsman out of the region during the dry
season (November to July), and the absence of seasonal workers typically
in the district only in June and July before the rainy season. The
number of rooms sprayed in March -- April 2008 (61,395) was 78% of those
sprayed in 2007 (78,575), but was 94% of the rooms the teams visited in
2008.

A new full round of spraying in all three districts was held between
June and August 2008, resulting in the spraying of 153,942 houses (95%
of those found by spray teams), protecting 645,346 people (96% of the
estimated total population in the three districts).  For this round
Senegal changed the insecticide formulation from ICON 10-WP (wettable
powder) to ICON 10-CS (capsular suspension) given the longer duration of
activity of the CS form.  Comparing the coverage rates between 2007 and
2008 is difficult because the type of data collected changed from
treated and untreated households to treated and untreated houses. 

Year 2 PMI funds also will support the expansion of entomological
monitoring into a fourth district where spraying could potentially be
undertaken by PMI or other partners in the future (expected to begin in
approximately June 2009). This activity will continue with FY09 funds.

Although Hygiene Service agents and MOH personnel at many levels of the
health system were implicated in IRS activities, in future rounds, PMI
will ensure that district health teams will be more involved with the
training, supervision, IEC, and microplanning for IRS, and that
increased emphasis is placed on capacity-building and development of a
sustainability plan.

[Proposed Year 3 Activities]{.underline}: (\$3,175,000)

In Year 3, PMI will support IRS and entomological monitoring in the same
three districts as in Year 1 and 2. In addition, PMI will continue to
support entomological monitoring in a fourth district that was initiated
with Year 2 funds. Although there are indications that transmission in
Richard Toll may not be as high as previously indicated, Nioro and
Velingara have moderate to high seasonal transmission. PMI will continue
to monitor data from these districts and hold discussions with the NMCP
if it appears that a transition to districts with higher transmission
may be warranted.

1.  *[IRS Operations]{.underline}: (\$2,875,000)*

> In Year 3 spray operations will be repeated between May and July 2009
> in the current districts of Vélingara, Nioro and Richard Toll. A
> second round of spraying will be done in Richard Toll as the duration
> of effective mosquito killing by ICON-CS will not be known until after
> the first round. The Community section of this MOP describes PMI
> support for IEC activities to encourage the population's cooperation
> with spraying their homes.
>
> In the coming months of 2008 and 2009, PMI partners will place
> considerable emphasis on strengthening national and local capacity for
> IRS in order to hand over IRS activities to the MOH by 2010. PMI hopes
> to establish, within the overall malaria coordination mechanism, an
> IRS oversight committee composed of members of MOH including the
> Hygiene Service, NMCP, RTI, and PMI team members, will develop a
> sustainability microplan for the MOH to lead. If Senegal possesses a
> sustainable, capable system for implementing IRS safely and expertly,
> then Senegal will be able to expand its IRS program and seek financial
> support and/or forecast from the national budget to take charge of the
> current operational cost of IRS activities. Other partners would then
> join PMI in providing support for equipment and commodities.

2.  *[Entomologic and insecticide resistance monitoring]{.underline}:
    (\$290,000)*

> PMI will continue to support entomologists from UCAD and IP to conduct
> entomologic monitoring and evaluation related to IRS. Again cone
> bioassays will be conducted immediately after spraying and at monthly
> intervals. Monitoring will continue after the June 2008 round to
> determine if only one round in March would be sufficient to cover both
> malaria transmission seasons in Richard Toll. Particular interest will
> be paid to insecticide susceptibility as resistance may be developing
> after repeated rounds of IRS and must be monitored closely.
> Insecticide susceptibility assays will be performed, as will molecular
> assays for the presence of genes associated with resistance to
> synthetic pyrethroids, such as ICON. Vector behavior will be assessed
> by monitoring indoor and outdoor biting rates and indoor resting
> densities. Parity rates will aid in determining female longevity and
> transmission potential. Finally, mosquito strains will be identified
> and checked for malaria sporozoites.

3.  *[Technical assistance for entomology:]{.underline} (\$10,000)*

> A CDC entomologist will provide technical assistance for the
> implementation of entomological monitoring activities and ensure the
> completion of OR projects.

**[Malaria in Pregnancy (MIP)]{.underline}**

This section describes facility-based MIP interventions. Please refer to
the "Community" section of this MOP for a discussion of community-based
status, progress to date, and proposed FY09 activities related to MIP.

[Current Status:]{.underline}

In 2003, intermittent preventive therapy for pregnant women (IPTp) with
sulfadoxine-pyrimethamine (SP) was adopted by the NMCP as one of the key
malaria control strategies in Senegal. The national IPTp policy is for
all pregnant women to receive at least two directly observed doses of
SP, during the second and third trimesters, with a minimum of one month
between doses.

The MOH has issued a directive to all health districts stating that they
should keep SP stocked and provide it to pregnant women free of charge.
Under Senegal's decentralization laws, the Ministry of Economy and
Finance sends part of the health budget to mayors and locally-elected
councils to manage together with the health districts, rather than
giving it all to the MOH. With these funds the peripheral levels have
been asked to ensure that SP is stocked and given free of charge to
women attending antenatal care (ANC). In some districts, however, local
planning has been inadequate, resulting in SP being sold to pregnant
women, or occasional stock-outs of SP.

The MOH's Division of Reproductive Health (DRH) policy recommends four
ANC visits for normal pregnancies. The 2005 Demographic and Health
Survey found that 87% of pregnant women make at least one visit to a
medical professional for ANC during pregnancy, with 88% of those coming
for ANC making two or more visits. However, the first visit is often
late: 35% of women make their first visit after the fourth month of
pregnancy and only 40% complete the recommended four visits.[^8] The
survey found that 83% of women took an antimalarial during pregnancy and
that 57% of women taking an antimalarial had taken 2 or more doses of
SP, or 48% of all pregnancies. Other sources give similar results, with
the percentage of women receiving two doses of SP remaining well below
the percentage attending two or more ANC visits (49% in the Malaria
Indicator Survey (MIS), 44% in 2005 and 61% in 2006 according to NMCP
data). The greatest challenges therefore are both convincing women to
attend the recommended number of ANC visits, beginning early in their
pregnancies, and improvement of health worker implementation of IPTp.

The NMCP intends to increase IPTp uptake through a number of strategies
including advocacy to health workers and the population at large and
training and supportive supervision of health workers. These strategies
are also being supported by PMI. The NMCP also intends to support
retraining and supportive supervision of health workers to improve the
diagnosis and treatment of cases of malaria among pregnant women.

[Progress to Date:]{.underline}

With Year 1 funds, PMI supported the production, dissemination and use
by health care workers of new ANC registers and ANC cards that allow for
accurate recording of IPTp treatments, and job aids to promote the
correct management of malaria in pregnancy and to improve the counseling
skills of health care providers.

To date, PMI has supported refresher training and supportive supervision
for 1,156 health care workers, including regional and district health
care teams from all 11 regions, on MIP interventions as an integral part
of the package of ANC services. This training included data collection
and record-keeping, the prevention of malaria in pregnancy including
IPTp with SP and use of LLINs, and diagnosis and case management of
malaria in pregnancy with quinine. PMI has supported the purchase and
dissemination of 1,243 water filters and 24,860 reusable cups to
facilitate directly-observed SP treatment for IPTp. With the efforts of
NMCP, PMI and other partners, IPTp implementation is underway in all MOH
ANC service delivery sites nationwide.

In Years 1 and 2, PMI funds have also been used to support health care
workers to provide MIP services, including IPTp, during their regular
outreach visits to health huts. As noted in the LLIN section, PMI funds
have also supported the program subsidizing the purchase of LLINs by
pregnant women.

[Proposed Year 3 Activities]{.underline} (\$550,000)

In Year 3, PMI will continue to support efforts to strengthen MIP
interventions nationwide.

1.  *[Reinforce provision of effective MIP services in health
    facilities]{.underline}: (\$450,000)*

> PMI will continue to support activities aimed at reinforcing the
> provision of effective MIP services in health facilities in all
> regions in Senegal. Support will include training of new staff on
> IPTp, importance of LLIN use in pregnancy, diagnosis and management of
> malaria in pregnancy, and counseling and interpersonal communication
> skills. PMI will continue to support monitoring and supportive
> supervision of MIP service delivery including outreach services to
> community level. These activities will be integrated as one component
> of PMI support for overall monitoring and supportive supervision of
> comprehensive malaria service delivery.
>
> PMI is providing on-going support for the improvement of data
> collection which includes IPTp data. PMI will continue in Year 3 to
> provide additional and replacement cups and water filters as needed
> for directly-observed treatment in health facilities. PMI will also
> advocate for implementation by all districts of the MOH's directive to
> provide SP free of charge for IPTp.

2.  *[Support for mass media activities to increase ANC attendance and
    promote IPTp]{.underline}: (\$100,000)*

> Infrequent and late ANC attendance is a limiting factor to reaching
> IPTp coverage goals. Efforts in the past two years have been aimed at
> improving the availability and quality of the service at health
> facilities. In Year 3 PMI will fund communications programs aimed at
> increasing ANC attendance early in pregnancy and increasing adherence
> to the recommended frequency of visits, in order to improve IPTp
> uptake as part of overall focused ANC. The PMI team will review the
> recent studies completed in Senegal on this issue and devise specific
> mass media approaches in collaboration with the NMCP and the MOH's
> health education service. The behavior change messages will be
> coordinated with the community based IEC/BCC activities described
> further in the Community section.

**INTERVENTIONS -- CASE MANAGEMENT**

This section describes facility-based case management interventions.
Please refer to the "Community" section of this MOP for a discussion of
community-based status, progress to date, and proposed FY09 activities.

**[Malaria diagnosis]{.underline}**

[Current Status:]{.underline}

In Senegal, health facilities with laboratories having the capacity to
conduct microscopy for malaria diagnosis are almost exclusively limited
to hospitals and district-level health centers, which represent only
about 10% of all health facilities (most health posts do not have
laboratories). In health facilities with laboratories, diagnostic
quality is often compromised by inadequate or non-functioning
microscopes, limited training of microscopists, and lack of supplies.
Efforts at quality control are made during supervisory visits, but these
visits have been infrequent and previously read slides were frequently
washed for re-use. These factors contributed to the low confidence of
clinicians in the results of laboratory tests.

To expand the availability of malaria diagnostic testing, the NMCP
purchased RDTs through its Round 4 Global Fund grant and commissioned
UCAD to conduct a year-long study of their sensitivity, specificity,
feasibility, and likely provider use and acceptability. Based on
favorable results from this study, the NMCP decided to require RDT
testing of all suspected cases of malaria in outpatient settings in all
health facilities where microscopy is not available. An algorithm for
the treatment of uncomplicated malaria using RDTs and ACTs was
developed, health care workers in all districts were trained, and RDTs
have been placed in all health facilities, though occasional RDT
stock-outs have limited effective use. The new treatment algorithm
defines a case of clinical presumed malaria as a patient of any age with
fever and no other symptoms indicating a different illness (such as
cough, draining ears, or sore throat). All presumed cases are tested
with an RDT for malaria and only patients with positive tests should be
treated with an ACT. Patients with a different source of fever are to be
treated appropriately, and if they remain febrile, may return in two
days for follow-up and RDT testing.

For cases of malaria requiring hospitalization, the NMCP requires a
blood slide be prepared and read before giving antimalarial treatment.
Exceptions, in which case testing may be done by RDT, include critically
ill patients where treatment may be started pending laboratory results,
patients admitted to centers without laboratories, and patients admitted
to centers with laboratories during hours when the laboratory is
normally closed.

The NMCP continues to receive technical support from the Department of
Parasitology of UCAD and SLAP for improving malaria diagnosis and in
training health worker and laboratory staff on the use of RDTs. In 2008
the NMCP commissioned UCAD to conduct a quality control of RDTs at the
central medical stores; the 11 lots tested gave results matching
microscopic diagnosis for all samples tested (positive and negative).
UCAD recommended continuing these tests at regular intervals, as well as
extending testing to RDTs found at peripheral stores and at points of
service and reinforcing supervisory visits to ensure their proper use.

[Progress to Date:]{.underline}

PMI in Year 1 conducted a district-level laboratory assessment with the
NMCP to assess training and equipment needs. Based on this assessment,
PMI purchased and is distributing 84 clinical microscopes, lab
consumables, and lamps that do not require electricity for reference
laboratories, hospitals, all regional and district medical laboratories
and a limited number of capable health posts. PMI also purchased and
provided to SLAP three teaching microscopes. Two of these have
multiple-viewing heads and the third is equipped with a digital camera,
a desktop computer and projector for storing and displaying images. In
Year 2, PMI supported the purchase of additional consumables for
microscopic diagnostics, including slides and reagents, to facilitate
high quality microscopic diagnosis.

In collaboration with the Department of Parasitology at UCAD, the
Network of Laboratories, SLAP and PMI, the NMCP developed a curriculum
for the microscopic diagnosis of malaria and a revised system of
supervision, quality assurance and quality control. Beginning in March
2008, laboratory technicians from the 82 sites selected to receive a
microscope are being trained using the new curriculum. Staff from
regional and national levels are also being trained on supportive
supervision, quality control and quality assurance in addition to
microscopic diagnosis of malaria. To date, 12 regional and national
staff and 70 laboratory technicians from the district level have been
trained, with 21 district-level staff having received post-training
follow-up visits.

Year 2 activities included training technicians from the remaining
laboratories, supporting the development of a system of quality
assurance for microscopic and rapid diagnosis, and supportive
supervision of RDT use.

[Proposed Year 3 Activities]{.underline}: (\$170,000)

PMI will focus efforts related to malaria diagnosis in Year 3 on ongoing
training in parasitological diagnosis of malaria, and strengthening the
supervision of laboratories in microscopy and of health facilities in
RDTs. PMI will also support the NMCP's initiative to pilot test the
introduction of RDTs at community-level health huts. If results are
favorable, PMI will facilitate subsequent scale-up of the approach (this
is further described in the Community Interventions section). Technical
assistance will be provided to support and extend the quality assurance
and quality control system and to conduct operations research examining
the predictive value of the new diagnostic and treatment algorithm.

1.  *[Supportive supervision, quality assurance, and quality control for
    microscopy and RDTs (\$100,000)]{.underline}\
    *

> PMI through various partners will provide supportive supervision of
> malaria diagnosis by microscopy and by RDTs for laboratory and health
> worker staff. PMI will also assist the NMCP and its partners to
> implement quality assurance and control standards for laboratories and
> other health facilities performing diagnostic tests. Supportive
> supervision of RDT use will also be part of supervisory activities
> listed in the Treatment and Community sections.

2.  *[Technical Assistance for diagnostics]{.underline}: (\$10,000)\
    *

> A CDC diagnostic expert will travel and work with staff from UCAD,
> SLAP, and NMCP to assist in extending the system of quality control
> and quality assurance of microscopy to include RDTs, and to follow up
> on earlier assistance in development of a curriculum for training
> laboratory technicians.

3.  *[Operational research to evaluate the new NMCP treatment algorithm
    (\$75,000)]{.underline}*

> Current WHO guidelines for IMCI recommend that all children under five
> with fever receive antimalarial treatment in addition to treatment for
> any alternative initial diagnoses. In addition, WHO guidelines
> recommend restricting RDT testing to people five years of age and
> older. Contrary to these guidelines, the Senegal NMCP testing and
> treatment algorithm restricts RDT use to patients of any age with
> fever and other signs of malaria who do not have signs suggesting
> other diseases, with only those who test positive being treated with
> ACTs. The rate of positive tests is used as an indicator of proper
> application of this algorithm, with the objective being 60% or more of
> cases testing positive. It is unknown what proportion of patients with
> fever and another apparent source may also have malaria and therefore
> merit treatment.
>
> The objective of this study is to determine the positive and negative
> predictive values of the current malaria diagnostic and treatment
> algorithm used in Senegal, for children under five and for older
> children and adults. The initial RDT study by UCAD looked specifically
> at the sensitivity and specificity of RDTs and did not examine all
> parameters of the new treatment algorithm in children or adults. To
> provide these data, year-long assessment of the algorithm will be
> conducted at the health post and health center levels to cover both
> low and high malaria transmission periods. For any patient presenting
> with fever, information will be collected on history of illness and
> presenting signs and symptoms so as to determine how the treatment
> algorithm should have be applied and then all patients will be tested
> using an RDT. The results should help to inform supervision of RDT
> usage and help reconcile IMCI and NMCP guidance on the management of
> malaria in children under five.

4.  *[Technical assistance for diagnostics/case management]{.underline}
    (\$10,000)\
    \
    *A CDC medical epidemiologist will support the development and
    implementation of the protocol to evaluate the use of the RDT
    diagnostic algorithm, and the implementation of PMI-supported case
    management and diagnostics activities.

    **[Treatment]{.underline}**

    [Current Status:]{.underline}

Since early 2006, AS-AQ has been available for treatment of
uncomplicated malaria in Senegal, and case management with ACTs is
currently implemented in all public health facilities nationwide (as
well as in all functional health huts). The medication comes
pre-packaged in blister packs in three different dosages: children less
than seven years old, adolescents 8-14 years old, and adults (children
under 1 year receive ½ of a child's tablet). On World Malaria Day 2008,
the Minister of Health announced that the user co-payments for these
drugs would be cut in half effective immediately; as a result the child
and adolescent dosage packs are now sold for 150 CFA (approximately
\$0.36) and the adult dosage pack is sold for 300 CFA (approximately
\$0.72). These prices are still higher than the cost of the previous
first-line monotherapy, but are in the range of co-payments for other
medications. PMI is not purchasing AS-AQ because the NMCP has planned to
meet all of its ACTs needs through 2012 using its Global Fund Round 4
and 7 grants. The NMCP is planning to transition from AS-AQ to
artemether-lumefantrine (AL) in 2010, given the large number of AS and
AQ tablets adults must take, the difficulties many patients report in
tolerating amodiaquine, and concerns that many patients may as a result
be taking only the artesunate tablets from the co-blistered dosage
packs. This transition will be supported with Global Fund monies, but
since instructions for treatment with AL were included in ACT training
for AS-AQ the NMCP is optimistic that minimal re-training will be
required.

Quinine is recommended by the NMCP for treatment of severe malaria. As
malaria in pregnancy is considered by definition to be severe,
injectable quinine is also the recommended treatment of malaria in
pregnant women. District medical funds purchase injectable quinine and
other supplies necessary for treating severe malaria, requiring in turn
that these supplies be purchased by patients. Drugs and supplies can be
relatively expensive, with costs varying across health facilities, and
time taken to seek funds often delays treatment. Senegal's malaria
treatment and referral guidelines for children under five, following
those of IMCI, do not include a recommendation for pre-referral
treatment for severe malaria.

In addition to supplying ACTs to the public sector and community health
huts, the NMCP allows private sector wholesalers to purchase Global
Fund-subsidized ACTs from the Central Medical Stores and distribute them
to retail pharmacies, where they are sold at the same prices as in the
public sector. In order to keep these prices equal to the end-user, the
CMS sells the drugs to the wholesalers at a lower price than it sells to
the districts, therefore allowing for a private sector profit margin. In
addition to AS-AQ, private pharmacies also sell numerous other
antimalarial drugs, including chloroquine and SP, artemether and
artesunate monotherapies, and ACTs including AS-AQ syrup for children,
Coartem ®, and other combinations.

[Progress to Date]{.underline}:

Funds to purchase ACTs through 2012 are included in the Global Fund
Round 4 and 7 grants. In Years 1 and 2, PMI supported refresher training
of 236 district health team members and 920 providers (as of July 31) in
malaria case management and interpersonal communication. PMI also
supported the development and distribution of job aids related to
malaria prevention, diagnosis and treatment (including durable posters
of the RDT/ACT algorithm and summary guidelines for the treatment of
uncomplicated and severe cases). PMI also funds supportive supervision
at all levels of the health system, as well as outreach visits from the
health post nurses to provide services at community health huts.
Supervision visits are carried out jointly by technical staff from PMI
implementing partners with MOH personnel from the central, regional, or
district level to lower levels.

PMI is also supporting on-going *in vivo* monitoring in five health
districts of AS-AQ efficacy through UCAD researchers. This activity is
critical to monitor the appearance of resistance to the first-line
drugs.

[Proposed Year 3 Activities:]{.underline} (\$615,000)

In Year 3, the PMI will continue to provide support to strengthen case
management of malaria with ACTs through supportive supervision and
monitoring, training of new health care workers, and preparation for the
transition from AS-AQ to AL in 2010. Since the Global Fund is covering
all ACT needs, the PMI Year 3 plan does not include the purchase of
ACTs, but does include drugs and supplies for treatment of severe
malaria. Additional support for implementation and supervision of
treatment with ACTs in health posts is included in the Community
Interventions section.

1.  *[Improve case management with ACTs]{.underline}:* *(\$365,000)*

> As part of the effort to support management of uncomplicated malaria
> with ACTs, PMI will support training of new health care workers in
> case management, as most of the health care workers currently serving
> will have been trained. PMI implementing partners will also work with
> the MOH to provide supportive supervision in management of malaria
> with ACTs at all levels of the health care system and outreach
> activities. The NMCP does not foresee a need for massive retraining of
> healthcare workers to accommodate the transition from AS-AQ to AL,
> since AL was also covered in the original transition to ACTs and its
> use is included in the current treatment guidelines. In preliminary
> discussions with the NMCP, support for the publication of
> communications materials for both providers and the public related to
> the transition was identified as a possible area of support that PMI
> could provide.

*[2. Treatment of severe malaria (\$240,000)]{.underline}*

> Initiation of treatment for severe malaria is often delayed when
> families first have to seek funds for the medication and intravenous
> administration kits, potentially increasing mortality. PMI will
> support the preparation and distribution of kits for one day of
> treatment of severe malaria, including quinine, intravenous tubing, a
> syringe, needle, glucose-containing intravenous fluid, and an
> antipyretic. The cost of this package will be subsidized to be equal
> to the cost of treatment of uncomplicated malaria for the same
> age-group. Kits for different dosing levels (such as children under 5,
> children ages 5-15, and adults) will be provided and distributed to
> all levels of the health system. PMI will work with the NMCP and other
> partners to ensure that the kits are being sold at the correct price.
> To ensure their correct use, PMI inputs include the training of
> healthcare workers in diagnosis and treatment of malaria, including
> uncomplicated and severe.

**[Pharmaceutical management and drug quality]{.underline}**

[Current Status:]{.underline}

The Central Medical Store (CMS) is responsible for national procurement
of drugs, health commodities and equipment, including antimalarial
drugs, ITNs, laboratory products, and treatment kits. The NMCP is
responsible for quantification of the needs of malaria commodities.
Forecasting of needs and budgeting are usually based on cases registered
at health facilities including community level health huts. Because of
the low utilization of health facilities in the country, this method of
forecasting can underestimate needs. In the case of ACTs purchased
through the Global Fund grant, the original quantification estimates
were based on all expected cases of fever rather than cases expected to
be treated in a facility.

Distribution of malaria commodities to the eleven Regional Medical
Stores is the responsibility of the CMS. Health districts are
responsible for identifying and quantifying the commodity needs for all
health facilities in the district and for purchasing these commodities
from their Regional Medical Store. Health facilities in turn identify
and quantify their commodity needs and then purchase them from the
district. Senegal has implemented the Bamako Initiative, a cost-recovery
system in which each level pays the higher levels for commodities. At
the health facility, the cost-recovery system requires patients to pay
user fees for consultations, drugs and other supplies.

In January 2006, the PNLP received its first ACTs - 3 million AS-AQ
doses (with expiry dates ranging from October to December 2007) from the
Global Fund. The second lot of three million doses of ACTs was received
by the NMCP in November 2007 and quickly put into the distribution
system. Nevertheless, stock outs of ACTs were noted in some health
districts during November and December 2007 due to either the delay in
arrival of drugs after previous stocks were exhausted, or a hesitancy to
purchase from the original lot of medicines as they neared expiration
(despite the NMCP's guarantee to reimburse health districts for expired
medicines).

CMS has set up a pharmaceutical management information system with forms
and guidelines. This system is separate from the health management
information system (HMIS), since the HMIS does not collect the data
needed to manage medicines and other health commodities. A plan is in
place for supervision and follow-up of distribution activities
countrywide, but CMS only supervises the distribution system to the
regional level. At the district and health facility levels, information
is not flowing as it should and so the NMCP collects data on LLIN, RDT
and ACT stocks during the quarterly review meetings (described in the
Monitoring and Evaluation section). Commodity tracking and management
are computerized at the central and regional levels, with a paper system
at the lower levels. Computerization of the pharmaceutical management
system down to the district level is planned but has not yet been
implemented due to a lack of funds to purchase the necessary software.

The Directorate of Pharmacies and Laboratories (DPL) provides quality
assurance and, in collaboration with CMS and the National Laboratory for
Drug Quality Control, is responsible for establishing regulations and
granting the right to market a drug. The national drug approval and
pharmacovigilance committees are based within the DPL. In 2007 the NMCP
initiated a separate pharmacovigilance program focused on reporting
adverse drug reactions related to ACTs. An adverse drug reporting form
was developed, a system for routine reporting up the levels of the
system has been established, and over 1,600 health personnel have been
trained. Sixty-four adverse reactions (none of them serious) were
reported for ACTs in 2007. Overall, the pharmacovigilance system is seen
as incomplete since there is neither agreement on the overall strategy
nor a coherent, integrated nationwide system to which all relevant
actors (including those from other MOH services such as HIV or
Tuberculosis) adhere.

The Ministry of Health has established an Antimalarial Quality
Surveillance Coordination Committee that brings together the CMS, DPL,
National Laboratory for Drug Quality Control, NMCP, and other partners.
It meets quarterly to review the status of ACT stocks at the national
and regional pharmacies, applications for drug licensing, and the
results of drug quality monitoring.

[Progress to Date:]{.underline}

In March 2007, PMI provided technical assistance to the NMCP to quantify
ACT needs and refresher training to three NMCP staff in drug need
quantification. Technical assistance is on-going to strengthen the
pharmaceutical management system in order to improve ACT implementation
with emphasis on ensuring good ACT prescribing and dispensing practices
at the facility and community levels. In 2008, PMI implementing partners
field tested and finalized a pharmaceutical management procedures manual
and supervision guide. In July, representatives from each of the 11
regional depots and the national medical stores underwent a training of
trainers using these materials, and 111 health post and health center
staff in the St. Louis region were subsequently trained on management of
antimalarial medicines.

In addition, PMI collaborated with UCAD in monitoring antimalarial drug
quality. Results of drug quality monitoring at five sites around the
country showed that nearly 30% of antimalarial drugs did not conform to
one or more quality standards (such as visual inspection and dosage of
active ingredient). Most of the non-conforming drugs were in the
informal sector and were expired. Monitoring results were shared with
stakeholders in various fora in 2008 but to date there has been no clear
national commitment to take action to address the problem of poor
quality drugs.

PMI is also supporting the participation of Senegal in the multinational
Quality of Antimalarials in Sub-Saharan Africa (QAMSA) study, jointly
sponsored by USP and WHO. During Year 2, UCAD and NMCP staff was trained
in the study methodology and samples of ACTs and SP were collected from
around the country.

As a result of coordination efforts by PMI, a National Pharmacovigilance
Committee was established and its first meeting held in January 2008.
Participants agreed on the need to create a national pharmacovigilance
center and to reinforce reporting of adverse drug reactions.

[Proposed Year 3 Activities:]{.underline} (\$375,000)

Achieving high rates of treatment with ACTs within 24 hours of the onset
of fever will require a reliable supply of high-quality drugs out to the
most peripheral levels. Ensuring an adequate supply of ACTs will
continue to be a major challenge for the NMCP and the PMI, in part due
to the relatively short shelf life of AS-AQ (about 24 months), and the
proposed extension of antimalarial therapy to villages lacking any even
a community health hut. Achieving high rates of treatment with ACTs will
require not only continuously improving the pharmaceutical management
system but also strengthening the drug quality system to ensure that
only high-quality drugs are being distributed.

1.  *[Drug management capacity building and training]{.underline}:
    (\$230,000)*

> PMI will build on the past several years of activities to continue
> strengthening the national logistics and pharmaceutical management
> systems for ACTs through improved drug quantification and forecasting,
> quality control, storage and inventory management, and supervision.
> These activities are complemented by similar USAID-funded work to
> improve the management of tuberculosis drugs. In addition, the
> Treatment section above describes the technical assistance that PMI,
> together with the MOH and other partners, will provide to public
> health facilities to ensure appropriate ACT prescribing and dispensing
> practices and appropriate use. This support will be critical during
> the planned transition from AS-AQ to AL.

2.  *[Drug efficacy testing]{.underline}: (\$30,000)*

> In collaboration with the NMCP and UCAD, the PMI will continue to
> support drug efficacy monitoring of first and second-line antimalarial
> drugs at three sites. This monitoring will include *in vivo* drug
> monitoring of patients.

3.  *[Drug quality monitoring]{.underline}: (\$100,000)*

> PMI in collaboration with the NMCP, UCAD, and the National Drug
> Quality Control Laboratory will continue to strengthen national
> capacity for drug quality surveillance. The current monitoring program
> will be expanded from six to nine sites, to cover more geographic
> zones and particularly border areas. In addition, more emphasis will
> be placed on IEC activities to inform the public about
> counterfeit/poor quality drugs. These activities could include
> engaging the media as well as targeting development or modification of
> policy. PMI will continue to advocate for regulatory action to be
> taken when poor quality drugs are found. Results of the Quality of
> Antimalarials in Sub-Saharan Africa study are expected to reinforce
> these activities.

4.  *[Pharmacovigilance]{.underline}: (\$15,000)*

> PMI will continue to support the institutionalization of an integrated
> national pharmacovigilance committee and strengthening of the
> reporting system.

**COMMUNITY- BASED INTERVENTIONS**

[Current Status:]{.underline}

Senegal's health care pyramid rests on a foundation of "health huts"
that serve rural populations and are operated by three types of workers:
community health workers (CHW), who offer preventive and curative
services or referral for more complicated medical care; *matrones*, who
are trained birth attendants (but not professional midwives) ; and
*relais*, who are health educators and communicators*.* Though not
officially part of the MOH system, functional health huts are supervised
by the nurse who runs the nearest health post. The health posts are
staffed by one nurse or midwife, and one or more *matrones* and
*relais*. Posts are in turn supported and supervised by the Health
District Management Team. Since many people do not seek care for malaria
at higher level health facilities, or go only when it is too late for
the treatment to be effective, community-level prevention and treatment
interventions are critical for reaching the coverage and mortality
reduction goals of the NMCP and of PMI. Working through community
channels is essential for ensuring that caregivers know how to recognize
and treat malaria, that LLINs in the household are being properly used,
that participation in IRS campaigns is high and that safety precautions
are taken, and that pregnant women understand the necessity of attending
prenatal care and receiving at least two doses of IPT.

Currently, all 1,297 functional health huts nationwide are enrolled in
the PMI-supported community health program. A functional health hut is
defined as one that has a trained community health worker (literacy is
preferred but not required), regular supervision by the chief nurse of
the health post, and the basic equipment and space needed to provide
services. CHW in each of these health huts have been trained to
administer ACTs for uncomplicated malaria. In addition to the health
huts enrolled in the program, PMI's community health partners work with
528 "sites", generally in more urban areas or places far from health
huts, where *relais* implement malaria IEC/BCC activities. In the five
regions where USAID implements community-level maternal and child
health, tuberculosis, and family planning activities, the malaria
activities are integrated and part of a comprehensive community health
program. In other regions where PMI is the sole funding source for
community interventions, the community activities only address malaria.

The NMCP also supports community-based malaria activities through its
ABCD program (*Atteindre les Bénéficiaires Communautaires à travers les
Districts* or Reach the community beneficiaries via the health
districts). Under this program, now operational in 41 districts, health
districts spend at least 60% of their Global Fund money from the NMCP on
contracts with CBOs. Under these contracts, the CBOs agree to provide a
package of malaria-control activities such as organizing community
meetings and home visits to discuss malaria, distributing bednets and
treatment kits, and hygiene and "clean environment" education. An
evaluation in December 2006 was generally positive, but recommended that
districts and CBOs urgently strengthen the introduction of ACTs at the
community level to ensure prompt and proper case management by community
health workers.

In 2008, the NMCP plans to introduce "home-based" management of malaria.
Under this program, villages currently not served by a health post or a
health hut would nominate someone who would be trained to manage a stock
of ACTs and RDTs. Anyone in the village with fever could go to this
village health worker for RDT testing, and if results are positive, ACT
treatment. Village health workers would be supplied and supervised by
community health workers at the nearest health hut and/or the nurse in
charge of the nearest health post.

[Progress to Date:]{.underline}

Through PMI support to a consortium of NGOs, more than 9,500 community
members have been trained in malaria prevention and control
interventions in accordance with Senegalese policies. This figure
includes community health workers, *matrones,* *relais* and village
health committee members who oversee the functioning of the health hut
and help carry out health promotion activities. Community interventions
reached national scale with FY07 funds, covering every district in
Senegal, and include two broad categories of activities: 1) community
case management of malaria, and 2) community mobilization for malaria
prevention and control.

*1. Community case management of malaria*

PMI partners and other stakeholders have updated, validated, and
disseminated training materials, job aids, and data collection tools for
use by CHWs offering case management services at health huts. Following
this exercise, CHW training began. During fiscal years 2007 and 2008,
3,469 CHWs were trained by PMI to diagnose and treat cases of
uncomplicated, clinically-diagnosed malaria using ACTs at health huts.
They are also trained to recognize danger signs and refer serious cases
or any malaria in pregnant women or young infants to the nearest health
post or center where they can receive more advanced care. From the
beginning of FY07 through the third quarter of FY08, 67,028 cases of
malaria/fever were treated with ACTs at these community sites. The
program only reached national scale in the second quarter of FY08, and
the NMCP experienced delays providing drugs in some areas so the numbers
of cases treated at community level is expected to continue to grow in
coming years. Community health workers have demonstrated excellent
adherence to the treatment protocol.

*2. Community mobilization and IEC/BCC for malaria prevention and
control*

PMI partners and other stakeholders have also updated, validated, and
disseminated training materials, job aids, and data collection tools for
use by community health workers undertaking community mobilization and
IEC/BCC activities in health huts and sites. Activities include both
ongoing malaria communication (mass and interpersonal) and communication
promoting specific events, such as IRS or LLIN distribution campaigns.

*Ongoing communications activities*

Typical activities in Senegal include community meetings on a specific
topic, home visits, theater, community radio (radio spots as well as
interviews and programming), and social mobilization (setting aside a
day to focus on a specific theme or topic and bringing the whole
community together around that topic -- for speeches, music, skits, with
banners and t-shirts with messages, etc.). Topics of ongoing IEC/BCC at
community level include the importance of owning and using ITNs, prompt
treatment-seeking at the health hut or health post in case of fever,
recognition of danger signs, the importance of attending ANC visits and
of receiving the recommended IPTp, environmental hygiene and cleanup of
standing water. From October 2007 through September 2008, CHWs working
with the PMI program carried out a total of 160,269 malaria-specific
IEC/BCC activities.

*Mobilization for IRS*

In the three districts where IRS is implemented, focus groups were held
to learn about the public's perceptions of IRS and any concerns they
might have regarding the spraying. Public information campaigns were
then organized to promote IRS and encourage the population's acceptance
of spraying homes. A training manual and a handbook were developed for
the *relais*, as well as information materials for the public --
including a poster and pamphlets in three languages. Radio spots,
community meetings, and house-to-house visits were also organized.
Partly as a result of these efforts, the refusal rate during the first
round of IRS activities in May-August 2007 was only 2%. These activities
were carried out again during the April 2008 round of spraying in
Richard Toll and for the June-August 2008 round for all three districts.

*Mobilization for LLIN distribution campaigns*

PMI community health partners worked through local CBOs, health post
nurses and community *relais* to organize and promote the distribution
of free LLINs in four districts of peri-urban Dakar during the Local
Supplementation Days in May 2007 and in five regions during the June
2008 campaign. The *relais* on the door-to-door teams gave information
about the importance of malaria prevention and those at the distribution
points also provided education about how to properly hang and use the
nets. More than 99% of the coupons distributed were redeemed during the
campaigns. Leading up to the campaign, the community health implementing
partner also carried out localized IEC and community mobilization
activities to raise awareness of the supplementation combined with LLIN
distribution, and the importance of obtaining and using LLINs. The
activity is further described in the LLIN section of this MOP.

*Other community-based LLIN activities*

With FY07 funding, PMI's community health implementing partners trained
more than 60 community *relais* and representatives of women's groups in
five districts on bednet retreatment, and 97,200 nets were retreated
with insecticide (K-O Tab and K-O Tab 1-2-3). An additional 28,432 were
re-treated with non-PMI sources of funding. In FY08, PMI focused ITN
resources on procurement of new LLINs rather than re-treatment of older
nets.

In addition, the LLIN voucher program (described in the LLIN section)
has been decentralized to the community level. Community health
implementing partners have trained CHW and health committee members to
manage and promote this system at community level. To keep the voucher
as part of a complete ANC package which only health post or center staff
are authorized to administer, vouchers are only distributed at the
facility level or during outreach activities in the community, but can
now be exchanged at health huts.

[Proposed Year 3 Activities:]{.underline} (\$2,200,000)

Community-level activities are integral to the success of all prevention
and case management activities. In Year 3 PMI will continue with the
community case management and mobilization efforts begun in Years 1 and
2 and will, in addition, support the NMCP in its plan to roll out RDTs
to the community level. The NMCP has requested that PMI and its
community health partners train, assist with supervision, and update job
aids and training materials for this activity.

*1. [Sustaining community mobilization activities]{.underline}:
(\$1,000,000)*

> Working through NGOs, CBOs and all types of community health workers,
> PMI will implement a variety of information, education and
> communication activities at all 1,825 community intervention points
> (health huts and sites) nationwide, aimed at:

-   Informing and mobilizing the population around interventions such as
    IRS and ITN distribution campaigns and ongoing ITN distribution
    through the voucher system, health facilities, other donor
    distributions, and other CBOs

-   Educating the population and following-up on correct hanging, use,
    and maintenance of ITNs and LLINs

-   Increasing knowledge of the causes of malaria and its prevention and
    correct treatment and recognition of the signs of severe illness in
    children

-   Encouraging early care-seeking and treatment

-   Promoting ANC attendance for pregnant women, including IPTp and
    prevention and management of malaria in pregnancy

*2. [Sustaining community-based case management with ACTs and
introduction of RDTs in health huts]{.underline}: (\$1,200,000)*

> Technical support and supervision on correct diagnosing, prescribing,
> stocking, and dispensing and referral practices will continue for
> community health workers. The project will also ensure timely data
> collection and integration of case management data with the NMCP's
> reporting system. Data collection tools, job aids, and IEC materials
> will be replenished as necessary at all 1,297 health huts. Systems for
> monitoring and supervision of these workers will also be strengthened
> (see Capacity Building section below).
>
> Furthermore, at the NMCP's request, CHW job aids will be updated to
> include use of RDTs at health huts and the transition from AS-AQ to
> AL, and all CHWs will be trained and supported to implement these new
> NMCP policies as they take effect.

[]{#Communication .anchor}

**HIV/AIDS AND MALARIA**

[Current Status:]{.underline}

The HIV/AIDS epidemic in Senegal is characterized by a low prevalence in
the general population (0.7% of adults 15 to 49 years of age), with
higher prevalence of infection among some risk groups: 19.4% among
commercial sex workers, 21.5% for men having sex with men, and 3.4%
among women in the Ziguinchor region. No significant differences exist
between urban and rural areas, though the regions in the Casamance have
higher rates: 2.0% in Kolda and 2.2% in Ziguinchor. According to UNAIDS,
there are an estimated 61,000 people infected with HIV in Senegal[^9].

USAID supports Senegal's strategic objectives to maintain the HIV
prevalence below 2%; to improve the quality of life of PLWHA and reduce
the socio-economic impact of HIV/AIDS. The approach is based on a strong
partnership with civil society and communities enlisted to participate
in key interventions.

In 2000, the Government of Senegal began a pilot program to introduce
anti-retroviral therapy (ART) use in the public health sector. By the
end of 2007, more than 5,000 Senegalese were estimated to be on ART out
of the approximately 11,000 PLWHA thought to be eligible. The Government
continues to expand the pilot program for prevention of mother to child
transmission of HIV (PMTCT) established in 2005.

To complement the Government's ART program, since 2002 USAID has
supported a comprehensive package of care and support services. The
USAID program began with a focus on psycho-social support and was
expanded to include nutritional education and food distribution in three
ambulatory treatment sites. Within the current program, focus is also
placed on building capacity of PLWHA associations to reinforce their
involvement in prevention and care and support, on integrated
tuberculosis screening and management; and income generation. The
program targets over 7000 PLWHA through these efforts. One ambulatory
integrated care and treatment unit and 15-20 sites for psycho-social
care will be established in each region over the life of the program.

USAID and the US Department of Defense also support HIV prevention
activities including behavior change interventions targeting high-risk
groups, including the military; promotion of voluntary counseling and
testing services, and prevention and treatment for sexually-transmitted
infections.

HIV increases the risk of malaria infection and clinical malaria in
adults, especially in those with advanced immunosuppression.
HIV-infected persons are at increased risk of severe malaria and death.
Providing integrated health services for malaria and HIV is crucial for
reducing the burden of the two diseases.

[PMI Progress to Date]{.underline}:

In Year 1, working closely with the GOS, the National AIDS Committee,
and civil society groups, PMI supported the free distribution of 2,121
LLINs to PLWHA through regional PLWHA networks and the AIDS ambulatory
treatment center in Dakar. This activity was launched by First Lady
Laura Bush on her visit to Senegal. In Year 2, PMI donated another 2,000
LLINs to PLWHA.

[Proposed Year 2 Activities:]{.underline} (\$25,000)

In FY09, activities are aimed at integration of malaria prevention and
treatment within HIV/AIDS prevention, care and treatment efforts. Key
components will include (i) promotion of positive behavior change for
malaria prevention and care-seeking behavior; (ii) integration of
malaria prevention and early treatment within HIV ambulatory treatment
settings; and (iii) capacity development of existing partners to be able
to effectively integrate scientific and programmatic knowledge for
malaria prevention and treatment within their existing program
portfolios.

As the ambulatory unit and care and support sites serve as the starting
point for the provision of a package of services for PLWHA, they, in
addition to PLWHA networks, will serve as a point of contact to increase
the access and use of ITNs and to strengthen diagnosis and treatment of
malaria for this vulnerable group.

1.  *[Distribution of LLINs to PLWHA & Integration of malaria messages
    into HIV/AIDS BCC activities targeting high risk
    groups:]{.underline}* (\$25,000) \[*cost of 2000 nets covered with
    FY08 PMI funding\]*

> In collaboration with the GOS and the USG-funded HIV program partners,
> PMI will support free distribution of 2,000 LLINs to PLWHA. Channels
> for net distribution will include PLWHA networks and HIV/AIDS peer
> educators trained to deliver malaria prevention messages including
> during home visits. The nets will come from nets leftover from the
> 2008 PMI free distribution and thus no FY2009 resources for net
> procurement are required. PMI will also support the training of peer
> educators, counsellors, and leaders of PLWHA associations to
> facilitate the integration of malaria prevention messages into
> interpersonal communication activities with PLWHA. Malaria prevention
> messages will include emphasis on correct and regular use of LLINs and
> early care-seeking behaviour for fever.

**COMMUNICATION/COORDINATION**

[Current Status]{.underline}:

In the framework of the Paris Declaration, the MOH put in place an
internal monitoring committee that includes multilateral and bilateral
donors in the health sector that meets every six months to share
information and strategies and discuss current issues in the sector.
Multilateral and bilateral donors in the health sector have their own
coordination mechanism chaired by the WHO Representative. This
coordination mechanism meets monthly to share information and strategies
and discuss current issues in the sector. The MOH is represented by the
Secretary General at these meetings where also, if needed, experts from
the MOH are invited to give clarifications on issues related to their
ongoing program.

The Country Coordinating Mechanism (CCM) for the Global Fund grants,
after some initial difficulties, now functions well in accordance with
Global Fund guidelines. It has a yearly agenda and holds regular
meetings to monitor implementation of Senegal's Round 4 and 7 malaria
grants, Round 7 Tuberculosis grant and Round 6 HIV grant, with
extraordinary meetings convened as necessary. USAID helped to form and
is a member of the Technical Secretariat, which facilitates
implementation of the existing grants and works closely with the three
disease control programs.

In the past, an active National Malaria Steering Committee, made up of
various stakeholders, met on a regular basis. It was responsible for
overseeing the activities of four NMCP commissions: (1) planning,
monitoring, and evaluation; (2) clinical and therapeutic training; (3)
communication and social mobilization; and (4) research. In the past
three years, this group has become inactive, although its working groups
on drug quality, IPT, ACTs, and ITNs remain active but uncoordinated as
a larger group.

[Progress to Date:]{.underline}

The Steering Committee has not recently been active. In May 2008 the
Minister created (and will chair) an internal committee to follow
HIV/AIDS, tuberculosis and malaria activities in Senegal. PMI staff
continues to advocate for creation of a sub-committee specific to
malaria, which is open to all technical and financial partners active in
malaria, and which the NMCP Coordinator is given the authority to
convene.

[Proposed Year 3 Activities]{.underline}: (*No additional cost to the
PMI*)

*1. Revive National Malaria Steering Committee*:

> In-country PMI staff will provide support to the NMCP to revive and
> coordinate regular meetings of the National Malaria Steering
> Committee, whose membership will include representatives of key
> stakeholders from public, donor, NGO, and private interests, and
> support and participate in the working groups within this Committee,
> and will work with the NMCP and partners to develop an annual work
> plan and establish clearly defined roles and responsibilities for
> Steering Committee representatives and their organizations.

[]{#MandEPlan .anchor}**CAPACITY BUILDING**

[Current Status]{.underline}:

The Senegal NMCP resides in the MOH's Division of Disease Control and
has a well developed strategy for malaria control, a clear
organizational structure, and an effective management team. The staff
includes four public health physicians, two pharmacists, two public
health nurses, an economist, an entomologist, and several other
experienced personnel who together manage all aspects of the NMCP's
activities (including training, supervision, M&E, research, etc.). In
addition, the NMCP has recently hired 24 recent medical or
pharmaceutical graduates who will supervise diagnosis and treatment in
the public and private sectors. Three entomologists work for the SLAP,
and several entomologists and parasitologists serve on the faculty of
the UCAD, School of Medicine. In addition, two French institutions (IRD
and IP) have many experienced parasitologists and entomologists who
collaborate with the NMCP. While there are no full-time malaria staff at
the regional or district levels of the public health system, health
workers and depot managers at all facilities are engaged in case
management and prevention of malaria in pregnancy, and ITN activities.
Employees of the Hygiene Service are involved in some limited non-PMI
spraying and bednet re-treatment campaigns.

Senegal is one of the beneficiaries of a WHO/Gates Foundation grant to
improve insecticide resistance monitoring capacity. Entomologists from
UCAD, the IP and SLAP, together with members of Hygiene Service, have
developed a detailed 12-day course to train Hygiene Service staff on
entomologic control and surveillance methods. Two sessions of the course
from June to July 2008 trained 42 staff of the Hygiene Service from 11
of Senegal's 63 districts. At present, it is unclear whether Hygiene
Service staff will carry out these methods independently or will assist
trained entomologists in the studies.

Thus, Senegal has a wealth of expertise and staff working on malaria
prevention and control at all levels and this has facilitated the
success of PMI assistance to date. However, PMI also recognizes that
there is still a need for capacity-building both at peripheral and
national levels in order to achieve the goals set out by NMCP and PMI.

[Progress to Date:]{.underline}

PMI's activities in capacity building address the improvement of
preventive and curative services at all levels. In addition to funding
training and supervision of health workers in all areas of malaria
prevention and control as described in previous sections, PMI has also
funded the training of six regional and national MOH staff to attend a
three-week course in data management, monitoring and evaluation at CESAG
(*Centre africain des études supérieures en gestion*), and will continue
to support up to ten health professionals to participate in this program
in FY08. With Year 3 funds, PMI will also continue to fund supervision
visits by the NMCP to all levels of the health system active in malaria
prevention and control.

[Proposed Year 3 Activities:]{.underline}

*1. [Support to NMCP to enable program supervision]{.underline}
(\$50,000)*

> PMI will contribute to supporting the costs associated with the NMCP's
> supportive supervision to peripheral levels. (Other PMI implementing
> partners also contribute significantly to supervision activities.)

*2. [Financing construction of additional NMCP office space]{.underline}
(\$100,000)*

This activity is contingent upon review by a Regional Engineering
Officer to determine: (1) the need for additional space at the NMCP; (2)
that the existing construction can be modified as required; and (3) the
estimated cost of the construction. The review will lay out the process
to be followed in order for an addition to the NMCP to be built and will
describe any potential pitfalls to completing that construction. Once
this information is available, PMI headquarters and the Senegal Country
Team will jointly review the proposed activity and make a final decision
about PMI support for the construction.

> The central NMCP team in Dakar is strong and has a sufficient number
> of technically-sound staff to manage its programs. The main constraint
> on its ability to function at maximum capacity is a lack of adequate
> office space to house its staff and visiting technical collaborators.
> When the current NMCP office space was planned, the staff was one
> fourth its current size. Three or more staff now share a small office
> designed for one and people often need to work in the conference room,
> which itself is too small to hold the number of staff and partners who
> are routinely convened for meetings. Furthermore, there is no storage
> space, and files, documents and project materials are piled around
> desks and in hallways. The NMCP has already had plans and estimates
> drawn up for this activity and has sought other donors' support, but
> without success. Specifically, the Global Fund rejected its request in
> part because a previous grant funded the construction of a building
> that the NMCP later lost in a property dispute. An addition to NMCP
> building would improve management and organizational capacity and
> would also facilitate ongoing collaboration with PMI.

3.  *[Training in monitoring and evaluation at CESAG]{.underline}:*
    *(\$30,000)*

> In FY09, the PMI will support the training of up to 10 additional
> staff at CESAG in data management and monitoring and evaluation. These
> staff may come from any level of the health care system and will be
> chosen in collaboration with the NMCP.

**MONITORING AND EVALUATION**

Monitoring and evaluation is critical for measuring progress against PMI
goals and targets, for identifying problems in program implementation
and suggesting what modifications should be made, and for confirming
that those modifications are having their desired effect. In Senegal,
monitoring and evaluating the rapid scale up of malaria prevention and
control interventions and achieving high coverage rates with ACTs, ITNs,
IPTp, and IRS are priorities not only of PMI, but also the NMCP, the
Global Fund, and other national and international partners working on
malaria.

[Current Status]{.underline}:

The Strategic Plan for Malaria Control 2006-2010 acknowledges the
generally weak state of the National Health Management Information
System (HMIS) and the monitoring and evaluation activities that rely on
this data. One reason for the cancellation of the Global Fund Round 1
malaria grant was the MOH's inability to provide adequate data to
measure the required outcome and impact indicators. As part of the
NMCP's successful application for a Round 4 Global Fund grant, the NMCP
developed a Monitoring and Evaluation Strategic Plan that focused on
monitoring the progress of the Global Fund-financed activities and
providing essential data for the development of new control strategies,
as well as developing the capacities at all levels of the program and
improving the collection and analysis of program data.

The NMCP conducts quarterly review meetings by zone (a grouping of
two-three contiguous regions) where each district presents key malaria
surveillance and program data, such as the number of reported clinical
and confirmed cases and deaths from malaria, stocks of drugs and LLINs,
and the number of pregnant women taking IPTp. These meetings allow for a
self-critique by the districts and allow the NMCP to provide feedback,
clarify existing guidelines, and disseminate new ones. In preparation
for this meeting, health posts send morbidity, RDT use, and ACT use data
to the district where it is combined with data from the health center.
Health facility surveillance data are entered into an RBM Epi Info v6
database and compiled; program data are compiled using a variety of
formats and transferred to Excel spreadsheets. The data are synthesized
into a quarterly report that is presented and discussed at the review
meeting, then summarized at the national level and submitted to WHO and
the Global Fund. Entomological and IRS related data are also being
collected in collaboration with UCAD. WHO/GMP is developing a database
management system in Microsoft Access to unify the various data
collection systems and hopes to have the system in use in Senegal in
2009. The quality of data collected from the districts is reviewed
during supervision visits, but a standard data quality audit tool is not
used.

The NMCP conducted an evaluation of the first year of phase one of the
Global Fund Round 4 grant in late 2006, roughly at the same time as the
baseline MIS for PMI. This evaluation was done in all 56 districts that
existed at the time, both at health facilities and in the community,
using a non-random, "targeted" selection of health facilities and
communities. An independent consultancy firm assessed adherence to
malaria treatment guidelines in the district health center and three
health posts, two in rural areas. The consultants also conducted a
survey of treatment-seeking, ITN use, and IPTp in communities near the
health facilities visited. This evaluation showed that the NMCP was
making good progress in the disbursement and use of funds and that
malaria was correctly managed in facilities for 66 -- 77% of cases. The
levels of ACT use and the coverage of IPTp and ITNs from the community
survey were roughly double the levels found through the MIS; the Round 4
evaluation results are those that are quoted by the NMCP.

In August 2007, staff from the NMCP participated in a workshop on the
Monitoring and Evaluation Systems Strengthening Tool. This tool was
designed to assess the data collection, reporting and management systems
used to measure indicators of program activities. The plan is to develop
a procedure manual for monitoring and evaluation, strengthen the
capacities for using data in decision making, improve the storage and
archiving of data, both on paper and electronic, train staff in the use
of geographic information systems (GIS), improve the collection of data
at the community level, and include the collection of community-level
data in the quarterly review meetings.

The PMI monitoring and evaluation framework selects specific activities
to be monitored on a regular basis to allow in-country program managers
to assess progress and redirect resources as needed.  Activities within
the four main intervention areas will be tracked through the quarterly
NMCP review meetings, periodic reports from groups providing
commodities, health facilities, and international and local partners. 
Types of activities that will be monitored include procurement and
distribution of commodities, including ITNs, SP tablets, RDTs, delivery
of services such as indoor spraying, ACT and IPT treatment, training of
health care staff to build capacity to improve service delivery,
behavior change communication efforts to improve health seeking behavior
and acceptance of IRS.

[Progress to Date]{.underline}:

In November 2006, PMI funded a Malaria Indicator Survey (MIS) to collect
baseline data for PMI related interventions. The survey was conducted by
ORC Macro in collaboration with local partners including the *Centre de
Recherche pour le Développement Humain*. The survey results are
discussed in the section "Current Status of Malaria Indicators."

During Year 2 the PMI resident staff actively participated in the
quarterly reviews and on a commission charged with following-up on
recommendations stemming from the reviews. The most significant
accomplishment of this commission was the revision of the data template
that the districts complete for the reviews, including clarifying the
definition of some indicators and adding a few key analyses. This is
expected to contribute significantly to improving data quality.

[Proposed Year 3 Activities:]{.underline} (\$565,000)

In Year 3, the monitoring and evaluation activities funded by the PMI
will be done jointly with the NMCP and other partners, and PMI will
support the NMCP's costed M&E plan. PMI will help build national
capacity in monitoring and evaluation of coverage and utilization rates
for ACTs, ITNs, IPTp and IRS through an MIS, and health facility and
community-level performance through supportive supervision, routine
record reviews, and service statistics. Rather than establishing
parallel sentinel sites as are used in other countries to collect
facility-based data, PMI in Senegal will instead support the NMCP M&E
plan, and will receive district-level monitoring data regularly from the
NMCP. Discussions will also be held with the NMCP on data quality audit
tools that could be used to strengthen the quality of routinely
collected data.

The PMI will focus on the following interventions for Year 3:

1.  *[Coverage of interventions and impact on malaria
    mortality]{.underline}: (\$500,000 for a nationwide MIS including
    anemia and parasitemia biomarkers, in addition to \$500,000 budgeted
    in the FY08 MOP)*

> To measure mid-point coverage for PMI-supported interventions, PMI
> will support a nationwide MIS in October-December 2008. This survey
> will be similar to the baseline MIS with the exception that it will
> include anemia and parasitemia testing. The MIS will provide data on
> the same indicators measured in November 2006, such as the proportions
> of children under five and pregnant women who slept under an ITN the
> previous night, the proportion of pregnant women who have received two
> or more doses of SP for IPTp during their most recent pregnancy, and
> the proportion of children under five with suspected malaria who have
> received treatment with an ACT in accordance with national malaria
> treatment policies within 24 hours of the onset of their symptoms. The
> NMCP has organized a MOH committee to supervise the MIS, including
> representatives of PMI, UCAD, WHO, UNICEF, the World Bank, NetMark,
> RBM and other partners. While the NMCP would prefer estimates for at
> least some indicators at a district level, the budget required could
> not be financed and instead the survey will provide estimates at the
> regional level for 8 regions and at the district level for the regions
> of Saint-Louis, Kaolack and Kolda.

2.  *[Support to the NMCP to improve archival and data back up systems
    (\$65,000)]{.underline}*

> The NMCP has developed a costed M&E plan; among the most pressing
> needs are a system for storage and archiving of data stored on paper
> forms at the district and national levels, and an improved computer
> network for the management and back up of the computerized data bases.
> In order to support the NMCP M&E system, the PMI will fund the
> purchase of these items.

**STAFFING AND ADMINISTRATION**

Two resident advisors oversee the PMI in Senegal, one representing CDC
and one representing USAID. In addition, several health team members,
including one FSN dedicates significant time supporting PMI. All PMI
staff members are part of a single inter-agency team led by the USAID
Mission Director or his/her designee in country. The PMI team shares
responsibility for development and implementation of PMI strategies and
work plans, coordination with national authorities, management of
collaborating agencies and supervision of day-to-day activities.

The two PMI professional staff work together to oversee all technical
and administrative aspects of the PMI in Senegal, including finalizing
details of the project design, implementing malaria prevention and
treatment activities, monitoring and evaluation of outcomes and impact,
and reporting of results. Both staff members report to the USAID Mission
Director or his/her designee. The CDC staff person is supervised by CDC,
both technically and administratively. All technical activities are
undertaken in close coordination with the MOH, the NMCP and other
national and international partners, including the WHO, UNICEF, the
GFATM, World Bank and the private sector.

Locally-hired staff to support PMI activities either in Ministries or in
USAID will be approved by the USAID Mission Director. Because of the
need to adhere to specific country policies and USAID accounting
regulations, any transfer of PMI funds directly to Ministries or host
governments will need to be approved by the USAID Mission Director and
Controller.

[]{#Staffing .anchor}

**ANNEX 1**

**Tables**

**Table 1**

**President's Malaria Initiative -- Senegal**

**Year 3 (FY09) Timeline of Major Activities**

<table>
<colgroup>
<col style="width: 22%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 4%" />
<col style="width: 4%" />
</colgroup>
<tbody>
<tr class="odd">
<td rowspan="2"><p><strong>ACTIVITY</strong></p></td>
<td colspan="5"><strong>2008</strong></td>
<td colspan="12"><strong>2009</strong></td>
</tr>
<tr class="even">
<td><strong>AUG</strong></td>
<td><strong>SEP</strong></td>
<td><strong>OCT</strong></td>
<td><strong>NOV</strong></td>
<td><strong>DEC</strong></td>
<td><strong>JAN</strong></td>
<td><strong>FEB</strong></td>
<td><strong>MAR</strong></td>
<td><strong>APR</strong></td>
<td><strong>MAY</strong></td>
<td><strong>JUN</strong></td>
<td><strong>JUL</strong></td>
<td><strong>AUG</strong></td>
<td><strong>SEPT</strong></td>
<td><strong>OCT</strong></td>
<td><strong>NOV</strong></td>
<td><strong>DEC</strong></td>
</tr>
<tr class="odd">
<td>LLIN distribution through Vitamin A campaign</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Distribution of subsidized and full-cost ITNs through expanded
voucher program and social marketing</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>National Malaria Indicator Survey</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>IRS activities in selected districts</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>IEC/mass media for early ANC attendance and IPTp uptake</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="even">
<td>Support NMCP introduction of RDTs at community health huts</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td>Construction of additional office space at NMCP building</td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

> **Table 2**
>
> **President's Malaria Initiative -- Senegal**
>
> **Planned Obligations for FY09** (\$000)

+------------+--------+----------+----------+-------------+----------+
| **Proposed | *      | **       | **Ge     | **          | **       |
| Activity** | *Mecha | Budget** | ographic | Description | Relation |
|            | nism** |          | Area**   | of          | to       |
|            |        | **(      |          | Activity**  | Interve  |
|            |        | *commodi |          |             | ntions** |
|            |        | ties)*** |          |             |          |
+============+========+==========+==========+=============+==========+
| **         |        |          |          |             |          |
| PREVENTIVE |        |          |          |             |          |
| AC         |        |          |          |             |          |
| TIVITIES** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **ITNS**   |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| P          | TBD    | 4,900    | Na       | 700,000     | ITNs     |
| rocurement |        |          | tionwide | nets at     |          |
| and        |        | (4,200)  |          | \$7/net     |          |
| di         |        |          |          |             |          |
| stribution |        |          |          |             |          |
| of LLINs   |        |          |          |             |          |
| for        |        |          |          |             |          |
| routine    |        |          |          |             |          |
| di         |        |          |          |             |          |
| stribution |        |          |          |             |          |
| to         |        |          |          |             |          |
| pregnant   |        |          |          |             |          |
| women and  |        |          |          |             |          |
| children   |        |          |          |             |          |
| under five |        |          |          |             |          |
| through    |        |          |          |             |          |
| subsidized |        |          |          |             |          |
| voucher    |        |          |          |             |          |
| program    |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| P          | D      | 1,500    | Na       | 200,000     | ITNs     |
| rocurement | ELIVER |          | tionwide | LLINs for   |          |
| and        |        | (1,500)  |          | the 2009    |          |
| di         |        |          |          | campaign;   |          |
| stribution |        |          |          | including   |          |
| of LLINs   |        |          |          | \$500,000   |          |
| 2009 free  |        |          |          | for         |          |
| campaign   |        |          |          | logistics   |          |
+------------+--------+----------+----------+-------------+----------+
| Support to | TBD    | 200      | Na       | Support of  | ITNs     |
| commercial |        |          | tionwide | full cost   |          |
| sales of   |        |          |          | ITNs in the |          |
| full price |        |          |          | commercial  |          |
| ITNs       |        |          |          | sector      |          |
+------------+--------+----------+----------+-------------+----------+
| IEC/BCC    |        | 0        | Na       | Included in | ITNs     |
| for LLIN   |        |          | tionwide | MIP and     |          |
| u          |        |          |          | Community   |          |
| tilization |        |          |          | m           |          |
|            |        |          |          | obilization |          |
|            |        |          |          | section     |          |
+------------+--------+----------+----------+-------------+----------+
| LLINs for  | FHI    | 25       | Na       | Integration |          |
| PLWHA      |        |          | tionwide | of malaria  |          |
|            |        | \(25\)   |          | prevention  |          |
|            |        |          |          | messages    |          |
|            |        |          |          | into        |          |
|            |        |          |          | counseling  |          |
|            |        |          |          | and         |          |
|            |        |          |          | com         |          |
|            |        |          |          | munications |          |
|            |        |          |          | and         |          |
|            |        |          |          | d           |          |
|            |        |          |          | istribution |          |
|            |        |          |          | of LLINs    |          |
|            |        |          |          | through     |          |
|            |        |          |          | peer        |          |
|            |        |          |          | educators   |          |
+------------+--------+----------+----------+-------------+----------+
| *          |        | *        |          |             |          |
| *SUBTOTAL: |        | *6,625** |          |             |          |
| LLINs**    |        |          |          |             |          |
|            |        | ***(5    |          |             |          |
|            |        | ,725)*** |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **IRS**    |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Indoor     | RTI    | 2,875    | 3        | One round   | IRS      |
| residual   | (incl. |          | di       | of spraying |          |
| spraying   | su     | *        | stricts: | in the same |          |
|            | bgrant | (1,160)* | Richard  | 3 districts |          |
|            | to     |          | Toll,    | as the      |          |
|            | S      |          | Vé       | previous    |          |
|            | ervice |          | lingara, | year with   |          |
|            | d'Hy   |          | and      | an          |          |
|            | giene) |          | Nioro,   | additional  |          |
|            |        |          |          | round of    |          |
|            |        |          | appro    | spraying in |          |
|            |        |          | ximately | Richard     |          |
|            |        |          | 650,000  | Toll        |          |
|            |        |          | people   |             |          |
+------------+--------+----------+----------+-------------+----------+
| Strengthen | WHO    | 265      | 3        | Entomologic | IRS      |
| e          | (sub   |          | d        | monitoring  |          |
| ntomologic | -grant |          | istricts | pre and     |          |
| ca         | to     |          | of       | post IRS    |          |
| pabilities | UCAD & |          | Richard  | imp         |          |
| and        | Ins    |          | Toll,    | lementation |          |
| e          | titute |          | Vé       | (current 3  |          |
| ntomologic | Pa     |          | lingara, | districts); |          |
| monitoring | steur) |          | and      | en          |          |
|            |        |          | Nioro;   | tomological |          |
|            |        |          | possibly | monitoring  |          |
|            |        |          | a 4th    | of a 4^th^  |          |
|            |        |          | district | district    |          |
|            |        |          | TBD      |             |          |
+------------+--------+----------+----------+-------------+----------+
| I          | WHO    | 25       | 5 sites  | Insecticide | IRS      |
| nsecticide | (sub   |          |          | resistance  |          |
| resistance | -grant |          |          | monitoring  |          |
| monitoring | to     |          |          | in areas    |          |
|            | UCAD)  |          |          | where IRS   |          |
|            |        |          |          | is done or  |          |
|            |        |          |          | c           |          |
|            |        |          |          | ontemplated |          |
+------------+--------+----------+----------+-------------+----------+
| Technical  | CDC    | 10       | N/A      | 1 visit     | IRS      |
| assistance | IAA    |          |          |             |          |
| for        |        |          |          |             |          |
| entomology |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **S        |        | *        |          |             |          |
| UBTOTAL:** |        | *3,175** |          |             |          |
|            |        |          |          |             |          |
| **IRS**    |        | ***(1    |          |             |          |
|            |        | ,160)*** |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **Malaria  |        |          |          |             |          |
| in         |        |          |          |             |          |
| P          |        |          |          |             |          |
| regnancy** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| S          | Intra  | 450      |          | Bring ANC,  | MIP      |
| upervision | Health |          |          | IPT, LLIN   |          |
| and        |        |          |          | for         |          |
| monitoring |        |          |          | pregnant    |          |
| of ANC,    |        |          |          | women to    |          |
| support    |        |          |          | community   |          |
| outreach   |        |          |          | level,      |          |
| strategy,  |        |          |          | Monitoring  |          |
| reinforce  |        |          |          | and         |          |
| MIP        |        |          |          | supervision |          |
| services   |        |          |          | of MIP      |          |
| in health  |        |          |          | delivery,   |          |
| facilities |        |          |          | Training of |          |
|            |        |          |          | new health  |          |
|            |        |          |          | care        |          |
|            |        |          |          | providers   |          |
|            |        |          |          | in ANC,     |          |
|            |        |          |          | IPT, LLINs, |          |
|            |        |          |          | MIP,        |          |
|            |        |          |          | in          |          |
|            |        |          |          | terpersonal |          |
|            |        |          |          | com         |          |
|            |        |          |          | munication, |          |
|            |        |          |          | replacement |          |
|            |        |          |          | of filters  |          |
|            |        |          |          | and cups    |          |
+------------+--------+----------+----------+-------------+----------+
| IEC/mass   | TBD    | 100      | Na       | Support     | MIP      |
| media to   |        |          | tionwide | IEC/mass    |          |
| promote    |        |          |          | media       |          |
| early ANC  |        |          |          | activities  |          |
| attendance |        |          |          | to mobilize |          |
| and IPTp   |        |          |          | women for   |          |
| uptake     |        |          |          | early ANC   |          |
|            |        |          |          | and IPTp    |          |
|            |        |          |          | uptake      |          |
+------------+--------+----------+----------+-------------+----------+
| *          |        | **550**  |          |             |          |
| *SUBTOTAL: |        |          |          |             |          |
| MIP**      |        | *        |          |             |          |
|            |        | **(0)*** |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| *          |        | **       |          |             |          |
| *SUBTOTAL: |        | 10,375** |          |             |          |
| Pr         |        |          |          |             |          |
| evention** |        | ***(6    |          |             |          |
|            |        | ,885)*** |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **CASE     |        |          |          |             |          |
| MANAGEMENT |        |          |          |             |          |
| AC         |        |          |          |             |          |
| TIVITIES** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **D        |        |          |          |             |          |
| IAGNOSIS** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Supportive | Intra  | 100      | Na       | Support for | D        |
| s          | Health |          | tionwide | supervision | iagnosis |
| upervision | / UCAD |          |          | of malaria  |          |
| of malaria |        |          |          | diagnosis   |          |
| diagnosis  |        |          |          | by          |          |
| with both  |        |          |          | microscopy  |          |
| microscopy |        |          |          | and RDTs    |          |
| and RDTs   |        |          |          | for         |          |
| with       |        |          |          | laboratory  |          |
| quality    |        |          |          | and health  |          |
| assurance  |        |          |          | worker      |          |
| and        |        |          |          | staff and   |          |
| control    |        |          |          | implement   |          |
|            |        |          |          | laboratory  |          |
|            |        |          |          | quality     |          |
|            |        |          |          | assurance   |          |
|            |        |          |          | and control |          |
|            |        |          |          | measures.   |          |
+------------+--------+----------+----------+-------------+----------+
| Technical  | CDC    | 10       | N/A      | 1 trip to   | D        |
| assistance | IAA    |          |          | continue    | iagnosis |
| for        |        |          |          | work with   |          |
| d          |        |          |          | quality     |          |
| iagnostics |        |          |          | control of  |          |
|            |        |          |          | microscopy  |          |
|            |        |          |          | and RDTs    |          |
+------------+--------+----------+----------+-------------+----------+
| O          | L      | 75       | Na       | Study to    | D        |
| perational | ocally |          | tionwide | determine   | iagnosis |
| research   | co     |          |          | the         |          |
| to assess  | mpeted |          |          | positive    |          |
| NMCP       |        |          |          | and         |          |
| diagnostic | mec    |          |          | negative    |          |
| and        | hanism |          |          | predictive  |          |
| treatment  |        |          |          | values of   |          |
| algorithm  |        |          |          | the current |          |
| for        |        |          |          | malaria     |          |
| unc        |        |          |          | diagnostic  |          |
| omplicated |        |          |          | and         |          |
| malaria    |        |          |          | treatment   |          |
|            |        |          |          | algorithm   |          |
+------------+--------+----------+----------+-------------+----------+
| **T        |        |          |          |             |          |
| REATMENT** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Improve    | Intra  | 365      | Na       | Support     | Case     |
| case       | Health |          | tionwide | transition  | ma       |
| management |        |          |          | to AL in    | nagement |
| with ACTs  |        |          |          | 2010        |          |
|            |        |          |          | (training,s |          |
|            |        |          |          | upervision, |          |
|            |        |          |          | monitoring, |          |
|            |        |          |          | job aids),  |          |
|            |        |          |          | Training of |          |
|            |        |          |          | newly hired |          |
|            |        |          |          | HCWs,       |          |
|            |        |          |          | Supportive  |          |
|            |        |          |          | s           |          |
|            |        |          |          | upervision, |          |
|            |        |          |          | monitoring, |          |
|            |        |          |          | outreach    |          |
|            |        |          |          | strategy    |          |
+------------+--------+----------+----------+-------------+----------+
| Technical  | CDC    | 10       | N/A      | I trip to   | Case     |
| assistance | IAA    |          |          | assist with | ma       |
| for OR and |        |          |          | OR and case | nagement |
| d          |        |          |          | management  |          |
| iagnostics |        |          |          |             |          |
| or case    |        |          |          |             |          |
| management |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Medication | D      | 240      | Na       | Kits for    | Case     |
| kits for   | ELIVER |          | tionwide | treatment   | ma       |
| severe     |        | \(240\)  |          | of one day  | nagement |
| malaria    |        |          |          | of severe   |          |
|            |        |          |          | malaria w   |          |
|            |        |          |          | medicines   |          |
|            |        |          |          | and         |          |
|            |        |          |          | supplies,   |          |
|            |        |          |          | \~2600 cfa  |          |
|            |        |          |          | per kit     |          |
+------------+--------+----------+----------+-------------+----------+
| **Phar     |        |          |          |             |          |
| maceutical |        |          |          |             |          |
| management |        |          |          |             |          |
| AND drug   |        |          |          |             |          |
| quality**  |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Drug       | SPS    | 230      | Na       | Drug stock  | Case     |
| management |        |          | tionwide | management  | ma       |
| training   |        |          |          | for         | nagement |
|            |        |          |          | dispensers  |          |
|            |        |          |          | at health   |          |
|            |        |          |          | centers and |          |
|            |        |          |          | health      |          |
|            |        |          |          | posts,      |          |
|            |        |          |          | including   |          |
|            |        |          |          | private     |          |
|            |        |          |          | pharmacies  |          |
+------------+--------+----------+----------+-------------+----------+
| Drug       | WHO    | 30       | N/A      | Therapeutic | Case     |
| efficacy   | (su    |          |          | efficacy    | ma       |
| testing    | bgrant |          |          | tests of    | nagement |
|            | to     |          |          | first- and  |          |
|            | UCAD)  |          |          | second-line |          |
|            |        |          |          | drugs       |          |
+------------+--------+----------+----------+-------------+----------+
| Pharmac    | USP    | 115      | Na       | Support for | Case     |
| ovigilance | DQI    |          | tionwide | a national  | ma       |
| and drug   |        | \(20\)   |          | system of   | nagement |
| quality    |        |          |          | pharma      |          |
| monitoring |        |          |          | covigilance |          |
| and        |        |          |          | and         |          |
| advocacy   |        |          |          | maintenance |          |
|            |        |          |          | system of   |          |
|            |        |          |          | drug        |          |
|            |        |          |          | quality     |          |
|            |        |          |          | assurance   |          |
|            |        |          |          | in 9 sites. |          |
|            |        |          |          | Also        |          |
|            |        |          |          | includes    |          |
|            |        |          |          | IEC         |          |
|            |        |          |          | activities  |          |
|            |        |          |          | to inform   |          |
|            |        |          |          | public      |          |
|            |        |          |          | about       |          |
|            |        |          |          | count       |          |
|            |        |          |          | erfeit/poor |          |
|            |        |          |          | quality     |          |
|            |        |          |          | drugs       |          |
|            |        |          |          | (possible   |          |
|            |        |          |          | sub-grant   |          |
|            |        |          |          | for this),  |          |
|            |        |          |          | and         |          |
|            |        |          |          | advocacy    |          |
|            |        |          |          | for policy  |          |
|            |        |          |          | enforcement |          |
|            |        |          |          | of drug     |          |
|            |        |          |          | quality     |          |
|            |        |          |          | standards   |          |
+------------+--------+----------+----------+-------------+----------+
| **S        |        | **1175** |          |             |          |
| UBTOTAL:** |        |          |          |             |          |
|            |        | *        |          |             |          |
| **Case     |        | *(260)** |          |             |          |
| Ma         |        |          |          |             |          |
| nagement** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **C        |        |          |          |             |          |
| OMMUNITY** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Community  | CCF    | 1000     | Na       | Co          | LLINs,   |
| mo         | Cons   |          | tionwide | mprehensive | IRS, CM, |
| bilization | ortium |          |          | malaria     | MIP      |
|            |        |          |          | community   |          |
|            | of     |          |          | m           |          |
|            | FBO    |          |          | obilization |          |
|            | s/NGOs |          |          | activities  |          |
|            |        |          |          | including   |          |
|            |        |          |          | IEC/BCC,    |          |
|            |        |          |          | support for |          |
|            |        |          |          | MIP, case   |          |
|            |        |          |          | management, |          |
|            |        |          |          | ITNs, IRS   |          |
+------------+--------+----------+----------+-------------+----------+
| Commu      | CCF    | 1,200    | Na       | Community   | CM, MIP  |
| nity-based | Cons   |          | tionwide | based case  |          |
| impl       | ortium |          |          | management  |          |
| ementation | of     |          |          | of fever in |          |
| of ACTs    | FBO    |          |          | 1297        |          |
|            | s/NGOs |          |          | functional  |          |
|            |        |          |          | health      |          |
|            |        |          |          | huts.       |          |
|            |        |          |          | Includes    |          |
|            |        |          |          | training,   |          |
|            |        |          |          | s           |          |
|            |        |          |          | upervision, |          |
|            |        |          |          | and         |          |
|            |        |          |          | monitoring  |          |
|            |        |          |          | of staff    |          |
+------------+--------+----------+----------+-------------+----------+
| **S        |        | *        |          |             |          |
| UBTOTAL:** |        | *2,200** |          |             |          |
|            |        |          |          |             |          |
| **C        |        |          |          |             |          |
| ommunity** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **CAPACITY |        |          |          |             |          |
| BUILDING** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Support to | NMCP   | 50       | Na       | Support     | Capacity |
| NMCP to    | (t     |          | tionwide | visits by   | b        |
| enable     | hrough |          |          | national    | uilding, |
| program    | WHO)   |          |          | staff to    | CM,      |
| s          |        |          |          | regional    | Di       |
| upervision |        |          |          | and         | agnosis, |
|            |        |          |          | district    | MIP      |
|            |        |          |          | level       |          |
+------------+--------+----------+----------+-------------+----------+
| Support to | TBD    | 100      | PNLP     | Adding to   | Capacity |
| adding     |        |          |          | PNLP        | b        |
| space to   |        |          |          | building to | uilding, |
| existing   |        |          |          | accommodate | CM, MIP  |
| PNLP       |        |          |          | increase in |          |
| building   |        |          |          | staff       |          |
|            |        |          |          |             |          |
| *(pending  |        |          |          |             |          |
| review by  |        |          |          |             |          |
| regional   |        |          |          |             |          |
| en         |        |          |          |             |          |
| gineer)\** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Support    | Intra  | 30       | Na       | Support for | Capacity |
| for M&E    | Health |          | tionwide | 10 people   | B        |
| capacity   |        |          |          | to          | uilding, |
| building   |        |          |          | participate | M&E      |
| for        |        |          |          | at the      |          |
| national   |        |          |          | annual      |          |
| program    |        |          |          | 3-week      |          |
| staff and  |        |          |          | health      |          |
| regional   |        |          |          | focused     |          |
| and        |        |          |          | francophone |          |
| district   |        |          |          | M&E course  |          |
| personnel  |        |          |          | based at    |          |
|            |        |          |          | CESAG in    |          |
|            |        |          |          | Dakar       |          |
|            |        |          |          | (p          |          |
|            |        |          |          | articipants |          |
|            |        |          |          | chosen in   |          |
|            |        |          |          | co          |          |
|            |        |          |          | llaboration |          |
|            |        |          |          | with NMCP)  |          |
+------------+--------+----------+----------+-------------+----------+
| **S        |        | **180**  |          |             |          |
| UBTOTAL:** |        |          |          |             |          |
|            |        |          |          |             |          |
| **Capacity |        |          |          |             |          |
| Building** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **         |        |          |          |             |          |
| MONITORING |        |          |          |             |          |
| AND        |        |          |          |             |          |
| EV         |        |          |          |             |          |
| ALUATION** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| Interim    | ME     | 500      | Na       | Midpoint    | M&E      |
| nationwide | ASURE/ |          | tionwide | data for    |          |
| Malaria    | DHS    |          |          | indicators  |          |
| Indicator  | fol    |          |          | to be used  |          |
| Survey     | low-on |          |          | within PMI  |          |
|            | with   |          |          | on          |          |
|            | local  |          |          | i           |          |
|            | part   |          |          | ntervention |          |
|            | ner(s) |          |          | coverage    |          |
|            |        |          |          | including   |          |
|            |        |          |          | biomarkers  |          |
|            |        |          |          | (Oct-Nov    |          |
|            |        |          |          | 2008);      |          |
|            |        |          |          | 500,000     |          |
|            |        |          |          | from FY08   |          |
|            |        |          |          | MOP for     |          |
|            |        |          |          | total of    |          |
|            |        |          |          | \$1 million |          |
+------------+--------+----------+----------+-------------+----------+
| Support    | Local  | 65       | PNLP     | Support for | M&E      |
| for        | tender |          |          | archival    |          |
| improving  |        |          |          | and data    |          |
| quality of |        |          |          | back up     |          |
| routine    |        |          |          | system for  |          |
| data       |        |          |          | PNLP        |          |
+------------+--------+----------+----------+-------------+----------+
| *          |        | **565**  |          |             |          |
| *SUBTOTAL: |        |          |          |             |          |
| M&E**      |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **         |        |          |          |             |          |
| IN-COUNTRY |        |          |          |             |          |
| MANAGEMENT |        |          |          |             |          |
| AND        |        |          |          |             |          |
| ADMINI     |        |          |          |             |          |
| STRATION** |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| In-country | CD     | 1230     | Na       | C           | All      |
| staff;     | C/USAI |          | tionwide | oordination | inter    |
|            | D[^10] |          |          | of all      | ventions |
| Admin.     |        |          |          | in-country  |          |
| Expenses   |        |          |          | PMI         |          |
|            |        |          |          | activities  |          |
+------------+--------+----------+----------+-------------+----------+
| *          |        | **1,     |          |             |          |
| *SUBTOTAL: |        | 230^9^** |          |             |          |
| Mgmt. &    |        |          |          |             |          |
| Admin.**   |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
|            |        |          |          |             |          |
+------------+--------+----------+----------+-------------+----------+
| **GRAND    |        | **       | ***Com   |             |          |
| TOTAL**    |        | 15,700** | modities |             |          |
|            |        |          | r        |             |          |
|            |        | **(      | epresent |             |          |
|            |        | 7,145)** | 45.5% of |             |          |
|            |        |          | total    |             |          |
|            |        |          | b        |             |          |
|            |        |          | udget*** |             |          |
+------------+--------+----------+----------+-------------+----------+

**Table 3**

**Senegal Year 3 (FY09) Estimated Budget Breakdown by Intervention**
(\$000)

  --------------------- ------------------ ----------------- ----------------
  **Area**              **Commodities      **Other (%)**     **Total**
                        (%)**                                

  Insecticide-treated   5,725 (86%)        900 (14%)         6,625 (100%)
  Nets                                                       

  Indoor Residual       1,160 (36%)        2,015 (64%)       3,175 (100%)
  Spraying                                                   

  Malaria in            0 (0%)             550 (100%)        550 (100%)
  Pregnancy - IPTp                                           

  Case Management       260 (22%)          915 (78%)         1175 (100%)

  Community             0 (0%)             2,200 (100%)      2,200 (100%)
  Interventions                                              

  Capacity Building     0 (0%)             180 (100%)        180 (100%

  Monitoring and        0 (0%)             565 (100%)        565 (100%)
  Evaluation                                                 

  Administration        0 (0%)             1,230 (100%)      1,230 (100%)

  **Total**             7145 (45.5%)       8555 (54.5%)      15,700 (100%)
  --------------------- ------------------ ----------------- ----------------

**Table 4**

**Year 3 (FY09) Budget Breakdown by Partner** (\$000)

  ---------------------------------------------------------------------------
  **Partner              **Geographic     **Activity**         **Budget\***
  Organization**         Area**                                
  ---------------------- ---------------- -------------------- --------------
  CCF-led consortium of  Nationwide       Community case       2,200
  NGOs/FBOs (World                        management with      
  Vision, Africare, Plan                  ACTs, IEC/BCC for    
  International,                          IRS, LLIN, treatment 
  Counterpart, and                        seeking, promotion   
  CRS/Caritas)                            of ANC and IPTp      

  CDC IAA                N/A              Technical assistance 30
                                          visits for           
                                          entomology,          
                                          diagnostics and case 
                                          management           

  DELIVER                Nationwide       Procurement of LLINs 1,740
                                          and severe malaria   
                                          medications, TA and  
                                          logistical support   
                                          for national LLIN    
                                          campaign             

  FHI                    Nationwide       Integrate malaria    25
                                          counseling into      
                                          materials for care   
                                          and support of       
                                          PLWHA, to accompany  
                                          ITN distribution     

  IntraHealth            Nationwide       Health worker        945
                                          training, promotion  
                                          of IPTp, ITNs, ACTs, 
                                          IEC, and support to  
                                          NMCP for supervision 
                                          and monitoring; M&E  
                                          training             

  MEASURE/DHS follow-on  Nationwide       MIS November 2008,   500
  with local partners                     midpoint data for    
                                          PMI indicators; will 
                                          complete the \$500K  
                                          budgeted in FY08     

  RTI                    Nioro, Richard   IRS commodity        2,875
                         Toll, and        procurement and      
                         Vélingara        operations           
                         districts                             

  SPS (MSH)              Nationwide       Drug stock           230
                                          management for       
                                          dispensers and stock 
                                          managers, assistance 
                                          to PNLP and PNA for  
                                          drug quantification  
                                          and management       

  USP DQI                Nationwide       National, integrated 115
                                          Pharmacovigilance    
                                          Center, drug quality 
                                          assurance sites and  
                                          drug quality IEC     

  WHO Umbrella Grant                                           
  local sub-grants                                             

  University Cheikh Anta Nationwide       Drug efficacy        290
  Diop (UCAD) (through                    testing, insecticide 
  WHO)                                    resistance           
                                          monitoring,          
                                          entomological        
                                          monitoring in 3 IRS  
                                          districts + 1 new    
                                          district             

  GOS (NMCP) (through    Nationwide       Support National     50
  WHO)                                    Level Program        
                                          Management and       
                                          Supervision to       
                                          Regions              

  Institute Pasteur      4 districts      Entomological        30
  (through WHO)                           monitoring in 3 IRS  
                                          districts + 1 new    
                                          district             

  (Subtotal via WHO)     To UCAD, NMCP,                        370
                         Institute                             
                         Pasteur                               

  TBD (locally-competed  Dakar with       Expansion of NMCP    100
  contract)              nationwide       office to improve    
                         impact           functioning of NMCP  
                                          team                 

  TBD (local             Dakar with       Support for backup   65
  procurement)           nationwide       of national malaria  
                         impact           data archiving       
                                          system               

  TBD (Locally-competed  Nationwide       Operations Research  75
  mechanism)                              on RDT algorithm     

  TBD                    Nationwide       Mass media effort to 100
                                          increase ANC         
                                          attendance and IPTp  
                                          uptake; mechanism to 
                                          be determined early  
                                          in FY09              

  TBD (new central LLIN  Nationwide       Distribution of      5,100
  project or                              LLINs (including     
  locally-competed                        reimbursement of     
  mechanism)                              vouchers) for the    
                                          subsidized voucher   
                                          system targeting     
                                          pregnant women and   
                                          children \<5 years   
                                          old and support to   
                                          private sector       
                                          social marketing     
  ---------------------------------------------------------------------------

\* Does not include staffing and administration

[^1]: Agence National de la Statistique et de la Démographie. Rapport
    National de Présentation des Résultats du Troisième Recensement
    General de la Population et de l'Habitat -- (2002), December 2006.
    Estimate for 2008 based on from the estimate for 2007 on page 124
    and an annual growth rate of 2.4%.

[^2]: Based on comparing the cost of a standard basket of food and
    non-food items to the per-captia annual consumption. République du
    Sénégal. Evaluation quantitative du DSRP-I (2003-2005), July 2007

[^3]: Human Development Report (HDR) Table 1, 2007/2008

[^4]: Ndiaye, S, Ayad, M. 2006. 2005 Senegal Demographic and Health
    Survey (DHS). Calverton, Maryland USA: Centre de recherche pour le
    développement humain (Sénégal) and ORC Macro

[^5]: UNAIDS and WHO. Epidemiological Fact Sheet on HIV/AIDS and
    Sexually Transmitted Infections for Senegal, December 2006

[^6]: Since 2007 the NMCP only procures long-lasting insecticide treated
    nets, however it continues to measure coverage and utilization based
    on the "ITN" definition above.

[^7]: RBM Working Group for Scaling-up Insecticide-treated Netting.
    Scaling-up Insecticide-treated Netting Programmes in Africa: A
    Strategic Framework for Coordinated National Action. 2^nd^ Edition.
    Geneva: Roll Back Malaria, 2005

[^8]: Ndiaye, S, Ayad, M. 2006. 2005 Senegal Demographic and Health
    Survey (DHS). Calverton, Maryland USA: Centre de recherche pour le
    développement humain (Sénégal) and ORC Macro

[^9]: UNAIDS and WHO. Epidemiological Fact Sheet on HIV/AIDS and
    Sexually Transmitted Infections for Senegal, December 2006

[^10]: This will cover : two PMI international staff and other
    in-country administrative expenses