Perception of Beneficiaries and Stakeholders about the Services Offered by Health Huts Put in Place by the Health Project — Community Health of USAID in the Goudomp Health District ( Senegal )

The Health Project—Community Health USAID is a community-based intervention that has been implemented by a group of NGOs, among which there is Africare, for a period of 5 years (2006-2011). It seeks to strengthen the community health system through a package of basic services offered at the health center, and as well as to improve the skills and knowledge of community actors. The main objective of this study is to capture the perceptions of beneficiaries and stakeholders about the services offered at the PSSC health posts located in the health district Goudomp. A qualitative cross-sectional study on the perception of the community of the USAID PSSC and quality of services offered by the health huts was conducted from the 2nd to 5th of May 2009 in the Goudomp health district. To achieve the objectives of this study, we conducted focus group discussions with all the community leaders and had individual interviews with the community health workers (CHWs) and the supervisor of the NGO Africare. From most of the discussions, it can be concluded that the activities of the health hut are not well known by the populations. The best known activities are those performed by the nurse: immunization and pre-natal care. The existence of health huts at the community level was considered beneficial by all the community leaders. For the majority of the participants to the focus group discussions, the health huts “provided access to basic care”. Some participants, however, pointed out the “frequent drugs shortages” which, according to them, would explain the low attendance of the health huts in favor of the health post. The majority of CHWs and matrons felt that supervision activities were done on a regular basis. During the interviews, they mentioned many difficulties. However, the most common problem is the fact that the CHWs and the matron “who have no other source of income” were not salaried workers. This assessment has identified some difficulties in the implementation of the PSSC in the Goudomp health


Introduction
The community approaches that have been initiated for nearly two decades by non-governmental organizations (NGOs) have proved to be effective and efficient when it comes to child survival and maternal health.The recent experience of the NGO "Christian Children's Fund" in the region of Thies (Senegal) has shown that the involvement of community actors leads to an extraordinary dynamism in health activities, and allows to achieve exceptional performance regarding the implementation of health programs [1].The main conclusion of this intervention is a community health worker (CHW) who has, at least, achieved the level of primary education, has been trained, equipped, and adequately supervised, can provide health care to a child aged between 2 months and 5 years who has an acute respiratory infections (ARI) [2].
A study in the district of Kébémer showed that health huts allow a better execution of reproductive health related activities like the distribution of modern contraceptives at the community level [3].The added value of Community involvement has been revealed in previous studies in the district of Thiadiaye [4] in those of Bignona, Popenguine, Thienaba, Touba [5] and more recently those of Dioffior, Meckhe, and Ranerou [6].For the past ten years, Senegal has not built more health huts.It did not equip them, nor has it provided salaries for the health huts staff.These structures are operated by communities that very often are not well prepared for their management responsibilities.This situation is the reason why they face many difficulties [7].
Thus, to improve their access to basic health services, some communities have built health huts and hired CHWs to deliver a minimum of health services.However, it is clear that most health huts have limitations in the delivery of basic curative services and the launching of promotional activities.
The Health Project-USAID Community Health (PSSC) is a community-based intervention that has been implemented by a group of NGOs for a period of 5 years (2006)(2007)(2008)(2009)(2010)(2011).It aims at strengthening the community health system through a package of basic services offered at the health center and at improving the skills and knowledge of community actors.Those basic services are the prevention and treatment of common diseases and injuries of the mother and child, and the promotion of maternal and child health.Some specific services such as the integrated fight against tuberculosis and AIDS, peri-neonatal care, post-abortion care, the fight against the ARI and female genital mutilation were associated with this basic package.
Since 2008, 25 health huts of the Goudomp health district have been enrolled by Africare (6 in 2008 and 19 in 2009).The project also set up around health posts intervention sites, where activities were taking place such as: IEC, the monitoring of nutritional and weight growth of the child, TB patients support and the distribution of treated mosquito nets.Six sites are located in the municipality of Goudomp and 14 in the rest of the district.The main objective of this study is to capture the perceptions of beneficiaries and stakeholders about the services offered at the health huts of the USAID Community Health project, in the Goudomp health district.

Research Type
A qualitative cross-sectional study on the perception of the community in relation to the PSSC USAID and quality of services in health huts was conducted from the 2 nd of to the 5 th of May 2009 in the health district Goudomp.

Study Population
The study population consisted of village chiefs, imams, priests, members of women's associations, youth leaders, and of any other person considered as a community leader living in the villages or neighborhoods where there existed one of the selected health huts for the study.
The community health workers (CHWs) and traditional birth attendants were interviewed as well as the district supervisor of the NGO Africare.The study was prospective cross-sectional in design which involved the use of structured interview assisted questionnaires containing both open and closed ended questions.

Method of Data Collection
To achieve the objectives of this study, we conducted focus group discussions with all the community leaders and had individual interviews with the community health workers (CHWs) and the supervisor of the NGO Africare.

Tools for Data Collection
A guide was developed and used for the focus group discussions.The following items were discussed according of the public health priorities of the area:  Knowledge of services offered by the health hut;  Community participation in the activities of the health hut;  Advantages the health hut brought to the health of the community;  Difficulties encountered in these health huts.
An individual interview guide was used to gather information from the CHWs on:  The quality of services;  Supervision of the health huts;  Management tools;  The main difficulties and motivation of CHWs.
A semi-structured guide was used in the interview with the Africare district supervisor.During the interview, using open questions we could get the views of the supervisor on the following items:  Services provided in the health huts;  Community involvement;  Supervision activities and the difficulties encountered in the implementation of the project.

Data Analysis
The analysis of group discussions focused on the most redundant words.Then all the data were organized by theme and processed and analyzed after categorization and synthesis.

 Knowledge of services offered by the health huts
From the vast majority of discussions, we gathered that activities of the health huts are not well known by people.The best known are the activities performed by the nurse: immunization and pre-natal care.In this regards, the CWHs play a vital role in informing the population before the arrival of the teams.
Amongst those specifically assigned to the CWHs, nutritional monitoring and the management of fever are the best known.By contrast, management of diarrhea and ARI activities are the least known.

 Community participation in the activities of the health huts
In the majority of focus group discussions, people feel they have supported activities undertaken at the health huts.They participate in outreach, hygiene and sanitation activities "whenever they are informed," according to the majority.Those who are the most involved in these activities are the women through women's groups. Advantages brought by the health huts to the health of the community In most cases, the existence of such health hut at the community level is deemed beneficial.For the majority of the participants to the focus group discussions, the health huts "provided access to basic care" such as immunization and ARI and simple malaria cares.According to some participants, the major benefit is the ability to "give birth in good conditions with the help of trained personnel without having to travel miles".In some villages, the participants appreciated the "availability of community health workers and midwives". Difficulties encountered in the health huts Some participants extensively discussed the "frequent shortages of drugs" which they said would explain the low attendance of the health huts in favor of the health post.It emerged from the discussions the need for substantial support by local authorities or the NGO Africare for the provision of an initial stock of essential drugs.Thus, this stock could be renewed regularly.
The second difficulty widely expressed is the lack of incentive for the health huts workers as they have "no source of income, despite their commitment to the health of their community".

The Perception of Community Health Workers (CHWs and Midwives)
 Difficulties perceived by community health workers In interviews with CHWs and matrons, two major difficulties related to the care of patients often come up.They are the occurrence of adverse effects associated with taking the artemisinin-based combination therapies (ACTs) and the prevalence of births at home.
The CHWs said they are struggling to get malaria patients to grasp the importance of taking the ACTs because most of them think that the prescribed number of tablets is "excessive".At the beginning, some patients do follow strictly the treatment instructions as prescribed by the community health worker but eventually stop the treatment once they start feeling the occurrence of certain adverse effects.
The second difficulty lies in the acceptance of giving birth in a health facility.Some women think that "for quite a long time now, their relatives have given birth at home without any major difficulty" Information's was obtained from the focus group and questionnaires.

 Supervision of the health huts
The majority of CHWs and matrons felt that supervision was done on a regular basis.However the frequency of supervision by the head nurse varies.It ranges from "one to two visits per month".At the same time, the majority appreciated the presence on a regular basis of the Africare supervisors at the health huts.

 Management tools
During interviews, investigators have noted the presence of activity reports in almost all the facilities that were visited.However, almost all of the CHWs insist on the "frequent shortage of the management tools".

 Community participation to the activities of the health huts
The CHWs and matrons are divided on their opinions regarding the community participation to the activities of the health huts.Some think that the community is involved in the sanitization and cleaning activities of the structure and in social mobilization.In three health posts, people have contributed for the purchase of medicines.For other CHWs the community participation is considered as not really significant especially regarding the health committees. Difficulties in the management of the "Africare" health huts During the interviews, many difficulties have been mentioned.However, the one that mostly mentioned is the facts that the CHWs and the matron "who have no other source of income" had no salaries.
The next most frequent difficulties to be mentioned are the lack of possibilities to refer the serious illnesses and the frequent shortage of drugs which leads to the decline in attendance of the health hut.

 Services offered in the health hut
The Africare supervisor believes that the services offered at the health huts are quality services being that "community actors have received training on the basic package offered at the health huts"; they also receive, on a regular basis, "supportive supervision of the CHWs".He also believes that "standards and protocols in the treatment of uncomplicated malaria, ARI, diarrhea are followed", serious cases are referred and the monitoring of patients at home is being done.However, there exist some weaknesses.They are mainly the "poor capacities of some community actors" and the mobility of some community workers being busy with other tasks, due to fact that they receive no salaries.The main recommendation is to put in place an incentive system for the community health workers who work at the health huts.

 Community Involvement
According to the supervisor of Africare, there is a dynamic community.The "establishment of management committees at the health huts and auto-evaluation meetings" that provides a space for sharing and exchanging on health problems helped reinforce this dynamism.The communities are involved in implementing innovative strategies (care-group, solidarity circle of pregnant women).Africare has worked in improving community participation by putting in place a system of "joint management of health huts and restitution to the community".However, the weak point is "the problem of mobilization of workers and the population especially during the rainy season and harvest period". Supervision of the health huts Supervision activities of the health huts are opportunities for on-site training of community actors and for correcting errors in the various health huts.However, the supervisor Africare complains about "the lack of frequency of supervisory training activities and lack of joint supervision activities between the district management team and the project". Difficulties in the implementation of the project "Community Health" The difficulties encountered in the implementation may be due to "difficulties in mobilizing people who are often in a precarious situation".They are "more inclined to engage in income generating activities" to put bread on the table.
The other factor may result from the fact that "the actors do not receive incentives from the project, or the populations" so they can cope with daily expenses.
Therefore innovative strategies (Care-group, Circle of solidarity pregnant women, Grand Mother-strategies) are implemented to overcome these difficulties.

Discussions
The existence of the health center was seen as beneficial by the leaders; this was the case with the women in a previous study [4].
The efforts of revitalizing of the health huts project face the crucial problem of the payment of salaries to community staff.This lack of incentive was mentioned by all stakeholders during the various investigations (CHWs, matrons; the population and the supervisors of Africare).This is contrary to the finding in a study in the health district of Foundiougne where it is estimated that for 39.3% of the health huts their CHWs were salaried workers [8].
In another study conducted in the Gossas district, the CHWs in all the health huts were salaried workers [9].The money to pay the salaries came from fees paid by patients, the sale of drugs, and contributions of the community.In addition to the salaries there were also in kind contributions and additional help of the CHW to his work in the fields [9].This current Senegalese system is a dynamic compromise in this area.It seems to work well as part of the Bamako Initiative with the payment of 20% of the revenue from ticket sales consultation to CHWs.The CHWs who work in dynamic structures, with a consistent load of work and therefore help generate substantial funds per month, may receive wages representing twice or sometimes more the minimum wage [10].
Health committees have been set up for better management of the activities of the health huts.However, their functionality is often confronted with the availability of its members.But monthly meetings are held in health huts to validate the monthly activity plans and share the difficulties.There are no official documents regulating the health huts committees.These, however, are put in place following the model of the health committees of the health posts [11].
The CHWs have mentioned the frequent shortages of management tools and poor community participation in the operation of the health committees.The CANAH project implemented in Senegal community-based activities in the area of child survival in partnership with two health districts: Joal and Thiadiaye.Management tools are used for health huts data entry.These data are included in the report of the health post.In addition, health committees are set up and community members are mobilized and made accountable [12].
Also, with the women's associations, under the leadership of "Africare" supervisors support groups or care group were set up in some health huts.These groups agreed on monthly dues.A member of the group is always chosen to collect the contribution of each member and a portion of the money will be used for medical care.This practice has been observed elsewhere in Senegal mainly in the District of Thiadaye in a program that was supported by another NGO [4].During the meetings, any member may talk about the health problems they are facing with and all can pitch in.This is also an opportunity to discuss real health problems of the community.

Conclusions
Most of the discussions reveal that activities of the health huts are not well known by people.The best known activities are those performed by the nurse: immunization and pre-natal care.The existence of health huts at the community level was considered beneficial by all the community leaders.For the majority of the participants to the focus group discussions, the health huts "provided access to basic care".
However, this assessment has identified some difficulties in the implementation of the PSSC in the health district Goudomp such as frequent drug shortages, low community participation and the lack of an incentive system for the CHWs and matrons.In order to solve the problems one would necessarily have to initiate a dialogue between the community and other stakeholders (health district, Africare, Local Government and CHWs).
It is necessary to expand the project in all the health huts of the district and reinvigorate community participation in the implementation of care group.Some organizations such as women's associations and youth groups should also be revitalized to enable greater involvement of people.The success of this project will undoubtedly improve the reduction of maternal and child mortality.