Organisation: Action Against Hunger (AAH)

Point person and Role: Fanta Touré Diop, Public Health specialist, Regional Advisor Health & nutrition, AAH ROWCA

Geographical area: Twelve countries in West Africa (Senegal, The Gambia, Mauritania, Mali, Burkina Faso, Ivory Coast, Sierra Leone, Liberia, Niger, Nigeria, Chad, Cameroon) and two countries in Central Africa (Central African Republic, the Democratic Republic of the Congo)

Unique characteristics of the setting: In most West and Central African countries, health systems were fragile before the start of the COVID-19 pandemic. Millions of people don’t have access to essential services and infrastructure such as primary health care services, nutrition or basic water, sanitation and hygiene. Maternal, neonatal and child mortality remains high and severe acute malnutrition rates are above 2% in several regions of the Sahel. Rural poverty is still affecting a large proportion of the population. The political and security situation is fragile in several countries in this region.

Number of cases and deaths due to COVID-19 at time of publishing: in July 2020, when we published our advocacy report, there were 98,412 cases and 2,158 deaths reported in West and Central Africa.

Briefly describe the motivation and goals for your advocacy strategy.

For more than 40 years, our international Non-Governmental Organisation Action Against Hunger (AHH), has been committed to saving the lives of malnourished children and supporting their families to beat hunger. Our programmes in more than 50 countries tackle both the causes and effects of hunger. We have built expertise in seven core areas of work: nutrition, water, sanitation and hygiene (WASH), mental health care and support, responding to emergencies, reducing the risk of disasters and their impacts on hunger, ensuring people have enough food so they can build a better future, and advocating for change. Our Regional Office of Western and Central Africa is active in 14 countries pursuing work in those seven areas.

Since the start of the COVID-19 pandemic, all the Western and Central African countries where we are active, have been affected by the virus. In response to this pandemic, governments in the region have adopted a range of safety, administrative, socio-economic and health measures designed to reduce the spread of the virus. Despite those measures, the COVID-19 crisis has hugely weakened, and sometimes disrupted, health systems in the region, impacting all health system pillars - human resources, financing, governance, health information systems, infrastructures, equipment and supply, and service delivery. While all attention has been focused on responding to the pandemic, the provision of other essential health services, such as nutrition or immunisation, has largely been left aside. This is predicted to have huge consequences on the supply and demand for health care and the continuity and monitoring of other health and nutrition programmes. Pregnant and lactating women and children under 5 years are likely to be the most impacted segments of the population, reversing progress made in recent years.

In the Western and Central African region, we have been collecting and collating qualitative and quantitative data in order to assess the impact of COVID-19 on health systems, and especially service delivery. Whereas needs for essential services are increasing due to the pandemic, a decrease in supply and demand for those services has been reported.

In many West African countries, preventive services such as immunisation, seasonal chemo-prophylaxis campaigns or screening for malnutrition, have already been discontinued. For instance, several polio, tetanus and measles immunisation campaigns targeting more than 3 million children and thousands of women have been postponed in Mali, Burkina Faso and Niger. Prenatal and or postnatal services are also at risk of cessation or postponement, which could lead to additional maternal and newborns’ deaths. These discontinuities are caused by several factors such as disruptions in the supply chain of vaccines due to international commercial restrictions and border closures, difficulties to access communities due to lockdowns and movement restrictions, or lack of health care staff.

In addition, demand for health services has also decreased. For example in April 2020 in Ivory Coast, the use of health services shrunk by up to 50% especially for prenatal care and immunisations. According to the Global Financing Facility, this decrease in health-seeking behaviours is associated with several factors such as reduced mobility due to movement restrictions; loss of financial resources to pay for care, medications and transportation; the fear of being contaminated in health facilities; and an increasing lack of confidence in health structures.

In parallel, needs for services, especially for nutrition, have increased. The quality and quantity of food is expected to decline due to loss of household income and disruptions to food systems and school feeding programmes. According to UNICEF and the World Food Programme, severe malnutrition among children could increase by 20% in Sahel countries in 2020.

With regard to the potential disastrous consequences of the COVID-19 pandemic on the continuity of other health and nutrition services, we have been advocating for revising current COVID-19 response plans. While reducing the spread of the virus should remain a priority, response plans should also focus on:

Which decision-makers were you hoping to influence with your approach?

Our approach is a multi-level advocacy strategy aiming to target decision-makers, leaders and organisations at all levels and on each of our advocacy goals throughout the region.

At the regional level, we have been targeting international organisations and regional bureaus of international organisations focusing on health and nutrition issues such as the WHO, UNICEF, the World Food Programme, UNFPA, the West African Health Organisation and several international NGOs. As one of our advocacy goals is around maintaining and increasing financial investments, we have also put our effort into advocating our strategy to donors. At the regional level, we have also advocated our goals to a network of West African Parliamentarians, an institution gathering one Parliamentary representative of each country.

At the national level, we have been sharing our findings with Ministries of Health and national networks of parliamentarians as well as health- and nutrition-focused Civil Society Organisations and national NGOs. Our goal has been to create synergy between our respective advocacy strategies and increasing data and experience sharing.

At sub-national levels, we have also been engaging with religious and community leaders to raise awareness about the importance of promoting safe health-seeking behaviours in their communities, in line with our third advocacy goal.

Although our advocacy strategy has primarily targeted decision-makers, we believe that direct advocacy with community members and populations is key, especially in promoting safe health-seeking behaviours. That is why we have also been engaging a lot with community members to ensure participation, adherence and sustainability of our activities advocating for continuous use of essential health services.

What actions or process did you follow to achieve your advocacy goals?

In order to develop an evidence-based advocacy strategy, we started by collecting high-quality quantitative and qualitative data ourselves or using national health information systems, study reports and publications from various NGOs and international organisations, and scientific articles and publications. We used data covering the period from March 2020 to July 2020.

We then analysed and collated this data and reported our findings in an initial report entitled ‘COVID-19: impact on health systems and the continuity of essential health services including nutrition’. This was published in French and English in July 2020. Based on this report, we have developed several advocacy messages using multiple delivery channels such as short-written pieces and several advocacy videos.

We have tried to disseminate our findings and advocacy messages as widely as possible. We started by targeting stakeholders and decision-makers working in similar core competencies as ours. We presented our data analysis and results to senior health and nutrition advisors and coordinators and diffused our advocacy messages in regional health and nutrition meetings and seminars. We then enlarged the scope of our target audience by presenting our conclusions and goals to the West African network of parliamentarians and Civil Society Organisations during high-level meetings. We finally focused on widely disseminating our initial reports and advocacy messages to all national stakeholders with the support of Civil Society Organisations and international and national NGOs.

Our report has also been widely shared by our partners through their own networks. For instance, the WHO supported our dissemination effort by endorsing our report and sharing our findings.

What is one aspect of your advocacy strategy that has been working really well so far and is there something other advocates could learn from this?

As an organisation, we have been working in West and Central Africa for many years now and we have a strong institutional and operational anchoring in the countries we are active in. We have been involved in regional coordination mechanisms, platforms and networks on several topics such as health and nutrition. We have also been recurrent partners of governments, national and international NGOs and Civil Society Organisations. These partnerships and our strong anchoring in the region have allowed us to share our findings and advocacy goals widely and to easily access decision-makers and key stakeholders at all levels.

In all the countries we are operating in, our governmental partners have revised their COVID-19 response plans to include the continuity of essential health services as a priority. Some countries, such as Senegal and Ivory Coast, have also started data collection activities to specifically measure the impact of COVID-19 on continuity of care and access and attendance to essential health services since the start of the pandemic.

What is one challenge that you have encountered and how are you trying to overcome this?

Collecting high-quality quantitative and qualitative health and nutrition data has been one of our main challenges. National Health Information Systems in the region are often facing issues with incompleteness, efficient and timely reporting, which have been worsened by the COVID-19 pandemic. These issues are compounded by the use of paper-based data collection systems. This has made it harder for us to collect reliable and complete sets of data.

In order to mitigate this issue, we encouraged Ministries of Health to partner with us and share their health data as much as possible. We also undertook a literature review of scientific articles and peer-reviewed publications as well as the grey literature published by other organisations and trusted media channels. We also conducted a series of key informant interviews in the health and nutrition sectors in several countries of the region.

How might your experiences responding to COVID-19 change the way your organisation does its future advocacy work?

Our experience responding to the COVID-19 pandemic and conducting advocacy work in this context has consolidated our conviction that evidence-based advocacy is important and that we should continue prioritising this type of work in the future. We shall continue to advocate for strengthening and financing health systems in the region so they are more resilient to shocks such as this pandemic. Stronger and more resilient health systems will likely be more able to ensure continuity of essential health and nutrition services in future disease outbreaks and public health emergencies.

We are currently working with the WHO to develop a webinar to launch an official platform for all countries and partners working on the continuity of essential health services. The platform will be dedicated to the issue of the continuity of essential health services such as nutrition, immunisations and sexual and reproductive health services and will gather resources to support countries preparing for the next disease outbreaks.