VITAMINASUPPLEMENTATIONREGIONALSYMPOSIUM

REPORTDakar,Senegal‐ (4‐ 6April2016)

TheGlobalAllianceforVitaminA(GAVA),throughitstechnicalpartners‒theCentersforDiseaseControlandPrevention(CDC),HelenKellerInternational(HKI),MicronutrientInitiative(MI),andtheUnitedNationsChildren'sFund(UNICEF)‒andinconjunctionwithGlobalAffairsCanada,hostedathree‐dayregionalworkshopinDakar,SenegalfromApril4‒6,2016.

Theworkshopwasattendedbyapproximately120participantsfrom23countriesinSub‐SaharanAfrica(SSA)representingbothnutritionandimmunizationsectors,policymakersandmanagersfromMinistriesofHealth(MoH),country,regional,andglobal‐leveltechnicalpartnersfromtheGAVA,andGlobalAffairsCanada(GAC).

Thegoaloftheworkshopwastore‐examinevitaminAsupplementation(VAS)programsinSub‐SaharanAfricainlightofepidemiologicandprogrammaticchanges,andtodevelopbroad,country‐specificroad‐mapsforVASforthenextfiveyears.Specifically,theworkshopaimedto:

• Reviewandre‐establishtherelevanceofVASasachildsurvivalinterventionintheregion;• Examinedeliverymodels,especiallyinlightofthephasing‐outofpoliocampaigns;• ShareexperiencesandbestpracticesonVASdelivery,emphasizingChildHealthDaysandothercommunityoutreachstrategies;

• IdentifywaystobetterintegrateVASintoexistinghealthcaredeliverysystems,including,butnotlimitedto,EPI;

• DevelopstrategiestoincreasesupportandinstitutionalizationofVASasanimportantcomponentofapackageofservicessoastoimprovechildsurvivalratesinAfrica.

DayOne

Understandingthereality‐exploringdeliveryoptions

DayTwo

Exploringthejourney–transition&monitoring

DayThree

Sustainability–Institutionalization

Symposium Process

ThekeypointsfromopeningremarksandinitialpresentationswerethatVASisstillVERYrelevanttomostSSAcountriesbecause:

• ThereisstrongscientificevidencethatVASimproveschildsurvival;

• VitaminAinfluencesthemajorcauseofchilddeathsinSSA(i.e.infectiousdiseases);

• Mortalityamongchildrenunderfivehasdecreasedbutstillremainsunacceptablyhigh;

• HighlevelsofVADpersistinmostSSAcountries.Asaresult,WHOVASrecommendationforbi‐annualdistributiontoallchildren6‐59monthsremainsrelevant.

Challengestoaddresswerethenhighlighted:• HighVAScoveragelevelsreflectthejointsuccessof

polioeradicationandVAS.However,aspoliodisappears,sotoodoestheVASdistributionplatform;

• VAScommitmentmustberenewedaspartofanintegratedchildsurvivalandhealthpackage;

• Governmentsneedtosupportcommunity‐linkedplatformstoreachallpreschoolerswithVAS.

• InvestmentsareneededtoimproveinterventionsthataddressVAdeficiencyanditsunderlyingcauses.

Throughthediagram oftheVAScontextintheirindividualcountries,participantshighlightedthat:

• InmanycountriesinWestAfrica,VASdeliveryremainsdependentonpoliocampaigns;

• CHDshavebeenimplementedinmanycountriesasanalternativetodeliveringVASviaNationalImmunizationDays(NiDs).Themainchallengesconsistinmaintaininghighcoveragewhilereducingcostsandintegratingwithhealthsystemroutinedelivery.

• LackoffundsremainsoneofthemainthreatsforVASandCHDs;Mostfundsavailableareprovidedbyexternaldevelopmentpartners

Objectives:• RaisingawarenessonthecurrentenvironmentaroundVASanddiscusstherationaleforVASineachcontext

• StartidentifyingthecriteriaforanalysisthestatusofVASineachcountry

RATIONALEFORVAS

Conclusion:“Businessasusualisnotanoption,ifwearetosustainchildsurvivalgainsattributabletoVASoverthenext5‐10yearsinSub‐SaharanAfrica”

Questions:• WhatistherealityofVASinyourgivencontext?• Whatarethestrengths,weaknesses,opportunitiesandthreatsassociatedwithVASinyourcontext?

• Opportunitiesexistinmostcountries,thankstotheincreasedfocusonnutritionstimulatedbytheScalingUpNutrition(SUN)Movement.

Polio

VAS

RoutinefacilityandcommunityVAS inSenegal

TheMinistryofHealthinSenegalisscalingupthedeliveryofVASthrougharoutinedeliverymodelthatcombinesfacilitylevelprovisionofVASandcommunity‐basedplatforms. VAScampaignscontinueindistrictsthatarenotenrolled,buttheobjectiveofthegovernmentistoultimatelygeneralizeroutineVAS.

MultipledeliverymodelsforVASinDRC

SeveraldeliverymodelsarebeingimplementedinDRCtoanswerthewidediversityofcontextsinthecountry:variousformsofCHD,polioandimmunizationcampaignsandroutinedeliveryofVASinhealthfacilities.Comparative studiesareunderwaytoinformthefuturedeliverystrategy.

6monthscontactpointinMozambique

TheMinistryofHealthofMozambiqueistestingtheintegrationofVASat6monthwithfacilitybaseddistributionofmicronutrientpowders andcommunitybasedbehaviorchangepromotion.Nationalscaleupofthe6monthscontactpointwillbeinitiatedin2016.

ThreeexperiencesfromSenegal,DemocraticRepublicofCongoandMozambiquewerepresentedtotheparticipantsonvariousdeliverymodelsforVASbeingimplementedinsub‐SaharanAfrica:

DELIVERYMODELSFORVAS

• Formanycountries,transitionfromaNationalImmunizationDays(NiDs)modeltoCHDsisrequired.ForothersalreadyinaCHDmodel,changesofdeliverymechanismmaybeneededfromdoor‐to‐doordistributiontoafacilityorcommunityoutreachmodel.Bothtypesoftransitioncreatetherisksofasignificantdropofcoverageexistsduringthetransitionprocess;

Severaldeliverymodelsexistthataimatansweringcountryspecificneedsandcontexts.Eachofthesemodelsneedstobecarefullydesignedtoaddressthefeaturesofthehealthsystemtheyare

integratedwithinandthehumanitarianneedstheyareanswering.

• Countrieswheremortalityandmorbidityarestillunacceptablyhighandwherethehealthsystemisweakmayhavetoconsidercontinuingrelyingonmasscampaignsforthecomingyears.

Objectives:• Exploredifferentmodelsofdeliveryandtheirrequiredcontext• Explorestrengths,weaknessandlimitationsofeachtypeofmodelandidentifymostsuitablemodelforeachcountry

Questions:• Whatarethemainindicatorsandfeaturestoconsidertodecidewhichmodelfitswhichcontext?

• Whatisthemodelmostsuitabletoyourcontext?

• TransitionfromaCHDtodeliveringVASthroughroutinehealthsystemcontactsishappeninginsomecountries.Inorderforcoveragenottodrop,routinehealthservicesneedtobestrengthened;

• Combinationofmaternalandchildhealthandnutritionservicestogetherincreasesimpactandcosteffectivenessofeachservice.

CoordinationamongVASstakeholdersvarieswidelybetweencountries.Reflectingabouttheroleeachactorisplayingintheircountry,participantsnoticedthatinsomecountries,eachactorhasadifferentviewofwhereVASshouldhead,whereitpresentlystands,andhowtotakeitforward.MinistryofHealthisoftentheactorleadingandguidingtheprocess,butinsomeinstancesUNagenciesandINGO’saretheonespromotingtheintegrationofVASinmaternalandchildhealthservices.Inallcases,strongcoordinationbetweenGAVAactorsandthegovernmentisarequiredbasisforVAStobedeliveredefficiently.

PREPARING FORTHETRANSITION

Motherandchildhealthandnutrition(MCHN)weekinMadagascar

DeliveryofMCHNservicesinMadagascarevolvedfromstand‐aloneimmunizationcampaignstoeventsdeliveringcomprehensivepackages.Thetransitionprocesswassuccessful,andhighcoverageofVASwasmaintained.

IntegrationofVASprograminthehealthsystem,Ethiopia

InEthiopia,transitiontookplacefromimmunizationcampaignstotheEnhancedOutreachStrategy(EOS)andthentoaroutineonlysystem.Afteraninitialdrop,highcoverageisbeginningtobereached,aschallengesarebeingaddressed.

Outofthe6buildingblocks,the4mainchallenges identifiedbymostcountriesfortheVAStransitionprocesswere:

• Thelackofawarenessofdecisionmakers(governanceblock);

• Weaksupplychainleadstostockoutsofessentialdrugs;

• Weak informationsystemdoesnotallowforaninformeddesignandmonitoringofhealthservices;

• Lackoftrainedfrontlinelinehealthfacilityandcommunityworkers.

Objectives:• Raisingawarenessandknowledgeofthetransitionprocessanditschallengesandrequirements

• Identifymainimmediatestepstoinitiatethetransitionprocess

TwoexamplesfromMadagascarandEthiopiawerepresentedtotheparticipantshighlightingthejourneyeachcountryexperiencedwhiletransitingtowardssustainabledeliverymodelsforVAS:

Transitionfromonemodeltoamoresustainableonerequirescarefulpreparation:minimumstandardsofperformanceofthehealthsystemshouldbeassessed,abalancedpackageofservicesdefined,andaprogressiveprocessthatdoesnotleadtomassivedropofcoverageimplemented.

Questions• Whatarethemainchallengesthatyoucanforeseeforthesuccessofthetransitionprocessinyourcountry?

• Whatarethefirststepsthatshouldbeundertakentostartthetransition?

FishboneAnalysisforBurkinaFaso

Someofthesolutionsproposedconsistedof:• Developandroll‐outcomprehensiveadvocacystrategiestailoredtoeachcountry’sfeaturesandneeds;

• AdoptaHealthSystemStrengthening(HSS)approachtoaddressVASasacomponentofacomprehensivepackageofservices.

MonitoringVASservicesisnecessarytoidentifywhetherthechildrentargetedactuallyreceivetheservices,tomeasuretheperformanceoftheservicesandtoidentifythebottleneckstoqualityservicesandhighcoverage.Results‐basedmanagementandequityshouldbeplacedatthecoreofthemonitoringstrategy.Themonitoringstrategyshouldalsoconsiderthewholeprogrammaticframework,monitoringinputs,outputs,outcomesandimpactsto informdecisionmakingfortheimprovementoftheprojectperformance.

MONITORINGVAS

Post‐EventCoverageSurveys(PECS)inMali:

PECSarebasedoncross‐sectionalsurvey methodology.ObjectivesaresimilartotheLQASones,butwhereLQASfocusesonverifyingpre‐determinedassumptions,PECScanbeusedtoassessinamorecomprehensivewaythedeterminantsoflowcoverageofVASandEPIcampaigns.PECSaresignificantlymorecostlyandlengthytoimplementthanLQAS.

DataDrivenDecision‐makingTools– DHIS2:

DHIS2isatoolusedbymanynationalinformationsystemsforcollection,validation,analysis,andpresentationofaggregatehealthstatistics.Itcanbeusedformicroplanning,stockmanagement,improvingprogrammereporting,andthetrackingofbottlenecks.UsingDHIS2forVAScanimprovedataquality and decentralizeddatause.

PostCampaigncoveragesurveyusingLQASinBenin:

LQAScanbeusedtosupporttheplanning,implementationandqualityofVASandEPIevents.ItassessescoverageofVASandimmunizationduringmasscampaigns,andcanbeusedtoidentifybarrierstoaccessandutilizationofVAS.The smallsamplesizerequiredmakes itquickandaffordable toconductandthus averyeffectivetoolforroutinemonitoringforVASservice

Objectives:• TopresentanoverviewofbestpracticesformonitoringofVAS• TointroducesomeofthemaintoolsandapproachesusedtomonitorVASandimmunizationprogrammes

AninitialpresentationwassubmittedtotheparticipantshighlightingthemainrationaleandprincipleformonitoringVAS.

GreaterinvestmentsandattentionareneededtostrengthencollectionanduseofdatatomonitortheperformanceofVASprogramsandinformprogramadjustments.

Threetoolsofdemonstratedrelevancewerethenpresented:DistricthealthInformationSystem2(DHIS2),LotQualityAssuranceSampling(LQAS)andPost–eventCoverageSurveys(PECS).

INSTITUTIONALIZATION

PublicFinanceandVAS:

InsightswereprovidedonchallengesandpotentialsolutionstoincreasedomesticfinancingofVASservices.Costingexercises,expendituretrackingandexamplesofsuccessfuladvocacyapproacheswereproposedthroughacase‐studypresentation.

StepsproposedfortheintegrationofVASinthehealthsystemconsistof

1.ConductingaSituationanalysis;2.AssessingthereadinessoftheHealthdeliverysystem,3.DrawingalandscapeanalysisofVASandotherchildsurvivalservices,4.Identifyingopportunitiesforsupport(technical&financial)

InstitutionalizationinBurkinaFaso:

Priorto2011,VASwasco‐deliveredwithPolioNIDs.Sincethen,thegovernmentdeliversVAStwiceayearduringVitaminAPlusDays(JVA+).However,thesecampaignsremaindonor‐supported,andsoarevulnerabletofinancialgapsifdonorcommitmentchanges.

InstitutionalizationinNigeria:

VASiswellinstitutionalizedinthenationalhealthpolicies. However,coverageislowinmanystatesandinequitiespersist.Manystatesdonotreleasesufficientfundsandoftenreleasethemlateforthecampaignsandthemajorityofhealthfacilitiesdonotimplementit.

InstitutionalizationinTanzania:

VASismanagedbydistrictsgovernmentforplanningandresourceallocation.FundingforVASisamixofgovernment andexternalsources.Factorsimpactingsustainabilityincludeenablingenvironment,amotivatedworkforce,supplymanagement,andsocialmobilization.

Objectives:• To define institutionalization and health systems integration; • To learn about public financing tools; • To identify practical challenges and solutions for institutionalization.

Twopresentationswereproposedtotheparticipants.ThefirstonehighlightedthebasicsofhealthsystemstrengtheningandthesecondoneprovidedsomeelementsofhowtopromotepublicfinancingforVAS.

InstitutionalizationisalongandcomplexprocessthatneedstobeprioritizedforVAStobefullysustainedthroughhealthsystemservicesandfinancingbynationalbudgets.Advocacyandahealth

systemwideapproacharerequired.

ThreepresentationshighlightedsuccessesandchallengesofpromotinginstitutionalizationofVASinBurkinaFaso,NigeriaandTanzania.

IntegratingVASintoPrimaryHealthCaresystem:

OpportunitiesforachievingandsustaininghighVAScoverageexistwithinthecountryspecifichealthsystem.IntegratingVASintothehealthsystemprovideopportunityforthenutritionprogramstoaddvalueandsynergytohealthsystemstrengtheningefforts.

Somekeyadvocacystepsthatwerecommontomostgroupsconsistin:

• Provideacomprehensivefeedbacktopartnersandactorswhodidnotparticipateinthesymposium,inparticularthedecisionmakersfromgovernments;

• Developacountryadvocacystrategytailoredtoeachcontext;

• AdvocateforadedicatedbudgetlinefornutritionspecificinterventionsincludingvitaminA;

• TargethighprofilepoliticalleaderssuchasmembersofparliamentstosensitizethemonthebenefitsandimportanceofVASforchildsurvivalandcanbecomeadvocatesforVAS;

• Useeveryopportunityexistingincountries,suchastheorganizationofbudgetingorstrategicnutritionandhealthworkshops,theexistenceofScalingUpNutrition(SUN)coordinationbodies,oranyotherrelevantstructureoreventstopromoteVAS.

WAYFORWARD

Mozambiqueparticipants:from left toright‐ OsvaldoNeto(HKI),MatthieuJoyeux(UNICEF),LuisaMaringue (MoH).

Objectives:• Toagreeonacommonoutcomestatement;• Toidentifysomekeyadvocacystepstoundertakeatcountrylevel.

OUTCOMESTATEMENT(1)The following consensus statement was endorsed by participants

VitaminAdeficiencyremainsapervasiveprobleminmuchofSub‐SaharanAfrica,havingchangedlittleoverthepasttwodecades.Themostrecentestimatessuggestthat48%,ofchildreninthisregionsufferfromdeficiency,placingthematagreaterriskofdying.Despiteprogress,unacceptablyhighratesofchildmortalitypersist.Furthermore,reductionsarenotequitablewithnationalaveragesmaskingareasofhighmortality.

Werecognizethatgreatprogresshasbeenmadeoverthelast15yearsinscalinguptheprovisionofhighdoseVAS.Estimatesshowthattheproportionofchildren,6‐59monthswhoreceivedtwoage‐appropriatedosesofVASin2014was69%,inlinewithpreviousestimates.Becausemanycountrieshavecontinuouslyachievedhighercoverage(>80%),theseeffortshavecontributedtorecentpopulationlevelreductionsinunder‐5mortalitysinceVASreduceschilddeathsby12‐24%whenprovidedeveryfourtosixmonthstochildren6‐59monthsofage,wherevitaminAdeficiencyisapublichealthproblem.

Effortstoreachallchildren6‐59monthsofagetwiceayearwithVAShavemadeasubstantialcontributiontomortalityreductionincountrieswithconsistentlyhighcoverage,butthereismuchmoretodo.FurtherreductionsarepossibleincountrieswhereVADisapublichealthproblemamongchildren,byimplementingspecificstrategiestoreachthosecurrentlynotreachedensuringallchildrenarereachedwithVAStwotimesperyear,byincreasingeffortstoreachchildrenimmediatelyatsixmonthsofage,andbystrengtheningintegrationwithimmunizationprogrammes.

Globally,therehavebeenshiftsinthepatternsandepidemiologyofunder5childdeathswithneonatalmortalityrepresentingagreaterproportionofunder5deathsthanitdidtwodecadesago.However,thenumberofdeathsinchildrenoversixmonthsofageremainsfartoohigh,reachingalmostonemillioninSub‐SaharanAfricain2015.IntheabsenceofVASprograms,thesedeathswouldbeevengreater.

Causesofunder‐fivedeathshavealsochanged,withfewerdeathsresultingfrommeasles,butwithinfectionscontinuingtoplayasubstantialroleinchilddeaths.SuchdeathsarethoseinwhichchildrenwouldbeexpectedtobenefitfromanimmunesystemrepletewithvitaminA,orahigh‐dosesupplementwherethisisnotthecase.Thus,weagreeuntilthereisasustainedriseinpopulationserumretinolwithareductionofvitaminAdeficiencytobelow5%,thecontinuedprovisionofVASindeficientpopulations,suchasinsub‐SaharanAfrica,isapriorityforchildsurvival.ThisisinlinewiththeGAVAdecision‐makingframeworkforscalingbackVAS.

WhilstcontinuingVASprograms,weagreethatthereisacriticalneedtoaddressthedirectandunderlyingcausesofvitaminAdeficiency:theinadequacyofvitaminA,oritsprecursor,inthediet,aswellas,poorhygieneandrepeatedinfections.Improvementisalongtermgoal,buteffortstoimprovebreastfeedingpractices,accesstofortifiedfoods,availabilityofhighqualitycomplementaryfoodsandimprovedhygieneandinfectioncontrolmustbeinitiatedandmoreexplicitlyintegratedintochildsurvivalstrategies.ThiswillbenefitallpopulationgroupsthatarevitaminAdeficient.AssessmentofprogresstowardthisgoalwillrelyonrecentpopulationdataonvitaminAdeficiency,whichiscurrentlylimited.

Weacknowledgethatprogrammaticdatatoidentifythosecurrentlynotreachedalsoneedstobestrengthened.Strengtheningthecollectionofcoveragedata,alongwithitsuseforcorrectiveactionandlinkstonationalhealthinformationsystems,iscriticaltoensurethatallchildrenthatneedVAScanbeidentifiedandreachedinatimelymanner.Furthermore,intermediateoutcomesshouldalsobemonitoredandprogramperformanceimprovedbyidentifyingandaddressingbottlenecks.Wethereforerecognizethatgreaterinvestmentsareneededtostrengthendatacollectionanduse.

Finally,werecognizethatthechangingglobalandregionallandscape,inclusiveofchangesinfinancinganddeliveryplatforms,willsignificantlyimpactVASprograms,andnowmorethaneverthereisaneedforbettercoordinatedeffortsbetweengovernmentsandpartners.

OUTCOMESTATEMENT(2)DeliverystrategieshaveevolvedsubstantiallyoverthelastfifteenyearswithChildHealthDaysandWeeksservingasaplatforminanincreasingnumberofcountriesandimmunizationcampaignsandpolioeradicationeffortscontinuingtoprovideaplatformforreachingmanymorechildren.BothapproacheshavehelpedtodriveupVAScoverageinnumerouscountries.

Weareawarethatsubstantialinternationalfinancinghassupportedthesedeliveryplatformsformanyyearsandthatitistimeforthislifesavinginterventionandplatformtobeinstitutionalizedinnationalhealthsystems,includingnationalbudgets,managementandcoordination,withcontinuedexternalsupportwherenationalresourcesarelimited.Aswelooktowardsthefuture,weareinagreementthatVASprogramsarehighlycost‐effectiveandthattherearewaysinwhichthiscost‐effectivenesscanbeimproved.Thus,thereisanurgentneedtofindinnovativewaystoembedVASindeliverystrategieslinkedtopublichealthcaresystemstoconsistentlyreachchildrenunderfivewithVASandotherlifesavinginterventions,particularlyincountrieswhereatransitioninstrategyandfinancingwilltakeplace.

Keycriteriaforselectingsuchadeliverystrategyshouldinclude:theopportunitytoreachallchildren6‐59monthsofage,particularlythemostvulnerable;maximizesallcontactswithinthehealthsystem,includingroutinecontacts;meetsneedsofcaregiversincentivizingtheirattendance,andhasamechanismtoensureaccountability.Webelievethatengagementinthepoliolegacyplanningprocessandexpandingnovelimmunizationapproaches,suchas“ReachingEveryCommunity”andotherplatforms,suchascommunitybasedscreeningforacutemalnutrition,arecriticaltoreachallchildrenunder5withVAS.

Weacknowledgethatinstitutionalizationisaprocess,whichwillrequiresubstantialtimeandeffortofmanystakeholders.Itmustbeprioritized,whilemaintaininganurgentfocusoncontinuallyreachingallchildren6‐59monthsofagewithlife‐savingVAS,everysixmonths.Achievingthisvisionwillrequirecontinuedadvocacytodecision‐makerstomakethemawareoftheevidenceforVASprogramsandtheneedforcontinuedprioritizationandsupport.

Assuch,weherebydeclarethefollowing:

• We,theparticipantsofthissymposium,pledgeoursupporttoimprovethedeliveryoftwice‐yearlyVAStoreachallchildren6‐59months,whichwillrequireafocusonthemostvulnerableandensuringequity,andweurgedecisionmakersinnationalgovernmentsanddonoragenciestomaintaintheirsupport.

• WewillworktoensurethatVASisintegratedwithinhealthsystems—includingthe6‐monthcontactpoint,andwillfacilitatetheco‐deliveryofVASwithotherhigh‐impactinterventions.Westronglyandurgentlyadvocateforbuildingonand/orexpandingnovelapproachessuchasReachingEveryCommunity(REC)andcommunity‐basedplatformsand,inrelevantcountries,engaginginthepoliolegacyplanningprocesstocapitalizeonearlierinvestments.

• Wespecificallynotethatroutinizationwithinhealthsystemsoftenincludesoutreachtoreachthemostvulnerable,butthattheplanningandmonitoringofsuchoutreachactivitiesshouldbefullyembeddedwithinthehealthsystem.

• WepledgetoleveragenationalinvestmenttosupportVASprogramsbecauseofitshighimpactanddocumentedcost‐effectiveness.

• WesupportthestrengtheningofinterventionstoaddresstheunacceptablyhighprevalenceofVADinsub‐SaharanAfrica.

• Wewillincreaseeffortstogeneratehigh‐qualitypopulation‐baseddataonVAstatus,interventioncoverageandquality,anddietaryintakeinordertouseittoguideprogramandpolicydecisions.

Averyspecialthanksto:

TheGovernmentofSenegalforhostingandclosingthesymposium

GlobalAffairsCanadaforitsfinancialsupport

VITAMINASUPPLEMENTATIONREGIONALSYMPOSIUM

REPORTDakar,Senegal‐ (4‐ 6April2016)

TheGAVAwishestothankparticipantsfromallthefollowingcountries,agenciesandorganizations:

Countryrepresentativesfrom:

BeninBurkinaFasoBurundiCameroonCentralAfricanrepublicCoted’IvoireChadDemocraticRepublicofCongoEthiopiaGhanaGuineaKenyaMadagascarMalawiMaliMozambiqueNigerNigeriaSenegalSierraLeoneSouthSudanTanzaniaTogo