 Good morning and welcome to the Center for Strategic and International Studies. I'm Steve Morrison, I'm the Senior Vice President here, and head up the Global Health Policy Center's work. A special welcome also to those who have joined us online. A number of our colleagues here at CSIS put in an enormous amount of effort to bring this program together and they deserve some special mention. Janet Fleischman, who for the past 10 years has pioneered our gender and family health work, has spearheaded this, joined with Catherine Strifle. Others from CSIS who've made quite an enormous contribution. Carolyn Schroet and pulling this together today. Travis Hopkins on the communications. Alexandra Sassoon and Arian Maladzadeh have helped us. Jesse Swanson and several others. Many people came a long distance, a particularly long distance to be here today. Most notably Senegal's Minister of Health and Social Action, Dr. Awa Marie Kolsek. I'll say a few words of introduction for her when I get to the end of my remarks here, but she's really the centerpiece of the program today and thank you so much for coming and being with us. She's joined by several others who've come from Senegal, Bokar Mamadou Daaf from the ministry, who's been a lead personality, and we'll hear more from him. Fatemata Si from the Ouagadougou Partnership, Ramo Tudlai Diyom from USAID Dakar. From London, we're joined by Maika von Kim, Marie Stopes International, who just completed recently five years of work in Senegal. Coming from the West Coast, Nomi Fuchs-Bungamri and Perry Sutton from the Bill and Melinda Gates Foundation and Margot Funnestock from the William and Flora Hewlett Foundation. And of course, from North Carolina, Pop Gay, a close friend from IntraHealth who has been with us for a very long time as a friend and partner. We're relying on all of these folks to pull programs of this quality and timeliness together. And we're very grateful to each and every one of you. Francophone West Africa is increasingly important and increasingly attracting attention. Obviously, the Ebola crisis last year and the continuing recovery work associated with that has put a new spotlight on it. But it's also very, very important for what we'll hear today, which is this compelling and powerful story that Senegal presents. And we chose months ago to try to tell that story here in Washington for a good reason because we think that Senegal possesses a powerful story of prioritizing health, of success and momentum, especially around family planning of strong country leadership, exceptional strong leadership, in the midst of a stable democracy, a place that is open and accountable, a place that is prioritizing maternal and child health while advancing access to family planning. It's the hub of Francophone West Africa. It's a leadership. What happens there matters significantly for the neighboring states and beyond. And there are concrete results that are coming forward as we will hear today. The contraceptive prevalence rate alone has risen in recent times from 12% to over 20% and heading towards the target of 27% this year. That's a major gain. The potential impact of expanding access to family planning could translate into lives saved, abortions averted and educational and economic opportunities improved for women and girls and for their communities. The Senegal's remarkable commitments to improve access to family planning has also provided the opportunity for strategic partnerships to form. Between Senegal and the U.S. government, particularly USAID, which has really distinguished itself in this period, the Bill and Melinda Gates Foundation, the UN Population Fund, the William and Flora Hewlett Foundation. It's opened the way for many new partnerships with implementing the implementing partners that are here today. We know there are complicated challenges that lie ahead for Senegal. We'll hear about those today. There are barriers and challenges that all of us need to focus upon for the U.S. and other donors. The big question is ensuring the continuity of commitment and investments in family planning and making sure that the significance, the impacts, the cost effectiveness and the quality are known and understood here in Washington and that the base of support among a sensible group of bipartisan supporters is there and is preserved and advanced. We know ultimately greater government financing and private sector support will be essential for these programs and that means private sector within Senegal and government support from the Ministry of Finance and the President, Makisal, himself. We'll hear more today about the need for special focus on youth, on engaging successfully and effectively and routinely imams and other community leaders, engaging the private sector, mobilizing and sustaining the commitment and interest of volunteers. The stakes are very high for Senegal and for the subregion and the need for continued progress to sustain the momentum in this period. This brings us now to our keynote speaker who has agreed to both open and close today's session. Leadership is arguably the sine qua non. It's the most essential factor in driving towards success and we have with us today a truly remarkable and revered leader in health, Dr. Awa Marie Colsec. She is a mother. She is a medical doctor. She's an activist on women's rights. She's a global implementer. She's the source of the global vision that we have today on malaria control, on family planning, on Gavi Alliance and immunization and others. She has been Minister of Health and Social Action of the Republic of Senegal since 19, since 2012. In that period she has shown very great courage. She's shown extensive innovation. She's empowered her colleagues. She's changed fundamentally the national dialogue underway in Senegal on women and children's health. She's carried that dialogue to countless communities within Senegal. She's been indefatigable. And that is no surprise for those of us who know her and who have had the honor of knowing her for the long course of her career. She brought the same passion, the same determination, charisma and perseverance to the post of Executive Director of Rollback Malaria which she served in that role from 2004 to 2011. More recently she's shown those great qualities in her role as a Gavi board member, as a member of the steering committee for maternal newborn and child health, as one of the driving personalities behind family planning 2020. And in this most recent period of crisis, in helping inform the WHO response as the situation worsened and it became so critical that informed personalities in the region, like the minister, were there to help advise. We're very blessed that she'll share her thoughts with us now at the opening and then as we close in the keynote that she will do, she will provide us then. So please join me in welcoming the minister to open things up this morning. Ladies and gentlemen, bonjour. I'm not sure that what has been said is real, but I'm trying. And I would like to just convene the strength of the people of Senegal, of the government of Senegal and of the head of states, President Makisal. Thanks to all the partners who are here, maybe others are not here, but all those who are really supporting our health program and particularly the family planning program. I will at the end go into more detail, but I think that we are all here to listen to these panels where we will have a lot of information. But thank you to the Center for International Studies for this excellent initiative. We all have been in the field. Some of us are also at global level, but to be together at the same time, those who are working on a day-to-day basis in countries, but also those who are coming, visiting us, and those who are just supporting us from far to have all these people together. It seems to me that it is a very important opportunity, and I hope that all the discussion we will have will help us to do more and to do better. I think that we will have to exchange our experiences, but also the success we have, a lot of people are insisting on good things happening in Senegal, but we are all so very convinced that we need to do more and we need to overcome a lot of challenges, and by having this frank discussion, this will help us again. My problem is always to say to do more, to save more lives because we know that a lot of women are still dying by giving birth, and this is unacceptable. It is why we will be continuing to be very strong in what we are doing and try to have more people supporting us in this fight. We have here decision makers, we have experts, we have people working in operation. We have, in fact, all the family planning family, and I think that we will together do a very good job. Let me just put on the table some of the environment in which what we will say it will be really linked to. First of all, in Senegal, Senegal is really experiencing rising population growth with a majority of young under, youth under 20 years, and some last studies are shown that we have almost more than 60% of children, of people under 25 years old. This is, all these people now are facing limited opportunity to access to employment and social services. This is why the President Makisal is very now really very focused on the demographic dividend. We need to do something. We cannot continue to have this population growing and we cannot give them all jobs. We cannot nourish all these children and it is why we have also a lot of malnutrition, etc., etc. This is very important but we have been part and we have done a lot of initiatives in this health sector to try to overcome this situation. We have a national health development plan until 2018, where we would like to see the reduction by two thirds of maternal mortality and three fourths for children under five. We have also a roadmap to reduce maternal and child mortality and we will have to do the evaluation at the end in 2015. We have been engaged also to the Waga-Dugu partnership in 2011 and to the family planning 2020 in 2012. We are now really repositioning family planning in Senegal and we have a very short accelerated plan from 2012 to 2015 and our objective is really to double the rate of contraceptive coverage and we would like in 2015 to go from 12% to 27%. Those who know Africa can say that if you compare it to some countries where they are 70% or 80%, it is very, I can say, a small number but we need to see also from where we are coming from and if we are continuing in the way we are starting because in 2012 we had 12% of coverage and in two years we have been now reaching 20% of coverage. This is showing that we are really doing a lot, not only the government, the NGOs, the civil society in general, the private sector and all the partners really supporting us and this is, I am sure, where we will do a lot of, we have a lot of results. I want to tell you also that we have now in Senegal what we call the plan Senegal emergent. This is our plan for economic growth in the short and long term and human capital has been key and center and it is why we have health and education very predominant in this plan. It's just to say that now the health sector, family planning is really part of our work and I would like to let you now look at the film, listen to the panel, contribute to the discussion and I am sure that a lot of things will be presented but also we will look at what are the challenges we have on our way to the success we are all hoping that we will reach and I would like to wish you a very productive session. I will be here all along and maybe you will have time to listen a little bit to what they call my key, not speak but I think it will be more a sort of summary and maybe some word of hope for Senegal but also for all the people who are helping us. Thank you. Thank you so much, Madam Minister and as Steve had said we are so honored that you could be here today and that all of our guests from afar and from near could come and join us for this important session. I want to just say special thanks to Catherine Streifel who has been so fundamental in all this work on Senegal here at the Global Health Policy Center and to the whole team at the CSIS Global Health Policy Center especially to the leadership of Steve Morrison who makes this event and this program possible. When I was in Senegal in November I had the pleasure to meet with the Minister of Health who is with us today and as she said we'll hear from more later in the morning and in our discussion about family planning in Senegal I asked her if she had a message for the Obama Administration and for the US Congress and at that point she switched from French to English and she looked at me and said, yes we can. Her government is clearly committed to expanding access to family planning and has set ambitious targets much of which was lauded at the London Summit for Family Planning in 2012 and her team, led by Dr. Daaf who is also with us today has gained the respect and admiration of Senegal's partners in how they've taken charge of the family planning program and there is, as we've said, much to celebrate in terms of Senegal's progress. Senegal launched a national family planning strategy and doubled its budget for contraceptives and the donor's support has encouraged innovative approaches and the results as we've heard have been exciting. Senegal's CPR among married women has increased from 12 to 20% with a 4% gain in 2013 to 2014 alone which is very impressive and we hope to hear more today about what the government other donors and implementing partners have learned about what accounts for this progress and how we're learning these lessons and using the data to make adjustments and further progress going forward. Especially noteworthy have been the partnerships between the public and private sector in Senegal. The informed push model which we'll hear more about later today has dramatically reduced the perennial problem of stock outs of contraceptive commodities. Social franchises and mobile outreach clinics are expanding women's access to a wider range of contraceptive methods including long-acting methods and the introduction of cyanopress is the new simplified injectable contraceptive could transform access at the community level. Within the public sector USAID has been promoting the integration of family planning with immunizations and is supporting more frequent data collection to support decision-making. As we've also heard many challenges lie ahead for Senegal and for its partners the challenges in Senegal are complicated by social, religious, and economic factors. Resistance to family planning from some religious leaders is a difficult and sensitive issue and their support will be critical to engaging men and to the overall success of the program in Senegal. Addressing the reproductive health needs of young people and with the significant proportion of the population that is under 24 right now has important demographic and economic implications. And these young people bring attitudes on family planning and reproductive health that often diverge from religious leaders and political leaders and we have to find how their voices can be heard. Finally, the questions of sustainability and institutionalizing the government's commitment to family planning will be very important as we move ahead. For the United States the Senegal shows that the investments in family planning lead to important results reductions in maternal and child mortality, critical support to country leadership, and leveraging U.S. investments with other donor and private sector contributions. So there's much for us to discuss today and I look very much forward to hearing from all of you in the Q&A that will follow. But now I'm delighted to share with you our new video about family planning in Senegal. We filmed this video in February to bring the voices of Senegalese women into this policy discussion and to ground us in some of their realities before we begin our own deliberations. The video follows a young woman named Antaba who lives in a poor urban area of Dakar in Gejuay and she describes why she decided to access family planning and why these services mattered in her own life and for women's health and empowerment in Senegal. Through her story and through the voices of Senegalese champions for family planning, government and NGO health workers and EMOM and the Minister of Health herself, the video illustrates why these new approaches to expanding access to family planning in Senegal are so important and what are some of the challenges that lie ahead. Before we show the video, I want to acknowledge our very talented videographer, Johnny Harris, who could not be with us today for watching on the live stream. The assistance of Sam Ellis in our Ideas Lab who helped with the editing and to our wonderful team in Senegal, Sheikh Manet, our second cameraman, Buguma Fahl, who was our wonderful translator, assisted in Washington by Jainaba Gay and special thanks to the Senegalese Ministry of Health for their support for this project, to Mary Stopes International and Intra Health for their assistance and guidance along the way and especially to the women and the men in Ghejwai who were so generous with their time and insights. So let's watch the video. My name is Antabah. My name is Angen. My name is Netidong. My name is Agben. My name is Ghejwai. My name is Ghejwai. My name is Ghejwai. My name is Ghejwai Lann. My name is Aseegh. My family name is Ajiz. My name is Palit. I'm 20 years old. My name is Zopital. My family has a rice farm. My son is a rice farmer. I'm a rice farmer. I'm a local rice farmer. Since we have a car and a market in Kempi, We want to make sure that we don't have to go to the hospital. We want to preserve the women and the men, the women, the children, the children, the children. I am not going to go to the hospital. I am not going to go to the hospital. I am not going to go to the hospital. I am not going to go to the hospital. Gegewai is one of the most populated parts of Dhaka region. And we have many vulnerable groups who didn't have access to health facilities. Issue is a band of Productive Health Initiative. It was founded by Bill Emelina Gate Foundation. We focus on both improving the self-delivery but we also focus on strategy to demand creation using the religious leader, using the community leader. The UCB project has led us to make sure that we have confidence in ourselves. We want to make sure that we really do our best. CPR is a contraceptive prevalent rate. It means a number of women who presently have a modern contraceptive method. That the Senegal reach a CPR of 20%. That's a big progress, Senegal. Frankly, I do think that these progress are still fragile. And we need more resources from both the government but also from our donors to reach the objective of reducing the maternal mortality rate. Mom, I don't want to go to the hospital, I don't want to go to the hospital. I don't want to go to the hospital. I don't want to go to the hospital. I don't want to go to the hospital. You have to do it, and you can do it all you want. You can do it for Senegal. You can do it on your own. I'm very informed that I'm not planning on my own. I'm not planning on my own. I'm very proud that I'm planning on my own. I'm very sorry. I'm very sorry. Because I'm very proud that I'm planning on my own. I'm very proud that I'm planning on my own. I'm very proud that I'm planning on my own. I'm very proud that I'm planning on my own. We have a lot of obstacles, but we have also a lot of opportunities. This is for us in our vision in Senegal and in the Ministry of Health and Social Welfare. It's very important to have the link between family planning and maternal mortality. This is also important, not to link family planning only to the woman, but link it also to the child. I'm very optimistic for Senegal. This is a way to give women all their capacity to show their potential to play their role in the society. I'm for women, I'm for women. So I'm going to ask the first panel to please come up. So welcome to the first panel. Can you all hear me okay? I'm not going to go through the bios of our distinguished panel because you have them in front of you, but needless to say we are delighted that they could be here to join us in this panel to talk about the opportunities and the challenges of implementing family planning programs in Senegal. And we are joined by Pap Guy from InterHealth, Dr. Daaf from the Ministry, and Maika Van Min from Marie Stopes. So we really have a fantastic group of speakers here to get us into some of the really important issues and innovations that are taking place in Senegal. And we're going to talk for a while, and then at the end we will open it up to Q&A so you'll have an opportunity to ask your own questions so we can get into some more of the detail. But let's start with Dr. Daaf who has traveled the farthest to be here, and who as many of you in the room know has been a real champion for family planning in Senegal and has really won the admiration of so many of us. And perhaps to start out, Dr. Daaf, what are some of the key reasons you think that Senegal is progressing? What are some of the programs that you have helped oversee that account for Senegal's success? Thank you, Janet. Good morning. I think Senegal thanks to the leadership of the Minister of Health use the partnership theory approach throughout the whole process of developing, implementing and monitoring the national plan for family planning. All stakeholders have owned this plan. In particular, the political will manifested in our well-known role in London Summit. The strong ownership of the plan in the regional and the district level. Consultations with different actors and your civil society, technical partners and financial partners. Implementation of monitoring plan with regular meetings about family planning services delivery, about demand creation and about security, contraceptive security. Regional reviews each semester to monitor the progress has been made and we have the opportunity to have what we call a continued DHS that gives us annual data on program performance. So this lead us to go through 12% in 2012 to 20% in 2014. You know that many interventions has been done, but I will mention some of them. The first one is we did in differently in terms of delivery services are the focus on long acting methods. The second one, we talked about it in the film is targeting the urban area with the urban reproductive health initiative. And also we introduced the initial offer of deals and injectables in the level, the community level. We have already put together the framework that we told 3D decentralization, demedicalization and democratization. This helped ease the access for family planning services and commodities. We also integrated services like immunization and family planning. I think Bob Guy will talk a little bit about that. And also we did the mobile services, strategies with MSI and maybe Mike will talk about that. And we did differently on the commodity security like the informed push model. And also the approach what we call Degasina. It has been led by our central Dasha. We do call Pena. We introduced the Cyanopress. To the demedicalization, we had a national campaign of communication known as Moitoneff. That means birth space. It is very crucial. I have seen some of the other members who are already here and I talked about that yesterday. This campaign has been implemented by Iremas, which is a local in Jaws. And we get great success on that. We have also a strong commitment for community health workers, like Bajenugok and so on. And we had also the religious, even they are not taking an official position. They support what we are doing when we talk to them. We need for the future to strengthen the community activities by the weekly market. This is an opportunity that I'm talking about for two years now to my partners to support that because we have around 5,000 local communities. And each week we have a weekly market there. We can use this opportunity to use mobile strategies maybe to support the women and the community level. And I think it is important also to extend the injectable in the community level. The multi-sectoral approach is also very important. We are trying to, we hope that in this year, 2015, we will develop our strategic plan since this one is ending this year, going to 2016 since 2018. And on that we will talk about religious youth and the multi-sectoral approach. And maybe also we got an opportunity this year by Meet Vives, which has hired thanks to the partners who support us. They are doing also mobile strategies. If we can stand it on to all the country, it will be very helpful. And as the minister said earlier, you know our challenge is to reach the seven point remaining in this year. What we call, we thought about earlier if we gather all that we think we can achieve this objective. And maybe we talk also about Africa, West Africa. Our experience is here. It is very difficult to talk about what we have done, but we know we share the same culture and the same environment with the Francophone countries in the West Africa. And Senegal can help those countries by sharing his own experience. Thanks to Partinale Adwogadougou, some of them have already started to do so when they come to our earlier review. Just mentioning that there is too difficult problem to address the issue of religious and the issue of youth and adolescent. So it is very sensitive question, but we know we have to do it. And we hope we'll find the way. In summarizing, the family planning is progressing in Senegal. We have found the way forward. We need to accelerate our work. And we hope that in 2020 we reached 45%. And to achieve that, we know also we need the support of everybody here. Thank you. Thank you, Dr. Da. So let me now turn to Pap. Obviously, IntraHealth is the main implementing partner for the government in family planning. And you have helped introduce some of the important innovations, the informed push model, work in public-private partnerships, the integration program under USAID, engagement with civil society. Can you speak a little bit about IntraHealth's work and why it has been so influential in Senegal? Well, thank you, Janet. And thank you CSIS for putting together this. What I would like to do actually is pick up where Dr. Daft just left is sort of looking at the bigger context of Francophone West Africa. Because in my opinion, the interesting part of the discussion today and the work being undertaken by Senegal is that maybe, maybe, for the first time in the longest time, we now have an opportunity to really not only move the needle but expand family planning and highlight the role of family planning in the economic development agenda in finding employment for youth, in dealing with a lot of the issues that the continent is dealing today. The reason why I wanted to do that is because we are in a time of history where Africa is on the rise. And despite the continuing negative press and all of that, this is the continent that has shown faster economic growth than any other parts of the continent. And we are seeing a new different workforce. We are seeing very vibrant, intelligent, smart youth. We are seeing a rise of social entrepreneurs in the region. So I think we have an opportunity that we haven't had in a long time to highlight why it is extremely important to focus on family planning. Let me offer a little bit of history because some of us gray hair and many of the champions in this room have been at it for a long time. And unfortunately, we have seen, and I hope we can learn from those lessons, we have seen the region going from really a period of momentum in the 1980s when things were beginning to pick up, there was sort of a mobilization around the countries. There was a commitment to family planning through developing policy guidelines. And then suddenly there was a stop and suddenly there was actually a dip. We didn't see any movement at all in family planning. We didn't see, and we lost ground. And several of us thought a lot. There was a lot of discussions about HIV AIDS, how the resources were sucked into there. There was a lot of people that said USAID, that really carried the mantle of leadership in this area when they decided to pull out from several of the countries in the region, it really had a negative impact. I just hope that we can reflect on that and really celebrate the power of coming together and the power of new types of partnership and the power of leadership as really being demonstrated in Senegal. I also wanna take us back to the genesis of the Waga-Dugo partnership. And I wanna congratulate all of those champions that were really at it, including Amy Choi that I don't see here, it's very instrumental, and Monica Kerrigan that I see sitting there. A lot of the commitment, very strong commitment to the region. People who just say we're not gonna let this region die. We're not gonna let family planning disappear from this region. So I wanna thank that and I wanna celebrate the perseverance and really that if you focus on it, you can do it. And I think we're all excited today. We wanna celebrate the success of Senegal. And I wanna take us back to leadership. Frankly, we've been talking about it and it is so nice to be sitting here and be able to say you see it, you can touch it. I was sitting there with several people in this room in London when Madam Minister got up and made this commitment on stage to the world about what Senegal was going to do in terms of increasing their budget for contraceptive and family planning, mobilizing, opening the doors to the public sector, making very good policy decision about democratizing, demedicalizing and decentralizing. So really setting the stage. So I think it can happen. What I wanna say is that I'm trying to see what can we learn from this success. What is really at the base of this success? Because if we do that and we know that, then we can try to apply this in the region which is really our target so that we can really make progress. So we have very hopeful results, no doubt. Some are saying, well frankly, given the resources that are being put in this country for the last 30 years, it's modest, yes it is modest. There are some other ways we can look at it. I hope Roy Jacobson here who is very committed to looking at progress from the lens of demand that we are satisfying. In fact, if we start looking at it from that lens, we're gonna see that actually the progress is even bigger. It's not just a contested problem to say it, but we are moving the needle. We are, if we focus on demand and filling that demand where, I hope Roy you can help us in the discussion, share a little bit of that. But let's look at the stuff that's working. Clearly, putting the government in the driver's seat for Senegal seems to be the way to go because it allows you both to have the very strong leadership, but it also gives you a plan. There is a development plan. In this particular case, there is an emergent plan for Senegal and all of the actors who are so committed can work toward that plan rather than having their separate activities uncoordinated. So that was one of the learning. We see the power of partnership. We see what you can do when these organizations really put their organizational hat at the door and come together and say, how can we use our different expertise to complement each other to support the government? So that seems to be working. We see the power of contraceptive security. If you solve that problem, you might just solve the whole issue because a lot of people are saying if the commodities are there, people will use it. And you see the woman in the movie saying, my husband is not interested, but I care about my own health. I'll go ahead and find my ways of doing it. And making sure that we have contraceptive supply is definitely part of the solution. If we can guarantee an interrupted supply, it would be good. So, and finally, we are seeing that it's possible because I think until Senegal is showing this very fast result, a lot of people were saying, we just never gonna do it in this region. So now we know that it's possible. So I am very, very hopeful. I'd like to come back in a little bit. I don't wanna monopolize the whole conversation, but I do wanna ask to come back in the challenges and come back to what is it that we really need to do? Because there's really no time to really celebrate and say because it's progress, it's good. It opens the door, but we have so much to do. And not only that, but we have so many opportunities we now have that we did not have. So again, thank you for all the donors. Thank you Senegal and your strong leadership for opening the door. And I think for those of us who care about the Francophone region and care about family planning and its incredible role, not just in health, but in economic development, I think we have a momentum. And I'd like us to build on that momentum moving forward. Thank you, Bob. So Micah, Mari Stopes has a long record of building, work on family planning with the private sector, social franchises and mobile outreach clinics. Can you talk about the experience of Mari Stopes in Senegal working with the private sector to expand access? Okay, thank you. Thank you, Janet. And thank you everybody for coming today and talk about Senegal and one of my favorite topics. And it's great to be here with this incredible leadership that we've mentioned and will continue to mention. I think one of the leadership aspect that I'd like to highlight is also the leadership of the women. And coming to your point, as Mari Stopes, we go out with more mobile outreach teams or we go engage the private sector. But actually the leadership is in the woman who chooses to go there. And what we do is we facilitate that access for her. And I think in general, in general for this amazing progress that Senegal has made, if we want that to really get cemented in the society, we need to look at her a little bit more even and maybe ask her revolutionary concept. Let's ask her, what does she want? Where does she want it? What is she willing to pay or not? Does she talk to her husband or not? Is she even married or not? So let's ask her how can we make sure that she has this access. And I think franchising and outreach teams and clinics and getting products available, all these things help her in getting this access. And there's not one woman in Senegal. There are a lot of women who have very different needs. And we as the government, as Mari Stopes, we need to know those needs. We need to know those needs so that we can be flexible. And obviously the role of the government is very different from the role of somebody or some organization like Mari Stopes. But together, and with InterHealth and other partners in Senegal, together we can make a network for her. But what I would say, taking forward and capitalizing on this success that we've seen over the last couple of years is to really get to know her a little bit better and to see how can we make it easier for her. Like, she can make these decisions. We know that. Let's give her that opportunity to make those decisions. And let's not assume that things are a problem which might not actually be a problem. There might be, in five years time, I hope that we will talk about different challenges than the ones that we're talking about today because we've spoken to her. And she's saying, well, actually, my main issue is I'm not gonna fill that in because I don't know because we need to talk about, not talk to her a little bit more. But some of the things I think also with Mari Stopes, our outreach team sometimes only starts at 4 p.m. Why? Because the woman has told us, like, it's no point of showing up at nine o'clock. I'm still preparing the food and I'm getting my kids ready and I'm at the field. And there we were at nine o'clock and we're like, it's nobody here. But we come at four and suddenly everything changes. So that's a very small example, very practical example of why outreach teams are really interesting. But for me, I've lived four and a half years, almost five years in Senegal. I am a better person because of the Senegalese woman. I dress better to stay. I dress better to stay, but not just that. Just a lot of things. They are extremely resourceful and they are extreme, not just Senegalese women, women everywhere, but the Senegalese women for this topic. And let's just listen to her. Let her lead a little bit, maybe. Thank you. Thank you, Micah. Dr. Daff, I wonder if you could speak a little bit more about your relationship with the US government and with USAID and how they have been supporting the work that you have been pioneering on family planning. Thank you. Yes, you know, when I came first in 2009 as the chief of division, one of my most support was USAID. The division was here for eight months without anyone on board. And you can suppose that there was anything there. But when I came, I got the visit from USAID I have fortunately read a lot of about this division. And when they came, I say to them, I want this, I don't want this. They say, okay, through the discussion, they understand and what they say is that we think we can support you because we see you are committed to do the progress. And since then, we are working together directly through USAID and through also the NGOs, the CIS who are making on the field the programs which have been funded by USAID. Really, what I can say there is they are just looking what was our plan, what we want to do, and they support it. They never go and try to influence what we are doing. I think this was very important for the country. And this maybe helped to strengthen our leadership on our position. And more and more the others came and help us. Now we see that they are going to support us in another way, but we call the direct fund. This is also very important because we are doing our work plan, annual work plan and go negotiation to USAID and they support us. I think this is a very good partnership and I hope they will continue on that. Also, we had other partners who are supporting us through the urban initiative. As an initiative, we have Bill and Melinda Gates, we have also the Hewlett Foundation who are supporting and I don't want to forget anyone, because the NFP also is supporting us and I think each of them is doing all what they can do to support really Selena. And their participatory approach, the understanding is very helpful and I hope they will continue and reinforce that. And hopefully we will get back to the issue of how do you coordinate all these donors and all these partners? But before we get there, I want to ask Pop to talk a little bit about in a little bit more detail about the informed push model which is both a remarkable success and it raises questions about whether it can be sustainable, whether it can be transferred to government control under the P&A. And I wonder if you can talk a little bit about why it's worked and whether its success is going to be assured in the months ahead when the initial funding is withdrawn. Well, I'm very thankful to the Bill and Melinda Gates Foundation for the initiative of introducing an innovation. I think that's probably the best way to look at that is that what can we learn from innovation? It happens to be the informed push model and it happens to be a very critical element of any family planning program if you don't have those supplies and if you don't have a steady supply of this. But the innovation itself is really pretty simple. It's just recognizing, and this will give me a chance actually to talk about the health workforce issue because this is really an intervention that is directly geared toward the health worker and maybe improving the environment in which the health worker works. That's really what it is because if you take that task from already a very, very sort of a tasked health worker who is expected to do so much and you say, you know, the task of forecasting and ordering the supplies and monitoring that could probably be done by somebody else who has more free time. It could really be focused and if that person is motivated to do this, then it will happen. So that's what the informed push model, that's a major intervention, is it is a public-private partnership model if you want to, but it just demonstrates the power of really having a little private sector initiative coming to supplement the public sector work. That's really what it is. But for me, the important part is that we probably have thousands and thousands of innovations like that. We just have to focus on it. We just have to focus what we normally do because innovation is generally bringing another way of doing something and being more efficient at it. I think it has a tremendous opportunity. I think the questions that are still there to be answered are real questions. How do we take this to the national level? The governments have the mean to actually support this. There is very quick interest developing not only in Senegal and the Africa region about applying this to other sectors. I know UNFPA is looking at applying this thing in Togo and some people are saying, why not apply it to other area too? But I think that's what it is. I think the lessons learned about IPM and the informed push model is that, is that our current system of fraud with inefficiencies. The fact that we need to do public-private partnership is just the current system is not performing at 100%. And there is a potential by actually focusing on what you have without any additional resources coming in. By shifting things around, you could do a lot. Because in most of the countries, I was in Kenya recently, had a good conversation about a vibrant private sector development group that's coming up. It is very clear that there is some excess capacity that you find in the private sector that could be tapped on, especially in terms of workforce and workforce production and workforce potential. And so if we do this, if we learn to tap into areas that we have not tapped, mostly because we've been blinded by our silos, by the way we see our work. It's music to my ear to hear the minister here say, everybody has their role to play, that we should open up the door, we should have. If we do that and we continue to do that, we will find hundreds and hundreds of other push models. But that's the beauty of the push model. It's just, it's an innovation. It's now proving that it can work. If you sustain this thing about going months and months without any interrupted supply, then immediately the good results will follow. So yes, it is a crucial part of the innovation that was introduced, but it takes everybody from the pharmacists to the depot manager, to the providers, and to the government. And you definitely need strong policies. So we will be focusing in the next few years about strategies for scaling this up. But it is a very, very important innovation. And I'm happy that we have a chance to see its results today. Micah, as promising as the work with the private sector is, there are big challenges also. And I wonder if you could speak about challenges that Mary Stopes is seeing, both in the work with expanding access through the private sector, but also in reaching young people, and perhaps your work with the clinic at the university. You could speak about those two challenge areas. So, thank you. As Mary Stopes International in Senegal, we have a very, I would say, very small innovation at the University of Dakar. This was actually something that was started because the student associations, or a student association from the Dakar University, knocked on our door and said, those services that you have, can you bring them to us? We want them. And we were like, oh, okay. And USAID actually was there to support this very small innovation. And so there's a little clinic embedded into the campus at the university that serves the reproductive health needs of young people. So very excited about it, very innovative. Lots of USAID people coming around. And I look at these results and I'm like, nobody's taking up a family planning method. Are we talking about that? Yes, we are talking about it. And we're seeing that change slowly, but surely we're seeing it change. It started off, I think, and Lee is speaking to the midwives and the students and the students who go around the campus and speak to the other students. People wanted to have information. And the level of, and I think going to a challenge, the level of knowledge that these students, educated, have about their reproductive health is quite shockingly low, to be honest. They have very little idea of how to protect themselves from sexual transmitted diseases or pregnancies for that matter. That's a big challenge. There's another very big challenge and my Senegalese colleagues can, I'm sure, vouch for this. We do not talk about this. Unmarried sexually active students don't exist in Senegal officially. But they do. And we know that they do. I can say this here in Washington. I wouldn't say this like this in Senegal. And it's a challenge because not only for the young woman to admit to herself, let alone to anybody outside of herself, that she is sexually active and therefore needs to protect herself is for her absolutely massive because she is then putting herself outside of the societal norm. If she admits this to herself, then that means that her mother or her aunt or her father or anybody will possibly reject her from the family. So it's a massive thing for a young person to ask for a family planning method because then you're admitting to yourself that you're sexually active, which we've had very interesting conversations with people who have STIs and they say, but I've never had sex. How is that possible? Because I have to say our midwives are amazing in finding the language to be able to talk to these girls and boys actually, obviously, very quite often it's the boyfriend that comes with. And these are extremely difficult challenges and we touched upon it yesterday evening during the dinner. We can't go around yet saying, oh, we need sexual health for young people in Senegal. It's so important. We can't do that. We'll break something. But again, we go back to maybe my first point. We can go back to the student or to this young person and try to find a way so that we can help her get the information she needs so that whatever choice she wants to make, she can make safely. And I think that is a challenge because I work for Maristopes. We're like, how many planning methods did you? How many? Three in the last month? It doesn't seem to rock your world, but it's actually making a massive impact. And I think we need to have that patience. As a government, we need to have that patience. As the donors, we need to have that patience. And we need to realize that this is a huge shift. And also, if we think of ourselves, we don't necessarily want to talk to our children or when we were children, talk to our parents about this kind of thing. So where do they go for information? Dr. Daff, I said I would come back to you about this issue of coordination because one of the lessons, I think, that we see in Senegal is that if the government is in the driver's seat and can coordinate the different partners and the different donors, then good things can follow. But it's not easy. And I wonder if you can talk a little bit about how you and your government have been able to do this coordinating role and what lessons you would have for other countries as they tried to sort of harness the different partners to support their plan. Yes. Then we elaborate the action plan on family planning. We put on site different platforms like committees, technical committee, subcommittees on demand creation, delivery services, and security for contraceptives. To be sure that everybody will be inside, we do some kind of co-lead and the government co-lead and the partner co-lead. So if we do the invitation, everybody can come and see what happens. No one is missing. And we propose that each semester we meet the minister to show the progress. That's what we do. The subcommittees are meeting each month and the technical committee is meeting each semester. That's what we do. And also, we propose to do different reviews with regents to see what is their progress. With partners, if you go to the regents, share with them. And this semester we call all of them into central level and each region presents its success and problems. That's what we do. And this helps everybody to stay committed on the plan. But as you know, we have the family planning but we have other programs like maternal health, child survival, nutrition. Last year, we proposed to gather all these committees because we had a lot of meetings. We had an RMLHA committee led by the minister. And we meet each semester and each semester we meet the minister to tell her what we have done. That's the way we did to follow our program and to be sure that we are making progress. If any problem happens, we try to find a solution together with the support of partners. Thank you. I have lots more questions I could ask but I know there's lots of people here who have important questions they'd like to ask our panelists. So I'm going to ask, there's a microphone that will be coming around. We'll take maybe three at a time. Please identify yourself and ask a question. And then we can do a couple of rounds, hopefully, for that. If you have a question for a specific panelist, let me know, but we're not going to have everyone respond to everything. We'll try to do it more targeted. So let's open up to some questions. Okay, we have them the way back. Thank you very much to the panel. I'm Lisa Nichols. I'm with APT Associates. We are the lead implementing partner for health systems strengthening. But I want to commend the panelists for speaking about how well Senegal has taken the lead in improving access. And I would like to ask if you could talk a little bit about community-based health insurance. There are some differentiators here that Senegal has compared to the rest of the region and that's in innovative health financing. And I know the Mutual DeSante and Access, the president has just made a commitment to universal health coverage. And how important that is to expanding access. Thank you. I think we had another question back here. Good morning, Honorable Ministers and Ladies and Gentlemen. My name is Rosemary Seguero. I'm a president of an organization called Hope for Tomorrow. We focus on conflicts, violence, and also rural areas of Africa. I'm from Kenya. Thank you so much, Madam Awa Honorable for your wonderful presentation. Mine is just a comment to say thank you for leading the women health. We focus in the rural areas. How do we, we want the women in the rural areas of Senegal and Africa to be rich and also work with us as civil society, the civil society on the ground and us here in the United States as women who are born and raised in Africa. We will support you and anything we can do, work with you as business or organization. Let us know. So thank you so much for reaching out for women in the rural areas and thanks for the men also for being concerned about the women in Africa and in your own country. Thank you so much. Thank you. Back here, Priya. Hi. My name is Priya Gaural. I'm Executive Director of Mothers and we've had the pleasure to work with Intra Health and the Ministry of Health on the informed push model. As you mentioned, we're actually now at that stage where we're thinking about how are we going to go in a dependent model to handing over to the government and there'll probably be some kind of transition phase that we're looking at now. There are other countries not in that region but actually in South Asia that are approaching us to implement a similar model. Is there something either from the Intra Health perspective or the government perspective that you would do differently if you were starting informed push now to enable that transition to the government sooner? Okay, let's take one more. Roger Mark. Thank you very much. Roger Mark, this was from the Woodrow Wilson Center. Papka, you specifically talked about looking at a bigger context for West Africa and you mentioned that maybe we have now an opportunity to expand family planning in the context of the economic development agenda. Could you talk more about that, please? Okay, thank you. Let's turn to the panel. I'm going to start with Pap on the question of the informed push model. What would you do differently? You know, I would probably have a lot more conversation with the government. Because this was an innovation, it had not been tried. There were few places where you could actually go to see how it would work because I think it was kind of a created tailored. But clearly what I would do differently would be much, much more dialogue about what the government might need in terms of scaling up rather than having a very successful intervention suddenly saying, God, it works so well. Let's do it. But I think it just, I would have pushed the envelope a little bit about the conversation. It's always one of my favorite subjects is that if we are the donors or the implementers or at least the people with the resources, what can we do to level the playing field? But the playing field is never leveled in our field because we are the ones with the resources and then the people who just will have a tendency to say yes. So we know that that is changing. We know that we really have leaders that have a vision that can engage in dialogue. So I would do that. I would engage in much more substantial discussion about the possibility of something like that and try to get a commitment, even know that it's going to be hard but a commitment. Rather than let's test it, it works and then now let's go and shop it with the government. That's what I would do differently. So Dr. Daff, would you like to come in on the community-based health insurance? It is not an expected question, but let's say, as you may know, our president made a very important commitment to address equity on the people. For that, he proposed to have universal access to services, health services, and he makes the emphasis on the vulnerable people, meaning the under five and the women. Now in Senegal, you know, services for under five people are free at the health post and the Santa de Santé. And the consultation is also free in the hospitals. The C-section is free for all women in the country. But this is not difficult to afford the health services for everybody. That's why we propose to have materials and we are organizing ourselves with the support of the government and now in the field, we are going to the department by department put together the committees to have at least a material by local governments. And each people who contribute, I think it is around 3,500 different CFA as a prime and government do the same. This is what we are now planning to do in Senegal and we expect to have maybe 75% by 2017. I think this is very crucial because even we have the services in place if people cannot afford the services, they don't go to the facilities. I think this was something missing and it is important to have it. But we know there are a lot of content to organize all that and maybe also to support the health system it is important to give support on that technical support, maybe financial support on some aspects. Thank you. And this last question about economic development harks back certainly to the importance of a multi-sectoral approach also. It looks at why this family planning matter not only for health but also for development and the importance of bringing in not just the minister of health but the minister of finance and education and all these issues. And I think that was directed to you Pop if you want to talk about that. I think it was Marc's question and I think the issue for me is the courage to have the conversation because right now there are so many other considerations that causes us to still kind of tiptoe around the subject. While there is an opportunity, Africa is growing, investment in the human capital, I think Madam Minister just said that in her opening word she said our population keeps growing and as long as the population is growing faster than the economy is growing then you are going to have this imbalance and the challenges are just going to. But it seems like the region is not yet ready to talk about it in those terms. I mean I think the demographic dividend is making sense, I think it's a good tool to talk to our legislature, decision makers and I think that's what it is. I think that's what the demographic dividend really is is that you are going to make these gains so that you can invest in education, you can invest to all of the pillars of good economic development. But it's just, I think it's right but I think we are underestimating the power of the youth and of the very educated population to understand these dynamics and be courageous to just talk about it. Everybody in West Africa, everybody in Sub-Saharan Africa will tell you that they want to become like the Asian Tigers, they want to become, when you say who you are looking at, they say Singapore or Thailand or these countries, what needs to be told to them is that these countries very early on factor in the family planning and population in their thinking. And we are still not having that straightforward conversation because we are still trying to manage the religious sensibilities and the cultural sensibilities and frankly the very big fertility preference that seems to still exist in a lot of countries in the region. People just like big families and so it makes this conversation difficult but I think that's what we need to do and I think it's clear that we have a lot of opportunity to engage in activities that could be very easily linked to economic development and other youth employment and so forth. All right, let's take one more round of questions and then we'll have to close up. All right, so let's start over here with Perry. Thank you. Minister Colsec, Dr. Daff, Pop, Micah, this is an excellent discussion. Thank you so much. It's a privilege to get to work with you, each of you. In two of the points that were made one by Dr. Daff in talking about his vision for the interventions that are going to achieve 27% by the end of this year and Pop also spoke to the importance of the public-private partnership and this is highly relevant in the mobile outreach that Dr. Daff is speaking of and the informed push model. It's a model of outsourcing to the private sector. So what I would love are comments from each of you about how we can think of doing this differently in the future so that we can see examples of the government making these contracts themselves to private sector actors. I think Senegal has the potential to be among the first to make this happen and I'd love to hear more about your appetite for that and how it might work. Over here, Susan. Thank you so much for this really informative and inspiring discussion and esteemed panelists. I'm Susan Cohen from the Gubmacher Institute and I'm reacting to a comment that Micah made about how unmarried young women in Senegal do not exist. Something else that doesn't exist is abortion except that now we know it does because my colleagues were just in Senegal a couple of weeks ago and released the first ever national incident study of abortion in Senegal with our partners. I'm going to mangle the French but it's the central for research on human development and I'm sure. Sorry about that. But what we discovered is that there are 50,000 abortions that occur in Senegal every year and half of them require treatment for medical complications. Now obviously this is a subject that is separate from family planning but integrally related and it's my understanding this is open to new conversation in Senegal about ways to deal with the issue of unsafe abortion there but relevant to this discussion directly is that this is clearly another very obvious and inescapable indicator of the unmet need for being able to prevent more unintended pregnancies and increased access to contraceptive services. So if any of the panels would like to comment about how to use how this new information may be able to be used to confront some of these difficult subjects but that are very much a reality in women's lives. Thank you. We have one last question. Let's go over to the back. Thank you. I'm Fatima Kone. I'm the Director of Marketing of Ademas Agency of Marketing in Senegal. I'm very proud to be here today with my colleague Momodou and we just want to add of what Mike said on the inside knowing that one of the key main... the key work pattern is for Ademas is to work with the Ministry of Health its division for... its division for reproductive health and also we are funding by USAID. Just coming back to inside Dr. Darf said that we worked on the communication for the planning family called MWNF we... we work based on evidence which means that we do research we base our findings on what have been done through the country we use lots of also studies that we've done by issue just to understand how Anta you've seen here lives how Anta behave what's her needs and what she lives for and that communication campaigns was based on it and we we put our focus on the determinant that we were sure that she can change her behavior but also what we found that was that study shows that yes as she said on the on the film, on the video yes she can have the leadership to go and take a modern method but in most of the case she also needs her husband's support that's why we stress our communication on how Anta and his husband can talk about PF and have the lead to go together and take that opportunity thank you I think we're going to have to it was just an input sorry just because of time we're going to thank you and because of time what I'm going to let I'm going to run through the panel and let you respond to any of these comments about Perry's comment about the private sector the question of unmet need for family planning that's reflected in this study on on abortion and the issues raised by our colleague from Ademas and then any other concluding remark she'd like to make so let's start with Micah okay thank you for the questions and thank you Susan for the challenging question of abortion I think you're absolutely right it shows the unmet need and it's I think in populations like the youth the consequences of having an unwanted pregnancy so severe that they very often opt for an unsafe abortion if they prefer that to suffering through an unwanted pregnancy and this is something that again in Senegal we need to acknowledge and face up to and I think there's a task force working on policy reform in Senegal and there's women's lawyers groups and other groups who are showing tremendous leadership in Senegal to change these abortion laws so that hopefully these numbers will go down and with the family planning concept of preference rate that's going up hopefully we'll see some really real changes in that and just maybe closing on the insight yes the husband of course the husband but or and not only the husband and I think we we in Senegal it's safer to say yes with the husband and that's obviously the ideal of course that's what we want but there are many women whose husband might not want it and who she wants it and she also can make that choice again and there's also many women who actually don't have a husband maybe not as many they're not the majority but they're there and we shouldn't we shouldn't forget about them and they might be a little bit more difficult to reach both if we talk about leadership both for her to show her own leadership because for her it's an even more difficult choice to get family planning so I will always hopefully we can always try to accommodate that as well thank you Dr. Daff any responses and closing remarks yes for the public private sector but I can say that obviously we do not have a lot of experience on that the government side and the private side but since the minister came on board in 2012 we see we are we are having some experience for example with orange we get some convention to send an SMS about diabetes and other programs coming back to family planning I think for the franchise we we must do a lot of effort to pursue that and to expand it even the private sector is really concentrated in Dakar but I think they are doing a very good job I know also we've ICF World Bank the minister have organized private sector who are working on the health area they are trying to do something and we have a decision are just focusing on this private public sector actions for the abortion just be clear let know that abortion is forbidden in Senegal and it's not only the issue for health sector it's the whole society and right now there are some activists who are working on that and they are trying to move on some issues like if the pregnancy came after rap or incest I think half of Senegalese people accept that in this case we can do the abortion I know also that many leaders like elected people on the National Assembly are supporting that but it's a long way to achieve that's the reality for the health system what we call post-abortion care program just add the technician if someone came we can help them support him and maybe if he needs family planning we help them to get it I think really if we develop the family planning program maybe this will be a secondary question in my my view thank you and Pap we're going to give you a brief last word so I too hope that Senegal and other countries will get to a point where our family planning programs are designed for all that need it I think it is restrictive to say that you're only going to look at married women I think especially in light of what you just said if we look at how young the population is so I hope that we collectively we can come up with ways to influence and change the policies so that the programs are really far reaching much further reaching than they currently are because they are restriction if you say you're only going to look at married women and all that having said that there are challenges but I do think we should put it on our site and we want to solve because the programs are going to continue to be inefficient unless we get to a point where that could be more inclusive and much broader that's what I want to say on that I want to make an appeal to the people in this room about bringing the private sector in family planning we're not seeing very good progress right now of all the initiative that we see if you take out the pharmaceuticals who clearly have an interest in this thing we're not seeing a lot of private sector engagement in family planning so we need to do our part of advocacy globally also we need to convince these companies why it would be important for companies in the extraction industry in the logistic industry there's room for them if people want to go beyond corporate social responsibility on development family planning would be a good way to do that and we need that message to be loud and clear for the companies up here before we can appeal to companies or while we're appealing to companies also in the north and since we are passionate and our core work is the health workforce I do want to make a plug also for that I think there's a lot of a tendency to either try to bypass or to continue to blame the health workers in this rightly so well taken so we have our work to do again we still have a lot of challenges a lot of barriers to access which I think can be solved by doing a better job with the health workers but again I think it's a critical element of the piece until we have a decent ratio of health workers to population again we're going to continue to be in a very difficult situation so I want to make an appeal for us to continue not to forget that investment that it just won't happen I think these will be the link these are the people who are the link between the system and the community and we need to find ways to correct the deficiency that exist but keep up the investment in that group and then finally I really would like to take the opportunity to thank USAID for its ongoing involvement in this CSIS of course for putting putting together this wonderful wonderful gathering and allowing Senegal to showcase its program Bill and Melinda Gates Foundation the Hewlett Foundation the Packard Foundation all of the good champions that keep caring for the region it's a right thing to do and I hope you'll keep at it well I think everyone can appreciate that we could have gone on much longer but in interest of our engaging next panel on the important issues of funding I hope you'll all join me in thanking this panel