EQUITY AND MONITORING PROGRESS OF THE NSHDP IN NIGERIA : THE PHC/HEALTH PLANNING AND REVIEW

DR EBOREIME EJEMAI
MDG DESK OFFICER

NATIONAL PRIMARY HEALTHCARE DEVELOPMENT AGENCY

PHC/Health Planning and Review is:

An initiative for

1. strengthening & institutionalizing States/LGAs PHC planning, implementation, quarterly review (at LGA level); 2. Identifying constraints, challenges or bottlenecks to programme implementation, service delivery and service utilization. 3. Identifying solutions for overcoming the bottlenecks/constraints and developing action plans for implementing those solutions. 4. Implement action plans 5. Repeat the process every quarter.

Components
Operational

Planning/Budgeting Implementation & Progress Review Capacity-building Monitoring & Evaluation; Data/Information Management Advocacy.

Background of PHC Review

The National Strategic Health Plan (NSHDP) was launched by Mr. President on Dec 16, 2010 Over-arching coordination body (Reference Group) was inaugurated by the Hon. Minister of Health The Hon. Minister of Health also inaugurated various Committees of the Reference Group Key responsibilities of the Committees include ensuring that states develop annual plans from SSHDP NPHCDA considered Quarterly PHC Review on the basis of geopolitical zones, to improve PHC performance.

PHC and Health Plan Review emerged. Quarterly PHC Review Meetings commenced in 2011

PHC Review Methodology

Approach:

Cascading Starting from State to Zones

State Level Review:

Duration of 2-days in each state

State Directors: PRS-SMOH, PHC (SMOH), PHC (SMOLG); Chairman SPHCB, State Epidemiologist, Programme Managers. LGAs PHC Coordinators; NPHCDA and Partners; DPHC (MOH) of other states in the zone,

Participants:

Feeds into Zonal level Review

PHC Review Methodology(2)

Zonal Level Review Duration: 4-days in each zone (focus on all States in each Zone) Participants:

FMoH: Director PRS, Head/State Coordination Unit, NMCP, DD PRS. NPHCDA: ED/CE, Director PRS, Director DC & I, Director PHCS, Director CHS, PRS Heads of Divisions, DD PPP, Secretariat. Zonal NPHCDA officials: ZC, Zonal PRS officer State Officials: DPRS-MOH, DPHC-MOH, DPHC-MoLG/State PHC Board. Selected Local Government health officials: PHC Coordinator for 3 selected LGAs Health Partners: UNICEF, WHO, UNFPA, DFID-PATHS2, DFIDPRINN/MNCH, USAID, MSH, FHI, NACA, NPC and other health partners investing in health development in the States

PHC Review Methodology (3)

Focus of State Presentation at Zonal Level Review Situation updates in respect of annual plans:

progress in the implementation of PHC programmes and activities, constraints/challenges, any other factor(s) affecting the PHC Development of State annual plans that feeds into their SSHDP

PHC Review Methodology (4)

Focus of State Presentation at Zonal Level Review Reports on:

No. of reported cases of communicable diseases. RI Coverage for BCG, DPT3 & Measles. Vitamin A coverage No of cases of Wild Polio Virus. No of deliveries supervised by skilled birth attendant. % New ante-natal attendance Proportion of 4 or more ante-natal visits. % PHC facilities with basic laboratory services

PHC Review Output

Status of States PHC interventions known and clearly articulated

PHC challenges in the implementation of State health plans identified and documented
State annual Plans developed for 36 States + FCT

State plans of action (POA) for addressing identified bottlenecks/constraints developed States orientated about SPHCB

The Revised Methodology1

At the request of FGN, a team from UNICEF Headquarters (New York) with other development partners supported by the local Core Technical Committee jointly met in Abuja from 16th 20th January 2012 to reinforce the effectiveness of the PHC Reviews

The Revised Methodology2

Following

findings from Joint Mission, decision was reached to harmonize indicators from various health interventions for the PHC and Health Plan review and the revised PHC review methodology was recommended

The Revised Methodology3

Programme Managers from various vertical programmes (HMIS, Immunization, Malaria, Tuberculosis, HIV/AIDS, MSS, Maternal and Child Health and IDSR) thereafter, met to harmonize indicators and align these indicators with the HMIS.

What is the Revised PHC Review Methodology?

A

systematic, flexible, outcome -based approach to equitable programming and real-time monitoring that strengthens the LGA health system, complementing and building on what exists (e.g. Minimum Standards of PHC).

The

Revised PHC Methodology is applicable to the entire health system.

Main objectives of the Revised PHC Review Methodology - 1

Addresses significant gaps (harmonization of indicators, coverage stagnation, inequity) Aims to build the capacity of LGA Health Managers to assess, analyze, act and be accountable for equitable service delivery so as to strengthen decentralized health systems increasing the capacity of LGAs management teams monitoring in real-time and local data use timely course correction engaging communities and stakeholders as key partners in improving the health of children and women

Main objectives of the Revised PHC Review Methodology - 2

To increase coverage of PHC high impact interventions, particularly for underserved populations. To increase work efficiency in planning (manageable process) and monitoring (real-time monitoring to quickly identify priorities). This requires: integrating and building on existing situation analysis and monitoring processes and methods already in place (e.g. integrating into local planning and review cycles of the MoH) tracking progress towards equity of access for the most underserved populations.

The Revised PHC Review Methodology can help to.

Identify underperforming high-impact interventions (low coverages), key supply and demand bottlenecks and LGAs /populations with the greatest needs Analyze main causes of underperformance and guide in finding acceptable, realistic solutions to address the problems; Perform regular verification to progress in bottleneck reduction; Adjust or modify solutions and strategies to improve coverage, quality and effectiveness.

Expected Outcome

Effective coverage of PHC high impact interventions, particularly for underserved populations, improved. Effectiveness & efficiency in planning, implementation & monitoring improved. Alignment & integration into LGA & State Planning cycles achieved in some states . Effective progress tracking towards equity of access for the most underserved populations attained. Quality PHC service availability and utilization, based on Ward Minimum Health care package, improved

18

Harmonization: Service Coverage Determinants & Interventions

COVERAGE DETERMINANTS
TRACER INTERVENTIONS
1. Immunization 2. PMTCT 3. Integrated Management of Childhood Illness 4. Antenatal Care 5. Skilled Birth Attendance 6. Infant & young child feeding 7. Vit A Supplementation 8. Community Management of Acute Malnutrition

.
1.Commodities 2. Human Resource 3. Geographic access

4. Utilization
5. Continuity 6. Effective Coverage

Criteria for selection of Tracers

Data

should be available for the six coverage determinants The tracer is an internationally recommended intervention with proven and quantified efficacy The tracer should be representative of other indicators within its intervention group in terms of facing similar health systems constraints at the chosen service delivery level, for accurate assessment of costs in overcoming bottlenecks

PMTCT AND ARV PROPHYLAXIS

DETERMINANT
COMMODITY

INDICATOR Percentage of ANC centres without stock out of any required ARVs for PMTCT in the reporting period

HUMAN RESOURCES Percentage of HF staff providing ANC services trained for PMTCT GEOGRAPHICAL ACCESS

Percentage of population living within 5 km radius of HFs offering comprehensive PMTCT services Percentage of pregnant women attending ANC services including PMTCT who know their HIV status Percentage of HIV-positive pregnant women who received ARV Percentage of infants born to HIV-positive women who receive ARV prophylaxis to reduce MTCT

UTILIZATION

CONTINUITY

QUALITY

Example: PMTCT Bottleneck Analysis Nigeria

GAP
100 % 90 % 80 %

83 %

Target Population

70 % 60 % 50 % 40 % 30 % 20 %

33 %

33 %

25 % 6%

10 %
0% Commodity Human Resources Geographical Access Utilization Continuity

Quality

21

Birnin-Gwari LGA Kaduna

PMTCT - Bottleneck Analysis
100 % 100 % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 25 % 6% 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 2% 0% 0% 0% 3% 11 % 14 % 27 % 46 % 64 % 58 %

ANC - Bottleneck Analysis

20 %
10 % 0%

Eti-Osa LGA Lagos State

PMTCT - Bottleneck Analysis
100 %
100 % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 23 % 14 % 6% 4% 0% 100 % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0% 5% 9% 28 % 18 % 42 %

ANC - Bottleneck Analysis

77 %

10 % 0%

1. PMTCT and ARV Prophylaxis Main Baseline as of bottlenec ks (mark Q1 "X") Plausible Causes (indicate if further investigation required) Responsible Target as person & of Time frame partners Q2 involved

Determinant

Corrective Actions

Commodity

100 %

Inadequate data on trained staff providing PMTCT services

Human Resources 6% X

Lack of funds to train personnel Inadequate no. of trained personnel Inadequate number of Health facilities offering PMTCT

Provide funds for and train 30 personnel

LGA M&E Off, RH Aug, 2012 Partners, LSMOH,LSAC Aug-12 A, LGHA Partners, LSMOH,LSAC Aug, 2012 A

40 %

Geographic al Access

4%

Provide/expand PMTCT Partners, services to more health LSMOH,LSAC Aug, 2012 facilities (public & A, LGHA Private)
LGHA, LSMOH, PARTNERS LGHA, LGHA,

40 %

No outreach services Inadequate awareness of the services

Utilization 23 % X

Conduct advocacy on LSMOH, PMTCT service PARTNERS Conduct sensitization on LSMOH, PMTCT service PARTNERS

2nd week of Aug

1st week of Aug, 2012 80 %

Continuity

14 %

Stigmatization, Poor compliance to treatment, drugs regimen,

conduct public enlightenment through Aug-Sept, community dialogue (4) LGA H/E Unit 2012 Follow -up Visit to ensure compliance Introduction to support group and experience sharing
Aug -Sept, 2012 75 %

Results Achieved: Planning & Capacity-Building1

States

25

2012 annual plans developed for all states. LGAs 2013workplans developed for 420 LGAs. 297 Resource Persons trained in all states + FCT;

115 for North Central and South South zones; in Abuja 1823 March 2012. 88 for South West and South East zones; in Enugu, 10-14 April 2012.
94 for North West and North East zones; in Minna 08-12 May 2012.

2,134

LGAs officers trained: PHCC, M & E, Officers, Immunization Officers, HMIS officers, LGAs.

Challenges:

Funding constraints Poor ownership by states and LGAs may inhibit continuity and sustenance of the reviews Poor computer literacy among some participants Poor data quality Non availability/ use of harmonized HMIS tools resulted in missing indicator elements during bottleneck analysis

Way forward

Source and pool funds from partners for harmonized implementation Advocacy to LGAs, state governments (SEC) and State assembly health committees to ensure buyin and ownership of the process at all levels Involvement of CDCs in the process to strengthen identification and solutions to demand side bottlenecks Ensure availability and use of harmonized HMIS tools at HFs Review of capacity building methodology

Next Steps
Training

28

of LGA Officers phase 2. Orientation of Ward Focal Persons & Officers in charge of HFs Development of LGA profiles & quarterly PHC/Health Plan review at LGA level using Health facility/programme data. Bia-annual PHC/Health Plan Review at State and Federal levels.

29

Cross Section of Participants at the National TOT, bottleneck analysis, Abuja

Minna, Niger State

PHC reviews in Kogi State

PHC reviews in Jigawa state

Conclusion

BNA is an effective tool for evidence based review of health system performance as well as advocacy at all levels The Revised PHC Review methodology using bottleneck identification and analysis will contribute to the successful implementation of the National Health Plan and the achievement of results in line with health-related MDGs as it monitors quality, equity, efficiency and effectiveness in health service delivery to the lowest level of implementation . Collective action and responsibilities are required from the Federal (All vertical programmes), State and LGAs levels as well as CBOs for improving the delivery of services for children, women and other vulnerable populations. Partners and Donors need to fully buy-in and support the PHC Reviews.

THANK YOU FOR YOUR KIND ATTENTION