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

• Participants:

– 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,

• 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, DFID-PRINN/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 Methodology…1

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 Methodology…2

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 Methodology…3

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.

• 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 - 1

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

Harmonization: Service Coverage

Determinants & Interventions

.

18

COVERAGE DETERMINANTS

1.Commodities

2. Human Resource

3. Geographic access

4. Utilization

5. Continuity

6. Effective Coverage

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

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 INDICATOR

COMMODITY 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

UTILIZATION Percentage of pregnant women attending ANC services

including PMTCT who know their HIV status

CONTINUITY Percentage of HIV-positive pregnant women who received ARV

QUALITY Percentage of infants born to HIV-positive women who receive

ARV prophylaxis to reduce MTCT

83 %

33 % 33 % 25 %

6 %

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

Commodity Human Resources Geographical Access Utilization Continuity Quality

Example: PMTCT Bottleneck

Analysis

Nigeria

21

Targ

et

Po

pu

lati

on

GAP

Birnin-Gwari LGA Kaduna

25 %

3 % 6 %

2 % 0 % 0 % 0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

PMTCT - Bottleneck Analysis

11 % 14 %

46 %

64 % 58 %

27 %

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

ANC - Bottleneck Analysis

Eti-Osa LGA Lagos State

100 %

6 % 4 %

23 %

14 %

0 % 0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

PMTCT - Bottleneck Analysis

77 %

5 %

42 %

9 %

28 %

18 %

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

ANC - Bottleneck Analysis

1. PMTCT and ARV Prophylaxis

Determinant

Baseline as of

Main

bottlenec

ks (mark

"X")

Plausible Causes

(indicate if further investigation required) Corrective Actions

Responsible

person &

partners

involved

Time frame

Target as of

Q1 Q2

Commodity 100 %

Human

Resources 6 % X

Inadequate data on trained staff providing PMTCT services

LGA M&E Off,

RH Aug, 2012

40 % Lack of funds to train personnel Provide funds for and train 30 personnel

Partners,

LSMOH,LSAC

A, LGHA

Aug-12

Inadequate no. of trained personnel

Partners,

LSMOH,LSAC

A

Aug, 2012

Geographic

al Access 4 % X

Inadequate number of Health facilities offering PMTCT

Provide/expand PMTCT services to more health facilities (public & Private)

Partners,

LSMOH,LSAC

A, LGHA

Aug, 2012

40 %

No outreach services

LGHA,

LSMOH, PARTNERS

Utilization 23 % X

Inadequate awareness of the services

Conduct advocacy on PMTCT service

LGHA,

LSMOH, PARTNERS

2nd week of Aug

80 %

Conduct sensitization on PMTCT service

LGHA,

LSMOH, PARTNERS

1st week of Aug, 2012

Continuity 14 % X

Stigmatization,

conduct public enlightenment through community dialogue (4) LGA H/E Unit

Aug-Sept, 2012

75 % Poor compliance to treatment, drugs regimen,

Follow -up Visit to ensure compliance

Aug -Sept, 2012

Introduction to support group and experience sharing

Quality

Results Achieved:

Planning & Capacity-Building…1

States 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 18-

23 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.

25

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 buy-

in 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 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.

28

Cross Section of Participants at the National

TOT, bottleneck analysis, Abuja

29

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