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This report is made possible by the generous support of the American peo-ple through the United States Agency for International Development (USAID). The contents are the responsibility of JSI Research and Training Institute, Inc. and do not necessarily reflect the views of USAID or the United States government.

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TARGETED STATES HIGH IMPACT PROJECT BAUCHI AND SOKOTO

Table of Contents

ABBREVIATIONS AND ACRONYMS 4 ACTIVITY SUMMARY 6 THE BROADER CONTEXT: KEY PARTNERS 8 INTRODUCTION 10 STRATEGIC APPROACH 11 ACTIVITIES AND ACCOMPLISHMENTS 12 SUB OBJECTIVE #1 12 SUB OBJECTIVE #2a 18 SUB OBJECTIVE #2b 24 SUB OBJECTIVE #3 30 SUB OBJECTIVE #4 34

PROJECT SUPPORT 38 COORDINATION, COLLABORATION AND PARTNERSHIP 40 MONITORING AND EVALUATION 44 PROJECT MANAGEMENT 45 OPPORTUNITIES AND CHALLENGES 48 Annex I: PMP TARGET VS PROGRESS CHART 50 Annex II: PMP COVERAGE RATES CHART 53 Annex III: Detailed Calculation Sheet for Indicator No. 9 55 Annex IV: Detailed List of Policies (Indicator No. 26) 56 Annex V: VISITORS TO THE PROJECT 57 Annex VI: SUCCESS STORY 58

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ABBREVIATIONS AND ACRONYMS ARH = Adolescent Reproductive Health BACATMA = Bauchi State Agency for Control of HIV/AIDS, Tuberculosis and Malaria BCC = Behavior Change Communication CBO = Community-based Organization CC = Cold Chain CEDPA = Center for Education, Development and Population Activities CHEW = Community Health Extension Worker CHIS = Community Health Insurance Scheme CIDA = Canadian International Development Agency CLMS = Contraceptive Logistic Management System COMDI = Community Mobilization and Development Initiative COMPASS = Community Participation for Action in the Social Sectors COP = Chief of Party CSO = Child Survival Officer D&G = Democracy and Governance DCOP = Deputy Chief of Party DELIVER = USAID DELIVER Project DPHC = Department of Primary Health Care DSNO = District Surveillance Notification Officer DPT = Diptheria, Pertussis, Tetanus EmONC = Emergency Obstetric and Newborn Care FMOH = Federal Ministry of Health of Nigeria FOMWAN = Federation of Moslem Women of Nigeria FP = Family Planning HF = Health Facility HIV/AIDS = Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome HMIS = Health Management Information System HSMB = Hospital Services Management Board IEC = Information, Education & Communication IP = International Partner IPD = Immunization Plus Days IPT = Intermittent Preventive Treatment ITN = Insecticide Treated Bed Net JSI = JSI Research & Training Institute, Inc. LEAD = Leadership, Empowerment, Advocacy, and Development LGA = Local Government Area LHI = Life Helpers Initiative LLIN = Long Lasting Insecticide Treated Bed Nets MDA = (Government) Ministry, Department, Agency MDG = Millennium Development Goals M&E = Monitoring & Evaluation MOH = Ministry of Health (or SMOH, State MOH) MLG = Ministry of Local Government MSA = Management Strategies for Africa MSN = Marie Stopes Nigeria MSS = Midwives Service Scheme MTI = Master Trainers Initiative

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ABBREVIATIONS AND ACRONYMS NDHS = Nigeria Demographic and Health Survey NEI = Northern Education Initiative NGO = Non-Governmental Organization NID = National Immunization Day NPHCDA = National Primary Health Care Development Agency NPI = National Program on Immunization NSHDP = National Strategic Health & Development Plan NYSC = National Youth Service Corps OPV = Oral Polio Vaccine ORS = Oral Rehydration Solution ORT = Oral Rehydration Therapy PFD = Partners for Development PHC = Primary Health Care PHCDA = Primary Health Care Development Agency PMP = Performance Monitoring Plan PPFN = Planned Parenthood Federation of Nigeria REW = Reaching Every Ward RH = Reproductive Health RI = Routine Immunization RUWOYD = Rural Women and Youth Development SHDSP = State Health Development Strategic Plan SMOH = State Ministry of Health SHDP = Strategic Health Development Plans SPHCDA = State Primary Health Care Development Agency TA = Technical Assistance TBA = Traditional Birth Attendant TBD = To Be Determined TFG = The Futures Group International TOT = Training of Trainers TSHIP = Targeted States High Impact Project UDUTH = Usmanu DanFodio University Teaching Hospital UNICEF = United Nations Children’s Fund UNFPA = United Nations Fund for Population Activities USAID = United States Agency for International Development USG = United States Government WHO = World Health Organization WOSDI = Women Support and Development Initiative YFS = Youth Friendly Services

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TSHIP/Nigeria JSI Research & Training Institute, Inc. (JSI)

USAID Cooperative Agreement No. 620-A-00-09-00014-00 12 August 2009 – 30 September 2010

*Current pipeline amount includes committed funds to sub partners and vendors for program activities and procurement. Available funds remaining from the current obligation totals $996,870.

Implementing Partner

JSI Research & Training Institute, Inc. (JSI)

Activity Name

Targeted States High Impact Project (TSHIP)

Activity Objective

To increase the use of high impact and integrated maternal, new-born and child health and family planning/reproductive health in-

terventions Life of Activity (start and

end dates)

August 12, 2009 – September 30, 2014

Total Estimated Agreement Amount

$85,453,015

Obligations to Date

$9,425,798

Current Pipeline Amount

$4,169,585*

Accrued Expenditures this Quarter (4th Quarter, FY10)

$2,537,377

Activity Cumulative Ac-crued Expenditures to Date

$5,256,213

Estimated Expenditure Next Quarter

$3,500,000

Report Submitted By

Mr. Marc A. Okunnu, Chief of Party

Submission Date

31 October 2010

ACTIVITY SUMMARY

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Champions receive training on the RAPID model, which

will be used to promote the use of health services and

education for girls in both Bauchi and Sokoto.

A child receives the DPT vaccination at a health facility

Involving religious leaders: Sarkin Yaki Gagi, repre-

sentative of the Sultan of Sokoto, monitors routine

immunization services at the Gagi clinic in Sokoto.

A service provider demonstrates how to prepare salt

sugar solution (SSS) to caregivers at Bini Community

Dispensary in Wamakko LGA, Sokoto.

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Action Areas and Components

Partners

Bauchi Sokoto

Gov’t MDAs

CSOs USAID Pro-jects

Dev. Part-ners

Gov’t MDAs

CSOs USAID Pro-jects

Dev. Part-ners

Health Systems Strengthening/Organization Development

• Health Services Management

• HR and Training

• Data Management/HMIS

• Infrastructure Development

• Commodity Security

SMOH, NPHCDA, FMOH

WO-FAN LEEMP

LEAD NEI DE-LIVER FHI-GHAIN SFH

UNI-CEF CIDA-CEIT WHO PATH-2

SMOH, SHS, HSMB, MAWCH MOLG, MWA

COMDI MTI LHI WOSDI RU-WOYD PPFN FOM-WAN

DE-LIVER FHI-GHAIN AC-QUIRE-FIS-TULA SFH

WHO UNI-CEF

Child Health

• Routine Immunization

• Polio Immunization

• Nutritional Supplements

• Breastfeeding & Infant/Child Feeding

• Childhood Ill-nesses Management

• Malaria LLIN Promotion

BSPHCDA, MOLG

Rotary UNI-CEF, WHO CIDA HKI

SHS, HSMB, MAWCH MOLG

YGC WHO UNI-CEF MSF

Maternal, Neonatal and Reproductive Health

• ANC

• EmONC

• Post-partum Care

• PAC

• Family Planning

• Adolescent & Youth SRH

• Gender

SMOH, SPHCDA, FMOH MDG

PFD, RA-HAMA, FOM-WAN LEEMP, WO-FAN ECWA-FHP

DE-LIVER

JHU-PF UNCEF CIDA-CIET MSN

SMOH, SHS, HSMB, MAWCH MOLG

FOM-WAN

DE-LIVER FHI-GHAIN AC-QUIRE-FIS-TULA SFH MSN

WHO UNI-CEF

THE BROADER CONTEXT: KEY PARTNERS

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Community Mobilization

• Social Mobilization

• Community Participation

• Behaviour Change Communication

• Information, Education and Communication

• NGO/CBO/FBO Participation

BSPHCDA, MOLGA, SSMC WDCs and VDCs MDG SUBEB

RA-HAMA, PPFN, FOM-WAN, RHISA, CHA, and PFD

NEI, LEAD BBC-WST

WB-CBDP UNI-CEF

SMOH, SSMC, MOLG WDCs VDCs MDG SUBEB

FOM-WAN SAIEB

LEAD NEI AC-QUIRE

UNI-CEF WHO UN-FPA

Enabling Environment

• Legislation and Policy Development

• Development/Refinement of Advocacy Models

• Financing and Re-source Mobilization

• Documentation and Dissemination of Evidence Base

SMOH BSA SPHCDA MOBEP

MTN, Ashaka Cement Rahama, FOMWAN, RHISA, CHA) dRPC

LEAD NEI DE-LIVER C-CHANGE FIS-TULA-CARE FHI-GHAIN

WHO UNI-CEF WB-ADB PATH 2

SMOH MOJ MOI SOHA MO-BEP

CCNN, MTN – Nigeria FOM-WAN

LEAD NEI

THE BROADER CONTEXT: KEY PARTNERS

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INTRODUCTION

Targeted States High Impact Project (TSHIP) is a five-year, USAID-funded project being imple-mented in all 20 Local Government Areas (LGA) in Bauchi State and all 23 LGAs in Sokoto State. The objective of TSHIP is to increase the use of high impact and integrated maternal, newborn and child health and family planning/reproductive health interventions. Using a tri-focus approach to improving community engagement, quality of health care services, and health system effectiveness, TSHIP aims to achieve four sub-objectives (see Box 1), and con-tributes to USAID/Nigeria’s “Investing in People” strategic objective. TSHIP is being imple-mented by a consortium of five organizations: Centre for Education, Development and Popula-tion Activities (CEDPA), Futures Group International, LLC (Futures Group), JHPIEGO, Man-agement Strategies for Africa (MSA), and JSI Research & Training Institute, Inc. (JSI) as the prime organization. TSHIP completed its first year of implementation at the end of September 2010. Project offices (rented or donated) were set up in Bauchi and Sokoto, including the central project office in Bauchi. Most planned staff (85%) were hired and assumed duties. Baseline and other critical data gathering activities (such as the health facilities assessment) were completed and findings used to support implementation planning and decision-making. Key project staff (from the field as well as the JSI home office) were oriented by USAID and introduced to other USAID pro-jects. Partnership development (linking with government MDAs at federal, state and local gov-ernment levels as well as local and international development partners) and internal TSHIP teambuilding activities were also undertaken. Many TSHIP staff come from previous USAID projects and bring with them skills and experi-ences that facilitated rapid start-up. Within the first year key activities (advocacy and sensitiza-tion, training and HR development, improvement of service delivery facilities, and community education) were accomplished and began to impact positively the health of mothers and chil-dren in the two states. While management structures were being set up during the first quarter, some “quick win” activities were identified to address critical health issues. For instance diar-rheal diseases account for 16 percent of childhood death (NDHS 2008) and the use of ORS is known to significantly reduce case fatality. To address this, as a “quick win” low-cost, high im-pact intervention, ORT corners were set up in 214 health facilities (94 in Bauchi and 120 in Sokoto) within the second quarter of the year. Building on these accomplishments, TSHIP’s subsequent quarters saw a rapid expansion and consolidation of activities, and initiation of ac-tions to facilitate delivery of high impact MNCH/FP/RH services. The following sections describe the strategic approach as well as program activities and ac-complishments and their impact during the first year of this five-year project.

1.

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STRATEGIC APPROACH

Led by JSI, the TSHIP consortium partners implemented the strategic approach presented in the TSHIP technical proposal and approved by USAID. The following are highlights of the broad strategic approach: Consortium partnership. Each consortium partner brings unique and acknowledged expertise to comple-ment one another: CEDPA brings community mobiliza-tion and community participation as well as gender and female participation; Futures Group brings advocacy, policy development and financing; JHPIEGO brings ma-ternal and newborn health and family planning/reproductive health service delivery including quality as-surance/management; JSI brings child survival, project leadership and management; and MSA brings program and organizational capacity development. Overall strategic framework. The basic strategic framework (Box 1) approved by USAID in the coopera-tive agreement with JSI (managing partner) remains un-changed. Sub-objective-based work planning. Based on the basic strategic framework and findings from baseline and other data gathering activities, the first annual work plan focused on the four TSHIP sub-objectives (capacity building, community mobilization, integrated service de-livery, and policy support). As part of the work plan de-velopment process, the strategy for each main compo-nent was reviewed and revised where necessary. Coordination, collaboration and partnership. Pur-poseful and systematic efforts were made to build part-nerships with other USAID projects (flagship and oth-ers), other development partners, federal, state and lo-cal government MDAs, and national and international NGOs. Strategic review and planning. In July, a strategic re-view and planning workshop involving USAID and key partners was used to validate the core strategic frame-work and develop a shared vision of success. In pursuing TSHIP objectives for the year, efforts were concentrated on facilitating creation or re-activation of integrated maternal, newborn and child health (MNCH) and family planning/reproductive health (FP/RH) ser-vices, and on strengthening the organization and man-agement development needs surrounding these services.

2.

Box 1: TSHIP Strategic Framework Overall Objective

• To increase the use of high impact and integrated maternal, newborn and child health and family planning/reproductive health interventions

Sub-objectives

• Strengthen state and local government capacity to deliver and promote use of high impact MCH/FP/RH interventions

• Strengthen delivery and promotion of high impact FP/RH/MCH interventions at PHCs and establish essential refer-ral levels

• Strengthen roles of households and communities in promotion, practice and delivery of high impact MCH/FP/RH interventions

• Improve policies, programming and resource allocation at the state and local levels

Overarching Strategies

• Applying standards-based manage-ment to improve quality and perform-ance

• Forging partnerships in all aspects of TSHIP

• Targeting the weakest links and build-ing on existing strengths

• Integrating MNCH and FP/RH services

• Harmonizing methods for community engagement and mobilization

• Transforming gender relations

Main Activity Areas

• Training

• Technical assistance

• Supportive supervision

• Infrastructure development and equip-ping

• Grants and financial assistance Organization

• Central Project Office, Bauchi

• State Offices (Bauchi and Sokoto)

• Sub-objective (SO) teams (5 in each state) for program implementation

• Field (zonal) offices (3 in each state)

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ACTIVITIES AND ACCOMPLISHMENTS

SUB OBJECTIVE #1 - Institutional Capacity Building: To strengthen state and local government capacity to deliver and promote use of high impact MCH/FP/RH interventions

Although anchored in this sub-objective, capacity building is cross-cutting throughout all four sub-objectives of TSHIP. A simple understanding of “capacity” for TSHIP is presented in Box 1. In line with this understanding, capac-ity is the ability of individuals and organizations or organ-izational units to perform functions effectively, efficiently and sustainably. Capacity building is a process and insti-tutional, organizational or technical capacity is an ability that enables an organization (or community) to systemati-cally mobilize, direct and use resources. These resources help the organization achieve its objectives in accordance with its mandate and values. Based on this understanding and within the context of WHO’s definition of “health sys-tem,” TSHIP focused on five activity areas for building in-stitutional capacity: health services management, training

and development of human resources, infrastructure development and equipping, and com-modity security. A major focus of attention is management of health services in general. In both Bauchi and Sokoto, the aim is to strengthen the sustainable capacity to manage the health system by de-veloping the capacity for strategic and operational planning, strengthening intra- and inter-organization coordination, establishing and maintaining functioning management systems, and generating and using knowledge and evidence for decision-making. Human resources is criti-cal (quantitative and qualitative). As TSHIP is not able to assist with the quantitative aspect of HR, efforts focus on the qualitative areas: strengthening human, managerial and technical ca-pacity with an emphasis on HR for service delivery. Along with service delivery HR training and development, TSHIP focuses on improving infrastructure for service delivery (renovations and equipment), and commodities security required for service provision, including contraceptives. During the year, action was based on findings from baseline and other assessments con-ducted at the beginning of the year.

BAUCHI STATE

Health services management State, LGA and HF organizational capacity assessments. At the beginning of the project initial interactions with government partners, institutions, health facilities and service providers indicated a weakened health system. This was characterized by human resource shortages, dysfunctional drug supply systems, decaying health infrastructure, and weak supervisory and governance mechanisms. These were later confirmed by the rapid situation analysis. Organ-izational weaknesses were examined to determine the capacity of the organization to carry out

Box 2: Capacity

Simple understanding of “capacity” as ability, to:

• Incorporate, integrate, accommo-date (within an organization or program mandate)

• Perform to a set standard; enable an institution or individual to perform to a set standard

• Fulfil or achieve objective

• Carry out activities more effectively

• Deliver to expectation in relation to objectives

3.

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the delivery and promotion of high impact FP/RH/MCH interventions. The areas for improve-ment that relate directly to the achievement of TSHIP results were prioritized. Information was analyzed with respect to human resources management, resource mobilization, governance and leadership, management systems, supervision, and monitoring and evaluation. One major problem identified is the fragmented nature of the health system in the state. A number of agencies had been created with the purpose of improving efficiency in health care delivery in the state but it turned out that these agencies were not well coordinated, leading to vertical program implementation and thus hindering the delivery of integrated services. The agencies include the SPHCDA, BACATMA, free maternity and under five programs, and the HSMB. TSHIP began a series of advocacy activities to bring the agencies under the supervi-sion of the SMOH and also to create an interagency forum for more coordinated implementa-tion of activities. This has yielded results and now the different agencies consult each other and work in harmony. One good example is the distribution of IPT, which was hitherto under the custody of BACATMA. However, since BACATMA does not run health facilities and there-fore has no outlet for the drugs, this was not an efficient set up. Through TSHIP’s advocacy, the drugs are now issued to the SPHCDA, which does run health facilities in the state. The new process helps ensure that the drugs reach the desired clients: pregnant patients. The agencies are now able to carry out their activities jointly or at least after consulting with each other. The agencies meet regularly to share data and address common problems under the auspices of the SMOH. When TSHIP started, there were a large number of other donor agencies and IPs implement-ing many MCH and FP/RH programs in the state. These programs virtually all operated inde-pendent of each other or with very minimal interaction. TSHIP successfully advocated for set-ting up a health partners forum where all IPs and donor agencies can come together to share their activities with the state and other agencies. The forum is now institutionalized, meets regularly and serves as a gateway for joint activity implementation. This type of coordination energized the state to call for a state council on health to share with all relevant stakeholders in the states, especially the LGAs, key decisions on the strategic health development plan for Bauchi state. TSHIP committed technical and financial support to the activity, scheduled to be held in October 2010. TSHIP’s suggested theme for the council meeting, Enhancing Maternal Health in Our Communities, was approved. At the LGA level, findings revealed weak programs with virtually no work plans, poor health financing (including use of a traditional historical budgeting system), and poor data manage-ment (collection, collation, storage, analysis and use). TSHIP organized workshops for key LGA staff to improve their budgeting skills. This process will continue in the coming years of the project. All LGAs have been supported by TSHIP to develop and cost their 2011 work plans, which are derived from the State Strategic Health Development Plan.

Human resources and training Capacity building of partners for resource mobilization. In a bid to strengthen organiza-tional capacity for resource mobilization and to improve resource diversification skills, the 20 LGAs and selected civil society organizations (CSOs) were trained in resource mobilization and proposal development. LGAs later submitted proposals for specific projects to be sup-ported by the MDG office in the state. Another critical capacity supported area is human re-source development. For sustainability and to reduce the costs of training, TSHIP embarked on

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TOT to form a critical mass of competent trainers in different clinical areas in MNCH, FP/RH and child survival services (such as ORT and malaria case management). The effect is that Bauchi now has a core of trainers who will continue to provide cascade trainings to all cadres of providers for improved high impact service delivery. Strengthen M&E unit and activities at the state, LGA and HF levels including record keeping, filing and reporting systems. During the first quarter, TSHIP started data collection and met a number of challenges including parallel data collection, use of custom-made tools to address donors or programs, and multiple reporting directions. To harmonize data collection and streamline the flow of the data (from HF to LGA to state), an M&E framework was devel-oped in collaboration with the SMOH and its agencies. This framework will serve as a technical tool that will eventually be used to gain the needed political backing and support for data col-lection. TSHIP is systematically building the capacity of all agencies in terms of having coordi-nated regular meetings; sharing data, experiences, and lessons learned; and above all, harmo-nizing data flow from HFs to LGAs and to relevant agencies in need of data for decision mak-ing. The new NHMIS forms will be introduced early in the first quarter of PY2 and this will reduce to a minimum the multiple register system in the health facilities (which is presently the norm). TSHIP staff and staff of the SMOH and its agencies have attended a TOT on the use of the forms and are ready to commence a cascade training early in PY2. This will ensure effective data generation, processing and transporting for timely decision making by policy makers. It also will increase the number of institutions that submit timely and complete HMIS reports. TSHIP has carefully mapped out follow-up actions for all participating organizations and institu-tions in the PY2 work plan. TSHIP also has built the capacity of data managers both at the state and LGA levels in preparation for the introduction of the new NHMIS. TSHIP has sup-ported the printing of state-specific data tools for supporting the existing system in addition to the revised NHMIS. Infrastructure Development and Equipment

TSHIP has facilitated the supply of FP, ORT, IPT, and other commodities as well as essential equipment to 30 HFs. The same health facilities were also provided with emergency trolleys containing essential emergency drugs and supplies for the prevention and management of the top three causes of maternal mortality: PPH, eclampsia and puerperal sepsis. These are tar-geted interventions with direct high impact in reducing childhood and maternal mortality and morbidity. The project has mounted strong advocacy for the government and communities to continue providing for the sustainability of these services. TSHIP has also provided supportive supervision for HF staff to ensure the maintenance of good skills and values for care. The process of upgrading HFs to improve quality of and access to services began with rapid assessments in 30 HFs in Bauchi. The assessments identified staff training needs, availability of equipment, contraceptive stock levels, services available, and client load. The selection process involved the active participation of the SPHCDA. Part of the outcome of the rapid HF assessment was the identification of strategic HFs with large client flows but poor physical con-ditions. Ten of these strategic HFs were identified for upgrade, renovation and provision of es-sential equipment. The contract for the upgrade and renovations was awarded after due proc-ess involving the SPHCDA. Six of the ten HFs were completed by the end of PY1, while the others are at various stages of completion. The renovation will support increased access to quality IMNCH/FP/RH service delivery. The TSHIP integrated approach of training, renovating,

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and providing basic equipment will result in supporting and achieving both government and TSHIP objectives. The state contraceptive store was also renovated, and this will ensure security and create an environment conducive for maintaining the potency of contraceptives. For closer engagement of the LGAs and communities, three TSHIP zonal offices were set one each in the three senatorial districts of the state. These offices are now appropriately staffed and are fully functional, easing communication between the state office and the LGAs. Commodity Security TSHIP is currently working with MSN to secure additional FP commodities for the state to sup-plement FMOH supplies. Discussions have also begun with PPFN, which also seems quite promising and disposed to supporting the supply of contraceptives to some selected HFs. TSHIP wants to ensure that while all the facility upgrades and human capacity development are ongoing, SDPs are sufficiently stocked with commodities with a good methods mix and minimal stock outs to provide clients with a range of choices. The RAPID tool will be used by TSHIP as an advocacy tool for the provision of additional budg-etary allocations for FP services in the tate and LGAs. DELIVER is collaborating with TSHIP to hold monthly review meetings with all the FP/RH coordinators from the 20 LGAs and the state PHCDA. Bimonthly meetings are also held with service providers to ensure smooth CLMS and regular checks on stock outs. Presently the forum is for collecting monthly reports, experience sharing, reviewing the level of program implementation, and deciding the way forward.

SOKOTO STATE

Health Services Management

In January 2010 a health facility census and data collection exercise revealed that LGA M&E/HMIS officers hardly keep records, and some lack the ability to complete the HMIS forms that are available. Officers who have some knowledge of how to complete the forms do not submit these reports/forms on time. Reasons include lack of skills and non-availability of data tools. This has contributed to inadequate data and information from the field needed for planning and decision-making by both the state and LGAs, which is important to ultimately improving the health status and welfare of the people. In order to stem these inadequacies it was necessary to reproduce and distribute HMIS tools. This was followed by a two-day workshop for 23 LGA and four zonal, HSMB and Specialist Hospital M&E/HMIS officers on how to use the tools. Hands-on trainings on using the filing system and developing charts to track and monitor the activities at the facility level were developed and displayed at the M&E units in each of the LGAs. Phased reorganization of record keeping at the renovated and equipped facilities was carried out during the year which will continue in PY2. Also supportive supervision during the monthly data collection was initiated. Outcome:

The combination of the availability of tools, training and supportive supervision has improved the skills of M&E/HMIS officers at both the state and LGA levels. Timely and complete submis-sion of quality data has improved greatly.

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Human Resources and Training

Baseline assessment results suggest that staffing levels are inadequate and vary across the state and there are a number of health facilities that do not meet the minimum staffing require-ment levels laid out in the Ward Minimum Health Care Package. A third of the PHCs in Sokoto do not meet the minimum requirements. Thus, human resources is an important advocacy is-sue for ensuring proper planning and resource allocation. Because of the perceived role that NGOs can play in advocating for resources, TSHIP pro-vided two separate, five-day training courses on resource mobilization and proposal writing, health systems management and local organization sustainability. A total of 20 people from the government and selected organizations (NGOs) attended the training. The training was de-signed to build the capacity of MDAs and CSOs to write fundable proposals and to access funds from donor agencies for activities that will promote and improve primary health care de-livery services at the community level in order to complement the efforts of the government as it cannot meet the health needs of its citizens alone. Also because of inadequate human resources, most facilities, especially in the rural communi-ties, are being manned by a single health service provider — many of whom are not ade-quately prepared (low level of qualifications). Having realized this gap, TSHIP embarked upon increasing the skills and knowledge of these staff with a view towards helping them provide integrated services. In this regard, various trainings were conducted through the state for CHEWS, nurses and other providers on family planning, contraceptives technology updates, management of diarrhea using ORT, case management and prevention of malaria and contra-ceptives logistics management (the latter in collaboration with DELIVER). The essence of this series of training is to provide an integrated approach to the delivery of health care in the state. Outcome: Of the seven NGOs trained, four are in various stages of securing funds for health care in the state. This is expected to help in filling some noted gaps in Sokoto’s health care delivery system. Infrastructure Development and Equipment

Few facilities in the state had access to the five key infrastructure items (water source, toilets, electricity, generator and medical waste disposal) as revealed by an assessment. Therefore, in addition to supporting renovations to improve the physical structure of many facilities, there is a need to collaborate with the government and other development partners to advocate and en-sure that more facilities gain access to these essential infrastructure items.

In terms of renovations to date, seven facilities across the state are in various stages of reno-vation with three already completely renovated and equipped by TSHIP. The selection of the facilities was based on analyzing the client flow to the facilities and the communities’ needs. The three completed facilities are Women and Children Welfare Clinic (WCWC), Bini Commu-nity Dispensary and Yabo WCWC. Other facilities (such as Arkila, Specialist Hospital, Shuni and Wurno) are in various stages of completion. While it is early to determine the impact of the renovation on the affected facilities, feelers from the communities and from the available record are indicating that the renovations have started attracting increased patronage. The facilities were supplied with HMIS registers and formats, which has helped them regularly supply infor-mation to the LGAs. The LGAs are analyzing and using that information for decision making.

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Commodity Security

According to the baseline assessment conducted in December 2009, there were only 64 family planning service delivery points in Sokoto. This number has since increased to 219 through capacity building for 219 service providers (192 males, 47 females) and 23 MCH/RH supervi-sors (all females). The capacity building focused on family planning updates, introducing the contraceptive logistic management system, and interpersonal communication counselling skills (IPCC). TSHIP also gave support to train 18 service providers on long term methods of family planning (implants), which has improved the skills of providers and ensured that they adhere to basic quality standards when providing services. TSHIP has provided seed stocks (45,960 condoms; 20,840 Depo Provera; 8,160 microlut; 14,740 Noristerat; 1,752 Lofeminal; and 35,480 syringes) to the state Ministry of Health, which has resulted in increased access, coun-selling visits (see M&E tables) and use in all the LGAs. To help Sokoto assure commodity se-curity, TSHIP renovated and equipped the State FP commodity store. Through supportive su-pervision and monitoring the performance of health providers, TSHIP has helped strengthen service provision, commodity security, proper recording, and ensuring compliance with family planning statutory requirements.

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SUB-OBJECTIVE 2A: Strengthen delivery and promotion of high impact child health interventions at PHCs and establish essential referral levels

BAUCHI STATE

Routine Immunization

Routine immunization was strengthened through tech-nical assistance to the monthly state task force review meetings, where operationalizing the Reaching Every Ward (REW) strategy was emphasized. The meetings have increased the topics and opportunity for feed-back by the LGA chairmen, the PHC director, and LGA immunization officers. Ninety-two state level, 131 LGA level and 257 ward level supervisors were re-trained to strengthen the quality of routine immunization delivery in the state. This led to identifying gaps in the provision of antigens (OPV, BCG, Hepatitis B, measles and DPT) at the lowest operational level, the ward. One hundred and twenty eight out of

323 wards have more than 20% unimmunized chil-dren (0-11 months). This statistic helped reactivate the regular monthly “State Task Force on Immuniza-tion” meetings. The meetings have enabled the criti-cal appraisal of LGA performance, which was shared at the recent 20th Expert Review Committee on Polio Eradication meeting as one of the suc-cesses in northern Nigeria. TSHIP also provided technical support to 60 health facilities for regular integrated supportive supervision and the provision of safe vaccines in wards. This has contributed to achieving the performance indicator (IIP1.6.11). See Graph 1. Polio Eradication

The recent 20th Expert Review Committee meeting on the eradication of polio in Nigeria found great improvement in the area of reducing the number of “zero dose children.” TSHIP’s strengthened support for reaching every newborn child with OPV as well as its work in increas-ing the involvement of traditional and religious leaders in primary healthcare activities have cer-tainly contributed to this improvement. Nine thousand, two hundred and twenty (9,220) newborns were tracked by 479 TBAs, who had been trained and supported by TSHIP to track newborns and improve referrals to the

Number of Children Immunized with

DPT 3

32319

36048

20267

0

5000

10000

15000

20000

25000

30000

35000

40000

Bauchi

2nd Quarter 3rd Quarter 4th Quarter

Graph 1

A child receives the DPT vaccination at a health facility

19


health facilities for routine immunization services (an average of 20 newborns tracked per month per trained TBA). The involvement of 250 religious and 75 traditional leaders from the four very high risk LGAs was exceeded as a result of improved stakeholder coordination and collaboration. In addition, this steady reduction in zero dose children in Bauchi and increased DPT 3 coverage have provided the ground for restarting BCC messages on exclusive breast feeding practices through the TBAs and the introduction of growth monitoring in health facilities by service providers. The active participation of TSHIP and USAID at the 20th ERC meeting provided the opportunity to learn about the steady reduction in zero dose children and the strong surveillance system. This activity intends to ensure that the number of wild polio virus cases in USG-assisted states (IIP 1.6.B) is met and sustained.

Nutrition

The re-introduction of growth monitoring that coincided with the July IPDs was responsible for the 143 health facilities tracking children’s growth (0-59 months). The arrival of Zincfant tablets for the management of diarrhoeal episodes and malnutrition in referral centres will reduce the mor-bidity period for patients under five years of age. ORT corners were set up in 90 HFs as an initial quick win activity and later on was scaled to a total of 350 HFs. The supply of ORS sachets was sup-ported by UNICEF and BACATMA. This scale up coincided with the cholera outbreak in Bauchi and the led to a reduction in case fatality in children. See Graph 2. TSHIP also conducted capacity building for nutrition officers, clinicians and service providers from 200 health facilities. Integrated Management of Childhood Illnesses (IMCI)

The IMCI trainers in the state have been dormant, but TSHIP has begun the process of getting them back into action. TSHIP conducted an initial meeting with stakeholders (Hospital Services Management Board, NPHCDA, BSPHCDA, UNICEF and WHO) and identified the need to up-date the skills of trainers from the 20 LGAs. TSHIP has therefore identified two institutions for the training of master trainers, Jos University Teaching Hospital and Federal Medical Centre in Gombe. Subsequently, cascade trainings of service providers from secondary health facilities and PHCs will begin. The trainings will commence in the first quarter of PY2.

Malaria The Global Fund round eight was successfully completed and 200,000 LLIN were distributed in six LGAs (Bauchi, Toro, Darazo, Bogoro, Shira and Dass) in the second quarter of PY1 con-tributing to (IIP1.3.2). There were challenges due to access and poor distribution. The LQA survey conducted by the national malaria program in Abuja also revealed that although 80% of the intended households received the nets, only 51% use the nets appropriately. TSHIP, in collaboration with WHO, ARFH, BACATMA and BSPHCDA, supported regular monthly reviews to track the number of health facilities providing Artemisinin-based combina-tion therapy (ACT) and IPT and this provided BACATMA with reliable data, which it is now us-ing to forecast 2011 projections. BACATMA provided Albendazole and ACT to primary and

Number of cases of childhood

diarrhea treated

1295

6109

8875

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

10000

Bauchi


Graph 2

20


secondary schools, which TSHIP supported with a one-day training for school service provid-ers. Now, a system is in place to improve the school health environment.

SOKOTO STATE Routine Immunization

Supportive supervision. As a best practice, supportive supervision plays a very vital role in ensuring the delivery of high quality routine immunization services to the community. The LGA health coordinators, state facilitators (these are personnel employed on a part time basis by WHO, UNICEF and state technical facilitators), LGA staff and TSHIP LGA polio monitors were the technical officers involved in applying the support supervision tools at the LGA and health facility levels. They were given group training on how to perform supportive supervision, put through the national checklist for routine immunization supportive supervision, and mentored on the process at selected LGA NPI offices and health facilities using the national abridged tool. A total of 15 supportive supervision visits were carried out to LGAs and 92 HFs in the state. Gaps were found in the areas of data management (monitoring and use of data for ac-tion) and planning for services. TSHIP took the following actions to correct or fill gaps: on the job training, advocacy to LGAs and communities to provide materials in support of RI activities, funds provision, mobilization of community members on session days, and follow-up with LGA/HFs to ensure compliance.

Training and engagement of traditional leaders in RI services. Traditional leaders were also trained to monitor routine immunization services in their various catchment facilities. The NPHCDA tool for monitoring RI by traditional leaders was introduced and TSHIP participated in the training which was conducted at the Sultan’s palace. A total of 64 leaders were trained, including district heads from all the 23 LGAs and emirate council members. The district heads, with support from LGA PHC staff, will step down the training to ward heads in their various communities. Involvement of traditional leaders in RI monitoring will ensure high coverage, sustainability of efforts and de-livery of quality immunization services. The tool (TSHIP

printed 1,600 copies of the tool) will be in use start-ing October 2010 after the trainings are concluded. Reaching Every Ward (REW) Training. TSHIP fa-cilitated the state/GAVI organized training on REW. The 93 participants included ward focal persons and in charges of health facilities. TSHIP was recognized as very experienced in REW strategy because of JSI’s experience implementing IMMUNIZATION-Basics in Sokoto. The REW strategy, when fully im-

Number of Children Immunized

with DPT 3

Graph 3

Involving religious leaders: Sarkin Yaki Gagi, repre-

sentative of the Sultan of Sokoto, monitors routine

immunization services at the Gagi clinic in Sokoto.

21


plemented, will improve the quality of routine immunization service delivery and entrench the sustainability of interventions. All the activities listed for routine immunization will contribute to the project indicator of number of children less than one year of age who received DPT3 and an overall reduction in child mor-tality due to vaccine preventable diseases. See Graph 3. Polio Eradication TSHIP’s contribution to polio eradication efforts commenced earnestly in the fourth quarter. Activities carried out were geared towards reducing the number of WPV cases reported and non polio acute flaccid paralysis (AFP) rate in the state. TSHIP engaged one polio eradication officer, 16 LGA polio monitors, 88 ward polio monitors, 176 CHEWs and 352 TBAs to work in the eight very high risk LGAs of the state. These personnel were all trained and worked with the existing teams at the state, LGA and ward levels to help improve the quality of micro plans and SIAs, strengthen in between round activities (including referral of newborns for birth anti-gens) and resolve cases of non compliance. During the course of their work, these personnel engaged 1,200 settlement heads to work with teams during IPDs, 88 ward heads to monitor routine immunization sessions in their catchment facilities, TBAs to track and refer 449 newborns for OPV0 and other birth antigens. The per-sonnel also tracked 322 RI defaulters and sent them back to continue their RI schedule and sent 1,743 children who never had received any immunization to start their immunization schedule in the health facilities. They also resolved the cases of 1,080 non compliant house-holds (with 3,827 children) and ensured that 3,242 previously non compliant children were im-munized. Meetings were held in all 88 wards to review the performance of the teams and dis-cuss immunization activities at the ward level.

Nutrition

TSHIP spent much of PY1 going through the process of identifying the best nutrition interven-tion strategy. The initial plan of scaling up UNICEF’s community management of acute malnu-trition (CMAM) model was questioned because of the cost involved and difficulties with sustain-ability. Growth monitoring was then considered and submitted as part of the PY2 work plan. However, the project met with UNICEF, the state, and CMAM pilot LGA staff to study CMAM, exchange ideas/best practices and discuss the modalities of scaling up. The meeting allowed for the exchange of materials and tools used by UNICEF and field visits to sites to conduct an on the spot assessment. These tools, personnel and the scale up strategy are still available to TSHIP and will be put into use in PY2 if needed. Nutrition, as it relates to diarrhoea and its management, is an aspect incorporated in the treat-ment protocol for diarrhoea for which 80 service providers have received training.

Integrated Management of Childhood Illnesses (IMCI) IMCI as a package was not introduced in PY1. The reason for this is that the trainings are in-tensive and span over weeks, which was not appropriate during the start up phase of the pro-ject. During PY1, TSHIP met with relevant stakeholders at the state and federal levels to dis-cuss how to introduce IMCI in Sokoto. The National Primary Health Care Development Agency

22


(NPHCDA) conducted IMCI training for MSS mid-wives in the first quarter of 2010 for which TSHIP gave technical and material support. A total of 80 MSS midwives were trained during that period. TSHIP also focused on diarrhea management, train-ing 80 people (27 females, 53 males) in groups across the three senatorial zones on the classifica-tion and management of diarrhea using ORT (ORS/SSS). Service providers were also given on the job training during supportive supervision. The project equipped 120 health facilities to set up ORT

corners. This was followed by on the job training to ensure the corners are put into operation. These ORT corners serve as easily accessible units for providing rehydration services to children with diarrhea and also for demonstrating to mothers how they can prepare and administer ORT at home. It will greatly improve the present situation in which only an estimated 33% of diarrhea cases in children are referred to any health facility for treatment (NDHS 2008) and will also help in decreasing the number of children that die from dehydration due to diarrhea. It also contributes to TSHIP’s indicator of number of persons trained in child health and nutrition. See Graph 4. Zinc was procured for inclusion in the management of diarrhea along with the use of ORT. Thirty-eight cartons of Zincfant tabs (each carton containing 7,200 tabs of zinc) were delivered to the field office at the close of the fourth quarter. Zinc will be introduced to the service provid-ers and distributed in the first quarter of PY2. Malaria LLIN. TSHIP distributed 1.3 million LLINs in collaboration with the state, UNICEF and other partners in the first quarter as part of Child Health Week activities. This quantity is 300,000 short of the 1.6 million universal coverage target set for the 800,000 households in the state. Further distribution did not occur throughout the reporting period due to the unavailability of LLIN in the state. The coverage for LLIN in the state stands at 90% in PY1. The MDG plans to institute routine distribution in some selected health facilities to make up for the remaining 10% and achieve universal coverage. ACT. The availability of Artemisinin-based combination therapy (ACT) in the state during the reporting period was dependent on supplies from the Global Fund through Yakubu Gowon Center. The Global Fund round four ACT used in PY1 was received in July 2009 and was only ACT 1 and 2. The second supply, which is Global Fund round eight, arrived in August 2010 and contains ACT 1 through 4. The quantities are ACT 1 – 180 doses; ACT2 – 30 doses; ACT3 – 150 doses and ACT4 – 150 doses. On a general note, ACT was not very available in the state in the project year just ending. The small quantity received by the YGC is only limited

Number of cases of childhood

diarrhea treated

43555581

23461

0

5000

10000

15000

20000

25000

Sokoto

2nd Quarter 3rd Quarter 4th Qaurter

Graph 4

A service provider demonstrates how to prepare salt

sugar solution (SSS) to caregivers at Bini Community

Dispensary in Wamakko LGA, Sokoto.

23


to the 230 health facilities it supports in the state. This has been a challenge. SP. Unlike ACT, no sulfacoxine-pyrimethamine (SP) was supplied to the state through the Global Fund during PY1. The last supply arrived in July 2009 and was exhausted before last quarter of PY1. MDG and NPHCDA supplies to the state were poorly documented and cur-rently not available except in a few facilities that have them as old stock. Quality of malaria service delivery. TSHIP works to ensure compliance to WHO and national malaria case management and prevention protocol. The project also works to improve the de-livery of high quality malaria treatment and prevention services. In light of this, TSHIP devel-oped a module for training health facility service providers. The module incorporates the latest standards for malaria case management and prevention as contained in the 2010 WHO guide-lines. In PY1, TSHIP trained 236 people (195 males and 41 females). Out of this number, 16 are women motivators while the rest are service providers. Other Activities Child health week celebration. TSHIP supported a celebration in Sokoto during which LLIN distribution, immunization, vitamin A supplementation and de-worming activities were con-ducted.

World Malaria Day. The state Ministry of Health marked the day, April 25, 2010, with activities aimed at creating community awareness on the dangers of malaria, how to prevent it and where to seek treatment. TSHIP supported the celebration of the day with the production of T-shirts, caps, and banners. TSHIP also supported a radio discussion on World Malaria Day in which the State Director of Public Health Services and the State Malaria Focal Person re-sponded to questions raised by members of the public on malaria through live phone calls.

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SUB-OBJECTIVE #2B: Strengthen delivery and promotion of high impact MNH/FP/RH in-terventions at PHCs and establish essential referral levels

BAUCHI STATE

Maternal and Newborn Care

More than half of maternal deaths in Bauchi, like in most of Northeast Nigeria, are due to three specific complications: PPH, eclampsia, and sepsis. It is therefore critical to ensure that women with these complications have access to lifesaving emergency obstetric care. To reduce maternal and neonatal mortality and morbidity in Bauchi, TSHIP conducted activities to increase access and use of quality essential and emergency obstetric and newborn care (EmONC) services by pregnant women, mothers and their newborns. TSHIP conducted in-depth facility assessments in 30 selected phase one health facilities, ten from each of the three senatorial zones. This was to determine performance gaps at service delivery points. TSHIP selected 10 health facilities needing urgent upgrades and renovation. The project went further to provide the HFs with service delivery equipment and job aids and liaised with the MOH and SPHCDA to ensure a supply of drugs and other supplies. This will provide an enabling environment for the provision of quality services. TSHIP trained a total of 104 health workers drawn from the selected 30 facilities for prevention and management of pregnancy-related life threatening complications. The aim of the training was to empower service providers with the knowledge, skills and attitudes required for prevent-ing and managing common and major complications of obstetrics such as postpartum hemor-rhage, eclampsia and sepsis. The training also focused on essential newborn care. This will minimize delays in receiving care at the HFs. A major highlight of the fourth quarter of PY1 was that TSHIP, in collaboration with the SMOH and BSPHCDA, procured and distributed emergency trolleys loaded with drugs and materials for the prevention and management of PPH, eclampsia and sepsis to 30 health facilities in the state. This will ensure availability of essential and emergency drugs and supplies for the pre-vention and management of the three major causes of maternal death. TSHIP facilitated a stakeholders meeting to present the emergency trolleys and discuss sus-tainability. The meeting was chaired by the Honorable Commissioner of the MOH who ap-plauded this initiative and stressed the government’s firm commitment to ensure sustainability through appropriate and judicious use. He assured TSHIP that the government is committed to providing free services for maternity and under-five care and that funds from this scheme will be made available to replenish the emergency trolleys. He made a public pronouncement to the effect that His Excellency the Governor of Bauchi has a new package for free maternity services, and that NHIS and MDG schemes will also make contributions to sustain the emer-gency trolleys. He also informed the stakeholders that 40 ambulances were purchased under the MDG program and these will be distributed soon to various health facilities for improved referral and to ease transportation of patients, especially in emergency situations.

25


TSHIP strengthened post-training supervision for providers in supported HFs. A supervisory checklist for following up with health providers, who were trained in EmONC, was reviewed, field tested, standardized and adapted. TSHIP reviewed, printed and distributed protocols for prevention and management of PPH in-cluding AMTSL, and use of magnesium sulfate for the treatment and prevention of eclampsia. This is aimed at the provision of quality services using evidence based interventions. NYSC doctors and other health workers in the scheme play a vital role in the provision of es-sential maternal, newborn, child and reproductive health services in rural areas where most of them are required to work. One hundred and ten corps members who were healthcare provid-ers (doctors, pharmacists, laboratory scientists, microbiologists, nurses/midwives) were given an orientation on critical clinical interventions for reducing maternal, newborn and child mortal-ity and morbidity, including family planning, quality of care, infection prevention and community mobilization as well as sensitized on their potential role in improving maternal health in the LGAs. To create a strong bond with NYSC management in the state, TSHIP assessed the NYSC camp clinic, and provided them with basic equipment and supplies for the care of the corps members during their orientation camp. TSHIP facilitated a clinical skills training (CST) course for co-trainers, tutors and preceptors on a mastery learning approach for providing competency-based training. This is necessary for delivering evidence-based, high impact interventions. This is building on the capacity of the core clinical trainers in Bauchi state.

Maternal Care

To improve the quality and standards of care in HFs, TSHIP supported the review of an orientation package for health care providers on focused antenatal care (FANC). This serves as a platform for basic care to support normal pregnancy as well as for counselling and services for cou-ples related to birth planning, complication preparedness, breastfeeding, postpartum family planning, ITNs, IPT for malaria in pregnancy and tetanus toxoid immunization. See Graph 5. Family Planning

The TSHIP approach to family planning and reproductive health is offered within the context of an integrated health package that aims to create an enabling environment for providing quality services. To this effect, TSHIP adopted the use of a multi-pronged strategy including capacity building of human resources for health, infrastructure upgrades, family planning commodity security strengthening and expansion of service delivery outlets. As a prelude, TSHIP conducted an in-depth facility assessment to determine service delivery gaps within 30 selected phase one health facilities. This assessment informed the FP/RH pro-gram focus for PY1.

Number of ANC visits and deliveries by

skilled birth attendants in Bauchi

21005

2498

31789

3793

52296

7921

0

10000

20000

30000

40000

50000

60000

ANC Deliveries


Graph 5

26


The knowledge, skills and attitudes of service providers were strengthened through trainings for different cadres of healthcare providers in FP/RH and CLMS. By the end of PY1, a total of 290 health providers received training. Nineteen service providers were trained in interper-sonal communication and balanced counseling strategy. These were part of the state core trainers (90), preceptors (6) and tutors (4) responsible for the training of pre-service and in-service providers so that they will be conversant with recent advances in training with an emphasis on the use of the mastery learning approach.

The trainings have led to the expansion of more service delivery outlets and increased FP use in Bauchi, result-ing in achieving TSHIP’s indicators of increased number of people counseled and increased CYP. See Graph 6. To ensure compliance with standards, trained service providers will be followed up with post training suppor-tive supervision using tools reviewed, adopted and field tested by TSHIP’s government partners.

To facilitate service provision and reinforcement of knowledge, selected service delivery sites were provided with basic FP/RH equipment such as IUCD and post abortion care kits. Job aids and assorted BCC materials were adapted for reprint. To improve commodity security, TSHIP renovated and equipped the state contraceptives stor-age facility, and trained service providers on CLMS to facilitate the availability of adequate con-traceptive stock and improved logistics systems for contraceptive commodities. Additionally, effective logistics systems and the availability of FP commodities was enhanced through part-nerships with DELIVER, FMOH and SMOH through the SPHCDA. Men as Partners (MAP)

In recognition of the critical role that men play in decision-making within families, TSHIP em-barked on a program that will encourage the participation of men in family planning and other reproductive health initiatives. So far 80 WDC, VDC and CC members have been trained on the MAP strategy in Bauchi. Gender and Female Participation

To reverse the trend of low access to health care programs including FP/RH services and to reduce high fertility rates among vulnerable groups of rural women, TSHIP has begun to en-gage women-focused NGOs in Bauchi. These include Partners for Development (PFD), De-velopment Exchange Centre (DEC), RAHAMA Women Development, Christian Initiative for Children Empowerment and Development (CHICHED), FOMWAN and WODAS. The aim is to to integrate FP/RH activities into their already existing micro-credit schemes and community based distribution (CBD) programs. TSHIP will engage these NGOs in PY2 to rehabilitate the existing CBDs and also train and equip more to provide services, especially in hard-to-reach communities. Adolescent and Youth Reproductive Health

In order to increase youth access to FP/RH information, counseling and services, TSHIP iden-tified HFs providing YFS under the defunct COMPASS project. TSHIP provided them with mini-mal support in the form of BCC materials and capacity building to empower them to continue

Number for counseling visits for FP

1822

4021

7882

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Bauchi


Graph 6

27


providing YFS. During TSHIP PY2, the project intends to conduct an assessment of such facili-ties to determine their needs and to bridge gaps as appropriate. More HFs will also be as-sessed and equipped to provide ARH services to both married and unmarried adolescents. TSHIP will also liaise with NEI to introduce ARH services in selected schools targeted by NEI.

SOKOTO STATE

Maternal Health

The 2008 NDHS showed that, in Sokoto, the number of women who delivered in health facili-ties within five years of the survey was 4.4% and that 91.4% of women had no postnatal visits. Similarly, many pregnant women had neither iron nor folate tablets during pregnancy. Further-more, there was very poor record-keeping to show the initial state of maternal health in the LGAs and health facilities. TSHIP’s interventions focused on reversing this trend through promoting evidence-based practices to stake-holders, building the capacity of service providers to de-liver essential obstetric care (focused antenatal care, intermittent preventive treatment of malaria, promotion of tetanus immunization, use of iron and folate in preg-nancy), creating awareness (radio jingles) of the danger signs in pregnancy, and sensitizing TBAs on maternal and child health. See Graph 7. HMIS approved maternity and antenatal registers and forms were provided to all the health facilities in the state and their use monitored through sup-portive supervision. The existing PHC facilities in many LGAs are being positioned to provide integrated MNCH/FP services through facility renovation/upgrading and equipping and training of service providers. In the same vein, the three major state-owned referral facilities (especially the maternity units ) are being renovated to improve quality of service delivery.

Maternal and Newborn Care

The establishment of the IMNCH strategy implementation committee, comprising relevant stakeholders, has helped strengthen MNH in Sokoto. Fifty-eight health workers were trained in the last quarter of PY1. TSHIP has supported the training of 86 MSS midwives on essential maternal and newborn care, record keeping and effective referral. TSHIP established a regular orientation training for NYSC doctors and nurses to ensure they embrace the use of high im-pact interventions (a total of 51 NYSC members have been trained in the last year). TSHIP is working on deploying mobile technology to reach service providers on a 24-hour ba-sis for emergency technical support. The project has established a consultative forum (for key stakeholders from the SMOH, SMLG and TSHIP) that meets to discuss issues and promote the effective coordination of activities at the PHC and dispensary levels. For the first time, a standard maternity record form has been adopted for use in the state (soon to be printed) to capture all necessary MNH data in primary and secondary health facilities (including for AMTSL and essential newborn care).

Number of ANC visits and deliveries by

skilled birth attendants in Sokoto

Graph 7

28


TSHIP established an integrated supportive supervision (ISS) team in collaboration with the NPHCDA, through which 24 facilities were supervised and identified gaps are being ad-dressed. In collaboration with UNFPA, TSHIP has unified the training modules for doctors and nurses on maternal and newborn care in the state with the introduction of evidence-based practices. The project also is currently reviewing the training module for the CHEWs in mater-nal and newborn health (to make it more interactive and easy to learn) because they constitute the bulk of providers at the primary care level. Family Planning

A baseline assessment conducted in December 2009 showed that the number of family plan-ning delivery points in Sokoto is 64. TSHIP worked to expand these points by building the ca-pacity of 219 service providers (192 males, 47 females) and 23 MCH/RH supervisors (all fe-males) on family planning updates, CLMS and interpersonal communication counselling skills. TSHIP also supported the training of 18 service providers on long term methods of family plan-ning (implants). The training has contributed to improving the skills of providers and ensuring adherence to basic quality standards when providing ser-vices. TSHIP has sponsored transport logistics for the effi-cient distribution of contraceptives from the state store to service providers in all LGAs. This has led to improved secu-rity and increased access to and use of services in all LGAs. Furthermore, the state’s dilapidated commodity store was renovated. The performance of health providers in service delivery, commodity security, proper record keeping and compliance with the FP statutory requirements were strengthened through monitoring and supportive supervi-sion. See Graph 8. Adolescent and Youth Reproductive Health

TSHIP has selected three facilities (Maryam Abacha Women and Children Hospital, Women and Children Welfare Hospital and Specialist Hospital) in which to implement its youth-friendly services for married adolescents. This is meant to increase access to quality integrated ser-vices and information. TSHIP will provide the needed technical support to service providers in these facilities to implement such services in PY2. Twenty-eight members of FOMWAN and LGA women development officers have been initiated to serve as women motivators. These women have provided family planning and reproductive health information to young women ages 18 to 25 in some Islamiya schools and regular meeting places. TSHIP has also begun to plan for community-based orientations and sensitization workshops on women’s health, in col-laboration with the state and LGAs. Gender and Female Participation

A state-wide inventory of stakeholders identified forty-four community based providers (CBD), thirty-four adult literacy classes for women and three active youth friendly centers. This infor-mation allowed TSHIP to assess and plan for community-based trainings, sensitization work-shops and dissemination of key FP/RH messages. TSHIP is also planning to help increase counselling, referrals and the provision of non-prescriptive family planning services at the com-

Number of counseling visits for FP

Graph 8

29


munity level. The training and sensitization workshops are meant to increase community awareness of women’s health issues, which in turn will increase community support for women’s access to MNCH/FP/RH services. Men as Partners (MAP) Forty-five men were mobilized to support and promote the use of FP/RH services in three com-munities (Yabo, Bini and Wanke) of three LGAs (Yabo, Wamakko and Shagari respectively). This work will continue in PY2. The celebration of World Population Day 2010 in collaboration with the state was used to create and promote awareness of the importance of partners and families cooperating to ensure the health of women and children.

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SUB-OBJECTIVE #3: Strengthen roles of households and communities in promotion, prac-tice and delivery of high impact MNCH/FP/RH interventions

BAUCHI STATE

Social Mobilization Community mobilization strategy development. In collaboration with the BSPHCDA, TSHIP convened a stakeholders workshop in May 2010 to review various community mobilization ap-proaches that have been implemented in the northern parts of Nigeria and other locations with similar socio-cultural backgrounds as Bauchi. The approach recognizes that each community has some potential to catalyze change, and thus is aimed to build on existing structures in the state through Village and Ward Develop-ment Committees (VDCs and WDCs) at the lower level and LGA and State Social Mobilization Committees (LGASMC and SSMC) at the LGA and state levels. The resulting draft consensus (Enabling Community Action: Bauchi State Mobilization and Communication Strategy) was shared among other TSHIP staff in a one-day debriefing in June 2010 for review and adoption, to enable the rolling out of community engagement across the state. The general consensus was that the strategy was well articulated and fits into the existing state social mobilization strategy. The strategy will now be used as a working document for all activities of state social mobilization over the life of the project. Community Participation Engagement of WDCs and VDCs. During the year, 30 WDCs were engaged through a series of activities including the joint celebration of World Population Day and World Breast Feeding Week in Bara community (Kirfi LGA) and the presentation of emergency trolleys to 30 health facilities to help reduce maternal mortality. As part of TSHIP’s overarching strategy, the project built on the existing strength of active com-munity coalitions (CCs) from the former COMPASS project and the current NEI project to form part of the 30 activated WDCs. These WDCs mobilized their communities around key health interventions such as benefits of birth spacing for a well-planned society and the benefits of exclusive breastfeeding for healthy babies. The WDCs played a key role in discussing the sus-tainability plan for the emergency trolleys (as part of their commitment is to set up emergency transportation and funds for women in labor as well as conduct advocacy events). In addition, 80 champions were identified within the 30 WDCs and trained as men as partners (MAP) in FP in the entire three zones. This is with a view to improve male participation in FP/RH activities and gain their support in using modern methods of FP/RH to increase CPR.

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BCC and IEC

TSHIP supported Bauchi to create awareness of positive health practices through radio jingles, posters and other BCC/IEC materials (e.g. T-shirts and fez caps) as well as provide job aids to health facilities. TSHIP also helped create awareness among the general public of cholera pre-vention and first aid remedies, which helped in stopping the cholera epidemic. Sixty-five thou-sand posters and job aids in English and Hausa were adopted, printed and distributed to health facilities and communities. These included (but are not limited to) posters on ORS, ma-laria and child spacing; job aids on clients rights, infection prevention and Tiahrt; a partograph chart for monitoring progress of labor; and a booklet about birth spacing methods. These mate-rials created awareness, improved health seeking behavior and improved the quality of ser-vices being rendered by health providers. Radio jingles on immunization, birth spacing, danger signs in pregnancy and ANC were aired 506 times on Bauchi Radio Corporation and Federal Radio Globe FM. TSHIP received N1,163,880:00 in cost shares from the two media companies. NGO/FBO/CBO Participation Identifying NGOs for Possible Program Collaboration. Profiles on 40 NGOs/CBOs across the state were prepared to capture their location, organizational structure, areas of activities, capacity building needs, achievements and funding sources. The information will help identify NGOs that can collaborate with TSHIP in community mobilization. Mapping of Existing WDCs, VDCs and CBOs. To support community mobilization activities in PY2, TSHIP conducted an inventory of the existing VDCs and WDCs in Bauchi. In collabora-tion with the BASPHCDA, TSHIP gave an orientation for LGA health educators on how to ad-minister an inventory form for documenting the VDCs/WDCs. The health educators will be in-volved working with state community structures. The inventory provides basic information about the number and types of activities that existing WDCs and VDCs are implementing to develop their communities. The result of the inventory, coupled with TSHIP’s phased approach to supporting health facilities, provided the basis for engaging the 30 selected WDCs in PY 1.

SOKOTO STATE

Social Mobilization Community Mobilization Strategy Development. TSHIP facilitated the conduct of the com-munity mobilization strategy consensus meeting with relevant state stakeholders, including the media, NGOs, religious and traditional institutions and all IPs. A draft strategy was presented, which is meant to address social mobilization, behavior change communication, advocacy, ca-pacity building and gender mainstreaming at state, LGA and ward/village levels. The content establishes that there should be four levels to implement the approach (the village and ward at community level followed by the LGA and state levels) for social mobilization.

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Community Participation Engagement of WDCS and VDCs. TSHIP conducted a meeting with the head of the PHC unit of the MLGA and CD on the issue of WDC activation across all LGAs. The meeting succeeded in getting the ministry’s commitment in directing all LGA PHC coordinators in the state to set up adequate machineries that will ensure reactivation and revitalization of WDC/VDCs. Similarly, TSHIP facilitated a series of consultations with relevant stakeholders (NPHCDA AC-QUIRE and UNFPA) involved in the formation of WDC/VDCs. So far, 40 WDCs have been identified to be active in mobilizing community health interventions. BCC and IEC

TSHIP compiled an inventory of BCC/IEC materials from past and present programs in North-ern Nigeria with a thematic thrust in maternal and child health and family planning. Some of the materials reviewed were obtained from the ACQUIRE project, UNFPA, UNICEF, COMPASS, and the SMOH. They include a TIAHRT poster; posters encouraging women to receive ANC; posters on family planning, nutrition and malaria prevention; and child immunization charts. The materials are expected to be reproduced in PY2. During the Muslim fasting period of Ramadan, TSHIP supported five prominent Islamic schol-ars to integrate in their preaching key messages on FP/RH/MNCH. Topics included ANC, hos-pital delivery, post partum, child health and nutrition (including effectiveness of ORS in treating diarrhea), men supporting women’s reproductive health, and women’s rights on family issues. An estimated 10,000 audiences were physically reached by these scholars. An even greater number were reached through radio and TV because the programs were broadcast. The activ-ity was aimed at encouraging positive health seeking behaviors among women and house-holds to increase hospital delivery and other child health care delivery. During the last quarter of the year, TSHIP developed and supported the airing of radio jingles to inform the public about the importance of the danger sings in pregnancy, focused ANC, birth spacing and ORS. The jingles further stressed the need to patronize health facilities for inte-grated health care service delivery. The jingles were run for three weeks with each spot airing in three slots per day, totaling about 252 slots. Similarly, during the flood disaster in Sokoto, TSHIP facilitated the production and airing of a jingle to educate people, particularly those in flood affected communities, on the necessary steps to avoid infectious disease. The jingle was aired three times per day for four days. NGO/FBO/CBO Participation Mapping of Existing WDCs, VDCs and CBOs. TSHIP collaborated with ACQUIRE and Kan-nawa Youth Vanguard to sensitize over 200 Wanke community members in Wanke village of Shagari LGA, on the benefit and importance of community ownership in providing health care delivery services. The community has adopted a model called “community action team,” com-prising various community representatives, and has provided a mechanism to support and monitor the progress of pregnant women and refer them for ANC. The model also supports SIA and RI activities. On WDC activation, TSHIP conducted a brainstorming meeting with the LGA health education

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officers on the need to identify existing WDCs and plan for the formation of new WDCs in their respective LGAs. The meeting ended with a review and distribution of a WDC inventory form which enabled the LGA health educators to obtain detailed information about the existing WDC structures and their functionality. The forms were entered into a developed database that will be used to determine the baseline of WDC activities across the 23 LGAs. So far the informa-tion obtained from the forms indicates that more than 70% of the existing WDCs are inactive, while even those that claim to be active seem to be engaged only in a few instances such as during IPDs and other special events. They were also able to identify the various IPs commit-ted to WDC activities in the LGAs in order to avoid duplication and also complement respective efforts. LGA and Community Support

Zonal offices were created in order to ensure closer support and contact with the LGA and other facility based interventions. So far the zonal structure seems to be stable in terms of co-ordinating field activities. The offices have been organizing LGA level trainings and supportive supervision. They also helped maintained adequate communication between TSHIP and LGAs.

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SUB-OBJECTIVE #4: Improve policies, programming and resource allocation at the state and local levels

BAUCHI STATE

Introduction

To achieve sustainable access for integrated MCH/FP/RH services, TSHIP works to provide an enabling environment that can be nurtured over the lifespan of the project. This necessitates supporting the state and twenty LGAs in a coordinated fashion to develop, disseminate and implement policies, plans, guidelines, laws and regulations that will support the delivery and use of high impact health interventions. In addition, TSHIP works to develop evidence-based advocacy models and mobilize additional resources to support increased access to MCH/FP/RH activities. Development and Implementation of Policies, Plans and Guidelines Bauchi State Strategic Health Development Plan (2010 – 2015). TSHIP supported the SMOH to develop a costed State Strategic Health Development Plan using participatory ap-proaches involving key players within the health sector. This plan has strengthened the health system of the state through the roll out and implementation of proven and cost-effective health interventions that would make the desired impact at the individual, family and societal levels of the state. In the same vein, the health departments of all the LGAs were supported by TSHIP to derive their 2010 annual health operational plans from the SSHDP.

Adaptation of the Ward Minimum Health Care Package to Bauchi State. In an effort to de-centralize and strengthen community health systems, TSHIP supported the adaptation of the Ward Minimum Health Care Package to the state incorporating relevant socio-cultural and demographic variables of the communities. The package incorporates roles and responsibili-ties of the different levels of care within the primary health care system including expectations from the Ward/Village Development Committees (WDC and VDC). Subsequently, implementa-tion of this guideline will be followed through with training, implementation, monitoring and su-pervision. Development of Referral Guidelines and Linkages within the State Health System. During the period under consideration, TSHIP commenced the process of facilitating the development of referral guidelines and linkages within the state health system in a bid to improve access to quality health care services. With over one thousand primary health care facilities and twenty-three general hospitals, there are no proper linkages between these facilities either for the pur-pose of emergencies or specialized care. TSHIP intends to strengthen the two-way referral system of the state for improved MNCH/FP/RH services. Development of Quality of Care Performance Standard Tools. TSHIP supported Bauchi and Sokoto state MOHs to develop draft performance standards for their secondary health fa-cilities. These standards when completed will be used as supportive supervisory tools to im-prove and promote joint problem-solving skills for better service delivery. The areas addressed

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in the tools include FP, ANC, PPH, DRud supply, RI, BCC, infection prevention and manage-ment of complications. When completed the tools will be disseminated and distributed to all general hospitals, a pool of trainers developed and roll-out monitoring and supervision con-ducted. Development of Evidence-based Advocacy Models

Use of the RAPID model. Using the RAPID model, TSHIP has developed an evidence-based advocacy presentation that will be used to engage policy makers, technocrats, gatekeepers and civil society groups to focus more attention on social sector development. Based on con-sensus among stakeholders, some of the critical areas addressed by RAPID for Bauchi include girl-child education, health services, family planning and status of women. Policy Dissemination and Advocacy Rapid Policy Assessment Findings. An assessment of prevalent national MCH and RH/FP policies in Bauchi State was conducted by TSHIP. The rapid assessment sought to find out the level of stakeholder involvement in policy planning, development, dissemination, implementa-tion, resource availability, service delivery and supportive supervision. The assessment also determined whether the policies have been adopted/adapted to the local scenario. An assess-ment tool was developed to capture relevant information from respondents. Findings from the assessment were disseminated during the inaugural work plan development workshop.

Dissemination of State Health Budget Analysis & Findings. Also disseminated during the workshop was the budgetary allocation to the health sector over the last four years (2006 – 2009). The budgetary provisions for health care services ranged from 6.4% to 14.8% from 2006 to 2009. The government budget for the health sector increased by two fold from 2006 to 2009. Thus in 2009, the Bauchi state budget for the health sector peaked at 14.8% compared to the benchmark set during the Abuja Declaration of 2001 of 15%.

Sensitization of Traditional and Religious Leaders towards MCH/FP/RH Interventions. During the year, TSHIP conducted workshops for traditional and religious leaders from the six emirate councils of Bauchi State. Findings from NDHS 2008 were disseminated with particular reference to some of the health indices of the state, particularly in MCH/FP/RH. Activity plans including ways forward were developed by participants to disseminate similar findings to their communities.

SOKOTO STATE

Development and Implementation of Policies, Plans and Guidelines

The Sokoto state MOH developed a five year State Strategic Health Development Plan (2010-2015) to address MNCH/FP/RH issues in the state. TSHIP has facilitated the operationalization of the plan by integrating it with TSHIP’s strategic and work plans. For the state to have and effectively implement national MNCH/RH/FP policies, TSHIP made available and distributed a number of samples of such policies. These included the new global policy on malaria control, the national clinical service protocol for obstetric and neonatal care and the national family planning and reproductive health service protocols. TSHIP also ob-tained the new WHO global strategies and guidelines on malaria control and shared them with

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the state MOH. With TSHIP support, the new malaria control strategies were incorporated into the existing ninety-four copies of the old strategies and distributed to health facilities. Sokoto state government introduced “free medical services for the pregnant and children under the age of five” to address the high maternal and infant mortality rates. To ensure that all stakeholders in the health sector fully understand and implement the provisions as contained in the statement, TSHIP initiated the process of developing a policy document for the program. The document is expected to be completed in PY 2. A diarrhea treatment chart that guided service providers at health facilities in the state had been developed and produced in English by the Sokoto MOH. The procedures as contained in the chart needed to be translated into local languages for easier comprehension and wider us-age. To achieve this, TSHIP facilitated the translation of the English version into Hausa. TSHIP shall further assist the MOH by printing and distributing 1,000 copies of the translated version. Development of Advocacy Models

In Sokoto, there is no advocacy model in the area of MNCH/FP/RH services being used. This somewhat affects the extent to which ad-vocacy efforts produce results. To facilitate availability of such a model, TSHIP supported the establishment of a group of “champions” and the process of developing a RAPID model with key messages on health, housing and education. The model portrays evidence-based situations in the state to promote use of health services and girl-child education. Documentation of Evidence Base

To establish budgetary provisions made and released by the state for MNCH/FH/RH services in 2007 and 2008 fiscal years, TSHIP did an analysis of the 2007, 2008 and 2009 state budg-ets. In particular, the analyses covered allocations and releases for EPI/ORT, vaccines, immu-nization/IPDs and malaria. The outcomes demonstrated the gaps between the amount planned to be spent and the actual amount released for such services. The results from the analyses will be used for advocacy purposes to increase allocation and release of funds for MNCH/FP/RH services. Dissemination of Policy and Advocacy Documents

Cultural and religious resistance to some aspects of IMNCH/FP/RH policies is widespread in Sokoto. To build support for these policies and strategies among traditional and religious lead-ers, TSHIP collaborated with the State Arabic and Islamic Education Board and the State Min-istry of Health to disseminate the contents, key strategies and importance of the IMNCH policy/strategies to 50 traditional and religious leaders in the state. Key findings from the 2008 NDHS

Champions receive training on the RAPID model, which will be

used to promote the use of health services and education for

girls in both Bauchi and Sokoto.

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were also shared with these traditional rulers and religious leaders to attract their support for relevant policies in the state. Financing and Resource Mobilization In order to find alternative sources to public sector financing for MNCH/FP and RH services in Sokoto, TSHIP took the initiative of profiling local NGOs and FBOS that have the potential to attract funding from other sources, especially donor agencies. Seven local organizations (FOMWAN, PPFN, Life Helpers Initiative, Women Support and Development Initiative, Rural Women and Youth Development, COMDI, Master Trainers) were selected and trained on re-source mobilization including fundable proposal writing, development of strategic and sustain-ability plans, financial management and organizational management. Public-Private Partnerships To introduce public-private partnerships (PPP) in health sector financing, TSHIP identified rele-vant corporate organizations, developed strategies for partnerships and made direct contact with the Cement Company of Northern Nigeria (CCNN) and MTN Nigeria. Areas for collabora-tion between the state and CCNN were jointly identified, including where TSHIP could provide technical support. The process is ongoing. TSHIP also brought to the fore the importance of PPP in health sector financing and method-ologies for doing so by the state at the Strategic Health Development Plan integration work-shop held in Zaria. The MOH asked TSHIP to assist by contacting companies such as Roads Nigeria, Mother Cat and Julius Berger.

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PROJECT SUPPORT

Service and Management Quality Assurance Stakeholders Orientation. Facilitated SBM-R evidence-based orientation meeting with state, LGAs and other relevant stakeholders as well as TSHIP staff to introduce, orient and promote the use of SBM-R performance standards in health facilities of Bauchi and Sokoto to improve the quality of health care services. Selection of Phase One SBM-R Health Facilities. In collaboration with states and LGAs, TSHIP selected 24 SBM-R phase one facilities (12 general hospitals and 12 primary health facilities each (a total of 24 facilities in Bauchi and Sokoto). This will enable TSHIP to start im-plementing the standards management and recognition approach for quality improvement of health care services in a phased and scaling up manner so that the implementation process will be systematic and focused. The best performing facilities will be recognized and implemen-tation will be scaled up to the next phase of facilities. Development of Performance Standards. TSHIP facilitated a three-day workshop to review and adapt performance standards for MNCH as well as immunization, malaria, nutrition, EPI, BCC, facility management, drug supplies management and infection prevention. The perform-ance standards will be use by service providers to improve health care service delivery across the two states. Capacity Development. In collaboration with the state PHCDA and other implementation part-ners (AID-STAR/IMM), TSHIP facilitated the training of 57 health care service providers from the 30 phase one health facilities on relevant issues related to quality of care. TSHIP also trained 76 SBM-R facilitators, couches, service providers and their supervisors on the use of SBM-R performance standards to improve the quality of health care services in all phase one facilities. These trainings have empowered service providers to use the standards based man-agement and recognition process and performance standards for quality improvement. Strengthening of Service Delivery Areas. In collaboration with GHAIN, TSHIP distributed 820 injection safety boxes that were placed in labor and delivery rooms, family planning areas and child care areas of the 30 phase one facilities thereby strengthening health facilities to pro-vide safe injection services to communities. In collaboration with the SPHCDA, TSHIP devel-oped, printed and distributed client rights posters and hand washing job aids. TSHIP also pro-cured and distributed infection prevention equipment (aprons, boots, utility gloves, plastic con-tainers for high level disinfection, hand washing buckets with tap heads, waste bins). Operations Research Development of TSHIP Operations Strategy. TSHIP developed a strategy that highlights the relationship between OR and TSHIP’s sub-objectives and activities, and aims to provide useful evidence (and support the use of this evidence) to inform TSHIP strategic activities. Development of Bauchi and Sokoto Profiles. A secondary analysis of NDHS, with specific reference to Bauchi and Sokoto states, was conducted that provides useful information in de-

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veloping sub-objective strategies as well as providing evidence continuously for advocacy to the states on relevant health issues. Establishment/Inauguration of Bauchi and Sokoto State Health Research Ethics Com-mittees. TSHIP facilitated the establishment of Bauchi and Sokoto health research ethics com-mittees in line with the states’ strategic health sector development plans. In each state, the committee will provide oversight to ensure that health research is in compliance with national and international ethical standards. Study on Operational Barriers to ITN Distribution in Bauchi and Sokoto States (2009-10).

TSHIP has undertaken a study on the operational barriers to ITN distribution in Bauchi and Sokoto. Findings will help TSHIP better understand the current operational practices related to ITN distribution and ensure better technical assistance to strengthen ITN distribution.

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COORDINATION, COLLABORATION AND PARTNERSHIP

BAUCHI STATE

Successful implementation of TSHIP hinges on effective collaboration and coordination with stakeholders at the state and even national levels. The management of TSHIP was in no doubt about the need for collaboration and coordination and from the onset identified and began en-gaging stakeholders in Bauchi. TSHIP convened a number of advocacy and sensitization meetings with key government de-partments and agencies. These included meetings with the commissioner and staff of the SMOH and its three main service delivery agencies, SPHCDA, HMB and BACATMA, to intro-duce and discuss the areas of focus for the project and share goals and objectives. By the end of PY1, TSHIP and the MOH had become strong allies and Commissioner Alh Muhammad Ya-haya Jallam and his senior staff members were always available to the project. A key activity conducted specifically with the MOH was the technical support TSHIP provided to produce the final version, including costing of activities, of the Bauchi SHDP. In March the three USAID flagship projects were launched and the commissioner for health facilitated a courtesy call to the Executive Governor of Bauchi state during which an MOU be-tween USAID and the government of Bauchi was signed. Throughout the year TSHIP had good working relations with the SMOH and its agencies. In June 2010 the project held a bilat-eral technical session with the SPHCDA to identify key areas of collaboration and support. During this meeting we came to an agreement on how to go about the upgrade and equipping of the 30 selected HFs. The agency provided the project with technical staff that assessed and costed the required upgrades and these HFs were renovated during the first year of the pro-ject. The project also collaborated with another agency of the SMOH, BACATMA, in many ar-eas including the distribution of nets. In collaboration with BACATMA, TSHIP supported the distribution of 1,493,303 LLINs to 14 LGAs. TSHIP is working in Bauchi state in close collaboration with the two other flagship USAID pro-jects, NEI and LEAD. NEI was initially accommodated in the TSHIP office before they secured their own accommodation. TSHIP participated in one of the first activities of NEI; this was the democratic selection of the 10 LGAs that NEI would be working in. This exercise took place in the Ministry for Budget and Economic Planning, was attended by key government stakeholders including the LGA protem chairmen, permanent secretaries, senior government advisors, and NGOs. The participation of TSHIP in this exercise served two purposes. TSHIP needed to identify with the LGAS where the education project will be implemented (10 LGAs were se-lected based on criteria such as school retention and prevalence of HIV). Secondly this was an opportunity to meet many of the leadership in the Ministry for Budget and Economic Planning as well as the LGAs. From these early contacts the two projects have maintained close work-ing relations with regular involvement in each other’s activities such as work planning, and IEC/BBC material development. The two projects of NEI and LEAD were actively involved in the development of the community and social mobilization strategy for TSHIP and even the WDCs profile conducted by TSHIP. This will be the strategy that will direct the way communities will be engaged for support to social services in the state.

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In March 2010 TSHIP, NEI, LEAD and GHAIN/FHI collaborated to conduct a joint launching of the three USAID flagship projects in Bauchi state. This was a successful joint activity, the high-light of which was the MOU signing by USAID/Nigeria Mission Director Ray Kirkland and the Executive Governor of Bauchi state, His Excellency Mallam Is Yuguda, on behalf of the gov-ernment and people of Bauchi state. This joint collaboration also provided an opportunity for the project teams to pay a courtesy call to the Bauchi Emirate council. The Mission Director met and interacted with the Late Emir of Bauchi Alhaji Suleiman Adamu who gave his whole support for the implementation of the respective projects. The Emir did not live long enough to witness the implementation of these projects; he died in July 2010. The projects have again connected with the new Emir, Alhaji Rilwan Suleiman Adamu, a promising young man with a lot of enthusiasm for the support of community engagement and he is a potential ally for the projects. TSHIP is working hand in hand with the GHAIN project. TSHIP and GHAIN are working in common HFs. Presently three HFs, Yalwa MCH, Durum MCH and Bayara General Hospital are enjoying the support of GHAIN with regard to PMTC and HIV care and support. TSHIP is upgrading the facilities and providing them with essential equipment for RH/FP services. DELIVER is another project with activities in Bauchi for contraceptives logistics management and is collaborating with TSHIP for the training of providers in CLMS: 74 providers were jointly trained. DELIVER and TSHIP have institutionalized bimonthly meetings with 21 LGAs and state RH/FP coordinators and service providers from 157 out of the 283 SDPs. These review meetings served to build the capacity of the providers and the supervisors in CLMS while en-suring regular supply of FP commodities in the supported SDPs. In the second year the meet-ing will involve all the service delivery points in the state. DELIVER has also worked with TSHIP to develop contraceptives needs for Bauchi and Sokoto. Regular contraceptive supplies are key to successful implementation of TSHIP and every op-portunity is explored to source for commodities. This desire has lead TSHIP into a potentially fruitful collaboration with PPFN and Marie Stopes Nigeria. A meeting was held with the PPFN northeast zonal office located in Bauchi and this has now been carried to the national level. Arrangements are in top gear to finalize a working relationship with PPFN in PY2. Marie Stopes Nigeria (MSN) already has a presence in Sokoto and is working to provide sup-port for LA/PM in some selected HFs. TSHIP has been in discussions to pave the way for MSN into Bauchi and for the two projects to work together in the two TSHIP states. Presently activity plans have been developed and agreed upon while an MOU is being finalized. TSHIP is leaving no stone unturned in Bauchi and every implementer is regarded as a poten-tial ally. The PDF, a Packard Foundation grantee, provides microcredit support to rural women with some activities in RH/FP. TSHIP has been in close discussion with PFD to explore any way of engaging them to provide more support for RH/FP, including referrals to HFs supported by TSHIP. This will be actualized in the second year of the project. Other players in Bauchi closely related to the government but who are activity involved in health care delivery are the MDG funded project and the NHIS. These agencies are involved with HF upgrades and supply of essential drugs. TSHIP is engaging these agencies for col-laboration especially in the area of supplies to HFs supported by TSHIP. Joint HF upgrades, human capacity development and sustainability of emergency trolleys supplied by TSHIP are areas being considered for this collaboration.

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The CIDA-CIET project, working in institutional capacity building and health systems strength-ening, is being implemented in Bauchi. They have conducted a social audit for maternal out-comes in all 20 LGAs in Bauchi. This document which CIET shared with all IPs will serve as a useful resource for community engagement by TSHIP. TSHIP is also exploring more areas of collaboration with the CIET project. ARFH is a recipient of the Global Fund for malaria and TSHIP has collaborated with them in the training of providers in malaria case management. Jointly 173 service providers across Bauchi state were trained in a three-day cluster activity of 30 per clusters. In collaboration with BACATMA, ARFH, and the Ministry for Local Government, TSHIP sup-ported the distribution of anti-malarials and RDT kits supplied by the Roll Back Malaria (RBM) program to trainees to increase availability of medicines in HFs, and thereby promote in-creased use of health facilities. ACQUIRE Fistula Care project is also coming to Bauchi and discussions have begun at the national level to identify areas of collaboration including joint production of IEC/BCC materials for both Sokoto and Bauchi. The Bauchi state designated center for fistula care is Bayara Gen-eral Hospital which is already a TSHIP supported facility and the ACQUIRE project will be based in this hospital. As it is Bauchi is presently endowed with many IPs and donor agencies and TSHIP is con-stantly looking out for new alliances for synergy and effective implementation of high impact MNCH/RH/FP services.

SOKOTO STATE The Sokoto office continues to develop new and strengthen existing partnerships, and to facili-tate collaboration with the MOH, local government, and women’s affairs as well as sister pro-jects (NEI, LEAD, GHAIN, ACQUIRE, SFH) and other development partners (WHO, UNICEF, MSF, UNFPA, DELIVER, MSN, etc.). When possible, we put our counterparts from the government in the driver’s seat when con-ducting most activities. These include planning meetings, capacity building, and supportive su-pervision. Even in deciding which facilities to renovate and what changes to effect (where nec-essary), we carry the state along. On a regular basis TSHIP meets with ministry officials for events and activities such as the monthly roll back malaria meeting, the quarterly malaria technical working group, and the task force on immunization. TSHIP also strongly supported the state in conducting Child Health Week and in celebrating World Malaria Day and World Population Day. Among efforts at collaboration and coordination with other stakeholders are: • Joint sensitization workshop for traditional and religious leaders to introduce the three

USAID flagship projects. • Regular monthly meetings of the five USAID-supported projects in Sokoto. One of the

achievements of such meetings is the harmonization of procedures such as per diem, transportation reimbursement, honoraria payment, etc.

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• Meetings with the Secretary to the State Government and the Committee on Bilateral and Development Projects in the State House of Assembly.

• Joint advocacy visit to Wanke Community in Shagari LGA (conducted together with AC-QUIRE).

• Community mobilization strategy development (in collaboration with UNICEF). • Participating in and supporting the health partners forum where all development partners in

the health sector meet monthly to brief one another on achievements and plans for the coming weeks and months. The meeting is chaired by the Commissioner of Health.

• Working very closely with WHO and UNICEF on polio campaigns. To this end, TSHIP de-ployed two polio monitors and 11 ward monitors to each of the eight high risk LGAs. In ad-dition, TSHIP worked with 352 TBAs to support the campaign tackling non-compliance and encouraging mothers to ensure that their babies get OPV0 drops and other birth antigens. TSHIP also supported some 1,600 settlement heads in monitoring IPDs.

• TSHIP also is working with the Yakubu Gowon Centre to scale-up ACT distribution beyond their present 230 facilities.

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MONITORING AND EVALUATION

Through a two-pronged strategy (strengthening M&E systems and promoting evidence-based decision making), TSHIP promotes the principle that M&E is a problem-solving and learning activity operating within the states’ existing M&E system and has spent PY1 establishing a strong foundation for this approach. TSHIP M&E activities fell into two main categories: 1) sup-porting the TSHIP sub objective teams to collect, analyze, and use data for strategic planning and decision making and 2) strengthening state level M&E systems including HMIS. The development of the performance management plan (PMP), which was carried out in a col-laborative process that included involvement of major stakeholders, established the project’s overall M&E strategy, indicators to be reported to USAID, description of data sources and flow of project data, and approach to data quality assurance. The PMP is grounded in the strategy that TSHIP will facilitate the collection, analysis, and use of data within the existing state infor-mation system while building its capacity over time. With close partnership from the Bauchi and Sokoto state Ministries of Health as well as key state agencies, TSHIP implemented a health facility rapid baseline assessment in a sample of health facilities in the two states from January to April 2010. The purpose of the assessment was to determine the extent to which health facilities in each state provide quality and integrated FP/RH/MCH services, serve as a reference in dialogue with state policy and decision-makers, aid project work planning, and es-tablish a project baseline. A baseline report was produced and disseminated to all key stake-holders. TSHIP developed internal M&E processes in order to collect, analyze, report, and use data. The project first developed procedures for HMIS data collection and quality assurance includ-ing a capacity building checklist to guide the process, gained initial feedback from LGA and state staff, and then familiarized project staff with the NHMIS and other state-based reporting forms. The sroject started its capacity building and data collection visits at the LGA level in January 2010. After each month, the process has been reviewed together with state and LGA staff and necessary adjustments have been made and progress over time has been tracked. During the LGA visits, data management processes were established and strengthened. For instance, LGA staff was trained to develop monitoring charts to track submission of different forms and were trained to develop and use data compilation forms to summarize monthly data. TSHIP also supported the states with printing and distribution of HMIS forms. Further, TSHIP has also started to develop a prototype M&E database to capture HMIS and other project data such as training information. TSHIP provided technical assistance and support to Bauchi and Sokoto states to build macro-level capacity for leading and coordinating state-level M&E and supporting LGAs, facilities, and communities to strengthen M&E systems. In Bauchi, the project supported several meetings between the state and LGA M&E officers to define roles and responsibilities and to institute a more coordinated system of data flow. Further, these discussions included a review of existing data collection tools and brainstormed plans on how to harmonize existing forms as well as how to roll out the NHMIS tools. In Sokoto, all twenty-three LGA M&E officers have been trained on how to use the NHMIS data collection tools. Further, TSHIP with the assistance of an M&E consultant, held several discussions in Bauchi and Sokoto States including all relevant ministries, agencies, and implementing partners regarding the development of a state level technical M&E working group, which would lead the development and implementation of a state M&E framework as well as lead and coordinate M&E activities within each state.

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PROJECT MANAGEMENT

Introduction

The finance and administration (F&A) team provided timely financial and administrative support to program technical teams to implement the overall project objective and sub-objectives. The F&A team also ensured that TSHIP business transactions at all levels of management were carried out in compliance with laid down policies, rules and procedures and importantly in com-pliance with USAID rules and regulations. Operational, financial and personnel manuals and guidelines were developed and implemented. Organization and Staff Structure

After considering several possibilities and options, sub-objectives were decided to be the basis for organizing staff. In each office (Bauchi and Sokoto), five sub-objective (SO) teams were created respectively for the four TSHIP sub-objectives (SO 2 was bifurcated into child health, and maternal and newborn health and family planning/reproductive health). The COP, DCOPs, directors of finance and administration and directors of monitoring and evaluation were consti-tuted as the senior management team (SMT). At the state level, the DCOP, five SO team lead-ers, assistant finance and administration specialist and M&E officer were organized as pro-gram management teams (PMT) for each of the two states. Quarterly and monthly SMT and PMT meetings, respectively, were instituted. Weekly review and planning meetings allow for information sharing and joint planning of activities. Staffing Though the recruitment process is time consuming, especially for highly skilled and competent personnel, by September 30, 2010 TSHIP had attained close to 85% hiring and deployment of the proposal planned staffing. This percentage excludes the 16 drivers whose recruitment is more dependent on the number of vehicles on the ground. By the end of the first quarter of PY2, TSHIP project staff on board (both planned and additional staffing) is expected to hit the ceiling mark of 103 staff. This total excludes the 28 polio staff that are hired on temporary bases and as local consultants. The recruitment is ongoing and in an advanced stage for the position of senior monitoring and evaluation specialist and communications and knowledge management specialist. As stated above, the two positions are expected to be filled before the end of the first quarter in PY2. Systems and Procedures

To ensure that sound internal financial and administrative controls are in place, the following operation manuals, policies and procedures have been developed, adapted and operational-ized:

• Finance and accounting manual • TSHIP operations manual • Staff personnel handbook • TSHIP organizational structure handout

7.

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These policies and procedures have been widely discussed with staff before adaption and op-erationazation of the same. These structures, policies and procedures are expected to guide the life of the project and accelerate project implementation at all levels of implementation. Procurement

Procurement committees have been established, one in each state office, to oversee the se-lection of vendors and work as catalysts to fasten the procurement process and ensure trans-parency, accountability and integrity in the all procurement processes. Most of the project start up procurement requirements have been achieved (office space in Bauchi, office furnishing and equipment, computers, generators, program procurements [e.g. medical suppliers, printing of IEC/BCC and HMIS forms, emergency trolleys, and suppliers for ORT canners and procure-ment of equipment and furniture for the renovated and improved health facilities]). Though the procurement and delivery of vehicles has taken longer than anticipated, major pro-gress has been made and the shipment of 11 vehicles is now expected to dock in Lagos on October 19, 2010. Before the end of October the vehicles are expected to be on the road. TSHIP has benefited earlier with two vehicles donation from USAID and the vehicles are in good shape and a boost to the pool. The IT communication systems procurement also is ex-pected to be finalized and functional before the end of October 2010. Zonal Offices

It took longer than anticipated for the SMOH to allocate office space in each selected senato-rial zone. When finally the allocation was done, we realized that in most of the structures, ma-jor renovations were required. However, by the end of third quarter, five out of the six zonal offices were fully furnished and functional. For the Sokoto central senatorial zonal office, the SMOH kept shifting the location from one health structure to another and that delayed the process of getting the space ready. However, the space now has been finally allocated and the renovation has already started and the office will be ready and functional by the end of October 2010. Staff Retreat and Planning Meetings

The planning and logistics requirement to ensure success of these two important meetings were accomplished by the F&A team. Each meeting hosted about sixty participants and were both held at Kaduna NAF Club hotel. The first meeting was planned to bring all the TSHIP staff together for team building and work planning to achieve a common understanding of the pro-ject objectives. The strategic planning meeting objective was to come up with a clear project implementation strategy road map for the remaining four years of the project. Both meetings were successful and achieved the intended objectives. In both meetings USAID, SMOH repre-sentatives, consortium partners and stakeholders were in attendance. Health Facility Improvement In order to improve service delivery and to motivate health personnel, TSHIP renovated and improved a total of six health facilities in both Sokoto and Bauchi. The improvement of 16 other health facilities was in progress in both states and expected to be completed by the end of Oc-tober. In Sokoto the renovated facilities are the family planning commodities store, WCWC

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Sokoto, Bini community dispensary, and WCWC in Yabo LGA. In Bauchi we have completed improvement/renovation of the Bauchi contraceptive commodity store and four VIP toilets in Yelwa domiciliary hospital. The renovations in progress and expected to be complete by end of October 2010 in Bauchi are DASS MCH, Durum MCH, Baima MCH, Yelwa MCH, Sakwa PHC, Itas Gadau MCH, Gel-jore MCH, Kubdiya MCH, Buskuri MCH, and Zadawa MCH. In Sokoto they are State Specialist Hospital Sokoto South, Arkilla PHC in Wammako LGA, Maryam Ababcha Women and Children Hospital, General Hospital Wurno, Shuni Upgraded Dispensary in Dage Shuni LGA, and PHC Rinjin Sambo in Sokoto South LGA. Reporting

Financial reporting to both the JSI home office and USAID was accomplished as scheduled. Similarly, the three required quarterly reports were submitted to USAID. The financial accrual for the quarter was done in a timely manner and this was positively acknowledged by USAID/Nigeria. The monthly financial reporting to the home office has significantly improved and by the end of June the reporting was done on a timely basis. The field office financial reporting has improved greatly and the same has been acknowledged by the home office and this im-provement trend is expected to continue in PY2.

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OPPORTUNITIES AND CHALLENGES

Challenges

Inevitably, there were challenges during the year, both internal and external to TSHIP. Within

TSHIP the major challenges were: interrupted project leadership due to delayed assumption of

duties by the COP, delayed completion of the year one work plan, poor activity coordination

among technical staff, unclear lines of reporting and definition of roles and responsibilities,

challenges with staff recruitment, and delayed procurement of service delivery equipment and

supplies, project vehicles and IT/communication equipment. Virtually all these challenges were

resolved by the end of the year (actual delivery of vehicles and equipment were scheduled for

PY2). Challenges in the external environment include: lack of database in the MOH; low level

or near absence of regular partners’ coordination meetings; weak database/documentation

and data collection system at the LGA level; poor terrain and distance of some LGA health fa-

cilities for zonal offices; and too many monetary expectations from state and LGA organiza-

tions resulting from monetization of IPDs. Although good progress was made, addressing

these challenges will take longer. The following are other challenges:

• The political situation is unpredictable. TSHIP has made landmark impressions among key policy makers which need to be sustained. With elections around the corner, it is hoped that the tempo will be maintained so that we can build on existing supports without rein-venting the wheel.

• Bauchi is one of the most fragile states in the country. It is easily prone to communal, reli-gious or political crises. It is hoped that where such conflicts do arise, they would be local-ized. The project could be hampered if conflict situations become generalized in the state.

• Inadequate skilled manpower including nurses/midwives and doctors. CHEWs form the bulk of health manpower. TSHIP will identify and empower these CHEWs with necessary skills required to provide quality, integrated MNCH/FP services.

• Inadequate availability of contraceptives stock and poor access to FP services. • Poor funding is inhibiting the swift implementation of the SSDHP by states and LGAs. • The forthcoming general election is diverting the attention of the governments from their

main functions of providing services to the populace. The possible change of leadership may slow implementation of the project.

• Inadequate distribution of qualified staff in HFs. • Uncommitted and very low capacity of the management staff at SMOH/agencies. • Verticalization of programs. • Low level of funding for IMNCH/FP/RH by state and LGAs. • Inadequate research skills and capacity. • Lack of readiness to partake in research work by state and LGA stakeholders.

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Opportunities

In resolving some external challenges, opportunities were in some cases also presented. Im-portant opportunities include: general consensus on the TSHIP community mobilization strat-egy produced with a wide stakeholder participation fitting into the existing State Social Mobili-zation strategy; availability and willingness of many implementing partner agencies to collabo-rate with TSHIP in various areas of project implementation such as diarrhea control, immuniza-tion, malaria, policy, M&E, and community mobilization; and availability of State Strategic Health Development Plans that set the direction for health interventions in the two states, ena-bling TSHIP to align its strategy and activities in each state with those of the states. The follow-ing are other important opportunities: • The leadership of the states and heads of collaborating ministries and agencies have

shown a willingness to partner with TSHIP in the provision of integrated and quality MNCH/FP/RH services. This was clearly stated by the Honourable Commissioner of Health, Alh. Muhammad Yahaya Jallam at one of our engagements, “TSHIP has strengthened our leadership position and improved our coordination role within the health sector in Bauchi State. Now, we hold regular coordination meetings among all the agencies of the SMOH. We look at the state as our common goal not our individual departments or agencies.”

• The on-going MSS scheme is a golden opportunity that TSHIP could buy into. TSHIP can identify and train midwives in facilities where they work in order to empower them to pro-vide quality MNCH/FP/RH services.

• The availability of three health training institutions involved in training of health manpower. • The availability of NHIS, MDGs and the states’ free maternity, under-five and nutrition pro-

grams. Even though they do not cover all facilities, this might still present an opportunity to increase access and use of health services by communities.

• Existence of QITs and WDCs established during the defunct COMPASS and IMMUNINI-ZATIONbasics projects presents opportunities for involving communities in taking the lead in improving their health situations. TSHIP will reactivate and strengthen these existing structures.

• The timely release of participants by employers for training and other project-supported ac-tivities.

• The continual presence of officials of the relevant state and LGA agencies in TSHIP activi-ties.

• Demonstration of commitment by participants during training.

Annex I: PMP Targets vs. Progress Chart

1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Annual

State Wide Performance





Bauchi 130,000 - 32,319 36,048 20,267 88,634 68%

Sokoto 70,000 37,927 38,154 29,545 105,626 151%

Total 200,000 194,260 97%

Bauchi 5,000 - 2,498 3,793 7,921 14,212 284%

Sokoto 1,350 - 366 2,544 2,783 5,693 422%

Total 6,350 19,905 313%

Bauchi 1,200 - 497 1344 663 2,504 209%

Sokoto 600 - 155 580 1,020 1,755 293%

Total 1,800 4,259 237%

Bauchi - - - - - -

Sokoto - - - - - -Total -

Bauchi 225 - 40 (F40, M0) 271 (F172, M99) 0 311 (F212, M99) 138%

Sokoto 200 - 69 (F14, M55) 73 (F19, M54) 77 (F15, M62) 219 (F48, M171) 110%

Total 425 530 (F260, M270) 198%

Bauchi 225 - 162 (F25, M137) 275 (F78, M197) 0 437 (F103, M334) 154%

Sokoto 200 0 124(F20, M104) 102(F9, M93) 226 (F29, M197) 113%

Total 425 663 (F132, M531) 156%

Bauchi 225 - 0 150 (F113, M37) 94 (67, M27) 244 (F180, M64) 108%

Sokoto 200 - 105 (F14, M91) 42 (F35, M7) 58 (F26, M32,) 205 (F75, M130) 103%

Total 425 449 (F255, M194 106%

Bauchi 225 - 15 (F13, M2) 200 (F133, M67) 160 (F106, M54) 375 (F252, M123) 167%

Sokoto 200 - 92 (F84, M8) 115 (F59, M56) 127 (F26, M101) 334 (F169, M165) 168%

Total 425 709(F421, M288) 250%

Bauchi 0 - - 38% 43% -

Sokoto 0 - - 46% 54% -

Total -

Bauchi 60 - 0 0 60 60 100%

Sokoto 20 - 0 0 23 23 115%

Total 80 83 104%

General comments: The figures represents TSHIP supported supervision as oppose to statewide supervision. Bauchi: 30 health facilities providing RI got SS visit from the Polio Consultants and 30 health facilities providing maternal and new born care got SS on AMTSL and ENC. Sokoto: A TSHIP SMOH team conducted integrated supportive supervision to 23 HFs.

General comment: The focus here is only on completeness (which indicators were reported on) as opposed to those reported on in a timely manor. Timeliness cannot yet be assessed on a state wide level since many LGAs have not set deadlines and time stamps for report submission. We shall be reporting timeliness in addition to completeness in PY 2. Bauchi: Q3 result has been adjusted from 43% to 38% to reflect the proper tracking indicators as stated in the PMP. Sokoto: Q3 and Q4 results have been adjusted to reflect the proper tracking indicators as stated in the PMP.

10. Number of health facilities receiving at least one supportive supervision visit during the quarter with observation of clinical skills included

5. Number of people trained in FP/RH with USG funds (maleand female) (IIP 1.7.2)

General comment: The figures represent TSHIP supported training as oppose to state wide training.

General comment: CYP data is received from DELIVER via CLMIS. Like DELIVER, TSHIP is reporting data per quarter in the following way due to the fact that CLMIS data is reported bi-monthly: Q1 (Sept - Oct,Nov - Dec), Q2: (Jan - Feb), Q3 (March - April, May - June), and Q4 (July - Aug). Thus 4th Qtr. data does not include September 2010 data which will be reported in PY2 Q1. Bauchi: Q3 result figure was updated because the previous figure given by DELIVER incorrectly included both Kano and Bauchi. Q4 result figure was updated because the previous figure included only May - June and not March - April as well.

9. Percentage of HMIS indicators reported on in a timely manor

8. Number of people trained in child health and nutrition (maleand female) (IIP 1.6.5)

General comment: The figures represent TSHIP supported training as oppose to state wide training. Bauchi: In 4th Qtr, TSHIP organized and trained 140 TBAs and 20 IPDs monitors on child tracking.Sokoto: In Q3, an arithmetic error was noticed on the total number trained and was corrected bringing the total number trained from 116 to 115, annual total from 335 to 334 likewise total for the two states from 710 to 709.

6. Number of people trained in malaria prevention or treatment(male and female) (IIP 1.3.3)

General comment: The figures represent TSHIP supported training as oppose to state wide training.

7. Number of people trained in maternal/newborn healththrough USG assisted programs (male and female) (IIP 1.6.3)

General comment: The figures represent TSHIP supported training as oppose to state wide training. Bauchi: In 4th Qtr, 50 NYSC co-members were trained in emergency obstetric and new born care, 44 health personnel (Doc, Midwives and nurses) were trained in management of PPH, sepsis and eclamsia.

% of TSHIP Annual Target

AchievedComments

Bauchi: In 4th Qtr, TSHIP provided supportive supervision to 60 HFs in10 high risk LGAs. We also confirmed the incidence of vaccine stock out in the month August and September, which may contribute to drop in Qtr. 4 # of children immunized. 97% of LGAs reported on this in Qtr. 4. Sokoto: TSHIP contributed in the area of trainings and TA. 100% of LGAs reported on this in Qtr. 4.

Bauchi: During the 4th Qtr, TSHIP has provided emergency trolleys to 30 HFs and trained 60 Nurses and Midwives on management of PPH. 68% of LGAs reported on this in Qtr4.Sokoto: 71% of the LGAs reported on this in Qtr. 4.

Program Objective: Increased Use of High Impact Interventions in Bauchi and Sokoto

1. Number of Children Immunized with DPT3

State

4. Modern contraceptive rate

Performance IndicatorTotal PY 1

Target

2. Number of deliveries with a skilled birth attendant in USG assisted facilities (IIP1.6.4)

Sub-Objective 1: State and local government capacity to deliver and promote use of high impact MCH/FP/RH interventions strengthened

3. Couple years of protection (CYP) in USG-supportedprograms (IIP 1.7.1)

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AchievedCommentsStatePerformance Indicator

Total PY 1 Target

Bauchi 3,750 - 1,822 4,021 7,882 13,725 366%

Sokoto 2,250 - 259 3,910 4,935 9,104 405%

Total 6,000 22,829 380%

Bauchi 150 - 202 284 284 284 189%

Sokoto 100 - 24 234 195 195 195%

Total 250 479 192%

Bauchi 52,000 - 21,005 31,789 52,296 105,090 202%

Sokoto 20,000 - 1,456 20,629 21,466 43,551 218%

Total 72,000 148,641 206%

Bauchi 10,000 - - 12,543 22,108 34,651 347%

Sokoto 6,000 - 7,217 7,503 14,720 245%

Total 16,000 49,371 309%

Bauchi 0 - - - 2,915 2,915

Sokoto 0 - - - 1,323 1,323

Total 0 4,238

Bauchi 3,000 - - - 6,147 6,147 205%

Sokoto 810 - - - 2,145 2,145 265%

Total 3,810 8,292 218%

Bauchi 80,000 - 6,629 1,079,021 0 1,085,650 1357%

Sokoto 120,000 - 0 573,858 0 573,858 478%

Total 200,000 1,659,508 830%

Bauchi 7,500 - 1,295 6,109 8,875 16,279 217%

Sokoto 7,500 - 4,355 5,581 23,441 33,377 445%

Total 15,000 49,656 331%

Bauchi 24 - - 6.4 7.3 7.3 30%

Sokoto 12.05 - - 12 10 10 83%

Total - 0

Bauchi 0 - - 0 0 0

Sokoto 0 - - 1 0 1

Total 1

Bauchi 10,000 - - 31,264 32,223 63,487 635%

Sokoto 4,785 - - 3,248 1,794 5,042 105%

Total 14,785 68,529 464%

18. Number of cases of childhood diarrhea treated in USAID supported programs (IIP 1.6.14)

Bauchi: TSHIP provided a follow-up supportive supervision to all the ORT corners that were re-activated for diarrhea management. 58% of the LGAs reported on this in Qtr4. Sokoto: TSHIP provided ORT corners in 120 HFs. TSHIP also provided training on use of ORT for management of diarrhea cases and on how to set up ORT corner. The large increase in the fourth quarter may have to do with recent flooding in the state. 96% of the LGAs reported on this Qtr. 4.

20. Number of wild polio virus cases in USG-assisted states(IIP 1.6.B)

Sokoto: In the Q3 report PMP table, no cases were reported,but in fact there was one case. This has been corrected here.

General comment: This refers to the number pregnant women which have received both IPT1 and IPT2. Bauchi: Only July and August data were available at the time of this report. Data source is BACATMA database. 97% of LGAs reported in Qtr. 4.Sokoto: 93% of the LGAs reported on this in Qtr. 4 and the data source is RBM.

21. Number of women who receive IPT in prenatal care

19. Rate of non-polio acute flaccid paralysis cases

14. Number of pregnant women who attend at least one antenatal care (ANC1) visit

Bauchi: In Qtr 4, TSHIP was able to facilitate general hospitals sharing their monthly data on maternal and child care with the LGA PHC department. Data source is the state MCH form and 68% of LGAs reported in Qtr. 4. Sokoto: 71% of the LGAs reported on this in Qtr. 4.

17. Number of children under 5 years of age who received vitamin A through USG supported programs (IIP 1.6.12)

General comment: No vitamin A was disbursed in IPDs this quarter in either state, which is the reason why there is no data for Qtr. 4.

16. Number of newborns receiving essential newborn care through USG supported programs (IIP 1.6.8)

General comment: Since SS has not been rolled out state wide, this indicator was estimated using data from the HF baseline (78% in HFs in Bauchi provide ENC and 77% in Sokoto). It is anticipated that these figures may be high and when SS is used as the data source next quarter it is possible these figure may decrease.Bauchi: TSHIP trained 30 HFs in ENC and conducted SS to these facilities. Based on the findings of trained HFs, an estimated 1,274 newborns out of 2,505 in these HFs received ENC. This is not being used as the statewide figure since it is not representative of the whole state.Sokoto: Using the integrated checklist,SS was conducted in a small sample (23 HFs) and the findings shown that no HFs provided ENC.

15. Number of women receiving active management of third stage of labor through USG supported programs (IIP 1.6.6)

General comment: Since SS has not been rolled out state wide, this indicator was estimated using data from the HF baseline (37% in HFs in Bauchi provide AMTSL and 48% in Sokoto). It is anticipated that these figures may be high and when SS is used as the data source next quarter it is possible these figure may decrease.Bauchi: TSHIP trained 30 HFs in AMTSL and conducted SS to these facilities. Based on the findings of trained HFs, an estimated 1,456 out of 2,505 possible deliveries received AMTSL. This is not being used as the statewide figure since it is not representative of the whole state.Sokoto: Using the integrated checklist,SS was conducted in a small sample (23 HFs) and the findings shown that no HFs provided AMTSL.

Sub-Objective 2: Delivery and promotion of high impact FP/RH/MCH interventions at PHCs strengthened and essential referral levels established

13. Number of ANC visits by skilled providers from USG assisted facilities (IIP 1.6.2)

Bauchi: In Qtr 4, TSHIP started to facilitate general hospitals sharing their monthly data on maternal and child care with the LGA PHC department, which is related to this quarter's increase. The data source is the state MCH form and 68% of the LGAs reported on this in Qtr. 4.Sokoto: 71% of the LGAs reported on this in Qtr. 4.

12. Number of USG assisted service delivery points providingFP or counseling services (IIP 1.7.7)

General comment: For this indicator, Cumulative refers to the most recent quarter.Bauchi: TSHIP provided training on contraceptive technology and facilitate for provision of seed stock for HFs. Sokoto: The number was 117 in the initial report because, at the time of reporting, not data from all facilities was captured.

11. Number of counseling visits for FP/RH as a result of USGassistance (male and female) (IIP 1.7.3)

Bauchi: In 4th Qtr, TSHIP provided training on contraceptive technology and facilitated provision of seed stock for HFs. 68% of the LGAs reported on this in Qtr 4 and the State MCH form is the data source for this indicator.Sokoto: 71% of the LGAs reported on this in Qtr. 4.

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AchievedCommentsStatePerformance Indicator

Total PY 1 Target

Bauchi 2,000 - - 59,981 38,313 98,294 4915%

Sokoto 9,672 - - 1,608 14,769 16,377 169%

Total 11,672 114,671 982%

Bauchi 1,500,000 1,493,303 0 0 0 1,493,303 100%

Sokoto 1,600,000 1,300,000 0 0 0 1,300,000 81%

Total 3,100,000 2,793,303 90%

Bauchi 9% - 0% 3% 9% 9% 100%

Sokoto 9% - 0% 0% 16% 16% 178%

Average 13%

Bauchi 0 - - - - -

Sokoto 0 - - - - -

Total

Bauchi 4 - 0 3 5 5 125%

Sokoto 3 - 1 4 5 5 167%

Bauchi 5 - - 20 59 79 1580%

Sokoto 5 - - 7 0 7 140%Total 10 86 860%

27. Number of local organizations provided with technical assistance to leverage additional resources for RH/FP/MCHservices.

Bauchi: 3 state agencies, 5 CSOs, 5 Private Hosp and the 20 LGAs were trained on effective record keeping and filling, Also 17 CSOs different were trained on resource mobilization and 9 health facilities were trained on hospital inventory management.

24. Proportion of Ward Development Committees (VDCs) thatare active during the reporting quarter

23. Number of insecticide treated bed nets (ITNs) distributed or sold with USG funds (IIP 1.3.2)

General comment: In the Q2 and Q3 reports, the distribution of ITNs was recorded as taking place in Q2, but in fact it took place in Q1 in both states. This correction has been made here. Sokoto: TSHIP provided training on the care and use of ITNs.

Sub-Objective 4: Policies, programming, and resource allocation at state and federal levels improved

26. Number of policies that are developed or adapted to support improved RH/FP/MCH services

General comment: Q3, Q4, and Annual result figures have been updated. Previously, these figures were improperly summed in the annual result column. This indicator is non-cumulative thus the last quarter shows the total figure in which each policy is only counted once.

General comment: For this indicator, Cumulative refers to the most recent quarter.Bauchi: TSHIP provided training to 30 WDCs to prepare sustainability plan for emergency trolley that were distributed to 30 HFs. Also supported the WDCs to prepare implementation plan for the year 2011 activities.

25. Percentage of people that report attending health services due to exposure to TSHIP community awareness and education activities

22. Number of cases of malaria in children treated with ACT

Bauchi: Number of ACTs given to under-5 years of age constitute ACT1 and ACT2, BACATMA is the source of data this indicator. 100% of the LGAs reported on this in Qtr. 4. Sokoto: Technical assistance is being provided. 93% of the LGAs reported on this in Qtr. 4 and the data source is RBM.

General comment: TSHIP started developing data collection and monitoring tools for this indicator and it will be reported on in PY 2

Sub-Objective 3: Strengthened roles of households and communities in promotion, practice, and delivery of high impact MCH/FP/RH interventions

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Annual Achieved

Value Definition Data Source

Bauchi 130,000 88,634 213,824 41% 1%

Sokoto70,000 105,626 166,440 63% 1%

Bauchi 5,000 14,212 267,281 5% 15.7%

Sokoto1,350 5,693 208,050 3% 15.7%

Bauchi 1,200 2,246 1,176,034 0.2% 1.8%

Sokoto600 1,755 707,371 0.2% -

Bauchi 225 311 1,639 19% -

Sokoto200 219 2,376 9% -

Bauchi 225 437 1,639 27% -

Sokoto200 226 2,177 10% -

Bauchi 225 244 1,531 16% -

Sokoto200 205 2,177 9% -

Bauchi 225 375 2,098 18% -

Sokoto200 335 2,177 15% -

Bauchi 60 60 875 7% -

Sokoto20 23 638 4%

Bauchi 150 284 295 96% -

Sokoto100 117 684 17%

# of total relevant technical staff (Doctors, Nurse/Midwifes, CHEWs) calculated from SSHP.

# of total desired SDPs in the state that falls under each type (except Private Facilities) and in each level of care (all facilities)

5. Number of people trained in FP/RH with USG funds (male and female) (IIP 1.7.2)

# of total relevant technical staff (Doctors, Nurse/Midwifes, CHOs, CHEWs) calculated from SSHP.

6. Number of people trained in malaria prevention or treatment (male and female) (IIP 1.3.3)

7. Number of people trained in maternal/newborn health through USG assisted programs (male and female) (IIP 1.6.3)

8. Number of people trained in child health and nutrition (male and female) (IIP 1.6.5)

10. Number of health facilities receiving at least one supportive supervision visit during the quarter with observation of clinical skills included

StatesPY1 Targets(Numerator)

# of total relevant technical staff. Calculated from # of health workers by cadre, FP/RH identify Doctors, Nurses, CHOs and CHEWs as their target trainees.

Calculated from # of pregnant women (5% of the total population) Bauchi: 5% of 5,345,611 Sokoto: 5% of 4,161,005


12. Number of USG assisted service delivery points providing FP or counseling services (IIP 1.7.7)

# of total relevant technical staff (FP/RH identify Doctors, Nurses, CHOs, CHEWs Nutritionist, EHO and EHA) calculated from SSHP.

# of total functioning health facilities that fall under each type (except Private Facilities) and level in the state.

Target Coverage

Rate

Population Figures (Denominator)

SSHP

2. Number of deliveries with a skilled birth attendant in USG assisted facilities (IIP1.6.4)

3. Couple years of protection (CYP) in USG-supported programs (IIP 1.7.1)

Performance Indicators

Annex II: PY1 Target Coverage Rates

# of married women (aged 15-49), calculated from 2006 census priority table. Bauchi: 22% of 5,345,611 Sokoto: 22% of 4,161,005

2006 Census (2010 estimates)


2006 Census (2010 estimates)1. Number of children under 12 months who receive DPT3

through USG supported programs (IIP1.6.11)

Coverage from NDHS

SSHP

SSHP

SSHP

SSHP

SSHP

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Annex II: PY1 Target Coverage Rates

Bauchi 52,000 105,090 267,281 39% 44.9%

Sokoto20,000 43,551 208,050 21% 13.8%

Bauchi 10,000 34,651 267,281 13% -

Sokoto6,000 14,720 208,050 7% -

Bauchi 0 2,915 267,281 1% -

Sokoto0 1,323 208,050 0.6% -

Bauchi 3,000 6,147 267,281 2% -

Sokoto810 2,145 208,050 1% -

Bauchi 80,000 1,085,650 1,069,122 102% -

Sokoto120,000 537,858 748,981 72% -

Bauchi 7,500 16,279 342,119 5% -

Sokoto7,500 33,377 244,667 14% -

Bauchi 10,000 63,487 267,281 24% 1%

Sokoto4,785 5,042 208,050 2% -

Bauchi 2,000 98,294 389,160 25% 8%

Sokoto9,672 16,377 80,724 20% -

Bauchi 1,500,000 1,493,303 1,033,973 UNICEF 144% 6%

Sokoto1,600,000 1,300,000 807,962

State Data / BACTMA

161% 6%

Bauchi 30 29 323 9% -

Sokoto9 39 244 16% -



21. Number of women who receive IPT in prenatal care

Calculated from # of pregnant women (5% of the total population) Bauchi: 0.05 x 5,345,611 Sokoto: 0.05 x 4,161,005


Total # of political wards in the States Bauchi: 323 for the state Sokoto: The two States planned to institute one WDC per ward by the end of its 5 yrs in SSHP.




NDHS/Census

SSHP


13. Number of ANC Visits by skilled providers from USG assisted facilities (IIP 1.6.2)

24. Proportion of Ward Development Committees (WDCs) that are active during the reporting quarter

14. Number of pregnant women who attend at least one antenatal care (ANC1) visit

15. Number of women receiving active management of third stage of labor through USG supported programs (IIP 1.6.6)

16. Number of newborns receiving essential newborn care through USG supported programs (IIP 1.6.8)

17. Number of children under 5 years of age who received vitamin A through USG supported programs (IIP 1.6.12)

18. Number of cases of childhood diarrhea treated in USAID supported programs (IIP 1.6.14)

22. Number of cases of malaria in children treated with ACT

Calculated from % of children under 5 with Diarrhea (2 weeks preceding NDHS) x Children under 5 years of age Bauchi: 32% of 1,069,122 = 342,119) Sokoto:

# of total malaria cases in children.Calculated from % of cases of fever (malaria) in children from NDHS by total number of under five pop from census data Bauchi: 36.4% of 1,069,122 Sokoto: 9.7% of 832,201

# of household receiving ITN (2 nets given per household).

23. Number of insecticide treated bed nets (ITNs) distributed or sold with USG funds (IIP 1.3.2)

NDHS/Census

NDHS/Census

# of children under 5 (minus 0-5 months old). Calculated from Census data, 18% of the total population Bauchi: 18% of 5,345,611 Sokoto: 18% of 4,161.005



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Month DPT3 ANC ANC 1 Deliveries FP Diarrhea Total % Complete

April Expected 857 353 353 345 241 884 3033

April Reported 137 122 122 109 90 467 1047

16% 35% 35% 32% 37% 53% 35%

May Expected 857 353 353 345 241 884 3033

May Reported 864 35 35 34 30 292 1290

101% 10% 10% 10% 12% 33% 43%

June Expected 857 353 353 345 241 884 3033

June Reported 541 70 70 65 58 277 1081

63% 20% 20% 19% 24% 31% 36% 38%


April Expected 684 281 281 281 684 684 2895

April Reported 396 135 132 126 135 359 1283

58% 48% 47% 45% 20% 52% 44%

May Expected 684 281 281 281 684 684 2895

May Reported 429 127 129 79 131 359 1254

63% 45% 46% 28% 19% 52% 43%

June Expected 684 281 281 281 684 684 2895

June Reported 407 158 148 117 161 430 1421

60% 56% 53% 42% 24% 63% 49% 46%


July Expected 857 353 353 345 241 884 3033

July Reported 598 182 182 177 149 338 1626

70% 52% 52% 51% 62% 38% 54%

August Expected 857 353 353 345 241 884 3033

August Reported 239 142 142 134 122 240 1019

28% 40% 40% 39% 51% 27% 34%

Sept. Expected 857 353 353 345 241 884 3033

Sept. Reported 631 129 129 120 109 154 1272

74% 37% 37% 35% 45% 17% 42% 43%


July Expected 684 281 281 281 684 684 2895

July Reported 319 195 191 131 194 499 1529

47% 69% 68% 47% 28% 73% 53%

August Expected 684 281 281 281 684 684 2895

August Reported 424 185 180 125 189 536 1639

62% 66% 64% 44% 28% 78% 57%

Sept. Expected 684 281 281 281 684 684 2895

Sept. Reported 417 165 156 113 195 448 1494

61% 59% 56% 40% 29% 65% 52% 54%

Quarter 4: Sokoto

Annex III: Detailed Calculation Sheet for HMIS Completeness (Indicator No. 9) Quarter 3: Bauchi

Quarter 3: Sokoto

Quarter 4: Bauchi

MOsborne

Typewritten Text

55

Annex IV: Policies worked on in PY1

Sub-objective 4: Policies, Programmes and resource allocation at State and

Federal levels improved.

Indicator 26: Number of policies, plans, strategies at various levels development or

review to support MNCH/FP/RH services Stages of the Policies:

1. Initiation;

2. Activation;

3.Development;

4. Approval;

5. Implementation

S/N Policies, Plans, Strategies or Job

Aids

State

(Bauchi/Sokoto)

1 2 3 4 5

1 Bauchi State Strategic Health

Development Plan 2010 - 2015

Bauchi

2 Adapted Ward Minimum Health

care Package

Bauchi

3 Guidelines on Referrals and

linkages in health care settings in

Bauchi State

Bauchi

4 Legislation on the establishment

of Bauchi State Drug and Medical

Supply Agency

Bauchi

5 Performance Standards for

IMNCH/FP/RH services in

secondary health facilities

Bauchi

6 Develop State free maternal and

under 5 health services

Sokoto

7 Review/translate Diarrhoea

treatment chart into Hausa

Sokoto

8 Develop Sokoto State Health Strategic

Development Plan

Sokoto

9 Develop State Malaria

Control implementation plan

Sokoto

10 Inventory and assessment of state

MNCH/RH/FP laws and regulations

Sokoto

MOsborne

Typewritten Text

56

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Annex V: VISITORS TO THE PROJECT

BAUCHI STATE

Scott Moreland, Principal Investigator, Futures Group International, LLC,USA Nicole Judice, Advisor, Futures Group International, LLC, USA. Dr. Marcelo Castillo - M&E Consultant Dr. M.D. Muhammad - Executive Chairman BaSPHCDA Dr. Rilwanu Mohammed – Executive Secretary BACATMA Alhaji Haruna Adamu Tiffi – DPR&S BACATMA Garba Abdu – TSHIP AOTR, USAID/Nigeria Dr. Kayode Morenikeji - Compliance Officer USAID/Nigeria Alhaji Aminu Abubakar – Director Public Health SMOH Hajiya Amina Abubakar – Permanent Secretary SMOH Dr. Saidu Aliyu Gital – Permanent Secretary BaSPHCDA Dr. Idiris Baba – Zonal manager FHI Bauchi Dr. Khalid Omer – CIDA-CIET SMOH Bauchi Dr. Adamu Isah – Deputy Country Director, ACQUIRE Project/Fistula Care. Ahmed Maikudi Yahaya – DPR&S SMOH Bauchi Professor Emmanuel Ototolorin (Jhpiego Nigeria Country Director) Dr. Edgar Necochea (Health System Strengthening Advisor Jhpiego) Debora Bossemeyer - Sr Technical Advisor Infection Prevention and Performance Improve-

ment Advisor and Jhpiego Country Director Mozambique

SOKOTO STATE

Mr. Peter Hubbard, Director, USAID/West Africa, Accra, Ghana Dr. Ray Kirkland – USAID/Nigeria Mission Director Mr. Joel Lamstein – President, JSI, Boston, USA Dr. Mikaela Meredth – Deputy Mission Director, USAID/Nigeria Mr. Kayode Morenikeji – FP Compliance Officer, USAID/Nigeria Dr. Marcelo Castillo, M&E Consultant Joint USAID/FMOH Team on Malaria and HIV – a fact finding Mission as part of Presidential

Malaria Initiative Improve Malaria Diagnosis (IMAD) Team from USAID Humanitarian assistance team from U.S. Department of Defense

57