Support to scale up Maternal and New born Health
Outcomes for the states of Northern Nigeria
Framework Contract Beneficiaries 2013 – Lot 8
Letter of Contract No. FED/20l5/367-253/ l .l
Draft Final Report
25 February 2016
Authors: Dr. Pat Youri
Dr. Iheadi Onwukwe
The project is funded by
the European Union
The project is implemented by
International Consulting Expertise EEIG
1
ICE on behalf of Delegation of the European Union to
Nigeria
ICE - International Consulting Expertise
150, Chaussée de La Hulpe
B-1170, Brussels, Belgium
Tel: +32.2.792.49.05
Fax : +32.2.792.49.06
www.ice-org.eu
The content of this publication is the sole responsibility of ICE
EEIG and can in no way be taken to reflect the views of the
European Union
2
Table of Contents
I.
Executive Summary .................................................................................................................. 4
II.
Background ................................................................................................................................. 5
III. Project Outline and Management .......................................................................................... 5
3.1 Project Outline .......................................................................................................................... 5
3.1.1 Objectives............................................................................................................................... 5
3.1.2 Components of the Project .................................................................................................. 6
3.1.3 Target Groups ....................................................................................................................... 6
3.1.4 Direct Beneficiaries .............................................................................................................. 6
3.1.5 Expected Results................................................................................................................... 6
3.2 Project Management ................................................................................................................ 7
IV. Objectives of the Assignment ................................................................................................ 7
V.
Methodology ............................................................................................................................... 8
5.1 Comprehensive review of the project and project-related documents and reports ............... 8
5.2 Briefing meeting and presentation of Evaluation Inception Report ........................................ 8
5.3 Key Informants Interviews (KIIs) ............................................................................................... 8
5.4 Field Visit to Project States ....................................................................................................... 8
5.5 Debriefing Meetings ................................................................................................................. 9
5.6 Data Analysis and Report Writing - currently ongoing.......................................................... 9
VI. Analysis ........................................................................................................................................ 9
VII. Findings of the Mid-Term Evaluation Of The MNCH Project .......................................... 9
7.1 Relevance of the Program ......................................................................................................... 9
7.2 Program Design and Implementation ..................................................................................... 10
7.3 Validity of Assumptions ........................................................................................................ 12
7.4 Efficiency of Program Implementation ................................................................................... 13
IX. Measuring Project Benefits and Impact ............................................................................. 29
X.
Lessons Learned and Collateral Benefits of the MNCH Project.................................. 31
10.1 Lessons learned .................................................................................................................... 31
10.2 Collateral Benefits ................................................................................................................. 31
10.3 Sustainability of Project Interventions ................................................................................. 32
10.4 Alternatives Approaches....................................................................................................... 32
XI. Recommendations................................................................................................................... 33
XII. Annexes ...................................................................................................................................... 34
3
Abbreviations and Acronyms
AIDS
ANC
BEOC
BNA
C4D
CHEWs
CHIS
CMAM
CORPs
CSOs
DART
DHIS2
DNA
EU
FMOH
FP
HIV
HMIS
HTC
HTS
iCCM
IDPs
IMCI
IMR
ISS
JCHEWs
KIIs
LGA
M&E
MBNP
MICS
MMR
MNCH
MNCH-N
NDHS
NEMA
NHMIS
NPHCDA
NSHDP
NSHIP
NURTW
OPD
PBF
PCR
PEPFAR
PHC
PHCUOR
PMTCT
PSC
RUTF
SAM
SBA
SMART
SMOH
SOML
SOPs
SPHCDA
SSHDP
SURE-P
TOT
U-5MR
UNICEF
WDCs
Acquired Immune Deficiency Syndrome
Antenatal Care
Basic Emergency Obstetric Care
Bottleneck Analysis
Communication for Development
Community Health Extension Workers
Community Health Insurance Scheme
Community Management of Acute Malnutrition
Community Own Resource Persons
Civil Society Organizations
Decentralized Action-Oriented Responsive and Transparent
District Health Information System 2
Deoxyribose Nucleic Acid
European Union
Federal Ministry of Health
Family Planning
Human Immunodeficiency Virus
Health Management Information System
HIV Testing and Counseling
HIV Testing Services
Integrated Community Case Management
Internally Displaced Persons
Integrated Management of Childhood Illnesses
Infant Mortality Rate
Integrated Supportive Supervision
Junior Community Health Extension Workers
Key Informant Interviews
Local Government Area
Monitoring and Evaluation
Ministry of Budget and National Planning
Multiple Cluster Indicator Survey
Maternal Mortality Ratio
Maternal, Newborn and Child Health
Maternal Newborn and Child Health - Nutrition
National Demographic and Health Survey
National Emergency Management Agency
National Health Management Information System
National Primary Health Care Development Agency
National Strategic Health Development Plan
National State Investment Program
National Union of Road Transport Workers Union
Outpatient Department
Performance Based Financing
Polychromase Chain Reaction
President’s Emergency Plan for AIDS Response
Primary Health care
Primary Health Care Under One Roof
Prevention of Mother to Child Transmission
Project Steering Committee
Ready to Use Therapeutic Food
Severe Acute Malnutrition
Skilled Birth Attendant
Standard Monitoring Assessment Relief and Transitions
State Ministry of Health
Saving One Million Lives
Standard Operating Procedures
State Primary Health Care Development Agency
State Strategic Health Development Plan
Subsidy Reinvestment and Empowerment Program
Training of Trainers
Under-5 Mortality rate
United Nations Children’s Fund
Ward Development Committees
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I.
Executive Summary
To be developed after all inputs from stakeholders have been received.
II.
Background
With an estimated population of 180 million people in 2014, a maternal morality of 574 per
100,000 live births and infant and under-5 mortality rates of 69 and 128 deaths per 1,000 live
births respectively (Nigeria Demographic and Health Survey 2013),Nigeria has one of the
highest maternal, infant and under-5 mortality rates in the world. These deaths are from
preventable causes and are higher in the north than in the south of the country. The North
East Zone that includes Adamawa State has MMR of 8851/100000, and IMR and U5MR of
77 and 160per 1000 live births respectively whilst the North West Zone that includes Kebbi
State has MMR of524/100000live births and infant and under-5 mortality rates of 89 and
185per 1000 live births respectively.
Adamawa and Kebbi State governments are committed to improving health outcomes for
mothers and children and have developed State Strategic Health Development Plans
(SSHDP) that seek to reduce maternal, newborn and child deaths by significantly improving
the health and nutrition status of women and children under 5 years through a strengthened,
equitable and sustainable primary health care delivery system. To assist Adamawa and
Kebbi States to successfully implement their strategic plans, the EU signed a €30 million
Contribution Agreement with UNICEF to support the two State Primary Health Care
Development Agencies to scale-up maternal, newborn, and child health outcomes over a 4
year period from May 2013 to April 2017. To ensure sustainability, it is understood the State
Governments would provide strong support and funding for the project, whose interventions
would be implemented through state structures and integrated into routine activities.
The general objective of the EU Support to Scale-up Maternal, Newborn and Child Health
Outcomes for Adamawa and Kebbi States of Nigeria is to improve the health status of
women and children through an improved and sustainable PHC delivery system.
The specific objectives for improving women and child health outcomes are: (i) increase the
proportion of women able to correctly recognize pregnancy complications and seek timely
healthcare, (ii) increase the proportion of poor, marginalized rural women with increased
financial access to health facility for pre-pregnancy, routine ANC, and emergency newborn
and obstetric care services, (iii) improve access to PMTCT interventions in Adamawa State,
and (iv) improve the nutrition status of women and children along the continuum of care from
preconception to childhood.
Similar specific objectives for improving PHC delivery system are: (a) improve the
functionality of health service provision for fixed and outreach services through adequate
and qualified health personnel, adequate supplies and equipment and (b) strengthen health
systems governance by improving decentralized planning and budgeting processes for
improved accountability and transparency in the delivery of maternal and newborn services.
III.
Project Outline and Management
3.1 Project Outline
3.1.1 Objectives
The Project has a one general and 5 specific objectives
General Objective: The overall objective is to significantly improve the health status of
women and children through an improved and sustainable primary health care delivery
system.
1Unpublished data from Baseline Survey Report March 2014: EU Support for Scale-up of Maternal, Newborn, and Child Outcomes for
Adamawa and Kebbi States of Nigeria
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Specific Objectives are:
1. Increase the proportion of women who are able to correctly recognize pregnancy
complications and seek timely care, when required;
2. Increase the proportion of poor, marginalized, rural women with increased financial
access to a health facility for pre –pregnancy, routine ANC and Emergency Newborn and
Obstetric Care services;
3. Improve the functionality of the health service provision for fixed and outreach services
through adequate and qualified health personnel, adequate supplies and equipment;
4. Improve the nutrition of women and children along the continuum of care from
preconception to childhood.
5. Strengthen health systems governance by improving decentralized planning and
budgeting processes for improved accountability and transparency in the delivery of
maternal and newborn services.
3.1.2 Components of the Project
To achieve the specific objectives, the project will address five components to reinforce
institutional strengthening and increase the utilization of MNCH-N services:
1) Improved communication and timely health seeking behavior by women and children;
2) Increased Health Financial and Geographical Access for the poor and marginalized rural
women and their families;
3) Improved Health Service Delivery through functional health facilities;
4) Improved maternal, newborn and child nutrition;
5) Improving governance systems following the DART (Decentralized, Action-Oriented,
Responsive and Transparent) principles
3.1.3 Target Groups
At the State and LGA level, health staff, health facilities and administration are the target
groups of the project.
At national level, FMOH and NPHCDA will benefit from the capacity building process
inherent to the project.
At community level, CORPS, community extension workers, opinion leaders (women
groups, informal leaders, community and Ward leaders, CSOs) will be the intermediary
beneficiaries of the social mobilization activities programmed under community capacity
development of the project. Their mobilization is expected to have substantial effect on the
direct beneficiaries improved behavior/practices resulting in increasing demand for
integrated MNCH-N services.
3.1.4 Direct Beneficiaries
The direct beneficiaries are 1.5m children under 5 and 380,000 pregnant women in both
Kebbi and Adamawa states annually.
The overall projected population of Adamawa (3,760,896) and Kebbi (3,889,673) – a total of
7,650,569 will benefit indirectly from the project.
3.1.5 Expected Results
1) Increased number of institutional deliveries; increased skilled birth attendants’ rate;
increased number of women who attend ANC at least 4 times; and Increased number of
children registered at birth.
2) A paying for performance scheme is established; Increased equity in access and use of
both preventive and clinical services; and Increased number of pregnant women, women
of child bearing age and children under five (vulnerable groups) with free access to a
package of basic preventive and curative services.
3) Increased number of health workers trained in Life Saving Skills; Improved availability
and retention of health workers in Kebbi and Adamawa States; and Ensure necessary
equipment and medical supplies are available in facilities.
4) Improved nutrition of women during the preconception and antenatal period; Intrapartum
interventions to improve nutrition of newborn, and Improved nutrition of the lactating
mother, newborn, infant and young child
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5) Strengthened mechanisms (Primary Health Care Under One Roof) and the Minimum
Standards for PHC) for effective participation of LGAs and communities in decentralized
planning and delivery of essential health services; Systems established to improve
6) budget execution for improved transparency and accountability; and Improved
Monitoring and Evaluation, including impact evaluation.
Budget: Total of €33 million comprising
Governments and
€1 million UNICEF contribution
€30 million from EU, €2 million from State
3.2 Project Management
The Project has governance structures at three (3) levels – Policy, Program management,
and Operational
1. Policy level: The governance structure at the Policy level is the existing sub-committees of
the National Reference Group overseeing the implementation of the State Strategic Health
Development Plans (SSHDP). These sub-committees include Health Financing, Program
Alignment and Scale-up of Services Delivery, Advocacy and M&E. UNICEF is represented
at the Reference Group and all Subcommittees and will continue to provide technical
support in strengthening these policy platforms. Available evidence indicates that the
NSHDP Reference Group and its sub-committees at the federal level are not currently
functional. However, the health systems coordination structures and systems are under
review by the Federal Ministry of Health.
2. Project Management: A Project Steering Committee (PSC) the Honorable Minister of
Health, the Executive Director of the National Primary HealthCare Development Authority
(NPHCDA) and Chief Executives of the State Primary Health care Development Agencies
(SPHCDA) of Adamawa and Kebbi States, LGA Chairmen on rotational basis, UNICEF and
the Honorable Minister of Ministry of Budget and National Planning as co-chair. The
Representative of the EU Delegation in Nigeria has an observer status. The PSC oversees
and validates the overall direction of project implementation, monitor, supervise, and
coordinates the overall progress of project activities. It approves the annual workplans, the
interim annual activity reports and the final report of the project. The PSC meets twice a
year, with the meetings organized by the implementing agency. In addition, there is
continuous participation and support by UNICEF and the technical staff to the National and
State Project Steering Committees of the Results Based Financing Project and the MDG
Debt Relief and the Subsidy Reinvestment and Empowerment Programs (SURE –P).
Operational Level: A dedicated staff member position at UNICEF Country Office supports
the implementation, coordination, and reporting requirements. Two technical staffs are
seconded to the 2 state governments to support project implementation. Although the
SPHCDA and the LGA PHC Management Committees are nominally responsible for the
daily implementation of the Project, in practice each State has developed an implementation
structure and mechanism that suits its health system. The NPHCDA and the North East and
North West Zonal Offices of the NPHCDA provide support for capacity building, intra-zonal
consultations, and supportive supervision. Beyond the Health program, UNICEF office
provides support from the Supply unit that manages all procurements like medicines,
commodities and equipment. The Finance units provide the support for cash management
and financial monitoring. External relations and communication unit supports visibility and
media management vis-à-vis the EU supported project.
IV.
Objectives of the Assignment
The general objective of the evaluation is to provide the EU and other partners with an
assessment of the Project performance in terms of relevance, efficiency, effectiveness, and
sustainability of the support provided to Adamawa and Kebbi States and key stakeholders
and its impact on improving maternal, newborn and child health outcomes.
The specific objectives are to assess to the Project’s relevance in terms of correctly
identifying the problems and that the means are appropriate and adequate; project design
and implementation; validity of assumptions; efficiency and effectiveness of program
implementation; review the allocation of funds per component in line with Project objectives
7
and evaluate the relevance of any existing set of indicators and mechanisms that have been
defined to measure benefits and impact.
The evaluation is to provide alternative implementation approaches that could achieve
similar results and recommendations for improving the overall implementation of the Project.
Specifically for Adamawa State only, the evaluation would explore the feasibility of State–
level Sector Reform Contract and carry out a preliminary analysis of the eligibility criteria
including elements that will contribute to drafting of an identification fiche. (See TOR in
Annex 5)
V.
Methodology
The approach for the mid-term evaluation of the “Support “Support to Scale-Up Maternal
Newborn and Child Health Outcomes in Two States of Northern Nigeria 2013-2017,”
encompassed the following:
5.1 Comprehensive review of the project and project-related documents and
reports
These documents include the proposal document on Scaling Up MNCH Health Outcomes in
2 States of Northern Nigeria 2013-2017; the EU Financing Agreement, UNICEF Contribution
Agreement; MNCH Project implementation and meetings reports including databases and
associated service statistics. Other important documents include SPHCDA Strategic Plans
and related reports for Adamawa and Kebbi States, NPHCDA Strategic Plan & Report,
Nigeria Health Sector Strategic Plan & reports, Primary Health Care under One Roof
(PHCUOR) policy, Nigeria Health Act and Nigeria Vision 2020
5.2 Briefing meeting and presentation of Evaluation Inception Report
Briefing meetings were held within a couple of days on arrival in Abuja with the EU
Delegation for Nigeria, the Ministry of Budget and National Planning (MBNP) which s the
National Authorizing Officer of the MNCH Project, UNICEF Nigeria Country Office. The
Evaluation Team made a PowerPoint presentation of the Inception Report including the tools
for the evaluation to the key stakeholders (Annex 1-List of Participants). Constructive
comments and inputs from the meeting were incorporated into the evaluation processes and
tools.
5.3 Key Informants Interviews (KIIs)
The Evaluation Team held key informant interviews by appointment on individual basis in
Abuja with key policy makers, decision takers, directors, and managers directly involved with
the MNCH Project in UNICEF, EU Delegation, NPHCDA, FMOH, and Ministry of Budget and
National Planning. The Evaluation Team also held key informant interviews with senior
MNCH Project backstopping staff in the UNICEF Country Office.
5.4 Field Visit to Project States
The Team carried out simultaneous Project evaluation in the 2 focus states for one week;
Team leader evaluated the Project in Adamawa State and Key Expert II evaluated Kebbi
State. The evaluation process included key informant interviews with the Executive Director
and Commissioner of Health in Adamawa State, the Acting Permanent Secretary, Kebbi
State Ministry of Health, Special Advisor (Health) to the Executive Governor of Kebbi State,
acting Chairman, Kebbi State PHCDA, and with relevant Directors and senior staff of the six
public institutions implementing specific components of the MNCH Project in Kebbi State
(SPHCDA, SMOH, MBNP, NPopC, Ministry of Information, and National Orientation
Agency). Extensive focus group discussions and individual interviews were held with
SPHCDA and MNCH project staff in Yola Adamawa State and Birnin Kebbi in Kebbi State
and with a wide cross section of stakeholders in selected health facilities and communities
visited by the evaluators including health care providers, chairs of WDCs, members of
CORPs and other volunteers, and beneficiaries attending OPD, ANC, and CMAM clinics in
both states. Discussions were also held with MENA staff and internally displaced persons
(IDPs) in two camps in Adamawa State.
8
5.5 Debriefing Meetings
These meetings were held in Adamawa and Kebbi States for stakeholders in the States and
in Abuja for the national level stakeholders other project staff, project beneficiaries, and staff
from other organizations providing similar services in selected LGAs in Adamawa and Kebbi
States
5.6 Data Analysis and Report Writing - currently ongoing
VI.
Analysis
Nigeria has some of the worst maternal and child health outcomes globally. The 2013 NDHS
estimates national maternal mortality ratio (MMR) at 574/100000 live births and infant and
Under-5 mortality rates at 69 and128 per 1000 live births. Northern Nigeria States have
much higher mortality rates than the national average. However, the NDHS database
currently provides zonal level and not state-specific rates. Using North East Zone and North
West Zones mortality rates as proxies for Adamawa and Kebbi States respectively,
Adamawa State has MMR of xx/100000 live births and IMR and U-5MR of 77 and 160 per
1000 live births respectively. Similarly Kebbi State’s MMR is xxx/100000 live births with an
IMR and U-5MR of 89 and185per 1000 live births respectively.
The causes of poor maternal, newborn and child health outcomes are preventable. For the
mothers these include malaria-related anemia in pregnancy, intra and post partum
hemorrhage, sepsis, obstructed labor, and hypertensive conditions in pregnancy and
malaria, pneumonia, diarrhea with malnutrition and under-nutrition playing important roles as
aggravating factors for infants and children under-5 years of age.
Three (3) delays are the key drivers of the causes of maternal and child morbidity and
mortality in especially northern Nigeria including Adamawa and Kebbi States. The delays are
(i) Recognizing signs and symptoms of ill health and timely seeking healthcare due to low
education status especially of women, socio-cultural beliefs, and poor health awareness; (ii)
Accessing care once the decision is made to seek care mainly due to distance and lack of
transport to a health facility; and (iii) Receiving timely and appropriate care, once at the
facility, due to inadequate numbers of qualified staff, suitable equipment, and supplies.
VII.
Findings of the Mid-Term Evaluation Of The MNCH Project
The Specific objectives of the Project that were assessed and the assessment findings are
detailed hereunder.
7.1 Relevance of the Program
The Program correctly identified the problems of poor maternal, newborn and child health
outcomes in Adamawa and Kebbi States in Nigeria as well as appropriate means to
addressing these problems. These problems include (3) key delays: (1) Recognizing signs
and symptoms of ill health and timely seeking healthcare due to low education status
especially of women, socio-cultural beliefs, and poor health awareness; (2) Accessing care
once the decision is made to seek care mainly due to distance and lack of transport to a
health facility; and (3) Receiving timely and appropriate care, once at the facility, due to
inadequate numbers of qualified staff, suitable equipment and supplies.
The causes of poor maternal, newborn and child health outcomes are preventable. For the
mothers these include malaria-related anemia in pregnancy, intra and post partum
hemorrhage, sepsis, obstructed labor, and hypertensive conditions in pregnancy. Malaria,
pneumonia, diarrhea malnutrition and under-nutrition are playing important roles as
aggravating factors in poor children health outcome.
The Project adopted acceptably appropriate strategies for addressing the identified problems
in a logical manner and allocated all the Project funding to fill the immediate gaps in deficits
in human resources for health, essential medicines, other basic supplies and commodities,
and equipment that enhances the State Primary Health Care Development Agencies’
(SPHCDA) efforts to achieve the following specific objectives: (i) Improve communication on
and timely health seeking behavior by women and children(ii) Increase health financial and
9
geographical access for poor and marginalized women and their families, (iii) Improve health
service delivery through functional health facility and outreach services, (iv) Improve
maternal, newborn and child nutrition, and (v) Strengthen primary health care systems
governance
Two years of Project implementation has elapsed but the problems remain intractable with
minimal discernible positive changes: health seeking behavior remains poor despite the fact
that many people are attending many more functional health facilities now than existed
before the Project began, financial and geographical access for poor and marginalized
women and their families remains a pipe dream as the implementation of major government
pro-poor social welfare policies (SURE-P, Saving One Million Lives etc.) have not achieved
the desired effects; household food security continues to be a serious challenge to improving
the nutritional status of women and children on a sustainable basis. And even though WDCs
are revitalized and are increasingly involved in in health systems governance and despite
LGA and State government commitment to PHC, release of approved budgetary allocations
is very often delayed and incomplete. Therefore, the Project is as relevant today as it was 2
years ago.
7.2 Program Design and Implementation
The Project scope is narrow, the design is good and the logic of the link between the specific
objectives and the expected results is satisfactory.
There are three major program areas that are contributing to the poor maternal, newborn,
and child health outcomes in the Adamawa and Kebbi States. These are:
a) Medical issues: (1) High maternal morbidity and mortality from malaria-related anemia in
pregnancy, intra and post partum hemorrhage, sepsis, obstructed labor, and
hypertensive conditions in pregnancy and (2) High childhood morbidity and mortality
from pneumonia, malaria, and diarrhea aggravated by acute and chronic malnutrition.
b) Nutrition Issues: (1) In Adamawa State about 15% of adult women are underweight/thin
and 11.6% overweight/obese whist in Kebbi State 16.6% are underweight/thin and
23.8% overweight/obese and (2) Undernutrition and malnutrition are major causes of
morbidity as an estimated 24% and 36% of children U-5 years are underweight and
stunted (chronic malnutrition) respectively in Nigeria. The situation could be worse in
northern Nigeria where poverty rates are much higher than the national average. An
estimated 14% of newborns suffer from intrauterine growth retardation (low birth weight)
c) Fertility Issues: (1) Total fertility rate in North West Nigeria (Kebbi) is very high at 7.2
births per woman vs. 5.7 nationally;(2) Low contraceptive prevalence (practice) rate of
18% in married women 15-49 years; and (3) Adolescent birth rate (15-19 years)is much
higher in Northwest Nigeria (Kebbi) at 170 births/1000 women vs. 89 nationally
The scope of the project focuses primarily on the health and nutrition aspects of improving
maternal, newborn, and child health outcomes with minimal attention to fertility aspects of
family planning and birth spacing needs of women in the reproductive age range of 15-49
years (including teenage girls) and household food security and water and sanitation
interventions that would normally be included and funded as core components in a typical
“Program” design that intends to improve maternal, newborn, and child health outcomes. A
narrow design, such as the MNCH project, is unlikely to make significant improvements in
reducing the levels of maternal, newborn, and child morbidity and mortality unless it is linked
to or implemented in partnership with others providing complementary services such as
????.
In implementing the project, however, UNICEF has sought to underscore and has
succeeded in underscoring the point that the MNCH project is meant to support (albeit
heavily) government’s effort to improve maternal, newborn, and child health outcomes, in
which case the Project design should clearly state what the complementarities are. As it
stands, family planning and birth spacing services and household food security may be
slipping through the cracks, as government is unable to provide adequately for these
services and the Project has not allocated resources for these key areas of interventions.
The high total fertility and adolescent birth rates and the low contraceptive prevalence rate
are clear pointers to the need for the Project design to include FP as an important
component worthy of additional funding either under the Project or through some other
funding arrangement e.g. another donor or by the government. This was not done and FP
10
services continue to be under-utilized in the two Project states. The unmet needs for family
planning and birth spacing have huge negative consequences on the health of mothers and
their young children including for maternal and neonatal deaths from the increased risks
associated with unplanned or unwanted pregnancy complications and for babies increased
risk for preterm, low birth weight, and frequent childhood illnesses.
Household food insecurity is often a condition precedent for the development of
undernutrition and malnutrition in women and children; they are important causes of
morbidity and significant contributors to child deaths. Both the preventive and curative
aspects of the nutrition component of the project design mainly address the symptoms and
not the causes of childhood malnutrition, which is likely to be largely due to household food
insecurity. There is precious little effort, if any, to improving household food security that
should be the bedrock of attempts to prevent nutritional problems of women and children
along the continuum of care from preconception to childhood. At a minimum, the Ministry of
Agriculture should have been an important implementing stakeholder in the project; but it is
not!
Thus a Program for improving maternal, newborn, and child health outcomes that does not
adequately address the needs for family planning and birth spacing and household food
security may have difficulties in improving maternal, newborn, and child health outcomes
including reducing maternal, newborn, and U-5 mortality rates. FP should be funded under
the Project and household food security should be sustainably addressed through significant
involvement of the Ministry of Agriculture in Project implementation
On the whole, logic of the link between the specific objectives and the expected results is
satisfactory but can be improved further for certain interventions including:
i.
Component 1: Improved communication and health seeking behavior leading to
“increased number of children registered at birth”: As a significant proportion (82% in
North East) of deliveries continue to occur at home it is likely many children may not
be registered at birth but activities of CORPs may ensure these kids get registered
by civil authorities later on.
ii.
Component 2: Difficult to ascertain theory of change or how the planned activities in
the Annual Work plan will lead to achievement of the expected results and the
strategic objective. In any event, the planned activities have not yet been
implemented. There is an imperative for a fundamental rethink of the project’s
strategies for achieving the component’s objectives.
iii.
Component 3: Improved Health Service delivery through functional health facilities
leading to “improved availability and retention of health workers”: Retention of health
workers is key but there are no incentives or motivation for HWs to remain at rural
and hardship locations. Adamawa LGAs with PBF facilities’ bonus payment is hugely
motivating. State and LGA health management capacity is not being adequately
addressed to enable them motivate health worker retention in a non-monetary
manner as monetary incentives are often difficult to negotiate and implement.
iv.
Component 4: Improved maternal, newborn and child nutrition leading to “improved
nutrition of women during preconception and antenatal period”: Pre-conception
nutrition improvement problematic in households with food insecurity; but household
food security omitted in project design. The inclusion of Ministry of Agriculture is
called for.
v.
Component 5: There is a general consensus that health systems coordination, public
financial management systems, managing and leading change expertise are
significant critical success factors for the achievement of the purpose and overall
goal of the MNCH Project / program, but are presently suboptimal in both States,
especially Kebbi. Consequently, it is imperative that a redesign of the project to
specifically build a sustainable capacity of the State health leaders and managers to
lead and manage the change is necessary. Importantly, it will forestall and prevent
the emerging “shifting the burden to the intervenor” systems archetype as UNICEF
and other development partners are gradually but inadvertently engendering in the
State. It is essential to emphasize that “building a sustainable capacity is beyond
“training of state officials”. Also, the capacity to analyze and utilize existing health
data and other project information to inform he management of the health systems in
the state needs to be emphasized in the redesigned project.
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7.3 Validity of Assumptions
Many of the original assumptions remain valid but a few have changed. Assessment of
changes in the original assumptions and how they affect the Project implementation are
detailed hereunder.
Component 1: Improved communication and health seeking behavior: The assumption that
there is “minimal likelihood of communities’ refusal to accept MNCH services especially
reproductive health services due to rumors and religious beliefs” still holds. This assumption
is stronger now and refusal is even less likely now that communities in both Adamawa and
Kebbi States are benefitting from the MNCH project with blessing and support of religious
and traditional leaders. It is no longer necessary to include it as an assumption in the log
frame.
Component 2: Improved health financial and geographical access: The assumption that
“Political commitment to prioritize and allocate funding for social protection programs in
health from SURE-P and MDG Funds” partially holds at the moment. Political commitment is
still loud and clear in both Adamawa and Kebbi States, but SURE-P was cancelled last year
and the fuel subsidy has been removed.. With the continuing decline in the price of crude oil
and gas, the economic situation is not likely to improve quickly. However, the Federal
Government of Nigeria is planning to rollout a distinct Social Protection Program soon. Such
Program may have a catalytic role on the two State Governments.
The Project funding earmarked for its Social Protection interventions should be used to
purchase health care services at PBF health facilities that are being rolled from 11 to all 21
LGAs in Adamawa State before the end of the year. In Kebbi State the government is in anongoing dialogue with the National Health Insurance towards institutionalizing a statewide
Health Insurance Program. Early dialogue with Shell PLC regarding a study visit to its
successful Obio community-based health insurance program Port Harcourt has been
initiated. Project Funds should be used as a catalytic pump-primer to support and register
beneficiaries into the statewide scheme.
Component 3: Improved health services delivery: The assumption that “Consistent fund
disbursement from LGA government for recurrent costs including salaries of health workers
to avoid strikes and disruption of services” is not holding at the moment, as disbursements
are very often incomplete and delayed. Salaries have not been paid for 3 months now and
there is disquiet among health workers. Health workers at Adamawa State PBF facilities said
they would not go on strike as they receive bonuses from the PBF approach for the services
they provide. Any strike by the health workers will negatively affect the provision of MNCH
and other health services. To minimize the risk of strike action due to delay or non-payment
of salaries, Adamawa State PHCDA should accelerate the process of rolling out its PBF
approach to the remaining 10 of its 21 LGAs.
The Boko Haram insurgency in northeast Nigeria has created a severe security situation
leading to GoN declaring a state of emergency and restricting movement of people
especially in Adamawa State and other affected States and curfews at night. This has
reduced the number of people attending health facilities due to insecurity and lack of
transport; the ban on the use of motorcycles has negatively affected the provision of
outreach services and supportive supervision to its 1233 hard-to-reach communities. The
SPHCDA has purchased tricycles (which are not banned at the moment) to support the
outreach services and supportive supervision activities. There is no evidence the insurgency
will stop anytime soon to allow normal services to resume. The influx of internally displaced
people as a result of the insurgency has placed much strain on Project resources; at its peak
the Project was providing health services to hundreds of thousands of people in several IDP
camps. These numbers have reduced significantly over the last couple of months but could
flare-up anytime without warning.
No security incidents in Kebbi State and staff receive their salaries regularly, albeit with reverification of payrolls. However, there are no provisions for regular imprest (petty cash
system) funds to manage recurrent maintenance costs. Given that the assumption is very
unlikely to hold true, it is essential that the project is redesigned to enable the facilities to
obtain funds for recurrent maintenance costs. Redesigning the social protection component
to ensure a functional community-based health insurance scheme portends the greatest
opportunity to enable the facilities to do better through efficient management of the
capitation funds from registered clients.
12
Component 4: Improved Maternal and Newborn Nutrition: The assumption that “there is no
major food insecurity causing deterioration in nutrition status of mothers and children and
undermining efforts of program and a major risk could be frequent strikes by government
staff undermining implementation of program” just about holds at the moment. Kebbi State
remains peaceful with no insecurity incidents and health workers’ salaries have been paid
and on time. Health workers in Adamawa State have not been paid for the last 3 months;
there is disquiet and unease, the potential for a strike is real. Some ingredients for
occurrence of food insecurity like the Boko Haram insurgency and the declaration of state of
emergency with restrictions on movement, public gathering, and use of motorbikes and high
volume of internally displaced persons have the potential to cause major food insecurity
situation in a State that does not have adequate household food security even in normal
times. The Nigeria National Emergency Management Agency (NEMA) should be kept
constantly appraised of the food situation. For long-term household food security, the State
Ministry of Agriculture must be involved in implementing the Project.
Component 5: Strengthening health systems governance: The assumption that “the State
Health and Strategic Development Plans fully financed for effective health care delivery”
does not hold at the moment. The 2010-2015 State Development and Health Strategic Plans
are fully developed and costed but have come to the end of the planning period. The followon SSHDPs have not been initiated. Given that it is very unlikely that this assumption will
hold true, the project should be redesigned in order to influence this factor.
Kebbi State: The redesign of the project to target and enhance the integration and
coordination function of the State Ministry of Health, State Primary Health Care
Development Agency and the State Ministry of Budget and Economic Planning will optimize
the project to leverage on the synergies inherent in several other projects in the State. The
opportunity for the project to adopt an enhanced systemic thinking to leapfrog the Kebbi
State health system exists. It is imperative that the project seizes the opportunity now.
Adamawa State: The State plans on ensuring that 80% of approved budget are disbursed.
However, disbursements are almost always below the minimum planned target of 80% and
these releases are very often incomplete and delayed. Adamawa State is one of the poorest
in the country and depends heavily on funding from the Federation Account. With the decline
in oil revenues, the national economy is faltering with an uncertain time for recovery. This
may result in Adamawa State receiving less funding from the Federation Account resulting
the State being unable to meet its budgetary obligations.
7.4 Efficiency of Program Implementation
Assessing the extent major activities have so far been implemented provides opportunities
to judge the efficiency and effectiveness of Project implementation.
Each Project
component is assessed separately. However, capacity building (a cross-cutting theme) is so
important to the success of the Project that it is assessed on its own.
Capacity building
“Capacity-building” is treated as almost synonymous and equivalent to “training” only.
Consequently, the general effectiveness of the capacity-building strategies is reduced
The aim of the training intervention of the Project is to address the huge and chronic deficit
of trained staff needed to provide quality MNCH and nutrition services with integrated
supportive supervision from appropriately trained supervisors. The intention is also to train
and retool data and M&E officers to accurately collect, collate, and enter the information into
the NHMIS on time as well as undertake local data reviews and analysis to effectively
monitor progress toward achieving Project objectives.
Analysis of the project’s training database for Adamawa State (Annex2) shows that a
significant number of training events were executed in the seventeen (17) months between
September 2014 and December 2015. The training program benefitted more than thousands
of participants that included SPHCDA senior management staff, health facility managers,
health facility and outreach MNCH and nutrition service providers, project officers, HMIS
project staff, project monitoring and supervision staff, WDC members, CORPs, and tutors
from two health training institutions in Adamawa State. Kebbi State has also trained many
stakeholders to improve delivery of MNCH and other health services including members of
all the 225 WDCs, CORPs, community volunteers and health workers at PHC facilities
13
including CHEWs, nurses, midwives, and doctors. However, the evaluators found no
evidence of a planned evaluation of the trainings to assess their effectiveness and efficiency
in both Adamawa and Kebbi States. Also, there was no linkage between the project’s
training events and the wider Kebbi State Ministry of Health Human Resources for Health
Unit’s Strategic development policies and procedures, including task-shifting.
The Project has an intense focus on bridging the huge gap in the need for trained health
care providers in appropriate numbers and skills mix required to provide quality, equitable,
and sustainable health care services in both Adamawa and Kebbi States. Training continues
to be extensive and covers the training needs of especially CHEWS and CORPs for the
delivery of promotive, preventive and curative health services at the Ward level and other
health care workers providing facility-based and outreach services as well as the training
needs for managers and others with oversight roles for delivery of health services at the
Ward, GA, and State level.
The Project has pursued an aggressive training program, which has narrowed the huge
deficit in the human resource required to deliver quality MNCH including HIV and AIDS and
nutrition services in the two States. Thousands of staffs have been trained to provide a fairly
good mix of skills across the various levels of the healthcare delivery system. At the Ward
level trained CORPs are generating demand and providing services under the guidance of
re-energized WDCs with integrated supportive supervision from the LGA and State level
whilst at the LGA level, trained health care providers are spearheading the delivery of quality
MNCH care including HIV and nutrition services from the many functional PHC facilities now
in existence and through an extensive array of outreach services designed to reach the
hard-to-reach communities in both States under the increasingly competent LGA PHC
authorities with support and guidance from an increasingly competent State PHCDA
operating under one roof in Adamawa State and an enthusiastic Kebbi SPHCDA that hopes
to legally operate under one roof soon.
To increase the multiplier effect, the Project provided TOT for 25 trainers (includes trainers
from Bauchi and Taraba States) who are conducting step down training on MNCH and
nutrition (especially IMCI) for health workers and community own resource persons
(CORPs) including nutrition program volunteers. Thirty (30) tutors from the Colleges of
Nursing and Midwifery and School of Health Technologies in Adamawa State and IMCI
training of Trainers in Kebbi State have been conducted to improve training in MNCH
including HIV and AIDS and Nutrition to students in health training institutions and to
women, mothers, and other caregivers at the community level. The TOTs are a constant
local resource that will available for local training of MNCH service providers for years to
come thus contributing to sustainability of the project.
Many health sector civil society organizations are training CORPs and this is commendable.
However, different organizations pay different stipends to the CORPs. This has the potential
to negatively impact the activities of organizations that pay less. The trainings in Kebbi State
are often not linked to the plans of Human Resource Unit, Department of Planning and
Statistics of the SMOH.
Annex 2 shows the training outputs between September 2014 and December 2015 for
Adamawa State. The cost of trainings is embedded within each of the five (5) components of
the Project. Therefore, the training outputs are directly attributable to funding support from
the EU-supported MNCH Project.
Recommendations
1) Training of CORPs to spearhead community level activities including iCCM is
commendable; however there is a need to ensure the use of CORPs does not become a
new “fix that fails” – “…effective in the short term but has unforeseen consequences
which may require even more use of the same fix” for example the failure of JCHEWs to
deliver on their mandate of spending 0.7 whole time equivalent at the community level,
has invariably led to the recruitment of CORPs.
2) It is important to harmonize incentives provided to volunteers and CORPs by different
organizations in each State. Volunteers and CORPs are invaluable resource for the
MNCH Project and significant disparities in incentive packages between different players
in the same State could be problematic in efforts to improve maternal, newborn, and
child health outcomes.
14
3) The MNCH Project training programs must be harmonized with the plans of Human
Resource Unit, Department of Planning and Statistics of the SMOH in Kebbi State.
Component 1: Improved communication on and timely health seeking behavior by
women and children
The Project is employing the Communication for Development (C4D) principles of dialogue,
empathy and understanding to build and empower communities to improve their health
seeking behaviors through multi-sectoral stakeholder platforms that include participation
from the print and audio-visual media, civil society including women and community groups,
and government ministries, departments, and agencies. The missing link is the absence of
the State Ministry of Agriculture that could bring expertise and other resources to address
household food insecurity that is manifesting itself as malnutrition in young children for which
the Project is investing funding resources. The MNCH Week, organized twice a year in both
States enhances Project visibility as well as providing an important platform to reach
hundreds of thousands of mothers and children with comprehensive MNCH and nutrition
services.
Preliminary results of the analysis of available data on the DHIS2 for Adamawa and Kebbi
States show that attendance at Out Patient Department, ANC clinics, and child health clinics
as well as deliveries at health facilities and children benefiting from CMAM have increased
significantly in both 2014 and 2015 (the first two years of project Implementation) relative to
the data in 20013(the year before he Project started). Using 2013 as baseline, Table
1.illustrates the huge increases in facility, outpatient, and ANC attendances in 2014 and
2015 for Adamawa State. Similar observations are made in Kebbi State.
Table 1. –Utilization of selected health services in Adamawa State
Baseline
Output Indicator
Jan-Dec 2014 Jan-Dec 2015
2013
1.
Facility Attendance
79,256
995,134
1,178,328
2.
Outpatient Attendance
50,696
655,887
670,884
3.
Antenatal 4th Visit
4,367
59,333
45,638
4.
Antenatal total attendance
23,510
233,204
217,573
Source: DHIS2 Data for Adamawa State Feb 2016
The increased utilization of health services shows the C4D interventions most probably are
responsible for the sharp increases in number of pregnant women and children accessing
the MNCH-N services. The investment in the 2-years of C4D programming can be said to be
yielding very good dividends already. Many health care providers indicate the last two years
are amongst the busiest they have been in a very long while and express gratitude to the
Project for catalyzing the resurgence in the use of MNCH and nutrition services.
Some of the critical success factors identified in both States for the increasing utilization of
MNCH services include:
a) Increasing community participation in MNCH activities through the involvement of WDCs
and engagement of trained CORPs who educate and generate demand for as well as
provide Integrated Community Case Management (iCCM) services for the management
of malaria, pneumonia, diarrhea, newborn care and malnutrition under the supervision
and guidance of trained CHEWs.
b) Community-level partnerships especially with National Union of Road Transport Workers
(NURTW) to address delays in accessing emergency obstetric and newborn care
services that are enhancing referral links between communities and health facilities.
c) The use of local drama groups for effective education on key MNCH issues. For
example, in Kebbi State, Kwaru roro” an independent drama group, conducts theatres in
with messages tailored on ANC attendance, immunization and benefits of postnatal care.
d) Increasing political will of State Government to PHC including refurbishing of health
facilities to improve MNCH services including basic emergency obstetric and newborn
care with the creation of centers of excellence in a number of health facilities at the LGA
level
Further analysis of the data on deliveries shows a worrying pattern in both States - a
significant disparity between the number of deliveries attended to by a skilled birth attendant
and the total number of institutional deliveries. Figure 1 illustrates this concern for Kebbi
State. Many pregnant women attend ANC at least 4 times but fewer deliver in a health
15
facility where one expects skilled birth attendants (SBA) would conduct the deliveries. But
evidence points to the contrary. It is necessary to explore the rationale for the difference
though a cursory inquiry suggests that a lack of adequate number of skilled birth attendants
in the health care facilities contributes to the observed low number of births attended to by a
skilled birth attendant. This factor could be a significant de-motivator to pregnant women
from coming to deliver in health facilities.
Fig 1.Trends in Institutional deliveries vs. Deliveries by Skilled Birth Attendants
Source: DHIS Data for Kebbi State Feb 2016
Significant barriers to effective and efficient Project implementation include the following:
a) Available evidence suggest that a lot of the information collected and collated during the
Integrated Supportive Supervision, PHC Reviews/Bottleneck Analysis, MNCH Week,
trainings etc. are not effectively analyzed and turned into useful management information
to inform the implementation of the Project. For example, whereas the ANC and skilled
birth attendance rates were issues addressed in bottleneck analysis, and given the
significant disparity between institutional deliveries and the number of deliveries attended
to by skilled birth attendants, the evaluators found little evidence of specific management
actions targeted to addressing the observed disparity.
b) The evaluation observed weak alignment and coordination between the Project and the
Department of Medical Services (responsible for managing secondary health care
facilities) in Kebbi State. This is particularly pertinent given the planned project activities
to “conduct renovations of BEOCs in line with NPHCDA’s minimum standard in Kebbi
State” and “provision of 21 vehicles for BEOC Centers to transport pregnant women to
ANC and Maternity clinics in Kebbi State”. Both planned activities would benefit
immensely in its design and execution if the Department of Medical Services were better
involved in its articulation, especially as the secondary health care facilities have existing
ambulances/vehicles whose effectiveness could be enhanced through an integrated
state-wide ambulance and patient transport service.
c) The emphasis on CORPs as a critical success factor in the sustainability of the
community-driven demand-side strategies is challenging, especially, given that there are
a group of “JCHEWs” whose SOPs include 0.7 whole-time equivalent of their time to be
spent in the communities who were trained by the State Government and other projects
in the past but who have failed to deliver on their mandates.
Recommendations
a) Where two organizations working in the same LGA have different stipend for motivating
CORPs, efforts should be made, perhaps under the supervision of the LGA PHC
authorities, to harmonize the stipends as much as practicable to improve cordial relations
at the grassroots.
Component 2: Increased health financial and geographical access for poor and
marginalized women and their families
Of the 5 components of the Project, this component has recorded the least progress.
Essentially, Component 2 is meant to catalyze national and state level health insurance
schemes in the two States, which have performed below expectation for those that exist or
have been incubating for some time now. The Project has not built on advocacy for the
passage of the draft enabling laws in both States. The Project supported key stakeholders to
undertake a study tour to Ondo State and South Africa; stakeholders are awaiting the
outcomes of the tours. Proactive steps are being taken to organize another study tour to the
acclaimed Shell PLC-supported Obio Cottage Hospital Community based health insurance
model, Port Harcourt, Rivers State.
16
Meanwhile, as part of the Nigeria State Health Investment Project (NSHIP), Adamawa State
is implementing a very successful World Bank supported Performance Based Financing
(PBF) model in 11 of its 21 LGAs. To meet the health needs of poor families and to ensure
equity, the PBF project has Indigene Committees in all its 420 functional health facilities that
exempt poor women and men from paying for the services. Additionally, the EU-funded
MNCH Project operates statewide outreach services to hard-to-reach communities (1,233 as
at February 2016). The MNCH Project and the PBF project enjoy very fruitful partnership
that enables the rich synergy of the two projects to be harnessed for the greater benefit of
the people of Adamawa State. The PBF project will roll out into the remaining 10 LGAs of
the 21 LGAs in the State before the end of 2016.
In both Adamawa and Kebbi States, there are evidence the State National Health Insurance
Scheme (NHIS) has conducted a mapping of existing health financing schemes and social
solidarity groups and developed IEC materials on the importance of community-based health
insurance scheme, ostensibly in preparation for possibly launching a statewide health
insurance scheme, most probably in Kebbi State soon. The Project should explore mutually
beneficial ways of supporting the NHIS in this laudable effort.
Key success factors for Component 2 include the fact that federal and state governments
are committed to formulating and implementing pro-poor social protection policies including
national, state and community based health insurance schemes. The PBF approach in
Adamawa State shows it is possible to find a locally grown, acceptable, and potentially
sustainable mechanism to provide equitable health care services including MNCH services.
In general, effective formulae for establishing health insurance schemes that are pro-poor
have been elusive thus far.
Significant barriers for the implementation of Component 2 are systemic and programmatic.
a) The lack of progress perhaps illustrates the weaknesses of systems thinking and the
inability of the Project to prevent ‘reinventing the wheel’ by coordinating and building on
other relevant initiatives beyond the Project. For example, in Kebbi State, the Project
should be working with the NHIS and the initial efforts by the State to establish a health
insurance scheme, whilst in Adamawa State the natural collaboration should be with the
PBF approach to financing primary health care services.
b) It is difficult to fathom how the planned activities in the Annual Workplan will lead to
achievement of the expected results and the strategic objective. In any event, the
planned activities have not yet been implemented. There is an imperative for a
fundamental rethink of the project’s strategies for achieving the component’s objectives.
c) The “provision of 42 vehicles for BEOC centers to transport pregnant women to ANC and
maternity clinics in Kebbi State” seems to be an inappropriate activity at this time given
the presence of “ambulances and other patient transport services on the ground”. What
is required is a rethink of how to optimize the value of existing assets (vehicles) through
creating a managed integrated state ambulance and patient transport services using
existing assets.
Recommendations
a) The MNCH Project should be supporting NHIS and State government efforts to establish
a statewide health insurance scheme in Kebbi State. In Adamawa State, the effort
should to enable beneficiaries to access services through some arrangement with the
PBF Project in that State
Component 3: Improved health service delivery through functional health facilities
and outreach services
For many years, the use of the PHC strategy as the main mechanism of meeting the heath
needs of the vast majority of citizens has led to a system that, in a large measure, is highly
dysfunctional resulting in the provision of low coverage, poor quality healthcare services
delivered through inefficient and ineffective approaches to disgruntled beneficiaries. Using
theory of change approaches, the MNCH Project is assisting the national and Adamawa and
Kebbi State PHC Development Agencies (SPHCDAs)to improve the functionality of PHC
facilities and outreach services to provide evidence-based high impact maternal, newborn,
and child healthcare services that is both equitable and sustainable. The aim of the Project
17
is to assist the Adamawa and Kebbi State governments to establish at least one (1)
functional PHC facility per ward in all 451 wards in Adamawa and Kebbi States comprising
226 and 225 wards in Adamawa and Kebbi States respectively.
Adamawa PHCDA is legally constituted and implements the PHC under One Roof
(PHCUOR) policy. Based on a combination of population size and ease of access to health
facilities, as at January 2016, Adamawa State PHCDA has established 420 functional PHC
facilities and conducts outreach services to 1,233 hard-to-reach communities. With adequate
numbers of trained staff and good skills mix (Annex 2: MNCH Training Output September
2014 – December 2015);adequate supplies of medicines and commodities, and basic
equipment in good working condition; and physical infrastructures in good state of repair that
guarantees adequate supplies of electricity (through mixed power supply sources including
the national grid, generators, and solar), piped water in almost all facilities, and good
sanitation and security, these functional PHC facilities are providing quality basic and
essential health services including emergency obstetric and newborn care 24 hours a day,
seven days a week (24/7). Service statistics from the DHIS2 database, whose reporting rate
is good, show a tremendous increase in the utilization of MNCH services in 2014 and 2015
relative to 2013, the year the MNCH Project started (See Annex 3: Adamawa State MNCH
Selected Service Statistics)
To reduce maternal morbidity and mortality, it is not only necessary to ensure the vast
majority of pregnant women receive ANC but also to deliver in a health facility and that
deliveries are well monitored. Fig 2- shows that the attendances at antenatal clinic were very
high but less a quarter of the deliveries in both 2014 and 2015 were in a health facility. Every
effort must be made to find out why pregnant women will attend antenatal care clinic and
then not deliver at the health facility and measures put in place to encourage delivery in
health facilities.
Kebbi State PHCDA is not yet constituted under the PHCUOR policy. It has adopted a
multisectoral approach (involving the SMOH, NPopC, SPHCDA, National Orientation etc.)
for the implementation of the MNCH Project. Many health care workers including ToTs,
CORPs, CHEWs, and midwives have been trained to provide quality care (See Annex 2 for
Training Outputs). As at January 2016, there are 221 functional PHC facilities (based on the
one functional PHC per ward strategy). However, only 68 of these are assessed as capable
of providing 24-hour service. In collaboration with the Department of Medical Services of the
SMOH, 21 of the functional facilities have been identified for upgrade into centers of
excellence to provide quality basic emergency obstetric care services. The Project has
provided much needed basic equipment including delivery kits to the PHCs, which also
receive regular supplies of essential medicines and basic commodities. Outreach services
are provided for hard-to-reach communities on regular schedules. Following the trainings on
the newly harmonized data tools, the State HMIS reporting rate on the DHIS has improved
tremendously.
Key success factors for improving the functionality of PHC facilities include the following:
18
a) There is continuing support and commitment by the SPHCDA and LGA PHC
Departments in both Adamawa and Kebbi States to establishing at least one functional
PHC in each ward.
 In Adamawa State, the SPHCDA is a legally constituted entity under the PHCUOR
policy and the excellent partnership between the MNCH Project and the World Bank
supported PBF project has accelerated the development of functional PHC facilities
and the capacity to deliver significant outreach services for hard-to-reach
communities. The MNCH and PBF partnership is available in the 11 LGAs where the
implementation of PBF currently occurs; it does not exist in the 10 LGAs, which do
not implement PBF. The SPHCDA has established 420 functional PHC facilities that
are providing health services 24/7 with 21 of them providing BEmOC services.
 Kebbi State MNCH Project demonstrated increase in utilization of PHC services
(ANC attendance, institutional deliveries, etc.) have been noted though it is difficult to
attribute any change in utilization to the EU-MNCH Project specifically. Sixty-eight
(68) of 225 PHCs are said to be running 24-hour 7 days a week (24/7) service
though evidence from visited facilities contradicts the effectiveness of the “24 hours” in the absence of stand-by power. The SPHCDA plans to “renovate” 21 BEmOCs in
line with NPHCDA Agency minimum standards” will have a strong link to contributing
to achieving the expected results and strategic objective of the Project. However, the
referral linkages to the one (1) functional PHC per Ward should be simultaneously
addressed.
b) Increased attention to developing the human resources for health in both States is
enabling the training and deployment of health staff to improve the delivery of quality
services at functional PHC facilities and at outreach services especially for hard-to-reach
communities.
c) Increased availability of MNCH drugs, supplies and equipment including safe delivery
kits procured and distributed by the Project for use at PHC facilities in the States to
support improved quality of basic MNCH services.
Significant challenges for improving the functionality of PHC facilities and outreach services
include:
a) The sustainability of the supply chain management component of the Project in both
States is in jeopardy when the excellent work being done by UNICEF comes to an end
with the expiry of the Project in 2017. Currently UNICEF is responsible for the
procurement and distribution of goods to the State Central Medical Store from where
LGAs collect their supplies for onward distribution to the health facilities.
b) In Kebbi State, the high level of disrepair of a number of PHC facilities compounded by
the lack of provision for imprest funds to manage recurrent maintenance cost, militates
against the successful achievement of the 24-hour service
c) The need for linking the Project’s training programs to the human resource needs of the
SMOH in both States could be further optimized especially in Kebbi State where the
evaluation noticed a significant flaw in the linkage to the Human Resources for Health
Unit, Department of Planning, Research and Statistics of the SMOH. There is also the
need to harmonize incentives provided by different civil society organization groups
working with CORPs. Incentives for volunteers and CORPs span from organizations that
provide monetary incentives to those that provide in-kind incentives to those that provide
no incentives at ll.
d) Continuing insurgency in the North East Zone creates security situations that result in
significant restrictions in movement of people to deliver or access services. Insurgency
incidents create general anxiety and fear, the declaration of dusk to dawn curfews
disrupts the provision of 24-hour health services, and the ban on the use of motorcycles
restricts especially the provision of outreach services for hard to reach communities. A
huge influx of IDPs also puts a huge pressure on Project resources.
Prevention of Mother to Child Transmission of HIV (PMTCT) Program in Adamawa
State
With HIV sentinel survey among pregnant women attending ANC at 3.8%, the HIV testing
service uptake among pregnant women in Adamawa State is only 1.7%; only 9.9% of HIV
positive pregnant women received ARVs to prevent mother to child transmission of HIV in
2013. The presence of the MNCH Project in Adamawa State provided an opportunity to
19
integrate PMTCT interventions into the activities of the MNCH Project. Integration of HIV
testing and counseling services (HTS) for pregnant women started in early 2014. Prevention
of mother to child transmission of HIV activities (awareness creation, sensitization, benefits
of knowing HIV status, demand creation, and urging pregnant women to get HIV test) have
been included in the routine assignments for CORPs, HIV testing services are initiated
regularly by health care workers at antenatal clinics, during labor and delivery, and at
postnatal clinics as well as children at severe acute malnutrition management (SAM) and
community management of acute malnutrition (CMAM). HIV positive pregnant women are
referred for ART and encouraged to bring their partners for testing. HIV exposed infants are
placed on prophylaxis and have their dry blood samples transported to Taraba State for
virological testing for early infant diagnosis (EID) using DNA PCR technology. Test results
are sent back via the Internet and results printed using an electronic printer. This ensures
the turnaround time is small so that Antiretroviral Treatment, if needed, may be commenced
soonest. The amount of money allocated is adequate for now but needs to be watched as
the coverage of PMTCT increases.
The number of pregnant women who received HIV testing services increased significantly in
2014 and 2015 relative to the baseline year of 2013. The vast majority (78-80%) of pregnant
women received HIV testing and counseling and received their results during the antenatal
period. The increase in the number of pregnant women accessing HIV testing and
counseling services is likely due the demand generation actives of the CORPs following the
integration of PMTCT into the routine activities.
Every antenatal care clinic visit presents an opportunity to provide HIV testing for pregnant
women. This opportunity was lost to the many pregnant women who attended ANC at least
once. In 2014, the number of pregnant women who received an HIV test was very low
relative to those who made 4ANC visits. However in 2015, the number of pregnant women
who were tested for HIV is the same as the number at 4th visit (Fig 3- Missed Opportunities
for HIV testing). This miss opportunity may occur because there were no test kits, which is
not very likely or the HIV test was not offered because the staff were not trained to do the
test. This calls for efforts to ensure HIV test kits are available all the time and that all staffs
that run antenatal clinics must be trained to provide HIV testing and counseling services.
Component 3 Recommendations
1) Less than half of the pregnant women who attend antenatal clinic eventually deliver in a
health facility. Findings from the Bottleneck analysis should be utilized to develop
appropriate solutions to ensure pregnant women deliver in health facilities
2) A Project focus is necessary to strengthen the State Central Medical Stores and the
entire State Ministry of Health supply chain management system in both Adamawa and
Kebbi States, especially given the new World-Bank funded ‘Saving One Million Lives’
project which has commenced in the two States
3) It is important to harmonize incentives provided to volunteers and CORPs by different
organizations in each State. Volunteers and CORPs are invaluable resource for the
MNCH Project and significant disparities in incentive packages between different players
in the same State could be problematic in efforts to improve maternal, newborn, and
child health outcomes.
20
4) The Evaluation commends and supports the statewide roll out of the PBF project before
the end of 2016 being contemplated by the Adamawa SPHCDA, as this will enable the
10 remaining LGAs to benefit from the hugely successful synergistic partnership
between the MNCH and PBF Projects
5) It is imperative that the renovation of health facilities in Kebbi State is commenced in
earnest to complement the procurement and distribution of medical supplies. This will
enhance the provision of quality health services including MNCH care 24-hours a day.
6) There are too many missed opportunities to provide HIV counseling and testing for the
tens of thousands of pregnant women who attend ANC at least once. All staff running
ANC and labor and delivery ward must be trained to provide HIV testing and counseling
services to all pregnant women and HIV test kits must be available at all ANC and labor
and delivery wards.
Component 4: Improved maternal, newborn and child nutrition
The NDHS 2008 shows among adult women 15% and 16.6% were underweight in
Adamawa and Kebbi States respectively. Traditionally, the practice of exclusive
breastfeeding in the first six months of life is uncommon. In both Adamawa and Kebbi
States. The 2011 MICS estimates 24% of children under-5 years are underweight and 36%
are stunted in Nigeria. The 2014 SMART Survey indicates malnutrition is a problem in
northern Nigeria. Among children under-5 years in Adamawa State 45.5% are stunted and
4.7% suffer from moderate acute malnutrition; similarly 46.5% of children under-5 ears in
Kebbi State are stunted and 7.9% have moderate acute malnutrition with a further 1.8%
suffering from severe acute malnutrition (SAM). Household food insecurity is a major cause
of malnutrition in women and children and malnutrition is an important cause of childhood
morbidity and mortality in Adamawa and Kebbi States.
Component 4 of the MNCH Project is designed to improve the nutrition of women and
children along the continuum of care from preconception to childhood through preventive
and curative nutrition interventions. The MNCH Project supports implementation of the
nutrition component in only 3LGAs in each of the two States. However, the government and
other organizations are implementing this component in all the LGAs in Kebbi State and in 7
other LGAs in Adamawa State. With many organizations implementing nutrition activities in
Kebbi State, coordination of this component among the different implementers is not as well
as it could be.
The Project design completely omitted to address household food security as an important
cause of the problem but dwelt heavily on the signs and symptoms of malnutrition in both
States. An opportunity was lost to engage the State Ministry of Agriculture to spearhead
efforts to improve household food security in the two States that would be very beneficial to
women in the preconception stage.
The Project is improving the nutritional status of children in many ways including providing
iron-folate during pregnancy and delay clamping the umbilical cord soon after delivery.
Hundreds of thousands of children, mothers and caregivers in both Adamawa and Kebbi
States are benefiting from the counseling and support that trained health workers, CORPs,
and volunteers provide including promoting exclusive breastfeeding in the first six months of
life and providing counseling and support on infant and young child feeding practices
including in the context of HIV. Hundreds of thousands of young children are also benefitting
from the massive Vitamin A and micronutrient powder (MNP) supplementation and
deworming program offered by the Project. Tens of thousands of children are benefitting
from admission to health facilities for the management of severe acute malnutrition (SAM)
and the community management of acute malnutrition (CMAM). The provision of ready to
use therapeutic foods (RUTF) is preventing many children with SAM from dying as well as
speeding up the recovery period from malnutrition.
The number of children benefitting from the Nutrition component of the Project has
increased dramatically in 2014 and 2015 relative to the pre-implementation year of
2013.Figure 4 shows the dramatic increase in number of children admitted to health facilities
21
for treatment of SAM; However SAM is still an important cause of death in children as the
treatment success continues to be low.
The Kebbi State government is heavily committed to the nutrition program and has made a
strategic commitment to scale-up the nutrition component of the Project: it has harmonized
the State Nutrition Operational Plan for use by all stakeholders as well as heavily investing in
the procurement of RUTFs and exploring the potential of manufacturing RUTF in the State.
Kebbi State government’s investment in the Nutrition Program is beginning to pay dividends
as shown in Table 2: Kebbi State Results from CMAM program. Implementation of the
CMAM program started in September 2014following 6 months of preparatory work. Between
September 2014 and September 2015, Kebbi State achieved an impressive cure rate of
91% among the 23,333 children under-5 years in the CMAM program. Less than 1.5% of the
children died and the defaulter rate was less than 10%.
Table 2: Kebbi State CMAM Program Results
Target
Achievement
Number
%
1. New Admissions
35,000
23,333
66.6%
2. Cure rate
>75%
18,679
90.8%
3. Death Rate
<5%
280
1.4%
4. Defaulter Rate
<10%
1,340
6.9%
5. Non-Recovered Rate
267
1.3%
Source: Kebbi State MNCH Report Sept 2015
The limitations of coordination amongst nutrition projects funded by different partners in the
Kebbi State could create significant impediment to the commitment of the CORPS as some
projects’ expenses reimbursement rate is higher than the EU-MNCH Project, which does not
reimburse any of the expenses incurred by CORPs in the course of their duties.
Indicator
Component 4 Recommendations
i. The MNCH Project should immediately engage the State Ministry of Agriculture as an
important stakeholder and resource expert for improving household food security in the
two States
ii. The Kebbi State government should improve the coordination of all nutrition interventions
by mainstreaming the coordination of Nutrition interventions into the three coordinating
structures of the KSPHCDA, CTC MNCH in the SMOH and the Partners Forum at the
SMOH and SMEBP.
iii. Kebbi State government should continue to explore all possible avenues for the local
manufacture of RUTF. This will enhance sustainability of the nutrition program.
Meanwhile, the State should continue to procure RUFT since it is a key intervention for
the State
Component 5: Improving governance systems following the DART (Decentralized,
Action-Oriented, Responsive and Transparent) Principles
This component is the heartbeat of the MNCH Project. It ensures accountability as well as
responsibility for a decentralized decision making for interventions designed to improve
maternal, newborn, and child health outcomes at the LGA level. Its implementation is
consistent with and contributes to the attainment of the goals of the current PHC policy and
those of the 2014 National Health Act that seeks to “reduce maternal and infant mortality “by
22
providing among other things dedicated funding resources a proportion of which shall be
managed by the State PHCDAs for the provision of essential PHC services.
Adamawa State
In Adamawa State the SPHCDA is legally established and functions effectively as PHC
Under One Roof (PHCUOR) with one management body, one strategic plan, and one
monitoring and evaluation system. It superintends an effective and integrated delivery of
PHC services with an integrated supportive supervisory system (ISS) and is improving the
effectiveness of the referrals within the PHC system as well as working with the SMOH to
improve the referral system between the primary and higher tiers (secondary and tertiary) of
the heath care delivery system. The ISS team that conducts quarterly visit is a mix of about
4 staff from finance, management, health, logistics, and health management information
systems. Team members always take the opportunities these visit present to provide
mentorship including appropriate skills building.
In Adamawa State, 226WDCs, twenty-one (21) LGA PHC Departments, and one State PHC
Board play important and effective roles in the governance of the delivery of and
accountability for PHC services. Capacities have been built in decentralized planning and
budgeting that has enabled the institutionalization of these processes. Strategic plans and
annual workplans have been developed through iterative approaches between LGAs and
SPHCDA in close consultation with WDCs and major civil society organizations involved in
the delivery of PHC services. Budgeting processes have improved through increased
iteration between and among LGA PHC Departments and the SPHCDA culminating in the
development of State PHCDA budget classified as revenue, which is incorporated into the
State Health Sector budget. Training programs are well coordinated at the LGA and
SPHCDA levels and respond to the training needs for implementing integrated PHC
activities.
Monitoring of releases of approved government budget by the LGA PHC Departments and
SPHCDA shows releases continue to be incomplete and delayed most of the time, which
adversely affects the implementation and completion of planned PHC activities. On-time
payment of salaries to health staff continue to problematic as evidenced by the fact that the
evaluation team was informed salaries had not been paid for the last three months. Staff in
health facilities not participating in the PBF Project expressed disquiet and anxiety about the
continuing delay in salary payment. The situation was slightly more tolerable in health
facilities implementing the PBF Project as the negative effects occasioned by the delays in
salary payments are modulated by the bonuses paid to staff for services provided under
PBF arrangement. Continuing advocacy efforts by the LGA and SPHCDA have been
intensified to ensure the State government honors its commitment to funding PHC activities.
Release of the approved budget for the MNCH Project by UNICEF is full and on time; this
enables most planned Project activities to be implemented. The implementation of
Component 2 (Increased health financial and geographical access for poor and marginalized
women and their families) is delayed, in part, due UNICEF Country Office’s challenges is
securing technical assistance for the Project. This challenge has now been resolved and
implementation of activities has started in earnest beginning of 2016.
Coordination of Project activities are incorporated into the established coordination systems
established under the SPHCDA including monthly WDC and LGA coordination meetings,
quarterly PHC Review meetings including discussion and resolution of issues identified
through a detailed bottleneck analysis (BNA), and the quarterly ISS visits to LGAs and
health facilities. Specifically for the MNCH Project, a functioning Project Steering Committee
exists and meets twice a year. Key activities include providing guidance, direction, and
oversight for the Project including approving the Project’s annual workplan and undertaking
observational visits to Project implementation sites to see firsthand how the Project is being
implemented and provide informed guidance on any necessary corrective actions.
Kebbi State
The situation of Project implementation in Kebbi State is slightly different than that in
Adamawa State. The State has established coordinating structures and committees with
specific terms of reference (TOR), which meet regularly. There is a general consensus that
the outputs of the coordination efforts needs to be enhanced as significant gaps in
coordination exist, and the implementation structure adopted for the project demands
significant coordination expertise. The Coordination structures are:
23
i.
ii.
iii.
iv.
Partners Forum (domiciled at Department of Planning, Research & Statistics,
SMOH): meets quarterly
MNCH Core Technical Committee (domiciled at the Permanent Secretary’s Office):
meets monthly
Technical Committee domiciled at the SPHCDA: weekly meeting of all technical
partners in the State.
LGA Coordination Meetings
The MNCH Project activities in Kebbi State closely mirror those in Adamawa State.
Six (6) public sector implementing partners currently receive direct cash transfers from
UNICEF Sokoto Zonal Office (the budget holder for the MNCH Project for Kebbi State) for a
multisectoral implementation of specific MNCH activities often within the same component,
which calls for intimate coordination that is currently less than optimal and in further need of
strengthening.
The implementing partners are:
i.
Ministry of Budget and Economic Planning (MBEP): responsible for leading and
coordinating component 5 in collaboration with the department of Planning, Research
& Statistics, State Ministry of Health
ii.
State Ministry of Health (Departments of Planning Research & Statistics,
Reproductive Health, Nutrition) implement component 1, 3, 4 and 5)
iii.
Primary Health Care Development Agency – Components 1, 2, 3, 4 and 5)
iv.
Ministry of Information – Component 1
v.
National Orientation Agency, State Office – Component 1
vi.
National Population Commission, State Office – Component 1
vii.
The State Ministry of Women Affairs and Federation of Muslim Women in Health
Association of Nigeria (FOMWHAN) have acted /act as sub-implementing partners
as appropriate
The following findings enhance the confidence that Kebbi State is making remarkable
progress in implementing Project activities that will escalate its achievements of results in
the next year:
1. Evidence of political will and exceptional strategic commitment from the State
Government:
The State government’s newly appointed Special Advisor to the Governor is both skilled and
innately motivated to lead the change process in collaboration with all relevant stakeholders
to ensure speedy and effective execution of Project activities; however, a Commissioner of
Health, whose mandate includes oversight role for the Project activities, is yet to be
appointed. To underpin its commitment, the State Government has released all budgeted
counterpart funding for the Project for 2015. And the funding from the EU-MNCH Project
(and other projects) is reflected in the State Budget and classified as revenues, thus
enhancing potential planning for sustainability
2. Accelerating progress towards establishing a sustainable statewide equitable and
sustainable PHC system
The revised enabling law for the State Primary Health Care Agency is presently going
through the relevant stages at the State House of Assembly whilst the draft enabling law for
the State Health Insurance Scheme has been reviewed by the State Ministry of Health and
the Secretary to State Government, and is due to be passed to the State House of Assembly
as an Executive Bill. The enabling environment for the implementation of the Primary Health
Care Under One Roof (PHCUOR) once the revised enabling law is passed, is being set in
place. For example, the State and Local Governments have a centrally coordinated payment
system though the State Civil Service Commission and the Local Government Service
Commission may have different conditions of service. The granting of loans to health care
workers for the purchase of motorcycles and vehicles to ease transportation to work is
intended to motivate health workers and address one of the key impediments to productive
work by the Health care workers.
Table 3: Kebbi State Scorecard for achieving PHCUOR status
Scores By Domain
%
1. Governance and Ownership
100
2. Legislation
80
3. Minimum Service Package
0
24
4. Repositioning
5. Systems Development
6. Operational Guidelines
7. Human Resources
8. Funding Sources & Structure
9. Office Set- Up
10. Total (average of all domains)
Source: Kebbi State MNCH Report 2015
22
0
25
20
10
50
34
Governance and Ownership and the necessary legislative framework are the most important
criteria for lawfully setting up a SPPHCDA under the PHCUOR policy. With the passage of
the enabling legislation, a lawfully constituted Kebbi State PHCDA will easily attain the other
domains. Kebbi State is working very hard to establish PHCDA as soon as possible and
then will be able to assume full and complete implementation of the MNCH project. This will
enable Kebbi State to accelerate progress towards achieving the specific objectives of the
MNCH Project.
Major achievements and challenges include the following
i.
ii.
iii.
iv.
All 225 Ward Development Committees (WDCs) in the State have been reactivated.
Between 70% and 80% of the members of the WDCs are village heads, because
“they are duty-bound, and tend to select literate persons acceptable by the people”
Regular Integrated Supportive Supervision (ISS) conducted quarterly: The ISS teams
[a mix of 4 persons (finance & management, pharmaceuticals and commodities; data
and MNCH interventions) from the State-level and the Director of PHC at the LGAlevel] are multidisciplinary, and incorporate on-the-job mentoring during visits to the
PHC facilities. Most recent round of ISS included visits to the General Hospitals. So
far twenty-one (21) rounds of integrated supportive supervisory visits have been
conducted
A Bottleneck Analysis (BNA) was conducted in 2014, and the outputs is said to have
contributed to the development of the 2015 Annual Operational Work Plan. However,
the extent to which the 2015 and 2016 Annual Operational work Plans were
structured to address the gaps from the BNA is not evident.
Many health sector civil society organizations are training CORPs and this is
commendable. However, different organizations pay different stipends to the CORPs.
This has the potential to negatively impact the activities of organizations that pay
less. Stakeholders should work with the SPHCDA to harmonize the stipends and
other incentives for CORPs as far as practicable.
Component 5 Recommendations
1) Continuing efforts to legally establish the Kebbi State SPHCDA is noted and deeply
commended. All efforts should be made to ensure the establishment and resourcing
of a legally constituted SPHCDA in Kebbi State
2) Meanwhile refocusing the project to target and enhance the integration and
coordination function of the State Ministry of Health, State Primary Health Care
Development Agency and the State Ministry of Budget and Economic Planning will
optimize the project to leverage on the synergies inherent in several other projects in
Kebbi State. The opportunity for the project to adopt an enhanced systemic thinking
to leapfrog the Kebbi State health system exists. It is imperative that the project
seizes the opportunity now.
3) The SPHCDA in Kebbi State plans to “renovate” 21 BEmOCs in line with NPHCDA
Agency minimum standards” will have a strong link to contributing to achieving the
expected results and strategic objective of the Project. However, the referral linkages
to the one (1) functional PHC per Ward should be simultaneously addressed.
4) The Project training programs must be harmonized with the plans of Human
Resource Unit, Department of Planning and Statistics of the Kebbi State SMOH.
5) As far possible and working with the SPHCDA, civil society organizations’ stipends
for CORPs should be harmonized to prevent leakage of CORPs from CSOs that
provide lower to those providing higher levels of stipend. Overall and in the long run,
this could have a negative effect on efforts to sustainably improve maternal,
newborn, and child health outcomes in the State.
a) Effectiveness of organizational structures in place to reach the program objectives
25
Key structures have been established to ensure effectiveness of Project implementation at
various levels. These structures have, in general, provided effective stewardship for the
Project. These structures include:
National level: The Project Steering Committee (PSC) is the highest policy organ for the
MNCH Project. The PSC is providing adequate and clear guidance, direction, and oversight
for Project activities including approving the Project’s Annual Workplan and budget. The
Executive Director of the NPHCDA, and the Minister of Budget and Nation Planning (MBNP)
co-chair the PSC. Other members include UNICEF, the Executive Directors SPHCDA of
Adamawa and Kebbi States, FMOH, and Executive Chairmen of LGA PHCs on rotational
basis. The PSC meets twice a year and the agenda and minutes of previous meetings are
sent to members to read before the scheduled meeting. However, the MBNP representative
indicates she is occasionally disadvantaged at meetings because the minutes and agenda
did not reach her beforehand. The meetings are held in Abuja, Adamawa or Kebbi States.
Going forward there it is planned the meetings would rotate between Adamawa and Kebbi
States as this will allow the PSC members to visit Project implementation sites and see
firsthand what is happening.
UNICEF level: UNICEF is playing a critical role in the implementation of the project as the
budget holder and prudent management of project funds in addition to providing focused
technical support. Technical professional staffs at the UNICEF Country Office in Abuja
provide critical backstopping and technical support for the MNCH Project whilst its Zonal
Offices in Bauchi and Sokoto States provide regular management and technical support for
Project interventions in Adamawa and Kebbi States respectively. UNICEF has embedded
Consultants in the State Primary HealthCare Development Agency (SPHCDA) in both
Adamawa and Kebbi States who are giving direct technical assistance, facilitating
implementation processes, as well as providing mentorship for the SPHCDA staff and other
stakeholders working on the Project. The Project staffs of both the Adamawa and Kebbi
SPHCDAs are highly appreciative of and very much value the assistance the UNICEFembedded consultants are providing.
State Level: TheSPHCDAsof Adamawa and Kebbi States directly implement the EU-funded
MNCH and Nutrition Project in their respective states. Established by the PHC under One
Roof (PHCUOR) law in 2011, Adamawa SPHCDA, in collaboration and coordination with the
Adamawa State MOH (SMOH) and other stakeholders is implementing the MNCH Project in
226 wards through its PHC Departments in all twenty-one (21) Local Government Areas
(LGAs) of the State. The Project coordination at the State level is through the quarterly PHC
Review Meetings and through monthly LGA Coordination meetings in all 21 LGAs and the
226 WDCs. In Kebbi State six (6) implementing partners from the public sector implement
the Project. These public sector entities are: Ministry of Budget and Economic Planning,
State Ministry of Health, State Primary Health Care Development Agency, Ministry of
Information, National Orientation Agency, National Population Commission. Project activities
are coordinated by 4 coordination structures; three of these coordination structures are at
the state level and one at the LGA level. The three state level committees are the Partners’
Forum that meets quarterly, the MNCH Core Technical Committee that meets monthly,
Technical Committee domiciled at the SPHCDA that is a weekly meeting of all technical
partners in the State. The 21 LGAs in Kebbi State also hold quarterly coordination meetings.
Effective Project coordination is a challenge in Kebbi State.
Internal Implementation Procedures: The Adamawa SPHCDA has formed Teams around
key themes of the Project that are ensuring timely and effective execution of planned Project
activities in fixed health facilities and outreach services in hard to reach communities; and
also monitoring and reporting results of these services. Teams made up of staff fromC4D,
Health, Nutrition, HMIS, ISS, Child Protection, Social Protection, and PMTCT ensure timely
and proper execution of Project activities. In Kebbi State, the six implementing partners from
the public sector implement specific components of the Project with coordination provided
through the Partners Forum, the MNCH Core Technical Committee, and the Technical
Committee.
Relationship
The Project has invested heavily in relationship building with key stakeholders including
beneficiaries and collaborators. These relationships are helping improve the MNCH Project
outputs and outcomes. Some of the effective relationships are with:
26
i.
Women and Children: Mothers are very appreciative of benefits they and their children
are enjoying from the project– especially from the visible benefits of treatment for SAM
and CMAM and iCCM (malaria, pneumonia, and diarrhea), safe deliveries and the
PMTCT program. As a result antenatal, delivery, and postnatal attendances have
increased astronomically over 2013 baseline when the project was not started. The
number of mothers who receive HIV test and know their results is also increasing. Most
of the HIV testing is provided at the ANC, with a few during delivery and at postnatal care
visits.
ii. Health Workers and CORPs: Relationship with health services providers, especially
clinical services providers, has been very beneficial as health workers(HWs) report the
training received has improved their knowledge and skills and has resulted in better
services to their clients, which has brought them great job satisfaction and appreciation.
HWs therefore continue to over-subscribe to the Project’s training programs whenever
they are available.
iii. SPHCDA Managers & WDCs: These entities provide leadership and direction for the
provision of PHC and community-based health care services. SPHCDA and WDCs have
very cordial and mutually beneficial relationship with the Project: the number of trained
CORPs and knowledge and skills of HWs have improved tremendously and drugs and
equipment are now available more than before. SPHCDAs and WDCs indicate they are
now providing better quality healthcare services especially MNCH and nutrition services.
iv. Development Partners and CSOs: the Project has established excellent relations with
the World Bank through the Performance Based Financing (FBF)Project that is very
complementary with the MNCH Project. A strong partnership has been established in
which the MNCH Project provides the hardware (training human resources, equipment,
supplies and drugs) and the PBF pays for the services provided including MNCH and
Nutrition services. This partnership is resulting in much higher benefits to the people of
Adamawa than any one of them one could have done alone. The Project has strong
collaborative relationship with FHI360 that is implementing HIV programs in Adamawa
State under the USAID PEPFAR and GF HIV Grants to Nigeria.
v. Most of the staffs work in the Health program, which is the largest program in the Project
and covers maternal, newborn and child health. Smaller number of staff is deployed in
the other programs –nutrition, PMTCT, PMTCT, Child Protection, Social Protection and
HMIS. With regards to Project reporting, the LGAs submit quarterly reports to the
SPHCDA. The SPHCDA submits 6 monthly reports to the MNCH Project Steering
Committee and UNICEF submits one report annually to the EU. The HMIS tools are
used for collecting and collating project data that are entered monthly into the DHIS2
database on the web. The Bottleneck Analysis is of Project Indicators is an important
activity whose results inform areas that need attention and possible reprogramming
VIII.
Means And Cost
The Project has three sources of funding: The EU contributes €30 million, UNICEF’s
contribution is €1 million and Adamawa and Kebbi States contribute €1 million each. The
allocation of the Project funds shown in the budget Table 4 represents only the EU
contributions of about €30 million. The Project budget and its allocation are shown in Table 4
Health: The Health component has nearly two thirds (64%) of the funding followed in a
distant second by the Nutrition component. Health is the centerpiece and most important of
the components of the Project and covers interventions of maternal, newborn, and child
health interventions that potentially benefits 1.5million children under the age of 5years and
380,000 pregnant women. It is both capital and labor intensive. The costs items include
medicines, consumables and supplies, and medical equipment for providing antenatal,
delivery, and postnatal services at health facilities and for integrated community care
management (iCCM) of pneumonia, malaria, and diarrhea undertaken by CHEWs, CORPs,
and mothers and other caregivers. It is therefore appropriate the Health component is
allocated the largest proportion of the funds.
27
Table 4: EU-UNICEF MNCH Project Budget by Components
HEALTH
NUTRITION
HIV/AIDS
C4D
CP
SP
TOTAL
Total Project
Allocation
19,570,942.00
4,833,259.46
1,093,424.05
1,853,504.00
2,118,184.00
937,966.00
30,407,279.51
2014 (€)
6,591,555.11
953,533.29
0.00
854,296.27
672,546.21
407,346.81
9,479,277.69
2015 (€)
8,305,359.00
1,201,451.00
600,000.00
500,000.00
847,408.00
407,346.00
11,861,564.00
2016 (€)
2,337,013.95
1,339,137.59
246,712.03
249,603.87
299,114.90
61,636.59
4,533,218.91
2017 (€)
2,337,013.95
1,339,137.59
246,712.03
249,603.87
299,114.90
61,636.59
4,533,218.91
19,570,942.00
4,833,259.46
1,093,424.05
1,853,504.00
2,118,184.00
937,966.00
30,407,279.51
Percent Share
64%
16%
4%
6%
7%
3%
100%
Rank
1
2
5
4
3
6
Source: UNICEF Nigeria Country Office
Nutrition: The Nutrition component receives the second largest allocation of€4.8 million
(16%) of the Project funds. Nutritional problems are common in children under-5 in Nigeria
and women in both Adamawa and Kebbi States. Malnutrition is a major cause of childhood
morbidity in Nigeria with an estimated one in four and one in three children being
underweight and stunted respectively. Malnutrition in women (Adamawa: thinness&
overweight – 15% and 11.6% respectively; Kebbi (thinness& overweight -16.6% and 23.8%
respectively) is associated with negative nutritional outcomes in childhood including low birth
weight. There are 1.5 million children under-5 years in both Adamawa and Kebbi States and
the funding allocation to the Nutrition component enables the provision of growth and
nutrition monitoring services, micronutrient powders (MNP)and Vitamin A supplementation to
children under-5 years, treatment for tens of thousands more who are admitted to health
facilities for management of severe acute malnutrition (SAM) and hundreds of thousands of
others who benefit from community management of acute malnutrition (CMAM). Mothers
and caregivers also receive education and support for exclusive breastfeeding in first 6
months of life and infant and young child feeding counseling (IYCF). Both SAM and CMAM
interventions provide opportunities to test children for HIV and link those who are positive to
care. Thus the funding allocation is appropriate.
Child Protection: Child Protection receives the third largest allocation of just over €2 million
to catalyze child protection services especially birth registration for children the vast majority
(82% in North East and 89% in North West) of who were born at home and most likely do
not have birth certificates. There are 1.5 million children below the age of 5 years in both
Adamawa and Kebbi States. To a large extent, lack of a birth certificate denies the children
the right to an official identity; and so the Child Protection component of the Project is
catalytic in efforts to register those children without birth certificates in the two States. The
Child Protection component has engaged with the Media to provide education on child and
social protection issues for the general public, the Association of Local Governments of
Nigeria (ALGON) and the National Population Commission (NPopC) on harmonizing of birth
certificates used in the country, supports the training of health workers and registrars on
birth registration, and printed birth certificates for use in the two States. A draft 2014
Baseline Study Report for the MNCH Project shows 64% of children under-5 years have
certificates as evidence of their registration with the civil authority in Adamawa State; the
corresponding figure in Kebbi State is only 20.5%.
C4D: Communication for Development (C4D) component receives the 4th largest allocation
of about €1.85 million (6% of Project funds) to support communication and dialogue
(community conversations and empowerment) on MNCH and related issues at the
especially the ward level and generate demand for and participation in the provision and
management of these and other health care services. Appropriate messages have been
developed and aired on community radios and TV stations and basic information on MNCH
issues especially on emergency obstetric and newborn care (EmONC) and the availability of
emergency transport through arrangements with the National Union of Road Transport
Workers (NURTW) and similar service providers are readily provided. Basic MNCH data for
public information is prominently displayed on community information boards (CIB) in
strategic locations in the ward. The C4D is instrumental in educating and strengthening the
capacities of community own resource persons (CORPs), traditional birth attendants,
CHEWs and midwives on effective dialoguing that enhances effective delivery of MNCH and
nutrition services.
28
PMTCT: HIV and AIDS component is a later addition to the Project. It has been allocated
about €1.1 million approximately 4% of Project funds to integrate PMTCT services into the
MNCH Project in part because of very high HIV prevalence in neighboring Taraba State
(10.5%) versus 3.4 % in Adamawa and also because PMTCT coverage among pregnant
women in Adamawa States is very low. With HIV sentinel survey among pregnant women
attending ANC at 3.8%, the HIV testing service uptake among pregnant women in Adamawa
State is only 1.7% and only 9.9% of HIV positive pregnant women received ARVs to prevent
mother to child transmission of VIV in 2013. The presence of the MNCH Project in Adamawa
State provided an opportunity to integrate PMTCT interventions into the activities of the
MNCH Project. PMTCT interventions have started in earnest and PMTCT activities have
been included in the routine assignments for CORPs, HIV testing services are provided at
antenatal clinic delivery, during delivery, and at postnatal clinics as well as children receiving
treatment for SAM and CMAM. HIV positive pregnant women are referred for ART and HIV
exposed infants have their dry blood sample transported to Taraba State for virological
testing for early infant diagnosis (EID) using DNA PCR technology. Results are then sent
back via Internet and results printed using an electronic printer. This ensures the turnaround
time is small so that Antiretroviral Treatment, if needed, may be commenced soonest. The
amount of money allocated is adequate for now but needs to be watched as the coverage of
PMTCT increases.
Social Protection: Social Protection received the lowest allocation of slightly under €0.94
million (3%) of the Project funds to provide technical assistance that improves the coverage
and quality of a number government-led social protection programs including the scale-up
phase of the Community Health Insurance Scheme (CHIS), the Performance Based
Financing Project (PBF) in Adamawa State, the Subsidy Reinvestment and Empowerment
Program (SURE-P), and the development of the Joint Financing Agreement which will offer
a “planning, monitoring and financing mechanism for State government and partners to
channel funds for the Free Health Care Initiative in and efficient and effective manner”.
Additionally, the Social Protection component of the Project is to help scale-up the use of
Rapid SMS to collect and transmit performance data and referrals by SMS. The Social
Protection component is labor intensive and beholden to the performance of government
social protection initiatives, which often suffer from the “here today, gone tomorrow”
syndrome. Few, if any, of the planned interventions have been carried due a number of
internal challenges within UNICEF (staffing), technology challenges (difficulties with SMS),
and political challenges (difficulties in starting CHIS) and discontinuation of existing projects
(SURE-P).
Even though UNICEF has just commenced the implementation the Social Protection
component of the Project less than a month ago in earnest and considering the presence of
a successful PBF project in Adamawa State and the imminent launch of CHIS in Kebbi
State, we would recommend the funds allocated to the component be used to purchase
premiums for deserving beneficiaries in the PBF project currently operating in 11 LGAs in
Adamawa State (and which is poised to expand to the remaining 10 LGAs before year’s
end) and the proposed statewide CHIS in Kebbi State.
IX.
Measuring Project Benefits and Impact
The Project Results Framework used the Multiple Indicator Cluster Survey (MICS) result of
2011, 2013 and 2014, the Nigeria National Demographic and Health Survey (NDHS) results
of2008 and 2013 and the 2014 Project Baseline Survey results to establish Project impact
and outcomes baselines. Subsequent surveys in 2016 and 2017 will be used to assess
Project performance. However, the State NHMIS data collected and collated in the DHIS2
database is the expressed source of data for tracking the performance of the State Ministry
of Health at the output level. The divergence or non-concurrence of the data elements and
indicators of the DHIS2 and the project monitoring data is a significant cause for concern.
The Project Logical Framework itself, derived from harmonization of the National Health
Strategic Development Plan results matrix and the World Bank-supported Performance
Based Framework (PBF) for healthcare financing, can serve as the basis for measuring
progress and final assessment of the Project.
29
However, it will be difficult to accurately determine the level of contribution of the Project to
the Outcome and Impact results, as many players are supporting MNCH interventions in
both Adamawa and Kebbi States. The major players in Adamawa State include UN Joint
Program on HIV and AIDS, PEPFAR HIV Prevention, Treatment and Care Project, and the
World Bank PBF Project. The major projects in Kebbi State include the Joint UN Program on
Maternal and Newborn Health Project (NH4+), UKAID-funded Working to Improve Nutrition
in Northern Nigeria (WINNN), USAID Expanded Social Marketing Project in Nigeria
(ESMPIN, and Fistula Care Project through Engender Health. To further complicate the
problem of attributing results, important government-led national programs being
implemented in the two States include the Midwives Service Scheme, National and
Community Health Insurance Schemes, Conditional Grants Scheme, and SURE-P. The
Global Fund, the Immunization Systems Strengthening Project (funded by GAVI) and the
UNICEF Nutrition and Water and Sanitation (WASH) projects are also strengthening the
health systems in both States.
We analyzed the indicators in the 2014 Results Framework EU-UNICEF Project in
Adamawa and Kebbi and cross-matched these with the indicators in the Project’s Annual
Workplan for January to December 2015, the indicators for SMART 2013and 2014, and
those in the Project Baseline Survey of 2014 to assess their relevance and the mechanisms
that have been defined to measure benefit and impact. As a result of the analysis, we have
put together a compendium (Annex 4 – Suggested Indicators for MNCH Project) of Impact,
Outcome, and Output indicators that may be appropriate for monitoring the MNCH-Nutrition
Project.
A total of 56 indicators are used to measure benefits and impacts in five (5) Project
components with a total of 14 sub-components. Whilst many of the indicators are relevant
and the mechanisms defined to measure benefits at output level are appropriate and can be
easily obtained from project data, some outcome and impact indicators measurement
require complex and expensive population based surveys. Some key indicators are missing
altogether for some important components HIV status of babies born to HIV positive
mothers; indicators for measuring increased health financial access for poor and
marginalized rural women and their families are confusing. The Project has good indicators
to measure the outputs from its nutrition interventions; many children with severe acute
malnutrition (SAM) are admitted to health facilities; some are discharged home as “cured”, it
is important to design an outcome indicator to measure the treatment success rate for SAM.
Some interventions will be performed once only in the life of the Project, e.g. a local firm to
manufacture Ready to Use Therapeutic Foods (RUTF). As such there is no need to design
an indicator for such interventions.
There are pretty few Project Outcome indicators, which is required to provide information on
how the Project is progressing towards its specific objectives. To do this, denominators must
be determined for the key specific objectives of the Project and population based prevalence
data are needed to determine the denominators. There are few state-specific prevalence
data of the key diseases and conditions the Project is addressing in Adamawa and Kebbi
States; what is readily available is national level prevalence data. There is therefore a need
to do operations research to provide state-specific prevalence data to allow a determination
of the number in need of particular interventions and a bird’s eye view of the size of the
problem.
The NDHS is a key source for measuring the ultimate desirable impact of the Project
(reduction in maternal, newborn, infant, and U-5 mortality). Adopted by many countries
including Nigeria as the gold standard for collecting and analyzing population-based
demographic and health data, the NDHS is conducted every 4-5 years; however, it provides
only zonal level data and not state-specific data. The North East Zone data is used as proxy
for Adamawa State whilst the North West Zone data is used as baseline for Kebbi State. The
NDHS was conducted in 2013 and the next will likely be in 2018, a year after the Project
ends. On the other hand, the Project Baseline Survey of 2014 was conducted purposely to
provide baseline data for the Project; the report has not been officially released and
uncertainty surrounds the accuracy of some the findings especially the MMR of 855/100,000
live births for Adamawa State and 524 for Kebbi State. The Baseline Survey data shows
nearly 70% increase in MMR relative to the 545/100,000 in the 2013 NDHS for Adamawa
State. The MMR for Kebbi State has virtually stood still relative to the 545/100000 live births
in the 2013 NDHS. Informed opinions believe the Baseline Report data is probably incorrect.
30
Comparing data sets using form different sources using different methodologies for the
Project can be so confusing! We recommend the NDHS and MICS continue as the
mechanisms of choice to measure the impacts of the Project, which should undergo an End
Term Project Impact Evaluation in 2017. The results of the impact evaluation can then be
compared with the findings of the MICS in 2017 and the NDHS in 2018. Going forward,
Annex 4 of this Mid-Term Evaluation Report contains indicator data sets at output, outcome,
and impact levels that could be adopted to measure the benefits and impact of the Project.
X.
Lessons Learned and Collateral Benefits of the MNCH Project
10.1 Lessons learned
Important lessons that have been learned from implementing the MNCH Project include the
following:
i. The implementation of the twice a year MNCH Week with heavy involvement of highlevel political leaders in both Adamawa and Kebbi States is an innovative and successful
mechanism of keeping the focus and visibility of the Project alive in the midst of other
competing state-level priorities
ii. The synergistic benefits of a well thought out and effective partnership in complementary
projects yields higher dividends than can be obtained by the sum total of the individual
projects. This is amply demonstrated by the highly successful partnership between the
EU-supported MNCH Project and the World Bank-funded Performance Based Financing
(PBF) Project in Adamawa State where increased access to quality health services
through effective and sustainable funding mechanism for health services is improving
health outcomes including MNCH for the people of the State.
iii. Ownership of a development project is strengthened when key stakeholders for the
delivery of results are effectively engaged in the design, implementation, and monitoring
of the Project. This is demonstrated by the MNCH Project’s highly improved collaboration
between revitalized WDCs, retooled LGA PHC authorities, and State PHCDAs focused
on delivering results.
iv. Advocacy effort especially to higher political authorities to honor commitments for
development projects is not an event but a long and often difficult process. This is
demonstrated by loud and clear political commitments to increase funding for PHC in
Kebbi State with the release of full counterpart funding for the MNCH project.
v. Where there is a will there is a way is a key lesson learned when Adamawa State
PHCDA replaced more maneuverable motorcycles with less maneuverable tricycles for
the delivery of MNCH services for hard to reach communities following the ban on the
use of motorcycles part of interventions to stop the scourge of the insurgency in the
State
vi. The result of generating demand for MNCH services by trained CORPs is hugely
enhanced when done in tandem with establishing adequate numbers of functional PHC
facilities providing integrated services including 24/7 capability for emergency obstetric
and newborn care and strategically planned outreach services for hard to reach
communities. This demonstrated by the MNCH Project in Adamawa State where the
huge number of trained CORPs is contributing to the heavy surge in OPD and facility
attendances and increased utilization of routine MNCH services at 420 fully functional
PHC facilities and outreach to more than 1000 hard to reach communities.
10.2 Collateral Benefits
Collateral benefits are the good side effects of the MNCH Project. These include the
following:
i. The Project is providing crucial evidence of operability of the NPHCDA concept of the
one (1) functional PHC per LGA for Nigeria
ii. The Project is a resource for rapid, effective, and continuing response mechanism for
dealing with the health impact of the insurgency in Adamawa State: Functional PHC
open 24/7 are important in dealing with life threatening injuries from violence and
31
accidents and providing integrated humanitarian and MNCH services in camps for
internally displaced persons (IDPs).
iii. Influencing national policy: Pioneering role that led to the endorsement of Micronutrient
Powder (MNP) supplementation as a national policy by the National Health Council with
huge implication for roll out in other states of the Federation
10.3 Sustainability of Project Interventions
While work is still in progress on key MNCH interventions, the health facilities and outreach
programs in 42LGAs of Kebbi and Adamawa have
1. Relatively improved governance structures, stronger managerial competencies,
improved and competent health care workers, PHC facilities better equipped, and health
information system more responsive
2. Improved supply chain management due in part to UNICEF’s assistance in building
Project staff capacity in quantification and logistics management and transport for
moving goods to the State Central Medical Stores. Sustainability could be a challenge if
the whole procurement and supply chain management of SMOH is not improved before
the expiry of the Project.
3. Stronger community participation and self-support through the reactivation and improved
functionality of 451 WDCs that now feel they own the interventions and training of
thousands of CORPs to spearhead community based activities
4. Increased number of LGAs conducting quarterly PHC reviews including bottleneck
analysis(BNA) of MNCH-N indicators
5. Improved capacity for planning, budgeting and financial management at LGA and state
level in both Adamawa and Kebbi States
6. Improved health financing for MNCH services in Adamawa due to partnership between
the MNCH Project and the World Bank supported PBF project in Adamawa State
10.4 Alternatives Approaches
A quest for full integration of the MNCH-N Project with core PHC interventions identified by
Adamawa and Kebbi SPHCDAs would have allow SPHCDAs to address the broader
determinants of poor maternal, newborn, and child health outcomes in the two States.
Efficiency gains would include consolidated training and skills building in community level
activities that incorporate broader development issues such as education, gender, equity,
environmental health, water, and sanitation as an essential part of WDCs and CORPs
activities, and training of health workers to include control of other communicable diseases
and medical emergency preparedness. It was much easier for Adamawa SPHCDA to
incorporate the MNCH Project into its existing core business since it the Agency is
implementing an integrated PHC program. The situation Kebbi State is slightly different and
more challenging as PHC interventions are presently implemented by a number of public
bodies including the Kebbi SPHCDA.
Alternative approaches for funding the MNCH Project could include the following:
i. Health Sector Reform Contract with the SMoH: This will ensure improved delivery of
health services at all levels of the delivery system – primary, secondary, and tertiary level
– that are well interconnected to provide a effective continuum for the delivery of quality
health care. However, the scope is too broad and funding resources may be thinly
spread and could result in little or no gain in improving health outcomes
ii. Health Sector Support Contract with a focus on PHC including MNCH and Nutrition: This
has the greatest potential to improve health outcomes for many people especially
pregnant women, mothers and young children. However, much attention should be given
to health systems improvement and not just for the delivery of services as a functioning
system is necessary for the delivery of quality care in an equitable and sustainable
manner.
iii. Contribution Agreement or Counterpart Funding Arrangement with NPHCDA or
SPHCDA: This may not be a viable proposition as government is almost always unable
to meet its commitment for counterpart funding. When government funding is available, it
is very often inadequate and release of funding allocation is delayed. This negatively
impacts the delivery of quality health care. Evidence from Global Fund grants for AIDS,
Malaria, and TB programs over the last decade indicates persistent government inability
to comply with counterpart funding agreements.
32
XI.
Recommendations
The Evaluation recommends EU should continue its support for the MNCH-N project through
UNICEF in its current with the following caveats:
(i)
UNICEF should provide technical assistance to start implementation of the social
protection component of the Project as soon as possible. The Social Protection
component of the Project should focus on assisting ongoing efforts at establishing
health insurance schemes in the States. For example, the Project could assist
Adamawa State to roll out its PBF Project and accelerate Kebbi State’s efforts at
establishing a statewide health insurance scheme.
(ii)
Since the GF Malaria Project has discontinued the distribution of long lasting
insecticide treated nets (LLIN) in Adamawa State, the Project should provide LLIN as
malaria continues to be a major cause of morbidity and mortality for pregnant women
and young children. The distribution of LLIN could be an important activity that is
incorporated into the iCCM program.
(iii)
Kebbi State should be encouraged to move quickly on enacting the law to establish
its SPHCDA so that it can takeover full and complete implementation of the Project
from the existing 6 implementing partners.
Project Component Specific Recommendations
Project component specific recommendations are provided under the specific components in
the Report. The main component recommendations include:
Component 1: Improved communication on and timely health seeking behavior by
women and children
i. The C4D intervention is enabling very many people and communities to improve their
health seeking behavior. This is commendable and should be intensified to enable more
people to use health facility and outreach services
Component 2: Increased health financial and geographical access for poor and
marginalized women and their families
i. The MNCH Project should be supporting NHIS and State government efforts to establish
a statewide health insurance scheme in Kebbi State. In Adamawa State, the effort
should to enable beneficiaries to access services through some arrangement with the
PBF Project in that State
Component 3: Improved health service delivery through functional health facilities
and outreach services
i. A Project focus is necessary to strengthen the State Central Medical Stores and the
entire State Ministry of Health supply chain management system in both Adamawa and
Kebbi States, especially given the new World-Bank funded ‘Saving One Million Lives’
project which has commenced in the two States
ii. It is imperative that the renovation of health facilities in Kebbi State is commenced in
earnest to complement the procurement and distribution of medical supplies. This will
enhance the provision of quality health services including MNCH care 24-hours a day.
iii. The Kebbi SPHCDA plans to “renovate” 21 BEmOCs in line with NPHCDA Agency
minimum standards” will have a strong link to contributing to achieving the expected
results and strategic objective of the Project. However, the referral linkages to the one
(1) functional PHC per Ward should be simultaneously addressed.
Component 4: Improved maternal, newborn and child nutrition
i. The MNCH Project should immediately engage the State Ministry of Agriculture as an
important stakeholder and resource expert for improving household food security in the
two States
ii. The Kebbi State government should improve the coordination of all nutrition interventions
by the many implementers in the state by constituting a Coordination Committee to have
oversight responsibility for this activity.
iii. Kebbi State government should continue to explore all possible avenues for the local
manufacture of RUTF. This will enhance sustainability of the nutrition program.
Meanwhile, the State should continue to procure RUFT since it is a key intervention for
the State
33
Component 5: Improving governance systems following the DART (Decentralized,
Action-Oriented, Responsive and Transparent) Principles
i. Continuing efforts to legally establish the SPHCDA in Kebbi State is noted and deeply
commended. All efforts should be made to ensure the establishment and resourcing of a
legally constituted SPHCDA in Kebbi State
ii. There is a need to urgently improve Project Coordination among the 6 implementing
partners in Kebbi State.
iii. The Evaluation commends and supports the statewide roll out of the PBF project before
the end of 2016 being contemplated by the Adamawa SPHCDA, as this will enable the
10 remaining LGAs to benefit from the hugely successful synergistic partnership
between the MNCH and PBF Projects
iv. Intensify advocacy activities to ensure governments increase funding to PHC activities
and to release in full and on time all approved budgetary allocations
v. Undertake Bottleneck Analysis (BNA) and use information for improving Project
performance: Available evidence suggest that a lot of the information collected and
collated during the Integrated Supportive Supervision, PHC Reviews/Bottleneck
Analysis, MNCH Week, trainings etc. are not effectively analyzed and turned into useful
management information to inform the implementation of the Project. For example,
whereas the ANC and skilled birth attendance rates were issues addressed in bottleneck
analysis, and given the significant disparity between institutional deliveries and the
number of deliveries attended to by skilled birth attendants, the evaluators found little
evidence of specific management actions targeted to addressing the observed disparity.
Training (Human Resources for Health)
i. Training of CORPs to spearhead community level activities including iCCM is
commendable; however there is a need to ensure they are properly supervised by the
JCHEWs, whose job description includes 0.7 whole time equivalent at the community
level, which mandate they are not fulfilling
ii. It is important to harmonize incentives provided to volunteers and CORPs by different
organizations in each State. Volunteers and CORPs are invaluable resource for the
MNCH Project and significant disparities in incentive packages between different players
in the same State could be problematic in efforts to improve maternal, newborn, and
child health outcomes.
iii. The MNCH Project training programs must be harmonized with the plans of Human
Resource Unit, Department of Planning and Statistics of the SMOH inn Kebbi State.
XII.
Annexes
Annex 1 - List of Persons-Organizations Met
Annex 2 - Adamawa MNCH Project Training Outputs
Annex 3 - Adamawa State Service Data Extracted from DHIS
Annex 4 - Suggested Indicator Set for MNCH Project
Annex 5 - ToR (see as separate attachment)
Annex 6 - Adamawa State Sector Reform Contract &Analysis of Eligibility Criteria Draft
Annex 7 – Abbreviations and acronyms
34
Annex 1: List of Persons/Organizations Met
Name
Jean Gough
Kennedy Ongwae
Aboubacar Kampo
Johnson Bareyei
Anthony Ayeke
Jens Hoegel
Daniel Salihu
Josephine Nneka
Okide
Arjan de Wagt
Dorothy MboriNgacha
Abiola Davis
ChristineKaligirwa
Norma Owens-Ibie
Rachel Harvey
Gariba Safiyanu
Nnenna N Ihebuzor
Anslem Audu
Christine Kaligirwa
Norma Owens-Ibie
Daniel Salihu
Babakunawa
Gambo Bello
Josephine Nneka
Okide
Aboubacar Kampo
Sarba Safiyanu
Anthony Ayeke
Jens Hoegel
Dorothy MboriNgacha
Zainab Bala
Kennedy Ongwae
Suleiman Lamorde
Zainab Mahmoud
Hapsatu Husaini
Dr. Fatima Atiku
Abubakar
Dr. Abdullahi
Dauda Belel
Dr. Barminus A.G.
Ibrahim Audu
Peter R Leha
Dr. Halima Abdu
Dr. Martins
Jackson
Dr. Asusuchi Okey
Organization
UNICEF Representative to Nigeria and
ECOWAS
MNCH Specialist, UNICEF Nigeria
UNICEF Abuja Nigeria
Assistant Director, Ministry of Budget
and National Planning Abuja Nigeria
EU Delegation to Nigeria
EU Delegation to Nigeria
MNCH Health Specialist, UNICEF
Nigeria
Health Officer UNICEF Nigeria
Email Address/Other
[email protected]
Chief Nutrition UNICEF Nigeria
Chief HIV/AIDS UNICEF Nigeria
[email protected]
[email protected]
HIV Specialist UNICEF Nigeria
Nutrition Specialist UNICEF Nigeria
Communication for Development
UNICEF Nigeria
Chief Child Protection UNICEF Nigeria
Health Specialist UNICEF
Director PHC Development Systems,
NPHCDA Nigeria
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Johnson.bareyei@nationalplannin
g.gov.org
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
MTE Inception Report Meeting Abuja
UNICEF HIV Specialist
[email protected]
UNICEF Nutrition Specialist
[email protected]
UNICEF Communication for
[email protected]
Development
MNCH Health Specialist, UNICEF
[email protected]
Nigeria
NPHCDA/EU/MNCH Desk
[email protected]
Health Officer UNICEF Nigeria
[email protected]
UNICEF Health
UNICEF Health
EU Delegation Nigeria
EU Delegation Nigeria
[email protected]
[email protected]
[email protected]
[email protected]
u
[email protected]
UNICEF HIV and AIDS
Ministry of Budget and National
Planning
UNICEF MNCH Specialist
National Primary Health Care
Development Agency
National Population Commission
National Population Commission
Adamawa State
Honourable Commissioner for Health
Adamawa State
Chairman Adamawa Primary Health
Care Development Agency
Director Planning Research and
Statistics
Adamawa SPHCDA
Media Consultant ADSPHCDA
Secretary State MOH Adamawa
Health Specialist UNICEF
Nutrition Officer UNICEF
HIV/AIDS Consultant
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
35
Name
Osuji
Dr. Bello Sikiti
Ladi S Williams
Wumi Ajayi
Dr. Dang Guful
Dr. Paul S Margwa
James T. Pukuma
Mohammed Isa
Tukur
Hauwa H Umar
Akammi Anamo
Joram Philip
Rashida A Tahir
Joshua Adashu
Pwanedo Karka
Sani Yusuf
Zainab Mohammed
Aidaticha Reuben
Hauwa Zookah
Rukaiya Suleiman
Dr. Martin Bimba
HS Buba
Dr. Bello Sikiti
Dr. Asuduchi Okey
Osuji
Dr. Fanen
Verinumbe
Dr. Paul S Margwa
Emmanuel Bwala
Joshua Adashu
Hauwa Musa
Benjamin Nashon
David Timothy
Dr.Attahiru M Bello
Mukhtar Jidda
Zainab Mohammed
Rashida Tahir
Hunpiya Makanto
Mathias Munekezi
Hauswa Zookah
Pwanedo H Karka
Rabiu Mohammed
Ahmed Ibrahim
Muazu Muazu
Mohammed Sadiq
Dr. Mbunya Simon
Hyelamada Ayuba
Ibrahim
UmaruMidly
Mohammed
Yerima
Moh’d Babiye
Organization
Email Address/Other
MNCH Consultant
Birth Registration Consultant
Nutrition Consultant UNICEF
Vaccine Security and Logistics
Immunization Consultant
Desk Officer EU-UNICEF Project
Adamawa SPHCDA
Psychosocial Consultant
Chairman Ward Development
Committee Yola South LGA
Health Facility Manager Nana Asmau
MCH Clinic
Yola South LGA
PHC (Center of Excellence) Facility
Manager
Demsa LGA
Chairman Community Own Resource
Persons (CORPs) Kade Village
Social Protection Officer Adamawa
SPHCDA
iCCM Program Officer Adamawa
SPHCDA
MCH Coordinator Adamawa SPHCDA
State Immunization Officer Adamawa
SPHCDA
HIV Officer Adamawa SPHCDA
M&E Officer Adamawa SPHCDA
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
07088844032
08076850281
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
Adamawa MNCH Project MTE Debriefing Meeting
PmI Adamawa PHCDA
[email protected]
ADSPHCDA
[email protected]
EU-UNICEF Consultant
[email protected]
EU-UNICEF Consultant
[email protected]
SPHCDA NSHIP PIU
[email protected]
ASPHCDA MNCH Project Desk Officer
ARFH State Consultant
ASPHCDA iCCM Project Officer
ASPHCDA DCHS
SMOH iCCM Team
SPHCDA NSHIP
SPHCDA Health Specialist
SPHCDA Laboratory Expert
ADPHCDA HIV Officer
ASPHCDA Social Protection Officer
ASPHCDA Admin Officer
AEDES/OPM RBF TA FP
ADPHCDA SNO
ASPHCDA MCH
ASPHCDA CSO
ADPHCDA AEO
ADSPHCDA Program Analyst
ADSPHCDA Program Analyst
OPM RBF TA
ADPHCDA A.O II
ADPHCDA PO Med Lab
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
ADPHCDA T.O
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
[email protected]
ADPHCA P.E.O.I
36
Annex 2: MNCH Training Output September 2014 – December 2015.
S/N
1.
2.
3.
4.
5.
6.
Training
Month
Trainings
in 2014
September
September
October
October
7.
November
December
Trainings
in 2015
January
8.
January
9.
March
10.
April
11.
April
12.
May
13.
14.
May
May
15.
June
16.
17.
18.
19.
June
August
September
September
20.
September
21.
22.
October
October
23.
October
24.
November
25.
November
26.
November
27.
December
28.
December
29.
December
2014+2015
Tittle of the Training
Training of programme officers on Integrated Support supervision
Training of programme officers on Knowledge of NHMIS
One day orientation for 21 Executive Secretaries on PHCUOF
One-day training for 21 Ex Sec and 21 Directors of MCH on
EMONC activities
One day training in four batches for 226 ward focal person on ISS
CMAM Expansion in Ganye and Yola North
Training on CMAM Quality Improvement in 3 LGAs (Ganye, Song
and Mubi North).
Training of LGA CORPS supervisors on Integrated Supportive
Supervision
Planning meeting/ Orientation of community Volunteers on
Integrated HIV and Nutrition service in CMAM OTP setting. (34
Participants)
One day orientation meeting with media on MNCH Project
Interventions
Training of Tutors of Colleges of Health Technology and
Nursing/Midwifery.
Training of MCH Directors and their assistants on supportive
supervision on Maternal Newborn and Child Health interventions.
CMAM scale up in 4 LGAs access to IDPs.
Training on NHMIS for WFPs facility managers and programme
officers
ToT for 12 Midwives on CBNC, 25 CHWs, from 2LGAs 12 from
Girei and 13 from Fufore.
One day preventive Technical Working Group meeting
Roll out of IYCF/CLTS/SSM in Ganye LGA
Training on HMIS tool for HCPs from 25 CMAM sites
Training of CORPS and CHEWs on demand creation towards
iCCM implementation
Training of Trainers on IMCI case management for Adamawa,
Bauchi and Taraba States
Training of CHWs on MLSS from 21 LGAs of Adamawa State
Training of 200 Health Care Workers, 100 Lab Technician and
100 HCPs on HCT
Training of CORPS and WDC chairmen on the use of Community
Information Board (CIB).
Mentoring/Supportive supervision for HIV data generation in
CMAM OTP.
Training of health workers in IDPs camps and outreach teams on
comprehensive health care services in emergency setting
Training of Trainers to train CORPS (914) on distribution of Safe
Delivery Kits and home visits in Adamawa
Training on PMTCT and OBS and SMS printer operation at PHC
level in Adamawa State.
Training of FOMWAN, CAN, WDC on EFP and other MNCH
services
Reviewing the social and communication strategy around up take
of PMCTC service in Adamawa State (51 participants)
Total number of people trained on MNCH activities Sept 2014
– December 2015
Number of
Participants
21
21
226
63
34
30
12+25
33
65
120
25
75
400
452
53
78
450
51
1,602
Source: Adamawa State Data Extracted from NHMIS 29January 2016
Annex 3: Adamawa State Service Data Extracted from DHIS2
37
Output Indicator
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
Facility Attendance
Outpatient Attendance
Antenatal 4th Visit
Antenatal total attendance
Pregnant women receiving LLIN
Pregnant women who received
malaria IPT2
Deliveries by skilled birth
attendants*
Deliveries monitored with
partograph
BCG
Fully Immunized Children under 1
year*
Oral Polio Vaccine 3 given
Measles < 5 years - new case
Pneumonia < 5 years - new case
Pneumonia< 5 years-new case
given antibiotics
Confirmed uncomplicated malaria
given ACT*
Fever cases
Fever tested by RDT
Malaria RDT tested positive
Diarrhea < 5 years - new case
Diarrhea < 5 years - new case
given ORS and zinc
Pneumonia < 5 years - new case
Pneumonia< 5 years-new case
given antibiotics
Confirmed uncomplicated malaria
given ACT
<5 years discharged healthy after
Nutritional Treatment
<5 years placed on treatment for
severe acute malnutrition
Child admitted into CMAM
program
Child defaulted from CMAM
program
Children 0-59 months weighed
Children 0-59 months weighing
below bottom line
Children 0-6 months exclusively
breastfed
Children 12-59months given
deworming medication
Vitamin A children 12-59 months
(200,000 IU)
Vitamin A children 6-11 months
(100,000 IU)
ANC women with previously
known HIV status (At ANC)
Pregnant women who received
HIV counseling and testing and
result (at ANC)#
Pregnant women who received
HIV counseling and testing and
result (at L&D)#
Women who received HIV
counseling, testing and received
results at PNC#
Live Birth
Baseline
2013
79,256
50,696
4,367
23,510
881
Jan-Dec 2014
Jan-Dec 2015
995,134
655,887
59,333
233,204
44,059
1,178,328
670,884
45,638
217,573
13,589
4,806
43,108
48,505
1,291
24,135
44,843
568
6,687
8,891
90,668
36,580
86,956
5,205
5,729
318
611
62,126
90,664
2,449
7,546
66,721
83,465
1,656
8,859
519
6,596
8,073
16,322
31,760
9,361
7,371
2,606
225,728
361,578
234,224
184,708
27,511
212,198
325,316
239,434
184,674
33,908
780
611
10,176
7,546
16,544
8,859
519
6,596
8,073
16,322
225,728
212,198
182
2,093
4,792
352
3,904
11,011
331
4,927
10,642
22
10,146
580
137,304
1,988
260,561
581
7,829
17,312
2,857
41,712
69,924
27,134
145,808
101,888
27,577
168,102
86,843
9,296
59,259
31,253
975
16,754
23,749
150
23,846
47,100
48
3,589
8,945
22
3,010
1,844
34,303
4,040
49,605
38
Annex 4 – Suggested Indicator Set for MNCH Project
Intervention Logic
General Objective
To significantly
improve the health
status of women and
children through an
improved and
sustainable primary
health care delivery
system
Project Specific
Objectives
1. Increase the
proportion of
women who are
able to correctly
recognize
pregnancy
complications and
seek timely care,
when required.
2. Increase the
proportion of poor,
marginalized, rural
women with
increased financial
access to a health
facility for pre –
pregnancy, routine
ANC and
Emergency
Newborn and
Obstetric Care
3. Improve the
functionality of the
health service
provision for fixed
and outreach
services through
adequate and
qualified health
personnel,
adequate supplies
and equipment;
4. Improve the
nutrition of women
and children along
the continuum of
care from
preconception to
Framework
Indicators
Impact Indicators
Maternal Mortality
Ratio (per 100,000
Live births) (or State
specific maternal
mortality rates)
Neonatal mortality
rate (per 1000 live
births)
% Children 0-59
months who are
stunted
% Children 0-59
months who are
underweight
Outcome Indicators
Suggested Change
% Children fully
immunized by 1 year
% Skilled attendants
at birth
% Children 0-6
months exclusively
breastfed
OK but to use SMART 2013 as source of
verification
OK but to use SMART 2013 as source of
verification
OK but to use SMART 2013 as source of
verification
% Children 659months who
received high-dose
Vitamin-A in the last
six months
OK but to use SMART 2013 as source of
verification
% Children breastfed
1 hour after delivery
% of wards with at
least 1 functioning
PHC centre
(according to WMHCP
definition) that deliver
MNCH-N services
% mothers and
caregiver who receive
counselling in
maternal nutrition and
infant and young child
feeding practices
% LGAs with up to
80% release of annual
budgeted amount for
PHC activities
% Children under five
diagnosed with
pneumonia receiving
timely care as per
iCCM
% Children under five
with diarrhoea who
receive appropriate
care (ORS and Zinc)
within 24 hours of
onset
% Children under five
with fever last 2
OK but to use 2013 NDHS as source instead of
2008
OK but to use 2013 NDHS as source instead of
2008
OK but to use 2013 NDHS as source instead of
2008
OK but to use 2013 NDHS as source instead of
2008
Delete
Delete/All LGAS have at least I functional PHC
Delete
Delete/Moved to Output level as Number of LGAs OK but to use SMART 2013 as source of
verification
OK but to use SMART 2013 as source of
verification
OK but to use SMART 2013 as source of
verification
39
Intervention Logic
childhood.
5. Strengthen health
systems
governance by
improving
decentralized
planning and
budgeting
processes for
improved
accountability and
transparency in the
delivery of
maternal and
newborn services
Framework
Indicators
weeks treated with
antimalarial drug
% Children under five
sleeping under LLIN/
% Pregnant women
making at least 4 ANC
visits
Suggested Change
OK but to use SMART 2013 as source of
verification
OK but to use SMART 2013 as source of
verification
Component 1: Improved communication and timely health seeking behaviour by women and
children
Intervention Logic
Old Output
Suggested New Output Indicators/OVI
Indicators/OVI
1.1: Increased number % Children under five
of
institutional diagnosed with
Number of children under five diagnosed with
deliveries
Pneumonia receiving
Pneumonia receiving timely care as per iCCM
timely care as per
iCCM
1.2: Increased skilled
% Children under five
Number of children under five with diarrhoea who
birth attendants’
with diarrhoea who
receive appropriate care (ORS and Zinc) within 24
receive appropriate
hours of onset
care (ORS and Zinc)
within 24 hours of
onset
1.3: Increased number % Children under five
Number of children under five with fever last 2
of women who attend
with fever last 2
weeks treated with antimalarial drug
ANC at least 4 times.
weeks treated with
antimalarial drug
1.4: Increased number % Pregnant women
Number of pregnant women making at least 4 ANC
of children registered
making at least 4 ANC visits
at birth
visits
% caregivers with
knowledge of
diseases against
Delete
which children are
immunized
% of children under
five sleeping under
LLIN.
% of pregnant
women sleeping
under LLIN.
% Pregnant women
accessing HTC at
ANC
% of children under 5
whose birth is
Delete
Delete
Number of pregnant women accessing HTC at
ANC
Number HIV positive pregnant women given ARVs
to prevent mother to child transmission of HIV
Number of HIV exposed infant given prophylaxis to
prevent mother to child transmission of HIV
Number of HIV exposed infants receiving a
virological test within 2 months of birth
Number of children under 5 whose birth is
registered with civil authorities
40
Intervention Logic
Framework
Indicators
registered with civil
authorities
Suggested Change
Component 2: Increased Health Financial and Geographical Access for the poor and
marginalized rural women and their families
2.1 A paying for
1) Number of women Social Protection Team to lead design of
performance scheme
appropriate output indicators
and children
established
covered by social
2.2 Mechanism to
increase access and
use of both preventive
and curative services
2.3 Increased number
of pregnant women of
child bearing age and
children under-5 with
free access to a
package of basic
preventive and
curative services
protection scheme
(community based
health insurance
and/or cash
transfer scheme
2) Number of women
and children
utilizing
subsidized /free
care based on a
defined package
Social Protection Team to lead design of
appropriate output indicators
Component 3: Improved Health Service Delivery through functional health facilities
3.1 Increased access
Number of health
OK
to comprehensive and
service providers
quality MNCH and HIV trained in maternal,
services
newborn, child health
live saving skills
Number of health
OK
workers trained on
infant and young child
feeding practices
including in the
context of HIV
Number of health
OK
service providers
trained in providing
PMTCT/EID services
Number of PHC
facilities offering HCT
in situ or by referral
% PHC facilities with
functioning water
supply sanitation and
electricity
Number of PHC
facilities stocked with
CNBC kits
Number of PHC
facilities using
partograph to monitor
labour
% PHC facilities with
no stock outs Vitamin
A, iron folate and
deworming tablets
Number of PHC
facilities with no stock
outs(ORS, antibiotics,
and anti-malarial
tablets) of essential
commodities
Number of PHC
centres that have
OK
Number of PHC facilities with functioning water
supply, sanitation and electricity
OK
OK
Number of PHC facilities with no stock outs Vitamin
A, iron folate and deworming tablets
OK
OK
41
Intervention Logic
Framework
Indicators
functional birth and
death registration
services in the LGAs
Suggested Change
4. Improved nutrition of women during the preconception and antenatal care
Improved nutrition of
Number of PHC
OK but in 3 LGAs when reporting for EU support
women during
facilities providing
only.
preconception and
infant and young child
antenatal period
feeding counselling
including in the
context of HIV
Intrapartum
% of expected PHC
Number of expected PHC facilities conducting HTC
interventions to improve facilities conducting
interventions during MNCH Week
nutrition of the
HTC interventions
newborn
during MNCH Week
Improved nutrition of
OK
Number of pregnant
the lactating mother,
women who received
newborn, infant and
iron folate
young child (Enhancing
supplements
Maternal and Child
Number of mothers
and caregivers who
receive counselling in
OK
maternal and newborn
nutrition practices
including HIV
Number of active
infant feeding support
groups
Number of children
OK
admitted in to CMAM
Number of CMAM
OK
sites offering HTC
Number of children 6
OK
to 59 months
receiving multiple
micronutrients
Number of certified
Delete
local firms producing
RUTF
Number of infant
Number of active infant feeding support groups
feeding support
groups
Number of children 6 to 59 months receiving
multiple micronutrients
% planned LGAs
quarterly coordination
meetings conducted
5.1: Strengthen
existing mechanisms
(Primary Health Care
Under One Roof) and
the Minimum
Standards for PHC) for
effective participation
of LGAs and
communities in
decentralized planning
and delivery of
essential health
services.
5.2: Develop systems
to improve budget
execution for improved
Number of planned
LGAs integrated
quarterly coordination
meetings conducted
Number of LGAs
conducting quarterly
PHC reviews for
bottleneck analysis
(BNA) of MNCH-N
indicators
Number of LGAs
implementing
developed operational
plans
2016 Operational Plan
for SPHDA including
HIV and AIDS
OK
OK
Delete
Delete
42
Intervention Logic
transparency and
accountability
5.3: Improved
Monitoring and
Evaluation, including
impact evaluation
Framework
Indicators
developed
Number of quarterly
PMTCT /PAR
meetings held
Number of LGAs with
up to 80% release of
annual budgeted
amount for PHC
% (Number) of
planned WDC
meetings conducted
% LGAs using
immunization
accountability
framework
% of wards reporting
with RapidSMS.
Number of LGAs
conducting quarterly
integrated supportive
supervisory visits to
all facilities in their
catchment area
Suggested Change
OK
OK
Number of WDC meetings held
Number of LGAs using immunization accountability
framework
Delete
OK
Feasibility of State-level Sector Contract for Adamawa State
1. Existence of a clear state health sector policy and strategy
Adamawa State has a clear state health sector policy and strategy. The Adamawa State Health Policy
is based on Nigerian National Health Policy; it is heavily anchored on the concept and practice of
PHC. As part of the Adamawa State Government Strategic Development Plan, the State Ministry of
Health (SMOH) developed the State Health Strategic Plan 2016-2020 following extensive and
inclusive consultations with government and non-government stakeholders at state, LGA, and
community levels. The Health Strategic Plan 2016-2020 is currently being reviewed to include
experiences and lessons learned from two important health projects the State is currently
implementing.
The first of the projects is the Performance Based Financing (PBF) approach for the delivery of
primary health care services: Adamawa State is one of three States (the others are Ondo and
Nasarawa) piloting the PBF approach since 2011 in the Nigeria State Health Investment Project
(NSHIP) supported by the World Bank. From a successful pilot intervention in one LGA, Adamawa
State has expanded the PBF approach to 11 of its 21 LGAs. The benefits of the PBF are so visibly
enormous that the State is poised to roll out the PBF to the remaining 10 LGAs by the end of 2016.
The second project is the 4-year Scale-up of Maternal, Newborn, and Child Health (MNCH) Project for
two States in Northern Nigeria (Adamawa and Kebbi States) with funding from the European Union
(EU) through a Contribution Agreement with UNICEF. Since April 2014, the Adamawa State Primary
Health Care Development Agency (ASPHCDA) has been implementing MNCH interventions in all 21
LGAs (PMTCT interventions were added later) and the Nutrition Component of the MNCH in only
three (3) LGAs in the State with UNICEF Nigeria providing technical support.
Sectoral Medium Term Expenditure Program
Adamawa State has anmedium term expenditure program that is consistent with the Nigeria national
medium term expenditure framework (MTEF). Adamawa State has developed a State Health
Strategic Development Plan (SHDSP) 2016-2020 that is currently being costed. This comprehensive
action plan, when fully costed will establish the level of available internal and external resources and
how these resources will be utilized in execute the Plan. Adamawa State is one of the poorest states
in Nigeria; about 11% of the State’s budget is on the health sector that is higher than the national
average of about 8%. It depends heavily on budgetary allocation from the Federal Government and a
few donors including the World Bank, the EU, and the UN System.
Performance Monitoring System
Adamawa State PHCDA is implementing an integrated delivery of PHC services. The National Health
Sector M&E Plan is the cornerstone of the M&E system for monitoring the performance of the PHC
program. The National M&E Plan has been adapted to incorporate the specific needs of the World
Bank –supported Performance Based Financing Project. The State conducts quarterly Integrated
Supportive Supervision (ISS) approach to measure progress towards the achievement of policy
43
objectives and planned results, distinguishing between male and female beneficiaries and ensuring
the needs of vulnerable groups (disabled, women and children, indigenes, and internally displaced
persons (IDPs)resulting from several years of Boko Haram insurgency. State and LGA level quarterly
review meetings examine progress towards achieving planned objectives including identifying
challenges through bottleneck analysis of program indicators and finding solutions for the resolution of
the challenges.Adamawa State regularly uploads its data on a quarterly basis into the web-based
DHIS2, the national HMIS database, and has ready access to the data for analysis and use.
Formalized process of donor coordination
The Adamawa State Planning Commission coordinates and chairs Steering Committee meetings of
all state level donor-funded projects. The SMOH and the SPHCDA are steering committee members
for health sector programs. There are agreed processes for moving towards harmonized systems for
reporting, budgeting, financial management and procurement of donor supported projects.
Inclusive Stakeholder Consultations
The inclusivity in consultations for the development of public health programs in Adamawa State is
improving all the time. This is particularly true of the development of the Adamawa State Ministry of
Health Strategic Development Plan (SMOH) Strategic Plan for incorporation into the Adamawa State
Government Strategic Development Plan 2016-2020 where there are ongoing consultations currently
underway between the SPHCDA, the LGAs, and communities through elected Ward Development
Committees (WDCs).
Preliminary Analysis of Eligibility Criteria that will contribute to drafting an identification fiche
for Adamawa State-level Health Sector Reform Contract
Assessment Criteria & Key
Questions
1) Does the country have a
sector/sub-sector policy?
2) Is it supported by a sector
strategy
3) Are the sector policies
underpinned by national
policies for socioeconomic
development and for meeting
EU accession requirements?
4) Is the sector policy authored
and endorsed by domestic
actors, including Civil Society
Organizations (CSOs)?
5) Are there enough political
support and stakeholder
involvement at the state level
to ensure ownership and
future sustainability?
6) Are policy objectives coherent
with national development
objectives?
7) Are the objectives sufficiently
SMART?
8) Is sector planning linked to
resource allocation and also
does it take into account
decentralization processes?
Yes
No
Remarks
1. Sector policy and Strategy
Yes
The health sector policy
Yes
Yes
Yes
Yes
Yes
Yes
Yes
2.Institutional setting and Capacity Assessment
1) What is the institutional setting Yes
Significantly separate and decentralized
and context including the
degree of decentralization of
public powers and resources?
2) Has the sector been defined
Yes
with institutional coherence in
mind?
3) Is there a lead Ministry in the
Yes,
Federal Ministry of Health at national
Sector?
level and State MOH at State level
4) What is the capacity of key
Capacity is good at federal level but weak
44
Assessment Criteria & Key
Questions
sector organizations and
critical stakeholders (including
CSOs)?
5) What is the level of
beneficiary's ownership of the
assessment process and its
willingness to improve its
capacity?
6) What (if any) are the
institutional structures required
by donors (including EC) and
how do they link to the national
structures?
7) Have workload analyses of the
institutions in the Operating
Structure been carried out?
8) Does the beneficiary require
capacity building and, if so, are
there options for
harmonization with other
donors' interventions?
9) If support to capacity building
is envisaged, how and when
will a needs assessment be
carried out during the
preparation of the Sector
Support Program?
1) Do appropriate coordination
mechanisms exist within the
responsible government
institutions?
2) Are there coordination
mechanisms between the
government and non-state
actors?
3) Are there functional donor
coordination arrangements in
place?
Yes
Should be carried out by a team of health
experts during the implementation of
Contract. Some key experts should be
embedded in especially the SMOH and
definitely in the Adamawa SPHCDA.
3. Sector and Donor Coordination
Yes
By the Ministry of Budget and National
Planning at national level and by the
State Planning Commission at State level
Yes
Between FMOH and Adamawa SMOH
and non-state actors especially with key
NGOs and Faith Based Organizations.
Yes
Steering Committees chaired by the
Ministry of Budget and National Planning
at national level and by State Planning
Commission at State level FMOH and
Adamawa SMO
Database is at the Ministry of Budget and
National Planning at Federal level and the
State Planning Commission at the state
level
Usually includes key ministries involved
and donors providing assistance in the
sector.
The Ministry of Budget and National
Planning takes the lead in coordinating
donors and the national level and the
State Planning Commissions take the
lead at the state level
Yes
5) Is the coordination effective
and inclusive?
Yes
6) Is there sector leadership and
willingness of government to
take the lead in donor
coordination or does the
government show potential to
develop leadership role
effectively in the short term?
Yes
2) What is the nature and scope
of the sector budget?
3) Does the budget fairly reflect
Remarks
in Adamawa State MOH and weak but
improving at Adamawa State PHC
Development Agency
Uncertain about ownership at FMOH and
Adamawa SMOH but very strong
ownership of Adamawa PHCDA PHC
program, which is very willing to improve
capacity
Donor coordination by State Planning
Commission or equivalent linked to
Ministry of Budget and National Planning
at the Federal level; Program Steering
Committee at State and Federal levels.
Uncertain at Federal level, but Adamawa
SMOH indicates this has been done.
Very probably yes at the Federal level
and most certainly yes at Adamawa
State.
4) Is there an up to date
database of donors?
1) Can the sector budget be
easily identified in the state
budget?
No
4. Sector Budget Analysis
Yes
Health sector budget is easily identifiable
in both the federal budget for the FMOH
and in the Adamawa State Budget for
SMOH.
Predominantly capital and recurrent
expenditures
No
Health sector policy overarching goal “to
45
Assessment Criteria & Key
Questions
the sector policies and
objectives?
Yes
4) What type of budget
classification system is in use?
5) What is the overall level of
sector financing?
6) Is the share of the sector
within total government
expenditures increasing?
7) If a sector MTEF is in place,
key assessment questions
include:
 Is it consistent with declared
policies and the national
budget/overall MTEF of the
country?
 Is it approved at a political
level or is it largely a technical
document?
1) Does a national monitoring
system based on performance
criteria exist and/or is its
development foreseen during
implementation?
2) Does the state have a
Performance Assessment
Framework (PAF) for health or
any other sector that it is
implementing. If not, is the
state amenable to adopting a
PAF?
3) What are the options foreseen
at this stage of program design
to support its
development/consolidation?
Yes
Yes
Approved at
political level
No
Remarks
significantly improve the health status of
Nigerians through the development of a
strengthened and sustainable health care
delivery system”. There is inappropriate
allocation of human and financial
resources mainly focusing on tertiary and
specialist care instead of on primary
health care, which is where most
Nigerians receive health care services.
Incremental system of budgeting but
transitioning to Zero-based budgeting this
year. This system is based on priorities
Inadequate as Health sector budget is
about 8% of the national budget; it is
lower than the ECOWAS commitment
that member states should attain 15%
national budget allocated to the health
sector by 2015. To further compound the
challenges of inadequate health sector
budget, releases of approved budgets are
almost always delayed and incomplete
with negative consequences on health
program execution.
Small increments. However, factoring in
inflation, the real increase in expenditure
is very small
The MTEF and the Fiscal Strategic Paper
(FSP) provide Federal Government the
basis for the annual budget estimates and
without them, an effective realistic
national budget is impossible. The
Federal government presents the MTEF
along with a Fiscal Strategy Paper (FSP)
to the National Assembly, which
assesses the prospects of achieving the
policy objectives of the Federal
Government and highlight any key issues
and areas of possible amendments to the
Appropriation Bill.
5. Sector Monitoring System
Yes
Permanent Secretary is Authorizing
Officer. Oversight is provided by National
assembly, Auditor General, and
Accountant General
No
The Federal
Government is
very keen to
roll out PBF
nationally if the
pilot proves
successful
Adamawa State is currently implementing
a PBF for the delivery of primary care
services in 11 of its 21 LGAs. The PBF
project is so successful that the State
intends to roll it out to the remaining 10
LGAs. By the end of 2016. The huge
success of the PBF is due to its strong
collaboration and partnership with the
Scale up of MNCH Outcomes in two
States in northern Nigeria funded by the
EU through UNICEF and implemented by
the State PHC Development Agency.
For many years now the Federal
Governments has been making efforts to
find a way of providing sustainable and
effective financing for health care delivery
that will reach a greater number of the
people of Nigeria especially the poor and
disadvantaged people. The government
46
Assessment Criteria & Key
Questions
Yes
No
Remarks
will be keen to roll out the PBF approach
to financing health care if the pilot shows
PBF is successful.
Based on the analysis, it is recommended that support should be given to the government to roll out
PBF to other states if the pilot is successful. In the case of Adamawa State that has a very successful
PBF in 11 LGAS, EU could support the State to roll out PBF to the remaining 10 LDAs.
6. Public Financial Management (PFM) Sector Reform Contract
1) Is there a public financial
Yes
Government Integrated Financial
management reform program
Management Information System recently
in place or about to be
introduced
implemented?
2) Is there an updated, overall
No
public financial management
review (like the Public
Expenditure and Financial
Accountability – PEFA review
and/or past/on-going
projects/programs)?
3) What are the PFM
Public
Public Procurement Act replaces the Due
mechanisms in place for the
Procurement
Process Office in the Presidency
sector?
Act
4) Based on information available
Effective operationalization of the Public
(from the government, DG
Procurement Act
ECFIN and DG Budget,
SIGMA, Bretton Woods
Institutions and where
available PEFA reviews), what
are the possible areas where
support could be considered?
5) How do the remaining
Federal government is fighting corruption
weaknesses affect the sector
through investigating and charging and
policy and what
prosecuting suspected wrong doers
recommendations can be
made to improve the situation?
7. Macro-economic Context Sector Reform Contract
1) What do the macroeconomic
Good
Oil-based economy. Sound economic and
fundamentals look like and
fiscal policies but suffering from global
what are the medium-term
impact of recent severe decline in price of
perspectives?
crude oil
2) What measures can be
Diversification of the economy to include
supported to improve the
non-oil sector
beneficiary's macroeconomic
policy?
3) How do these measures
Potential to reduce Federal Government
influence the beneficiaries'
funding to the health
sector policy?
1) Is the sector assessed as
being satisfactory on the three
key criteria for a sector
approach?
i.
Policy process and
ownership
ii.
Quality of policy
objectives
iii.
Implementation
arrangements
2) Can the problems revealed by
negative assessments be
addressed with domestic /IPA
/other donor resources
3) Can the problems revealed by
negative assessments be
mitigated and if “yes’ how soon
Yes
Overall Assessment
Policy process and ownership are
adequate, quality of policy objectives are
broad and very ambitious whilst current
implementation arrangements and
funding focus more on secondary and
tertiary care than on primary health care
Yes
Will need the political will to shift
resources away from secondary and
tertiary care and invest heavily in PHC
Yes
Over the medium to long term.
47
Assessment Criteria & Key
Questions
can this be done
Yes
No
Remarks
48
ANNEX 5 – SEPARATE ATTACHMENT
49
ANNEX 6
Feasibility of State-level Sector Contract for Adamawa State
2. Existence of a clear state health sector policy and strategy
Adamawa State has a clear state health sector policy and strategy. The Adamawa State Health Policy is based on
Nigerian National Health Policy; it is heavily anchored on the concept and practice of PHC. As part of the
Adamawa State Government Strategic Development Plan, the State Ministry of Health (SMOH) developed the
State Health Strategic Plan 2016-2020 following extensive and inclusive consultations with government and
non-government stakeholders at state, LGA, and community levels. The Health Strategic Plan 2016-2020 is
currently being reviewed to include experiences and lessons learned from two important health projects the
State is currently implementing.
The first of the projects is the Performance Based Financing (PBF) approach for the delivery of primary health
care services: Adamawa State is one of three States (the others are Ondo and Nasarawa) piloting the PBF
approach since 2011 in the Nigeria State Health Investment Project (NSHIP) supported by the World Bank.
From a successful pilot intervention in one LGA, Adamawa State has expanded the PBF approach to 11 of its
21 LGAs. The benefits of the PBF are so visibly enormous that the State is poised to roll out the PBF to the
remaining 10 LGAs by the end of 2016.
The second project is the 4-year Scale-up of Maternal, Newborn, and Child Health (MNCH) Project for two
States in Northern Nigeria (Adamawa and Kebbi States) with funding from the European Union (EU) through a
Contribution Agreement with UNICEF. Since April 2014, the Adamawa State Primary Health Care
Development Agency (ASPHCDA) has been implementing MNCH interventions in all 21 LGAs (PMTCT
interventions were added later) and the Nutrition Component of the MNCH in only three (3) LGAs in the State
with UNICEF Nigeria providing technical support.
Sectoral Medium Term Expenditure Program
Adamawa State has an medium term expenditure program that is consistent with the Nigeria national medium
term expenditure framework (MTEF). Adamawa State has developed a State Health Strategic Development Plan
(SHDSP) 2016-2020 that is currently being costed. This comprehensive action plan, when fully costed will
establish the level of available internal and external resources and how these resources will be utilized in
execute the Plan. Adamawa State is one of the poorest states in Nigeria; about 11% of the State’s budget is on
the health sector that is higher than the national average of about 8%. It depends heavily on budgetary allocation
from the Federal Government and a few donors including the World Bank, the EU, and the UN System.
Performance Monitoring System
Adamawa State PHCDA is implementing an integrated delivery of PHC services. The National Health Sector
M&E Plan is the cornerstone of the M&E system for monitoring the performance of the PHC program. The
National M&E Plan has been adapted to incorporate the specific needs of the World Bank –supported
Performance Based Financing Project. The State conducts quarterly Integrated Supportive Supervision (ISS)
approach to measure progress towards the achievement of policy objectives and planned results, distinguishing
between male and female beneficiaries and ensuring the needs of vulnerable groups (disabled, women and
children, indigenes, and internally displaced persons (IDPs) resulting from several years of Boko Haram
insurgency. State and LGA level quarterly review meetings examine progress towards achieving planned
objectives including identifying challenges through bottleneck analysis of program indicators and finding
solutions for the resolution of the challenges. Adamawa State regularly uploads its data on a quarterly basis into
the web-based DHIS2, the national HMIS database, and has ready access to the data for analysis and use.
Formalized process of donor coordination
The Adamawa State Planning Commission coordinates and chairs Steering Committee meetings of all state
level donor-funded projects. The SMOH and the SPHCDA are steering committee members for health sector
programs. There are agreed processes for moving towards harmonized systems for reporting, budgeting,
financial management and procurement of donor supported projects.
Inclusive Stakeholder Consultations
The inclusivity in consultations for the development of public health programs in Adamawa State is improving
all the time. This is particularly true of the development of the Adamawa State Ministry of Health Strategic
Development Plan (SMOH) Strategic Plan for incorporation into the Adamawa State Government Strategic
Development Plan 2016-2020 where there are ongoing consultations currently underway between the SPHCDA,
the LGAs, and communities through elected Ward Development Committees (WDCs).
Preliminary Analysis of Eligibility Criteria that will contribute to drafting an
identification fiche for Adamawa State-level Health Sector Reform Contract
Assessment Criteria & Key
Questions
Yes
No
Remarks
1. Sector policy and Strategy
50
Assessment Criteria & Key
Questions
9) Does the country have a
sector/sub-sector policy?
10) Is it supported by a sector strategy
11) Are the sector policies
underpinned by national policies
for socioeconomic development
and for meeting EU accession
requirements?
12) Is the sector policy authored and
endorsed by domestic actors,
including Civil Society
Organizations (CSOs)?
13) Are there enough political support
and stakeholder involvement at
the state level to ensure
ownership and future
sustainability?
14) Are policy objectives coherent
with national development
objectives?
15) Are the objectives sufficiently
SMART?
16) Is sector planning linked to
resource allocation and also does
it take into account
decentralization processes?
Yes
No
Yes
Remarks
The health sector policy
Yes
Yes
Yes
Yes
Yes
Yes
Yes
2.Institutional setting and Capacity Assessment
10) What is the institutional setting
Yes
Significantly separate and decentralized
and context including the degree
of decentralization of public
powers and resources?
11) Has the sector been defined with
Yes
institutional coherence in mind?
12) Is there a lead Ministry in the
Yes,
Federal Ministry of Health at national level
Sector?
and State MOH at State level
13) What is the capacity of key sector
Capacity is good at federal level but weak in
organizations and critical
Adamawa State MOH and weak but
stakeholders (including CSOs)?
improving at Adamawa State PHC
Development Agency
14) What is the level of beneficiary's
Uncertain about ownership at FMOH and
ownership of the assessment
Adamawa SMOH but very strong ownership
process and its willingness to
of Adamawa PHCDA PHC program, which is
improve its capacity?
very willing to improve capacity
15) What (if any) are the institutional
Donor coordination by State Planning
structures required by donors
Commission or equivalent linked to Ministry
(including EC) and how do they
of Budget and National Planning at the
link to the national structures?
Federal level; Program Steering Committee at
State and Federal levels.
16) Have workload analyses of the
Uncertain at Federal level, but Adamawa
institutions in the Operating
SMOH indicates this has been done.
Structure been carried out?
17) Does the beneficiary require
Very probably yes at the Federal level and
capacity building and, if so, are
most certainly yes at Adamawa State.
there options for harmonization
with other donors' interventions?
18) If support to capacity building is
Should be carried out by a team of health
envisaged, how and when will a
experts during the implementation of
needs assessment be carried out
Contract. Some key experts should be
during the preparation of the
embedded in especially the SMOH and
Sector Support Program?
definitely in the Adamawa SPHCDA.
7) Do appropriate coordination
3. Sector and Donor Coordination
Yes
By the Ministry of Budget and National
51
Assessment Criteria & Key
Questions
mechanisms exist within the
responsible government
institutions?
8) Are there coordination
mechanisms between the
government and non-state actors?
9) Are there functional donor
coordination arrangements in
place?
Yes
Yes
Yes
10) Is there an up to date database of
donors?
Yes
11) Is the coordination effective and
inclusive?
12) Is there sector leadership and
willingness of government to take
the lead in donor coordination or
does the government show
potential to develop leadership
role effectively in the short term?
Yes
8) Can the sector budget be easily
identified in the state budget?
9) What is the nature and scope of
the sector budget?
10) Does the budget fairly reflect the
sector policies and objectives?
11) What type of budget classification
system is in use?
12) What is the overall level of sector
financing?
13) Is the share of the sector within
total government expenditures
increasing?
14) If a sector MTEF is in place, key
assessment questions include:
 Is it consistent with declared
policies and the national
budget/overall MTEF of the
country?
 Is it approved at a political level
or is it largely a technical
document?
Yes
No
Remarks
Planning at national level and by the State
Planning Commission at State level
Between FMOH and Adamawa SMOH and
non-state actors especially with key NGOs
and Faith Based Organizations.
Steering Committees chaired by the Ministry
of Budget and National Planning at national
level and by State Planning Commission at
State level FMOH and Adamawa SMO
Database is at the Ministry of Budget and
National Planning at Federal level and the
State Planning Commission at the state level
Usually includes key ministries involved and
donors providing assistance in the sector.
The Ministry of Budget and National
Planning takes the lead in coordinating donors
and the national level and the State Planning
Commissions take the lead at the state level
4. Sector Budget Analysis
Yes
Health sector budget is easily identifiable in
both the federal budget for the FMOH and in
the Adamawa State Budget for SMOH.
Predominantly capital and recurrent
expenditures
No
Health sector policy overarching goal “to
significantly improve the health status of
Nigerians through the development of a
strengthened and sustainable health care
delivery system”. There is inappropriate
allocation of human and financial resources
mainly focusing on tertiary and specialist care
instead of on primary health care, which is
where most Nigerians receive health care
services.
Incremental system of budgeting but
transitioning to Zero-based budgeting this
year. This system is based on priorities
Inadequate as Health sector budget is about
8% of the national budget; it is lower than the
ECOWAS commitment that member states
should attain 15% national budget allocated to
the health sector by 2015. To further
compound the challenges of inadequate health
sector budget, releases of approved budgets
are almost always delayed and incomplete
with negative consequences on health
program execution.
Yes
Small increments. However, factoring in
inflation, the real increase in expenditure is
very small
The MTEF and the Fiscal Strategic Paper
(FSP) provide Federal Government the basis
Yes
for the annual budget estimates and without
them, an effective realistic national budget is
impossible. The Federal government presents
the MTEF along with a Fiscal Strategy Paper
Approved at
(FSP) to the National Assembly, which
political level
assesses the prospects of achieving the policy
objectives of the Federal Government and
highlight any key issues and areas of possible
amendments to the Appropriation Bill.
52
Assessment Criteria & Key
Questions
4) Does a national monitoring
system based on performance
criteria exist and/or is its
development foreseen during
implementation?
5) Does the state have a
Performance Assessment
Framework (PAF) for health or
any other sector that it is
implementing. If not, is the state
amenable to adopting a PAF?
Yes
Yes
No
Remarks
5. Sector Monitoring System
Permanent Secretary is Authorizing Officer.
Oversight is provided by National assembly,
Auditor General, and Accountant General
No
Adamawa State is currently implementing a
PBF for the delivery of primary care services
in 11 of its 21 LGAs. The PBF project is so
successful that the State intends to roll it out
to the remaining 10 LGAs. By the end of
2016. The huge success of the PBF is due to
its strong collaboration and partnership with
the Scale up of MNCH Outcomes in two
States in northern Nigeria funded by the EU
through UNICEF and implemented by the
State PHC Development Agency.
6) What are the options foreseen at
The Federal
For many years now the Federal Governments
this stage of program design to
Government is
has been making efforts to find a way of
support its
very keen to roll
providing sustainable and effective financing
development/consolidation?
out PBF
for health care delivery that will reach a
nationally if the
greater number of the people of Nigeria
pilot proves
especially the poor and disadvantaged people.
successful
The government will be keen to roll out the
PBF approach to financing health care if the
pilot shows PBF is successful.
Based on the analysis, it is recommended that support should be given to the government to roll out PBF to other
states if the pilot is successful. In the case of Adamawa State that has a very successful PBF in 11 LGAS, EU
could support the State to roll out PBF to the remaining 10 LDAs.
6. Public Financial Management (PFM) Sector Reform Contract
6) Is there a public financial
Yes
management reform program in
place or about to be
implemented?
7) Is there an updated, overall public
No
financial management review
(like the Public Expenditure and
Financial Accountability – PEFA
review and/or past/on-going
projects/programs)?
8) What are the PFM mechanisms in Public
place for the sector?
Procurement Act
9) Based on information available
(from the government, DG
ECFIN and DG Budget, SIGMA,
Bretton Woods Institutions and
where available PEFA reviews),
what are the possible areas where
support could be considered?
10) How do the remaining
weaknesses affect the sector
policy and what recommendations
can be made to improve the
situation?
Government Integrated Financial
Management Information System recently
introduced
Public Procurement Act replaces the Due
Process Office in the Presidency
Effective operationalization of the Public
Procurement Act
Federal government is fighting corruption
through investigating and charging and
prosecuting suspected wrong doers
7. Macro-economic Context Sector Reform Contract
4) What do the macroeconomic
Good
Oil-based economy. Sound economic and
fundamentals look like and what
fiscal policies but suffering from global
are the medium-term
impact of recent severe decline in price of
perspectives?
crude oil
5) What measures can be supported
Diversification of the economy to include
to improve the beneficiary's
non-oil sector
macroeconomic policy?
53
Assessment Criteria & Key
Questions
6) How do these measures influence
the beneficiaries' sector policy?
Yes
No
Remarks
Potential to reduce Federal Government
funding to the health
Overall Assessment
4) Is the sector assessed as being
satisfactory on the three key
criteria for a sector approach?
iv.
Policy process and
ownership
v.
Quality of policy objectives
vi.
Implementation
arrangements
5) Can the problems revealed by
negative assessments be
addressed with domestic /IPA
/other donor resources
6) Can the problems revealed by
negative assessments be mitigated
and if “yes’ how soon can this be
done
Yes
Policy process and ownership are adequate,
quality of policy objectives are broad and
very ambitious whilst current implementation
arrangements and funding focus more on
secondary and tertiary care than on primary
health care
Yes
Will need the political will to shift resources
away from secondary and tertiary care and
invest heavily in PHC
Yes
Over the medium to long term.
54
ANNEX 7 –
Annex 7 - Abbreviations and Acronyms
AIDS
Acquired Immune Deficiency Syndrome
ANC
Antenatal Care
BEOC
Basic Emergency Obstetric Care
BNA
Bottleneck Analysis
C4D
Communication for Development
CHEWs
Community Health Extension Workers
CHIS
Community Health Insurance Scheme
CMAM
Community Management of Acute Malnutrition
CORPs
Community Own Resource Persons
CSOs
Civil Society Organizations
DART
Decentralized Action-Oriented Responsive and Transparent
DHIS2
District Health Information System 2
DNA
Deoxyribose Nucleic Acid
EU
European Union
FMOH
Federal Ministry of Health
FP
Family Planning
HIV
Human Immunodeficiency Virus
HMIS
Health Management Information System
HTC
HIV Testing and Counseling
HTS
HIV Testing Services
iCCM
Integrated Community Case Management
IDPs
Internally Displaced Persons
IMCI
Integrated Management of Childhood Illnesses
IMR
Infant Mortality Rate
ISS
Integrated Supportive Supervision
JCHEWs
Junior Community Health Extension Workers
KIIs
Key Informant Interviews
LGA
Local Government Area
M&E
Monitoring and Evaluation
MBNP
Ministry of Budget and National Planning
MICS
Multiple Cluster Indicator Survey
MMR
Maternal Mortality Ratio
MNCH
Maternal, Newborn and Child Health
MNCH-N
Maternal Newborn and Child Health - Nutrition
NDHS
National Demographic and Health Survey
NEMA
National Emergency Management Agency
NHMIS
National Health Management Information System
NPHCDA
National Primary Health Care Development Agency
NSHDP
National Strategic Health Development Plan
NSHIP
National State Investment Program
NURTW
National Union of Road Transport Workers Union
OPD
Outpatient Department
PBF
Performance Based Financing
PCR
Polychromase Chain Reaction
PEPFAR
President’s Emergency Plan for AIDS Response
PHC
Primary Health care
PHCUOR
Primary Health Care Under One Roof
PMTCT
Prevention of Mother to Child Transmission
PSC
Project Steering Committee
RUTF
Ready to Use Therapeutic Food
SAM
Severe Acute Malnutrition
SBA
Skilled Birth Attendant
SMART
Standard Monitoring Assessment Relief and Transitions
SMOH
State Ministry of Health
SOML
Saving One Million Lives
SOPs
Standard Operating Procedures
SPHCDA
State Primary Health Care Development Agency
SSHDP
State Strategic Health Development Plan
SURE-P
Subsidy Reinvestment and Empowerment Program
TOT
Training of Trainers
U-5MR
Under-5 Mortality rate
UNICEF
United Nations Children’s Fund
WDCs
Ward Development Committees
55
56