Federal Republic of Nigeria “Saving One Million Lives” Accelerating improvements in Nigeria’s Health Outcomes through a new approach to basic services delivery Program Document August 13, 2012 Office of the Honorable Minister of State for Health Federal Ministry of Health
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Federal Republic of Nigeria
“Saving One Million Lives”
Accelerating improvements in Nigeria’s Health Outcomes
through a new approach to basic services delivery
Program Document
August 13, 2012
Office of the Honorable Minister of State for Health
Federal Ministry of Health
TABLE OF CONTENTS
Table of Contents
EXECUTIVE SUMMARY 7
PROGRAM CONTEXT 8
RATIONALE FOR CHANGE 9
PROGRAM OBJECTIVES 10
PROGRAM COMPONENTS 11
Program Component 1: Improving Maternal,
Newborn and Child Health (MNCH) 12
Program Component 2: Improving routine
immunization coverage and achieving polio
eradication 15
Program Component 3: Elimination of Mother
to Child Transmission of HIV (eMTCT) 18
Program Component 4: Scale up of childhood
essential medicines and commodities 23
Program Component 5: Improve Malaria
Control 27
Program Component 6: Improving childhood
nutrition 30
ENABLING Component: Logistics and Supply
Chain Management 33
ENABLING Component: Increase innovation
and use of technology to improve health
services 36
IMPLEMENTATION AND PARTNERSHIP
ARRANGEMENTS 37
A. Governance and Coordination 38
B. DATA TRANSPARENCY AND PERFORMANCE
MANAGEMENT 41
C. PROGRAM DELIVERY UNIT 44
FINANCIAL MANAGEMENT, DISBURSEMENTS AND
PROCUREMENT 47
APPENDIX: Programmatic targets and costs 54
GLOSSARY
AA Artesunate Amodiaquine
ACT Artemisinin-based Combination Therapy
AIDS Acquired Immune Deficiency Syndrome
ALGON Association of Local Governments of Nigeria
ANC Antenatal Care
ARI Acute Respiratory Infection
ARV Antiretrovirals
BCG Bacillus Calmette-Guerin
BMGF Bill and Melinda Gates Foundation
CBOs Community Based Organizations
CCT Conditional Cash Transfer
CDC Center for Disease and Control
CHAI Clinton Health Access Initiative
CHEW Community Health Extension Worker
CHWs Community Health Workers
CIDA Canadian International Development Agency
CIFF Children Investment Fund Foundation
CMAM Community-based management of severe
acute malnutrition
DALY Disability-adjusted life year
DFDS Department of Food and Drug Services
DFID UK Department for International Development
DOTS Directly observed therapy, short course (for
tuberculosis)
DP Development Partners
DPT Diphtheria, Pertusis and Tetanus
DQS Data Quality Self-Assessment
EID Early Infant Detection
EMP Environment Management Plan
eMTCT Elimination of Mother-to-Child-Transmission of HIV
EPI Expanded Programme on Immunization
FCT Federal Capital Territory
FM Financial Management
FMoH Federal Ministry of Health
FMS Federal Medical Stores
FOREX Foreign Exchange
GAVI Global Alliance for Vaccines and Immunization
GDP Gross Domestic Product
GFATM Global Fund for AIDS, Tuberculosis, and Malaria
GH General Hospital
GON Government of Nigeria
HBB Helping Babies Breathe
HCT HIV Counseling and Testing
HCW Healthcare Workers
HERFON Health Reform Foundation of Nigeria
HiB Haemophilus Influenza B
HIV Human Immunodeficiency Virus
IDA International Development Association
IMNCH Integrated Maternal, Neonatal and Child Health
Strategy
IPT Intermittent Preventive Treatment
ITN Insecticide Treated Nets
IUFR Interim Unaudited Financial Report
IYCF Infant and Young Child Feeding
JFA Joint Financing Agreement
JSI John Snow International
KPI Key Performance Indicators
LGA Local Government Area
LiST Lives Saved Tool
LLINs Long Lasting Insecticide-treated Nets
M & E Monitoring and Evaluation
MDG Millennium Development Goals
MDG-DRG MDG- Debt Relief Grant
MDTF Multi-Donor Trust Fund
MICS Multiple Indicator Cluster Survey
MIS Malaria Indicator Survey
MMR Maternal Mortality Ratio
MNCH Maternal, Neonatal and Child Health
MSS Midwives Service Scheme
NACA National Agency for the Control of AIDS
NAFDAC National Food and Drugs Administration and
Control
NARHS National AIDS and Reproductive Health Survey
NASCP National AIDS and STDs Control Programme
NDHS Nigeria Demographic Health Survey
NDP National Drug Policy
NGO Non-governmental organization
NHIS National Health Insurance Scheme
NNR Neonatal Mortality Rate
NPC National Planning Commission
NPHCDA National Primary Health Care Development
Agency
NSHDP National Strategic Health Development Plan
OPV Oral Polio Vaccine
ORS Oral rehydration solution
OSSAP-MDGs Office of the Senior Special Assistant to the
President on MDGs
OTP Outpatient Therapeutic Programme
PCV Pneumococcal Vaccine
PDU Program Delivery Unit
PEPFAR The President’s Emergency Plan for AIDS Relief
PHC Primary Health Care
PIU Project Implementation Unit
PLHIV People living with HIV
PMTCT Prevention of Mother to Child Transmission of
HIV/AIDS
PNC Postnatal Care
PPMV Proprietary Patent Medicine Vendors
PPP Public Private Partnership
PSC Program Steering Committee
RBM Roll Back Malaria
RDTs Rapid Diagnostic Tests
RF Result Framework
RI Routine Immunization
RUTF Ready-to-Use Therapeutic Foods
SAM Severe Acute Malnutrition
SC Stabilization Center
SCMS Supply Chain Management System
SDPs Service Delivery Points
SFH Society for Family Health
SIAS Supplementary Immunization Activities
SMART Standardized Monitoring and Assessment of
Relief and Transition
SMF Social Management Framework
SMOH State Ministry of Health
SOML Saving One Million Lives
SP Sulphadoxine Pyrimethamine
SQEAC Semi Quantitative Evaluation of Access and
Coverage
SURE P Subsidy Re-investment and Empowerment
Programme
TA Technical Assistance
TB Tuberculosis
TH Tertiary Hospitals
TOR Terms of Reference
TT Tetanus Toxoid
U5 Under 5
UNDP United Nations Development Program
UNICEF United Nations Children’s Fund
USAID United States Agency for International
Development
VHW Village Health Worker
WB World Bank
WHO World Health Organization
YF Yellow Fever
EXECUTIVE SUMMARY
Nigeria’s population health outcomes are relatively low
compared to other countries with similar levels of resources and
endowments. The country is constrained by inequitable
distribution of resources, inadequate quality of health services,
and a complex federalized structure. Despite best efforts to
address these challenges, Nigeria still comprises a large share of
the world’s burden of child and maternal morbidity and mortality.
It is estimated that approximately one million women and
children die every year in Nigeria from largely preventable causes.
The status quo is an obstacle to success, and obstacle to making
Nigeria’s people healthier and saving lives. Excellent policies and
programs designed will not lead to an improvement in outcomes
without strong execution and dramatic innovation in the way
health programs are delivered.
“Saving One Million Lives” is not a new health program. It builds
on existing policies, strategic documents and frameworks as
outlined by the National Strategic Health Development Plan and
Mr. President’s Transformation Agenda.
Rather, it is a drive to focus on outcomes, through strengthening
execution and delivery of Nigeria’s existing basic health services
by setting clear, ambitious targets for real impact and a simple,
yet laser-focused system of performance management to
achieve them. It is a new delivery mechanism, working towards
real change on the ground. With this approach, Nigeria will save
one million lives (predominantly women and children) by 2015.
Three factors underpin this new approach: (i) A robust data
management system to support performance management; (ii)
A steering committee comprising public, private sector and
development partners to enhance coordination, transparency
and mutual accountability for results and outcomes; and (iii) A
Program delivery unit to drive execution and routines necessary
for effective delivery.
PROGRAM CONTEXT
1. Nigeria underperforms other countries with similar levels of
resources and endowments in its average population health
outcomes. With an estimated 545 maternal deaths for every
100,000 live births in 2008, Nigeria contributes about 10% of
global burden of maternal deaths. The under-five mortality
rate, at 157 per 1,000 live births (2008), is also declining too
slowly to achieve the MDG4 target of less than 67 per 1,000 live
births by 2015. The infant mortality rate of 75 per 1,000 live births,
as at 2008 is on a steady decline, but still higher than that of
other countries in Sub Saharan Africa.
2. In addition to the poor outcomes, the distribution of the health
outcomes and utilization of health services is highly inequitable.
For example, the difference between the wealthiest quintile
and poorest quintile in access to skilled birth attendance at
delivery is almost eight fold. Similarly, the difference in full
immunization coverage between the wealthiest and poorest
quintiles is almost 10 fold. Inter-regional and inter-state
disparities in health outcomes are also stark. Coverage of key
interventions is low, and the most basic services do not reach
the poorest segments.
3. Consequently, it is estimated that approximately one million
women and children die every year in Nigeria from largely
preventable causes; 33,000 women are estimated to die from
pregnancy-related causes, and about 946,000 children under-
5 die of which 241,000 are newborns. The preventable causes
of morbidity and mortality among women include pregnancy,
anemia due to malaria, intra-partum and post-partum
hemorrhage, post-partum sepsis, eclampsia, and
complications from obstructed labor. Among children, these
include malaria, vaccine preventable communicable diseases
(tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis,
measles, bacterial pneumonias), diarrheal diseases, pediatric
HIV, and the underlying problem of malnutrition.
4. The quality of health services provided in most facilities
remains inadequate. Most of the 23,000 frontline Primary Health
Care (PHC) facilities often lack skilled practitioners, and a large
percentage of the facilities do not have basic
pharmaceuticals and commodities consistently in-stock. Not
surprisingly, more than 50% of the households are dissatisfied
with the services in public facilities and use them infrequently.
The private sector, which provides at least half of the health
services is fragmented, poorly regulated, poorly understood
and practically unengaged by the public health sector,
especially at the primary care level.
5. This is despite relatively modest levels of health spending,
compared to other parts of Africa, both in absolute terms and
as a proportion of gross domestic product (GDP): total health
expenditure per capita, PPP (constant 2005 international dollar)
was $121 as at 2010; total health expenditure per capita
(current US dollar) was $63 as at 2010, amounting to about 5.1%
of GDP 1 . Comparing the data from 2003 and 2008
Demographic and Health Surveys (DHSs) it is evident that
Nigeria has made limited progress in delivering critical health
services.
6. Nigeria’s health system also faces a structural constraint with
the fiscally decentralized system of government whereby
Federal, States and Local Governments all have concurrent
constitutional responsibilities regarding health, yet there are no
intergovernmental accountability mechanisms. Whilst the
national health policy of 2004 places responsibility for the
implementation of primary health care in the Local
governments, Federal and State governments are not
absolved of the responsibility to improve the health of
Nigerians.
RATIONALE FOR CHANGE
7. In spite of best efforts by the government and its partners to
address the health issues in Nigeria, outcomes have remained
sub-optimal. A review of programs shows that while there are
good policies and strategies in place, there are clear
challenges in their delivery and execution. There is often
significant fragmentation of efforts, suboptimal coordination,
and focus on inputs and processes, rather than the outcomes
and results.
8. “Saving One Million Lives” (SOML) is an approach to delivery
that reflects lessons learned from previously implemented
programs and analyses of the health sector in the country. It
includes: (1) A shift in focus from inputs to focusing on results
1.
1 World Bank, World Development Indicators 2012.
and outcomes; (2) Strengthened local ownership and
accountability mechanisms, especially at the ward levels; (3)
Better coordination and engagement across agencies,
between different tiers of government and amongst
development partners; (4) Testing of innovative approaches
that fit the Nigerian context; (5) Strong capability and skill
building and technical assistance to address constraints within
the system. (6) Stringent monitoring and evaluation
/performance management framework. Overall SOML will
focus significantly on execution and program delivery. It will set
clear, ambitious targets for real impact and a simple, yet laser-
focused system of performance management to achieve
them.
9. Continuing business as usual is not a viable option. As Nigeria
marches towards attaining Universal Health Coverage, no time
should be wasted in improving the health status of people
through delivery of known, effective health interventions.
10. Bold innovations and changes in the approach to delivery in
the sector are necessary to shift the focus from inputs and
processes to strengthening direct service delivery and improve
health outcomes. This inevitably requires a paradigm shift in
approach to basic health services in the sector. This approach
remains entirely consistent with the Transformation Agenda of
Mr. President and with the NSHDP.
PROGRAM OBJECTIVES
11. The objective of the program initiative is to save one million
lives in Nigeria by 2015, through integration of essential priority
interventions into primary health care, equitably increasing
access to, and utilization of quality cost-effective basic health
interventions. A breakdown of the lives saved by program
component and disease area is specified in Annex 1.
12. The program comprises 8 components, which will contribute to
the above stated objective – to save one million lives. Within
each program, ambitious goals have been set, namely:
a. Improving Maternal, Newborn and Child Health: delivering
an integrated package of MNCH interventions at 5,000
primary health care clinics to increase the rate of skilled
attendants at birth and the coverage of 4 ANC visits to 80%;
b. (ii) Improving routine immunization coverage: eradicating
polio and achieve DTP 3/pentavalent, OPV3 coverage of
87% and to introduce new Hib and pneumonia vaccines;
c. (iii) Elimination of Mother to Child Transmission of HIV;
d. (iv) Scaling up access to essential medicines and
commodities: treating 80% of children with diarrhea,
pneumonia or malaria with the recommended treatment ;
e. (v) Malaria control;
f. (vi)Improving child nutrition; treating 90% of children with
severe malnutrition with CMAM services.
13. In addition, two enablers have been included, namely: (vii)
Strengthening logistics and supply chain management and
(viii) Promoting innovation and use of technology to improve
health services.
14. This will be achieved with a new, strong performance
management vehicle – a delivery unit - that will closely track,
troubleshoot, and hold accountable Nigeria’s health
programs. The program will be government owned and led,
and implemented in close coordination and cooperation with
the development partners (DP). A joint financing arrangement
(JFA) for this partnership is planned to guide investments, and
a steering committee will oversee progress. The program
components and its goals, and the accompanying delivery
unit are described in detail herein.
15. Overall program costs stand at $ 5.8 billion with existing donor
and government commitment of an estimated $ 2.2 billion by
2015 (See Annex 3). While the current costing exercise has
incorporated key on-going programmatic and funding
interventions and commitments, a bottom-up refinement of
individual cost elements is on-going.
PROGRAM COMPONENTS
16. As outlined above, this program comprises eight (8)
components, which will contribute to the above stated
objective. The components are: (1) Improving Maternal,
Newborn and Child Health; (2) Improving routine immunization
coverage and achieving polio eradication; (3) Elimination of
Mother to Child Transmission of HIV; (4) Scaling up access to
essential medicines and commodities; (5) Malaria control; (6)
Improving child nutrition; (7) Strengthening logistics and supply
chain management; and (8) Promoting Innovation and use of
technology to improve health services.
Program Component 1: Improving Maternal, Newborn and Child
Health (MNCH)
17. Current statistics for maternal mortality indicate that 33,000
women die every year in Nigeria due to complications from
pregnancy and delivery 2 . The under-five mortality numbers
show that approximately 1 million children do not live to see
their fifth birthday each year. 70% of these deaths are due to
preventable and treatable causes such as malaria,
pneumonia, diarrhea, measles and HIV/AIDS3.
18. There have been efforts to scale up maternal and child health
care in Nigeria with measurable success. Maternal mortality
rate fell by 32% from 800/ 100,000 live births in 2003 to 545/
100,000 live births in 20084. However in order to meet the target
for MDG 4 and 5 by 2015, the current MCH services need to be
improved.
19. The National Council on Health approved the Integrated
Maternal, Newborn and Child Health Strategy (IMNCH) in 2007
as part of efforts to scale up maternal and child health in
Nigeria. The strategy aims to address the causes of 90% of
deaths of women and children under the age of 5 years,
through: i) focused ANC, (ii) Intrapartum care (III) Emergency
Obstetrics and Newborn (iv) Newborn Care. (v) Routine
Postnatal Care (Vi) Infant and Young Child Feeding. If
implemented, it would have saved up to 6 million children and
more than 200,000 women by 20152. However implementation
thus far is not on track to achieving such outcomes.
20. Recently, a revised approach has been developed to include
supply and demand side interventions. On the supply side,
each PHC will receive a full complement of skilled health
workers, basic commodities, equipment and refurbishment of
infrastructure. On the demand side, health promotion and
education will be intensified through campaigns at the
national, state and local government levels. The Ward
1.
2 Nigeria.unfpa.org
3 www.unicef.org
4 www.ng.undp.org/mdgsngprogress.html 4 World Development Indicators
Development Committees (WDCs) will be activated to boost
community engagement in decision-making. Conditional Cash
Transfers (CCT) have been introduced through the SURE P MCH
program to address the indirect costs of care seeking that may
partially contribute to the low demand for ANC and delivery
services at the PHC facilities.
21. Several programs that work towards these objectives are
already underway; they include the Midwives Service Scheme
and more recently, the SURE-P MCH program and the Helping
Babies Breath initiative. A total of up to 4300 facilities (2,000
PHCs to be covered under the ongoing MSS and SURE P MCH
projects and 2,300 PHCs through the National Health Insurance
Scheme MCH, project funded by MDG-DRG) will be reached
in this program.
22. At the facilities, Frontline Health workers will be trained on the
Helping Babies Breathe (HBB) initiative, to increase their skills in
neonatal resuscitation in a bid to reduce the incidence of birth
asphyxia and neonatal deaths. The HBB interventions will focus
on training provision of equipment for resuscitation. The HBB
interventions include immediate thermal care, initiation of
exclusive breastfeeding within the first hour, hygienic cord and
skin care, neonatal resuscitation with bag and mask, case
management of neonatal sepsis, meningitis and pneumonia,
kangaroo mother care for preterm and low birth weight babies,
management of newborn jaundice and extra support for
feeding small and preterm babies.
23. Birth attendants at the primary health care facility level will be
primarily targeted, but the interventions will also be adapted to
care within the community and at the secondary level of
referral care.
24. The MSS program under NPHCDA is responsible for the
upgrade of PHCs and human resources. The SURE-P and MSS
facilities will serve as points of integration for all healthcare
services provided by the 8 components under the SOML
Program.
25. IThis component aims to ensure the availability of essential live-
saving maternal and neonatal health commodities in the PHCs,
as outlined in the table below:
Continuum
of Care
Commodity Usage
Reproductive
health
Female
Condoms
Family
planning/Contraception
Implants Family
planning/Contraception
Emergency
Contraception
Family
planning/Contraception
Maternal
Health
Oxytocin Post- Partum Hemorrhage
Misoprostol Post- Partum Hemorrhage
Magnesium
sulphate
Eclampsia, severe Pre-
eclampsia/Toxaemia
Newborn
Health
Injectable
Antibiotics
Newborn sepsis
Antenatal
Corticosteroids
Respiratory distress
syndrome for preterm
babies
Chlorhexidine Newborn Cord care
Resuscitation
equipment
Newborn asphyxia
26.
27. Impact: The above outlined interventions have the potential to
save up to 662,900 lives, of which there are 16,800 maternal
lives, 180,800 neonatal lives, 465,300 post neonatal and child
lives by 2015. The program aims to achieve the following
a. Reduce maternal mortality ratio from 545/100,0005 live births
to 250/100,000 live births by 2015
b. Reduce the neonatal mortality rate from 40/1,0005 live births
to 14/1,000 live births
c. Increase the proportion of births attended by a skilled birth
attendant from 38.9% in 20085 to 85% in 20156
d. Increase the proportion of pregnant women attending 4 or
more ANC visits from 45%5 in 2008 to 80% in 2015
1.
5 Nigeria Demographic Health Survey 2008
6 Nigeria Strategic Health Development Plan
e. Increase the number of upgraded primary healthcare
facilities from 1,000 MSS sites in 2012 to 5,000 sites in 2015.
28. Data tracking and monitoring: At each level of government,
there is a MCH liaison officer responsible for the collection of
data. Monitoring and evaluation officers visit MSS facilities
monthly to collect data at the LGA level and report to the
State liaison, who then reports to the Federal level. Under the
MCH Program, data is collected at the facility level as well, to
mitigate the delays in data flow across different levels of
government. Monitoring and evaluation officers from the
national level visit MSS facilities monthly to collect data at the
LGA level and report directly to NPHCDA.
29. Resources required to achieving targets: Current plans to
scale-up the MSS model of maternal and neonatal health
services delivery at the PHC-level target an additional 5,000
facilities by 2015. This scale-up, combined with demand
generation activities—including conditional cash transfers—is
estimated to cost $ 783 million from 2012 to 2015 (See Annex 3).
Federal Government of Nigeria committed funding stands at
$ 581 million, hence a funding gap of $ 202 million.
Program Component 2: Improving routine immunization coverage
and achieving polio eradication
30. In the past, coverage levels for immunization under the
Expanded Program on Immunization (EPI) have fluctuated due
to inadequate funding, weak cold chain and logistics
management, weak service delivery capacity at the frontlines,
lack of community involvement, poor outreach services, and
inadequate awareness of the immunization schedule and
social support7.
31. In recent years, the routine immunization program has
improved as demonstrated by rising coverage rates. Full
immunization coverage increased from 23 percent in 2008 to
more than 50 percent according to the National Immunization
Coverage Survey 2010. The DPT3 coverage increased from 42
percent in 2008 to 67 percent in 2010. Polio incidence has
declined dramatically in recent years compared to the past
when thousands of Nigerian children were paralyzed by the
1.
7 Comprehensive EPI Multi-year Plan 2011-2015
virus annually. However, the programs have struggled to
sustain this rate of progress.
32. Recognizing the need to sustain recent gains, the Federal
Government has increased its own financing for the
immunization program. In 2012, the Government allocated
USD 30 million to the polio eradication effort and appointed a
Presidential Task Force on Polio Eradation. The Government
also allocated USD 38 million to the routine immunization
program. With support from the Global Alliance for Vaccines
and Immunization (GAVI), the Federal Government began the
phased introduction of pentavalent vaccine (DPT+HepB+Hib)
in collaboration with 12 States. The remaining States and FCT
will be covered in 2013. The pneumococcal vaccine is
planned to be introduced to the country in 2013 with the
support of GAVI.
33. This component of the program will focus on saving lives of
children through further strengthening of the immunization
program to deliver the following key interventions:
a. Working with State governments to strengthen Routine
Immunisation, improve Immunization plus Days and Reach
Every Ward,
b. Ensuring continued operational finances and procurement
of components of bundled vaccines,
c. Extending cold chain and logistics networks to rural wards,
developing a comprehensive, timely and complete
reporting system with necessary feedback mechanisms,
thereby further strengthening the supply chain for vaccines
in Nigeria,
d. Stepping up social mobilisation and advocacy to stimulate
the uptake of Yellow Fever and Hepatitis B vaccines, the
new pentavalent vaccine,
e. Stepping up Polio Supplementary Immunization Activities
(SIAs) with OPV mass campaigns targeting 0-59 months.
f. Social mobilization and community awareness activities
(media campaigns, engaging Ward Development
Committees, traditional leaders, CCTs, vouchers)
g. Using facility-level consumption data to inform forecasting,
stock management processes and other logistics
h. Conducting monthly supportive supervision at national, state,
LGA and facility levels to train each level of the
immunization system on the following tasks:
□ Immunization session planning
□ Conducting monthly vaccine quantifications
□ Disease tracking
□ Outreach planning and execution
34. Impact: The Country Multi Year Plan of the EPI targets a
coverage rate of 87% of vaccine-preventable diseases in
infants (under-12 months of age) by 2015 and ensures the
introduction of new vaccines and technologies. It is estimated
that the introduction of the new Hib vaccine to the
immunization schedule will result in 29,514 deaths averted by
2015 while pneumonia vaccine is estimated to add 40,495 lives
saved8.
35. Under the Saving One Million Lives Program, the key target
indicators that will be monitored to track success include
a. The proportion of infants receiving DPT 3/Pentavalent
vaccine in target PHC facilities and communities. The target
is to increase this from 47% in 2011 to 87% in 2015;
b. The percentage coverage of OPV3. The target is to increase
this from 73% in 2011 to 87% by end of 2015
c. Facility-level consumption data used to inform forecasting
and procurement processes
d. Proportion of facilities conducting planned monthly
immunization fixed and outreach sessions
36. Data tracking and monitoring: The NPHCDA receives Routine
Immunization and Logistics reports on a monthly basis from the
facilities. These reports are broken-down by the coverage of
antigens based on fixed RI sessions at the health facility and
coverage during outreach activities carried out. The reports
are compiled and reported quarterly by the NPHCDA. To
assess the quality of the monthly data collected, the
government and partners conduct a Data Quality Self-
Assessment (DQS) quarterly9.
1.
8 An Introduction plan for Pneumococcal Conjugate Vaccines in Nigeria’s EPI Programme (2011)
9 Report of Data Quality Self-Assessment on Routine Immunization in Nigeria
37. The cost of conducting the DQS is covered by the Federal
Government budget for NPHCDA while the costs associated
with carrying out the monthly data collection is embedded in
the Monitoring and Evaluation budget line.
38. Resources required to achieving targets: The total costs for
immunization activities are drawn from the Final Immunization
Mid-Year Plan, 2011-2015, and include both routine and
supplemental activities necessary to reach target coverage
levels of 87% by 2015. Total immunization costs from 2012 to
2015 are estimated at $ 1.5 billion (See Annex 3). Committed
funding stands at $ 842 million, hence a funding gap of $ 611
million.
Program Component 3: Elimination of Mother to Child
Transmission of HIV (eMTCT)
39. Nigeria reported its first case of HIV/AIDS in 1986, and by 2011,
there were 3.1 million people living with HIV/AIDS (PLHIV) in the
country with 281,180 new infections of HIV each year10. The
statistics are sobering:
40. An estimated 360,000 children currently live with HIV and AIDS
in Nigeria. Nearly 230,000 pregnant women are living with the
disease each year.
41. The rate of transmission from these HIV positive pregnant
mothers to their infants is 30%, resulting in approximately 69,300
new HIV infections in children each year (whereas in the
developed world and in other Sub-Saharan countries, the rate
of transmission is less than 2%). This accounts for almost 30% of
the world’s new HIV infections in children annually11.
42. The rate of mother to child transmission and resulting number
of new infections in children has barely improved over the past
years, with only a 2% decline in number of new infections in
children since 2009 (70,900 in 2009, 69,300 in 2011).
43. This picture means that, at the current rate, Nigeria will not
come close to virtual elimination of mother to child
transmission of HIV by 2015, the target, set as per the Global
Plan Towards the Elimination of New HIV Infections Among
Children by 2015 and Keeping Their Mothers Alive, launched in
1.
10 Fact Sheet 2011: Brief on HIV Response in Nigeria
11 Together We Will End AIDS, UNAIDS (2012)
2011 in Abuja by Her Excellency, the First Lady, Dame Patience
Jonathan.
44. Despite these dire statistics and a tremendous amount of
external resources directed toward PMTCT, Nigeria’s eMTCT
program is not operating at scale. Coverage of essential
PMTCT services in Nigeria is still very low with only 13% of
pregnant women being tested for HIV in 2009, with 27% of
those tested positive receiving ARVs. These coverage rates are
unacceptable.
45. Slow progress is being made to address this gap in coverage
of interventions; for example, the coverage of pregnant
women living with HIV and AIDS who have received
antiretroviral drugs (ARVs) to prevent MTCT increased from 7%
in 2007 to 22% in 2009. The majority of these services in Nigeria
are supported by The United States President's Emergency Plan
for AIDS Relief (PEPFAR) and the Global Fund for AIDS,
Tuberculosis, and Malaria (GFATM). The National AIDS and STIs
Control Program at the Federal Ministry of Health plays a
leading role in policy, with the National Agency for the Control
of AIDS (NACA) acting as a coordinating agency for all
HIV/AIDS programs in the Nation.
46. Nonetheless, the program remains sub-scale, with only 1040
clinics providing PMTCT services in March of 201212. Nearly all of
these facilities are within the public sector, notwithstanding the
fact that, in many parts of the country, more than half of all
pregnant women seek care for maternity services from private
providers.
47. As with many programs, there exists a strong national policy
that faces challenges in being translated into execution and
delivery. The current set of PMTCT guidelines, which were
revised in 2010, provide the recommended standard of care
for the administration of antiretroviral drugs for treating HIV
positive pregnant women and preventing HIV infections in
infants.
48. The National PMTCT scale up plan in Nigeria has set specific
targets for 2015 under Prong 313:
a. At least 90% of all pregnant women have access to quality
HIV testing and counseling by 2015 from 13% in 200914
1.
12 Exact number of facilities offering PMTCT sites fluctuates by source
13 National Guidelines for Prevention of Mother to Child Transmission of HIV (PMTCT) 2010
b. At least 90% of all HIV positive pregnant women and HIV
exposed infants access more efficacious ARV prophylaxis by
2015 from 22% and 8%15 for positive pregnant women and
exposed infant respectively in 2009
c. At least 90% of HIV positive pregnant women have access to
quality infant feeding counseling by 201516
d. At least 90% of all HIV exposed infants have access to early
infant diagnosis service by 201517
49. These targets are highly ambitious and, since 2010, Nigeria’s
progress toward them has not been steady; however,
renewed energy among FMoH and NACA leadership,
increased focus from international partners and donors, hard
work of implementing partners in-country, and an urgent
deadline are contributing to a turning of the tide on PMTCT in
Nigeria.
50. At the federal level, the National PMTCT Scale-Up Technical
Working Group is helping 12 states plus the FCT form concrete,
achievable actions plans for scale-up. State-level Ministries of
Health and State AIDS Control Agencies are beginning to take
the reins on these plans.
51. Development partners, such as PEPFAR, the Global Fund, the
World Bank; corporate partners, such as Chevron; and
normative partners such as UNICEF and WHO are increasing
their focus and attention on PMTCT in Nigeria to support the
country in identifying innovative ways to scale the program.
Under this program, the approach to scaling up includes, but is
not limited to the following:
a. Scale-up of PMTCT services where women need them most,
at the primary care level: The focus should be on scaling up
services within primary care facilities, where they will be most
accessible to women and families. Currently, the “vertical”
approach to PMTCT programming is being revised in favor of
an integration of PMTCT interventions into existing MNCH
services offering a continuum of care package including
focused antenatal care (ANC), skilled birth attendance at
2.
14 Towards Universal Access: Scaling up Priority HIV/AIDS interventions in the Health Sector
15 The 8% is assumed to be due to home deliveries
16 This indicator is currently not tracked by the NDHS but contains the underlying assumption that every mother
who has access to ANC services should have access to infant feeding and counselling
17 Clinton Health Access Initiative
delivery, immediate postnatal care (PNC), and family
planning. The primary health care centers, have the network
with the largest reach. The implementation will follow the
existing hub and spoke model within these programmes,
with linkages to secondary referral facilities.
b. Know your status: rapid scale-up of HIV counselling and
testing, into public and private facilities not currently being
supported for HIV services
c. Introducing PMTCT services into quality private provider
settings: currently, there is no organized mechanism at scale
for private providers to offer their patients HCT or ARVs,
despite the fact that, in many parts of Nigeria, over half of
maternity care is sought in the private sector. Efforts are
underway to understand and pilot a mechanism to harness
this potential.
d. Task-shifting the initiation of ARVs for PMTCT: enabling a
larger cadre of health workers to initiate ARVs for pregnant
women living with HIV
e. Implementation of Option B (or B+): where appropriate,
Nigeria and its partners are implementing Option B (and, in
some cases, B+) for PMTCT, which operationally simplifies the
steps required to prevent new infections in children in many
Nigerian contexts. The scale up will prioritize 12 States and
the FCT initially, and then expand to the other states as
already prioritized by the National PMTCT Scale-Up Technical
Committee.
52. An assessment and revamping of the Logistics Management of
PMTCT supplies is essential to drive anticipated results.
Procurement and distribution of HIV test kits and ARVs are
currently managed in large part by PEPFAR. Within the FMoH,
distribution is out-sourced to Dalex18. Due to the short half-life of
PMTCT drugs, the current distribution method is carried out in a
2 tier system. The Federal Medical Store (FMS) packages their
commodities based on the bi-monthly reports/requisition
submitted by healthcare facilities18.
53. A Push system has only been used for the distribution of drugs
for opportunistic infections when the drugs were nearing
expiration. It is discouraged to minimize wastage due to the
lack of storage at the healthcare facilities. This can be avoided
1.
18 HIV/AIDS Division Response to 2nd quarter meeting (unpublished)
through the prompt distribution of drugs. On the other hand,
the Pull system is used for ARVs based on facility
report/requisition.
54. A central National Logistics System is important to improve
logistic system for Nigeria and is currently being developed
with DFDS leading the process18.
55. Data tracking and monitoring: Monitoring and evaluation
within the PMTCT program is coordinated by NACA. The Save
One Million Lives program will track the progress of the key HIV
indicators by collecting data from the PMTCT sites on a
monthly basis, to constantly monitor the progress of PMTCT at
the facility level, and use the ANC HIV Sentinel, and NDHS for
verification. Performance management conversations will be
had on a monthly basis to troubleshoot areas that are facing
challenges and implement fast-acting solutions.
56. Key Implementing organizations like PEPFAR already collect
monthly data from their respective PMTCT sites, and compile
and report to NACA. NASCP carries out the major nationwide
monitoring and evaluation exercise on the status of HIV/AIDS in
the country by conducting the National AIDS and
Reproductive Health Survey- NARHS (biennially) and the ANC
HIV Sentinel Survey reports at the facility level, which includes
information on PMTCT. A new ANC HIV Sentinel survey is
currently being conducted.
57. Impact: The program targets that by 2015, 90% of women
attending ANC and delivering in intervention PHCs will have
access to PMTCT, with a resulting 80% reduction in new
paediatric infections. In addition to contributing to the
projected lives saved, the additional adoption of this
integrated approach is expected reduce new HIV infections
in line with the Global Plan for Elimination of Mother-to-Child
Transmission (eMTCT).
58. Resources required to achieve impact: The cost of scaling up
PMTCT services through decentralization to the PHC level is
about $665 million using the National PMTCT scale-up plan
2010-2015 as a basis for calculation. (See Annex 3) The plan
targets 90% coverage by 2015. Most investments have been
frontloaded in 2012 and 2013, due to planned infrastructure
improvements. The cost model is also based on the
implementation of the Option B ARV initiation plan. Donor
committed funding stands at $ 180 million, hence a funding
gap of $ 485 million.
Program Component 4: Scale up of childhood essential
medicines and commodities
59. Nearly 600,000 children under the age of five die annually in
Nigeria due to pneumonia, diarrhea, and malaria, which
together represent 55% of Nigeria’s under-five mortality.
60. In spite of promising reductions in child mortality in the past
decade, Nigeria needs to accelerate progress in reducing
under-five-mortality rate including NNR by 13% per year to
reach MDG 4 of cutting child mortality by two-thirds between
1990 and 2015. To achieve parity with developed countries by
2035, Nigeria will need to sustain mortality reduction by at least
7.5% per year.
61. The Childhood Essential Medicines Scale-Up Plan has been
developed as an evidence-based response to Nigeria’s high
under-5 mortality rate. This plan aims to reach 80% coverage of
recommended treatments for childhood diarrhea, pneumonia,
and malaria by 2015. Indeed, achieving 80% treatment
coverage for all children with these effective treatments has
the potential to save over 458,000 lives by 201519. This rapid
progress will only be possible through ambitious, concerted
actions that address the greatest drivers of child mortality –
diarrhoea, malaria, and pneumonia.
62. In order to ensure such rapid progress, the National Essential
Medicines Scale-Up Plan identifies and addresses the following
three barriers to scale-up of effective treatment: (i) Low care-
seeking behavior for childhood illnesses. While care-seeking
varies depending on the child’s symptoms, on average, 30% of
children with fever are treated at home (USAID, 2011).
Moreover, for children with symptoms of diarrhea, pneumonia,
or malaria, at least 29% receive no treatment at all (USAID,
2011);
63. (ii) Primary health providers in the public sector are often ill-
equipped and ill-stocked to confront the most common
childhood illnesses effectively. Community Health Extension
1.
19 Lives Saved by intervention (ORS, 112,667; zinc, 30,511; cotrim/amox, 125,331; ACTs, 190,434) were
calculated using the Lives Saved Tool, developed by Johns Hopkins. Projections used baseline coverage data
from national surveys and programmatic data and assume linear scale-up of interventions.
Workers (CHEWs) lack appropriate job aides and commodities
for the diagnosis and treatment of these diseases—with over 75%
of Primary Health Centers (PHCs) reporting regular stock outs of
essential medicines;
64. (iii) Primary health providers in the private sector often fail to
treat the most common childhood illnesses effectively. No
formal requirements or structures for the training and ongoing
education of Proprietary Patent Medicine Vendors (PPMVs)
exist, despite these retailers accounting for the majority of
private-sector health provision for common childhood illnesses.
As a result, caregivers often determine the treatment received
from these providers, but poor awareness among caregivers of
zinc and ORS means that few request these treatments for their
children’s diarrhea.
65. The package of interventions described in this section aims to
rapidly transform the treatment landscape for diarrhea,
pneumonia, and malaria in Nigeria by addressing the primary
precipitants of poor care-seeking and the low use of
appropriate treatments.
66. Four areas for action have been identified with key
interventions under each: (i) Generate Demand and Promote
Care seeking through conducting national action campaigns
for child health leveraging mass media, key opinion leaders
and free ample distribution; (ii) Improve availability and use in
the public sector through leveraging existing central supply
chains to increase public sector availability; improving
knowledge and skill of PHC staff to increase appropriate
treatments; and support increased procurement of essential
medicines at state and local levels; (iii) Improve affordability
through encouraging production of affordable high quality
ORS and zinc; identifying and supporting actions to reduce
cost and price of zinc and ORS; (iv)Transform the private sector
retail landscape through continuous education of private
retailers, facilitation of supplier marketing to boost retail sales
67. Many of these interventions will build off and accelerate the
progress of existing essential initiatives. For example, the
recommended actions in the National Scale-Up Plan aim to
strengthen the impact of the Integrated Management of
Childhood Illness (IMCI) approach, which has been a
cornerstone of Nigeria’s child health strategy but has faced
challenges in reaching its targeted scale. Additionally, the
National Scale-Up Plan identifies new opportunities to
dramatically accelerate progress, including expanding access
to high-quality, appropriate, and affordable treatment through
the private sector, which is the source of treatment for more
than half of children (USAID, 2011).
68. In general, the interventions recommended in the National
Scale-Up Plan aim to overcome barriers to child health services
overall as well barriers specific to the three target diseases:
69. For diarrhea, the aim of the strategy is to break the ‘market
trap’ that currently inhibits improved treatment coverage for
zinc and ORS whereby low demand leads to and reinforces
limited supply. To break this cycle, strategic interventions will
simultaneously increase demand for zinc and ORS (e.g.
through a large-scale creative marketing campaign to
reshape caregivers’ perceptions of effective diarrhea
treatment, engagement of key opinion leaders) while ensuring
widespread availability of high-quality products at an
affordable price.
70. For pneumonia and malaria, significant emphasis will be
placed on improved care-seeking, especially around the
recognition of fast breathing as a warning sign for pneumonia.
As with diarrhea, the greatest focus will be placed on raising
awareness of and demand for the recommended treatment
among caregivers, health providers, and retailers. Another
core component of the malaria and pneumonia scale-up
efforts will be improving effective diagnosis through increasing
the availability and appropriate usage of diagnostic tools and
ensuring the appropriate treatment or care is provided.
71. Job aids, guidelines, and key messages on diarrhea, malaria,
and pneumonia treatment will be incorporated into federal
government led service delivery platforms such as MNCH
Weeks, and the MSS and SURE Programme. Training modules
incorporating the job aids and guidelines will be used in the
training of primary health care workers who are part of these
programmes.
72. Pharmaceutical retailers will be engaged with information,
training, and behaviour change techniques on child illness
management and product recommendations to ensure
access to appropriate treatments. The project will tackle
inadequate retailer knowledge for diarrhoea, malaria, and
pneumonia treatment by cultivating and training networks of
PPMVs to distribute appropriate treatments. The training will
provide pharmaceutical detailing and skills improvement for
PPMVs on the management of childhood illnesses.
73. Targeted technical support will be provided, focused on
improving supply chain management to ensure availability of
essential medicines at the PHC facilities. Initiatives will be
pursued to identify and expand commodity distribution
initiatives to include essential medicines. Please see section on
Supply Chain for details.
74. The program will aim to shift consumer preferences toward
appropriate treatment by working closely with key
manufacturers to develop co-packaged Zn/ORS products that
are no more expensive than the combined individual products.
This will enhance the use of both products and uptake of zinc
could be increased by leveraging the existing high awareness
and comparatively high usage of ORS. ORS would also benefit
from rebranding within a co-pack to drive excitement around
a “new”, more effective diarrhea treatment.
75. Providers and where legally permitted, community health
workers (CHWs) will be trained to use improved diagnostic tools.
The improved diagnostic skills and tools—such as job aides and
rapid breathing counters—made available to CHWs will be
leveraged to ensure the appropriate use of pneumonia
treatments. Moreover, antibiotic packs for pneumonia
treatment will be given special labeling to clearly indicate the
appropriate indication and usage for each pack.
76. This plan includes the availability of live saving commodities
identified by the UN Commission of live saving commodities,
currently co-chaired by His Excellency, Mr. President. These
include:
Care
Continuum
Commodity Usage
Child health Amoxicillin Pneumonia
Oral rehydration salts Diarrhea
Zinc Diarrhea
77.
78. In order to track the impact on treatment coverage attained
through public PHCs, monitoring systems will be established in
targeted PHCs that allow for near-real-time tracking of service
provision, providing regular reports on children under-five
receiving appropriate treatment. This data will be regularly
cross checked against estimates of diarrhea, malaria, and
pneumonia incidence in covered localities (prepared by the
monitoring and evaluation arm of the PDU) to track the key
performance indicators.
79. Table 1: Key performance indicators, current status, and
National Scale-Up Targets for Essential Medicines Scale-UP
KPIs Current Status Scale-Up
Target (2015)
% of under-five diarrhea
episodes treated with
ORS and zinc
1% combination;
ORS alone, 25.5%;
zinc alone, <1%
(NPC, 2008)
80%
% of under-five malaria
episodes treated with
ACTs within the 24 hours
5.9% (NMCP, 2010) 80%
% of under-five
pneumonia episodes
treated with co-
trimoxazole or
amoxicillin
22.5% (NPC, 2008) 80%
80.
81. Resources required achieving the targets: To achieve the
national targets for Essential Medicines Scale-Up an investment
of $ 147 million is required until 2015 (See Annex 3)
Program Component 5: Improve Malaria Control
82. Malaria, a preventable and curable disease, remains a key
public health problem in Nigeria, contributing 30% of
childhood mortality and 11% of maternal mortality. It costs the
nation at least $1bn every year20. Nearly 110 million clinical
cases of malaria are diagnosed each year 21 . It exerts a
significant social and economic burden on families causing
the nation an annual loss of over N1billion (Jimoh et al., 2007).
1.
20 SunMap: Support to National Malaria Programme
21 Malaria Indicator Survey (MIS) 2010
Nigeria is responsible for a quarter of the deaths and suffering
from Malaria in Africa.
83. The treatment of malaria currently covers about 49.1% 22 of
Nigeria’s population; with 13% and 87% of this population
receiving services from the public and private sector
respectively. All Nigerian states have adopted Artemisinin-
based Combination Therapy (ACT) i.e. Artemether
Lumefantrine (AL), Artesunate Amodiaquine (AA) and
Sulphadoxine Pyrimethamine (SP) as appropriate treatments of
malaria. These medicines are accessible over the counter and
administered at primary health facilities across Nigeria.
84. Some progress has been made in Malaria control, for instance,
according to the LiST model, an estimated 57, 216 deaths were
prevented between 2001 and 2010 in Nigeria. 1,314 of those
lives saved were in children under 523. Counting the Lives -
Since 2001, an estimated 166,000 children under five have
been saved by malaria control interventions and
approximately 136,000 (or 82%) of the lives saved occurred in
2009 and 2010 alone.
85. Despite these efforts, Nigeria’s progress towards achieving the
Millennium Development Goals (MDGs) on Malaria struggles to
remain on target. Key barriers towards this effort include poor
awareness of ACTs as the most effective treatment for malaria
and lack of access to and appropriate training on diagnostic
tools. On the supply side, barriers such as poor availability of
ACTs due to lack of appropriate forecasting and
quantification of malaria medicines in the public sector as well
as the high cost of ACTs in the private sector also contribute to
Nigeria’s current status on Malaria.
86. Ensuring the availability of and training on Rapid Diagnostic
Tests (RDTs) in private pharmacies and Private Patent Medical
Vendors (PPMVs) is critical to ensure access to acute malaria
diagnosis and appropriate treatment and reduce the burden
of Malaria. RDTs are currently being introduced to 6 states in
the north by NMCP, and 6 states in the south by SFH24. The
availability of any diagnostic test for malaria in facilities is
currently 3%. In addition, improving the management of severe
1.
22 UNICEF (2010). Nigeria Multiple Indicator Cluster Survey (MICS) Preliminary Report. Abuja: Nigeria. Accessed online at: http://www.unicef.org/statistics/index_24302.html
23 Progress and Impact Series: Saving Lives with Malaria Control (2010)
24 Independent Evaluations of the Affordable Medicines Facility – Malaria (AMFm) Phase I
malaria (e.g. rectal Artesunate) – through the introduction of
suitable and easily applicable pre-referral treatment at
peripheral health facilities – is needed to reduce malaria case
fatality in Nigeria.25
87. The Nigeria Malaria Control Programme aims to reduce
malaria-related morbidity and mortality by 50% by 2013 and to
minimize the socio-economic impact of the disease using the
following approaches:
a. Increase in the percentage of children under-5 sleeping
under ITN in the previous night from 29% in 201026 to 80% in
2015.
b. Increase in the percentage of pregnant women sleeping
under ITN in the previous night from 65%27 in 2010 to 80% by
2015.
c. Increase in the number of all eligible pregnant women
receiving Intermittent Preventive Treatment (IPT): The 2008
NDHS reports that when IPT uptake was assessed using ANC
facilities as the delivery point, 8% of women reported
receiving at least one dose of SP for malaria prevention
during an ANC visit and 5% received the recommended two
doses of SP during ANC.
d. Prompt diagnosis and treatment with effective medicines.
From 200 NDHS, only 33% of children with fever (suspected
malaria) receive anti-malarial medicines.
88. Key enablers. Given the lessons from the past and the current
status of the Malaria program in Nigeria, reaching the set
targets will depend on several key activities. These include:
a. Co-ordination: Create effective central project
management for Malaria programme nationwide to ensure
tracking and
b. PHC/PPMV Training: Appropriate staffing and training at
PHCs and PPMVs to ensure complete Malaria Case
Management (Administering of Appropriate Treatment,
Severe malaria intervention, RDT, IPTp)
1.
25 CHAI-Essential Medicines. Nigeria Strategy – draft, 2011.
c. Data tracking: Design appropriate methods to track KPIs (or
proxies) on a monthly basis leveraging existing monthly
facility level data capturing mechanism; Ensure creating of
escalation mechanisms on intervene on underperforming
facilities / areas.
d. Supply Chain: Use facility-level consumption data to inform
forecasting, stock management processes and other
logistics to ensure consistent availability of ACT, RDTs, IPTs
and other interventions. Build mechanisms to ensure
appropriate feedback / incentives to the local facilities to
ensure results
e. Education/awareness campaign: Build grass-root level
campaigns to build awareness in end-users on appropriate
malaria prevention and treatment methods
89. Resources required achieving the targets: The total cost for the
malaria program component is estimated at $ 2.2 billion until
2015 (See Annex 3). This estimate is based on the commodities
and distribution costs for LLINs, ACTs, and RDTs, M&E using
quantifications drawn from the national gap analysis which
uses the global RBM methodology. Committed funding stands
at $ 380 million, hence a funding gap of $ 1.8 billion.
Program Component 6: Improving childhood nutrition
90. Malnutrition is the underlying cause of about half the number of
deaths recorded in children under the age of 5 years in Nigeria.
There has been no significant improvement recorded in
Nigeria’s efforts at addressing malnutrition with 41% of children
under the age of 5 years stunted, 14% wasted and 23% under-
weight (NDHS 2008).
91. According to the 2008 NDHS, about 23.1% of children under 5
are considered underweight. Today, Nigeria is ranked high
amongst the countries with the highest underweight in the
world with over 6 million children underweight. It is being
estimated that Nigeria will have an additional 1.6 million
stunted children by 2015 28 , and in 13.4 million due to
malnutrition in the country if no drastic interventions are done
to improve the interventions in the country.
1.
28 Life Free from hunger
92. In response to this current state of nutrition, Nigeria launched its
National Policy on Food and Nutrition in 2002 with the overall
goal of improving the nutritional status of all Nigerians. This
policy sets specific targets, which include reduction of severe
and moderate malnutrition among children under five by 30%
by 2010, and reduction of micronutrient deficiencies
(principally of vitamin A, iodine and iron) by 50% by 2010.
93. This effort included the fortification of staple foods with Vitamin
A, so that children will naturally consume Vitamin A in their
food. This effort resulted in Vitamin A fortification of 70% sugar,
100% wheat flour and 55% vegetable oil sold on the market.
Nigeria is also fortifying wheat flour with iron, thereby helping to
protect children and mother’s physical and mental health.
94. The Federal Government also launched the Home-Grown
School Feeding and Health program in September 2005 under
the coordination of the Federal Ministry of Education. The
program aimed to provide a nutritionally-adequate meal
during the school day. In addition, Nigeria currently has over
350 Community Management of Acute Malnutrition (CMAM)
sites across Northern Nigeria serving approximately 140,000
lives.
95. Nigeria recently held its first Nutrition Summit to create a
Roadmap to Scaling up Nutrition in Nigeria. Recommended
interventions include, promoting optimal infant feeding
practices, controlling micronutrient deficiency and anemia
through vitamin and mineral supplementation, food
fortification and dietary diversification and eliminating Iodine
Deficiency Disorder through a salt iodization programme in
Nigeria29. Recognition was also given to the role that other
sectors e.g. agriculture play in improving food security.
96. The program is complimentary to other ongoing activities
aimed at combating malnutrition and improving food security
in the country, such as fortification programs, breast feeding
promotion, health and nutrition education received by
mothers from the community health workers. The specific
program aims to ensure that every child suffering from severe
acute malnutrition (SAM) be able to access an effective
CMAM intervention, provided free of charge by a public
1.
29 UNICEF - Nigeria. June 2006
health facility. The nutrition program will be integrated with
other existing primary health care intervention services.
97. Community mobilization: CMAM and IYCF are community-
based programs that require and encourage community
participation in the early detection of severely acutely
malnourished children. Traditional and religious leaders and
leaders of core peer groups will be sensitized for optimal
support in accessing CMAM services available within their
localities.
98. Human resources capability will be strengthened. Each health
facility providing CMAM services as well as Stabilization Care
(SC) for referral of complicated SAM would need at least five
health workers and 25 community volunteers attached to
CMAM site for optimal service delivery. Additionally,
Community Support groups that are members of Ward/Village
Development Committees will be trained for the scale-up
program.
99. The health workers will provide screening, admission, and the
management of non-complications by feeding with RUTF for 8
weeks or more. Referrals to a stabilization centre will be made
by the health worker for cases with medical complications.
Community volunteers are responsible for the detection of
acute malnutrition within the communities and referral to the
Primary Healthcare Centers.
100. CMAM sites (OTP & SC) will be established within MSS and
SURE Programme cluster facilities. Each facility will have C-IYCF
activities integrated in order to scale up IYCF/CMAM
interventions in MSS communities and, by extension, in Nigeria.
Linkages with community support groups within catchment
areas are part of the structures for service delivery
101. The program aims to save up to 100,000 – 120,000 child
deaths being averted (lives saved) based on scale up of IYCF
and CMAM. Indicators that will be tracked and targets that
must be met include the following:
a. Cure rates: Consistently achieve a cure rate of 75% of
children admitted with for acute malnutrition from 71.4%24
b. Number of CMAM sites: Increase the number of primary
healthcare facilities offering CMAM services from 378 sites in
the Northeast and Northwest only, to cover all 1,000 MSS sites
nationwide
c. Case fatality rates: Consistently achieve a death rate of less
than 10% of children admitted from 1.2% 201230
d. Default rates: Consistently achieve a default rate less than 15%
from 25% of June 201230
102. A national data tracking mechanism needs to be instituted
by the Federal government from the facility level to the
national level to effectively track data flow from the CMAM
sites. The Standardized Monitoring and Assessment of Relief
and Transition (Smart Survey) is currently used to monitor
CMAM data flow in 8 northern states, two times a year. This
survey is used for rapid assessment of acute emergencies and
based on the Nutritional Status of children under 5 and the
mortality rate of the population. Expansion of this data
tracking system to attain national coverage will enable the
effective monitoring of the indicators needed to reach CMAM
targets.
103. The SMART survey is a monthly report that will be verified bi-
annually using a Semi Quantitative Evaluation of Access and
Coverage (SQEAC) method. The cost of conducting the
monitoring and evaluation exercise is factored into the
Monitoring and Evaluation section of Annex 6.
104. Resources required achieving targets: Nutrition interventions
covering CMAM are based on information provided by
UNICEF’s nutrition department. The total cost needed to
provide 90% coverage of CMAM services in primary
healthcare facilities by 2015 is estimated at $ 515 million.
Committed funding stands at $ 69 million, hence a funding
gap of $ 446 million. The yearly cost to scale up CMAM services
was calculated by multiplying the unit cost per facility to the
anticipated target coverage for the year.
ENABLING Component: Logistics and Supply Chain Management
105. The availability of good quality, safe, efficacious and
affordable health commodities in a timely manner to
beneficiaries is a key enabler to meeting the objectives of the
saving a million lives program and attaining the health related
MDGs.
1.
30 State CMAM report June 2012
106. The National Drug Policy, NDP (reviewed in 2005) provides
the broad policy framework for the financing, selection,
quantification, procurement, storage, distribution, sale and use
of medicines and health commodities in both public and
private facilities.
107. Despite several efforts by various actors – including the
department of food and drugs (FMOH), federal medical store,
States, partners (USAID, DFID), implementing contractors (JSI,
SCMS), NAFDAC, and local private sector partners – to reach
the NDP's goal of ensuring uninterrupted supply of essential
medicines, there continues to be a fragmented,
uncoordinated and sub-optimal supply chain and distribution
system between Federal programs, States and facilities for the
procurement, storage and distribution of medicines and
medical supplies.
108. As a result, frequent stock outs, procurements of medicines
with less than 80% shelf life, expiration of products and
counterfeit penetration in service delivery points (SDPs)
continue to be key challenges. The main causes of stock outs
include error in quantification and forecasts of medicines and
supplies, delay in delivery and insufficient transport facilities.
109. According to indicative facility based baseline data from
John Snow International, as of 2011, the national average
stock out rates for reproductive health commodities, ARVs and
ACTs were; 30 – 40%, 15% and 90 - 95% respectively. In addition,
the FMOH in collaboration with WHO, DFID and the European
Union undertook an in-depth baseline assessment of the
procurement and supply management systems in Nigeria in
2010 / 2011. Key findings include:
a. Quantification: Only 44% of partners worked with the FMOH
in the quantification process of their own programs.
b. Expiry: 30% percent of procurements had remaining shelf life
at delivery below the 80% requirement for rational
procurement. Some medicines were procured with as low as
20% of remaining shelf life with the full price paid for them.
c. Coordination: Only 38% of partners belonged to a working
group in which procurement activities were coordinated;
and of these, only 33% were under the leadership of the
FMOH.
d. Stock out: On average 54% of essential medicines were not
available at public health facilities
110. As a result of the above constraints, the program will set up
a system that will complement existing supply chain sytems
within the country, with the support of a central logistics unit
within the saving one million lives program delivery team. This
unit will engage with relevant public and private sector
stakeholders / partners leveraging on Steering Committee
members to coordinate, align and problem solve any
bottlenecks. This central logistics unit will be data driven and
manage a logistics management information system (and
online dashboard) to inform planning and decision making
that is tied to services in a real and practical way.
111. Pilot two tiered system: This system will be run as a pilot in the
first instance for a defined list of essential commodities in two
tiers, consisting of the central level and the SDPs level – with
the FMS and warehouses (public or private) strategically
selected in States to support delivery.
112. Up to 5,000 retail outlet will serve as service delivery points
that will be covered as part of the program. In the initial phase
of this program, these retail outlets will include the 1,250 MSS
PHCs and general hospitals in the country. In the mid term
include up to 5,000 primary healthcare centres and genaral
hospitals, run under the MSS, SURE-P MCH and NHIS MDG
programs will be included.
113. While the states play an important role in the provision of
commodities in SDPs, an informed push system using an
appropriate data collection mechanism, managed by the
central logistics unit will reduce the burden on States (and SDPs)
and ensure constant tracking and reporting of logistics
performance metrics such as consumption and stock on hand
information. These will form the basis of service level
agreements with the private sector and donor partners – who
will support various components of the supply chain and
ensure the availability of essential commodities at SDPs.
114. Service Level Agreements will be signed with private sector
and partners to allow the distribution of health commodities
through private sector partners at agreed intervals,
performance standards and maximum / minimum stock
threshhold levels. Reconciling total stock on hand (physical
count), residual stock balance, adjustments (plus/minus);
adjustment type; calendar days since last delivery; and days
stocked out will be done by delivery partners at the SDP level
and managed by the central logistics unit using developed
tools and logistics management information system to inform
delivery.
115. A Financing and procurement framework which stipulates
funding types and arrangement (parralel and pooled) will be
mapped and streamlined taking into consideration the
financing and procurement arrangement of existing programs
and funding / commodity gaps – which will be supported by
independent procurement agents. The procurement schedule
will be coordinated and aligned with the funding cycle – and
bridge financing mechanisms explored to mitigate against
delays, interruptions in commodity flows and other risks.
116. In the mid to long term, there will also be a strategy and
implementation roadmap with a focus on strengthening the
existing government supply chain system.
117. The central logistics unit will routinely track a number of
performance indicators. These indicators include the following
(i) Stockout rates of a defined list of essential commodities; (ii)
average months of stock on hand; (iii) coverage rates with
respect to targeted facilities; (iv) rate of expired stock and
losses / wastage; (v) shelf life of commodities on delivery and
(vi) timeliness of deliveries.
118. Resources Required: Based on distribution and storage cost
estimates of the six key interventions, supply chain resources
required will total $418 million. This was estimated from
distribution and supply chain budgets for essential medicines,
nutrition, routine immunization, and MNH as well as 10% of
commodity cost for malaria and e MTCT.
ENABLING Component: Increase innovation and use of
technology to improve health services
119. This component of the program will strive to promote
innovations in approach to delivery of basic health services to
the “last mile”.
120. This will entail development of creative approaches to
problem solving, from resource mobilization, accountability
and governance, human resources and task shifting,
regulation, service delivery arrangements, public-private
interface, supply chain and logistics management and
demand creation.
121. The component will also promote the use mobile phone
technology as a means of leap-frogging in the areas of health
information, point of service support, financing, client
engagement, quality assurance and logistics management.
Further research on the use of mobile and other technologies
for health will be commissioned as part of the program.
122. In addition, innovative financing mechanisms and other
demand side innovations will be explored, such as the
expansion of the conditional cash transfer program, results-
based financing and other schemes and incentives.
123. As part of this program, the Federal Ministry of Health in
Collaboration with the Federal Ministry of Communication
Technology, will partner with organisations such as GSM
Alliance, MHealth Alliance and other private sector partners in
(i) Developing an mhealth strategy for the country; (ii) Piloting
the use of mobile applications to improve access to services in
hard to reach areas, train frontline staff and educate/remind
patients on basic services and interventions.
124. Another key innovation is the explicit engagement of the
Private Sector and the harnessing of its potential.
125. Engagement with the private sector is being carried out in
two principal ways. The first is through unlocking the market
potential of the private sector, in several aspects of the
healthcare value chain, such as (i) health service provision
especially of basic services; (ii) Payer and health insurance; (ii)
pharmaceuticals and medical products, including essential
medicines and live saving commodities; (iv) Access to finance
and (v) support services such as supply chain and logistics.
126. The second approach is through engaging the business
leaders in the broader private sector through the Nigeria
Private Sector health Alliance. This Alliance would assist with
advocacy, provide technical assistance, impact investing, for
example, through the local manufacturing of essential
commodities in Nigeria, and investing in local manufacture of
bed nets.
IMPLEMENTATION AND PARTNERSHIP ARRANGEMENTS
127. “Saving One Million Lives” is not a new government policy. It
is rather a fundamental difference in approach to delivery and
accountability. It draws from existing government policies such
as Mr. President’s transformation agenda and the National
Strategic Health Development Plan (NSHDP 2010-2015), and is
consistent with the aspirations of the Federal Government and
most development partners. This is a sub-sector-wide program
built around health outcomes in a federal system of
governance.
128. The Program will support the existing government structure.
It will not substitute this, but rather, it will strengthen the system
through focused technical support to the Federal Ministry of
Health and its Parastatals and improvement of accountability
for results.
129. A review of existing programs in Nigeria reveals a pattern of
poor execution, despite strong political support and good
policies. Programs tend to suffer from the following:
a. Disproportionate focus on measurement of inputs, rather
than outcomes (e.g., number of workers trained vs. number
of deaths averted from malaria);
b. Fragmented implementation of programs with unclear
mechanisms for accountability and coordination (e.g., no
government single point accountability for any one program
or set of programs); and
c. Significant capacity and capability constraints (e.g.,
programs not staffed with sufficient number of people nor
those with the appropriate skill sets)
130. “Saving One Million Lives” therefore presents a new
approach that promotes a focus on outcomes, better
coordination around results and effective program delivery. As
a result, its implementation rests on three key factors:
a. Governance and coordination among the public and
private sector coalition partners supporting the initiative;
b. Performance management and data tracking;
c. Delivery mechanism to support Program implementation.
131. Actual implementation of the program will largely occur
through existing mandated institutions, Federal level MDAs
such as FMOH, OSSAP-MDGs, NPHCDA, NHIS, NACA; State
Government Primary Health Care agencies and parastatals;
and contracted non-governmental entities.
A. Governance and Coordination
132. The program will be government-owned and led. The
Honorable Minister, whose key responsibility is coordination of
implementation of primary health care, will lead the program
in a multi-stakeholder collaborative manner together with
relevant Federal MDAs and the State Governments. National
and International development partners (multilateral, bilateral,
non-government agencies and private sector) will also play a
very important role.
133. The overall Governance and Coordination will be driven by
a Program Steering Committee (PSC) at the Federal Level. This
PSC will build on the existing steering committee for the Results
Based Financing Project supported by the World Bank Group.
It’s expanded membership will include: Key national public
health sector leaders: Minister (of State) for Health, Permanent
Secretary of Health, SSAP-MDGs, Director-General of NACA,
Executive Director of NPHCDA, Executive Secretary of NHIS,
National Coordinator of the Malaria Program, Director-General
of the Nigeria Governor’s Forum, 6 Representative State
Commissioners of Health (3 in addition to the 3 in the RBF PSC),
Representatives from ALGON, World Bank, WHO, UNICEF,
UNFPA, USAID, CDC, CIDA, DFID, HERFON, CIFF, CHAI, BMGF,
and 2 representatives from the Nigerian Private Sector Health
Alliance.
134. The PSC will provide leadership to the program by(i) Aligning
priorities, (ii) setting and agreeing on performance
expectations with implementers; (iii) reviewing progress of
implementation by focusing on results (program/state based
scorecards) rather than processes; and (iv) assist to address
any high level bottlenecks to attain the desired outcomes.
135. The PSC and the PDU will work with the various
implementing partners to align approach to achieveing
outcomes, and foster better coordination across implementing
agencies and partners. It will also be a forum for increased
transparency of different programs. In addition, the PSC will
agree the performance expectations based on the respective
program objectives and indicators as well as the potential
number of lives to be saved by the interventions. This will form
the basis for the review of implementation progress on a
quarterly basis. Specific technical units within the PDU will meet
with the implementing agencies at more frequent intervals
and then update the members of the PDU monthly. If there is a
major performance issue, this will be flagged and the PSC
convened, if required. The PSC will also problem-solve and
address critical bottlenecks to implementation.
136. As part of its oversight functions, the PSC members may
conduct supervisory missions with the PDU at the state of local
government levels.
137. In some programs, such as the maternal and child health
programs, oversight will be provided by the communities
through the ward development committees, which are being
activated in the wards where the programs are in place.
Coordination with the State Governments
138. Nigeria operates a federal system of government, with fiscal
devolution. Accordingly, states and local governments enjoy
significant fiscal autonomy. Health provision is on the
concurrent list, therefore primary and secondary care, are
responsibilities of the local and state governments respectively.
Therefore, given the central role of the primary health care
system in the frontline service provision, engagement with the
states is a critical element for the practical implementation of
programs.
139. The PSC at the federal level will therefore actively engage
with the states, through ‘soft power’. This will be carried out
building on existing memoranda of understanding or other
coordinating mechanisms present in the respective programs.
The role of the governor’s forum is also important and the close
collaboration that has already commenced in the planning
stages of this program will be sustained throughout
implementation. In addition, performance information
disaggregated at state level through state score cards will be
used to measure state level performance and serve as a tool
for dialogue and advocacy with the state governments.
140. There are four main areas of engagement with the states.
These include:
a. Program design: The Saving One Million Lives Program was
developed in consultation with the state governments. The
governor’s forum, represented through the director-general
and the health adviser, has been involved in review
meetings during the preparatory phase of the project. In
addition, a consultation was held with the commissioners of
health and other representatives of the State governments
in Abuja, where unanimous support was given to the
program.
b. Governance and Coordination: We will work with the states
to provide oversight on the programs that currently exist.
Secondly, the PSC will comprise the Director General of the
Governors’ Forum as well as six State Commissioners of
Health (one from each geopolitical zone, representing the
three from the RBF PSC plus three others).
c. Data collection: States will be required to facilitate the
sense-checking of the data being collected at PHC level,
using the State M&E officers as focal persons. Data will also
be sent directly to the central PDU.
d. Implementation support: The program will build on existing
agreements such as the MOUs that MSS currently has with
state governments. Efforts to modify the PDU will also be
undertaken
B. DATA TRANSPARENCY AND PERFORMANCE MANAGEMENT
141. Results Monitoring and Evaluation: The Project will ensure a
robust Results Framework and M&E system that will enable the
effective tracking of results and implementation progress. The
progress of the Project will be monitored against the results
described in the Result Framework (RF) which will also feed into
the Annual Review.
142. Performance management will involve five steps: (i)
Developing results targets (ii) Designing data tools and
templates, (iii) Creating data collection and collation routines
and (iv) Analyzing and synthesizing data and (v) Establishing
feedback loops with the respective implementing agency,
stakeholders and the public.
143. First the program will select the appropriate indicators and
expected trajectory towards achieving the set outcomes.
Indicators will comprise a mix of outcome and output
indicators. The program will minimize the use of inputs
indicators to monitor progress. Examples in other systems show
that this is best practice to select a limited number of KPIs that
provide critical information on the progress of implementation.
144. Not all possible indicators will be tracked. Every program
area already has indicators that are being measured. A sub-
set of these indicators that are outcome focused and critical
towards determining success of the program and lives saved,
will be selected. These are the indicators that will be tracked
by the Program Delivery Unit.
145. Secondly, tools, templates and an integrated MIS system for
collection will be developed. This will allow for effective
monitoring across project areas. A combination of existing
data reports and new databases for handling large amounts
of data will be developed. This data collection tools and
templates build on the existing HMIS templates and are
currently being piloted in the MCH program. Different
programs already have data collection templates and tools
that will be built on.
146. Most of the data templates are paper-based. In the
medium term we aspire to build a mobile data collection
platform to create a more robust, reliable and faster system for
managing data. This approach will be tested under the
enabling component on innovation. In addition, surveys will be
conducted periodically to monitor outcomes. The program will
also leverage existing surveys where appropriate, such as
health facility surveys and the resource tracking surveys.
147. The third step in the process will involve the data collection
and reporting routines. For facility based data, they will be
reported monthly and simultaneously to the state and Federal
levels.This allows the PDU to analyse data faster, while allowing
for the state to carry out verification of the information. Where
needed, specific, focused surveys will be conducted. At the
PHC levels, data officers collaborating with the Local
Government M&E offices will have the responsibility for
collecting data from the facility. This activity will be monitored
by the State M&E officer and the state level PDU officer, who is
a federal PDU employee, resident in the state. This person is
responsible for assuring the quality of data being presented.
Data collection will also be carried out by the agencies
implementing the respective programs.
148. At the facility level, data will be compiled and recorded by
a dedicated facility data collector that already exists within
the State and LGA Primary Healthcare Development agencies.
The information will be submitted to the State Liaison Agents
from the facility using the standardized templates at the end of
every week. Transportation allowances will be provided to the
facility collectors pending the installation of a technological
and more efficient method of collecting the information
remotely.
149. The State Data agent collects and compiles all facility
reports and submits to the Regional Coordinators on the first
Wednesday of the subsequent month. This allows the State
Agent a lag in time to compile a full month’s data from the
facility.
150. Creating accountability in the system will be critical to
making this program more than just a promise. The national
and state level targets and progress against them will be
made fully public, which will enhance accountability and
create competition amongst states and implementers.
151. Fourthly, the collated data will be analysed and synthesized
centrally by the data analysts within the PDU. The key insights
will be synthesized and detailed in meaningful ways for the
PSC and other audience such as the state government.
Quarterly Scorecards for the states will also be developed
based on the analysed data.
152. The Regional coordinators work with Data Analysts and the
Technical Assistants within each programmatic area of
intervention to collate, review, and analyze the reports. There
will be a maximum of one month’s lag time between data
submission by the facilities to the analyzed and reviewed
monthly report at the Federal Level.
153. A program review is carried out every quarter by the
Steering Committee to determine progress made, bottlenecks,
constraints, propose corrective plans of action. Plans of action
are made at the end of the review and implemented at the
start of the next cycle. Please see (Annex 10) for a diagram
illustrating this process).
154. The PDU will and PSC will then use this information for
feedback conversations and discussions with the implementing
agencies and the state governments on the progress towards
achieving the agreed health targets. It will also provide the
basis for problem solving and addressing critical bottlenecks.
FIGURE 2.
155.
C. PROGRAM DELIVERY UNIT
156. Effective delivery and implementation requires human
resources with the right skills and ‘execution’ mindset as well as
the necessary routines for a robust performance management
system. The ‘Program Delivery Unit’ (PDU) will be constituted to
provide this support to the PSC and to the implementing
agencies. This PDU will have highly skilled resources that the
states can draw on as well as the capacity needed to plan
and manage the program. The PDU will also provide coaching
and capability building to the Government staff that will be
working alongside.
157. The PDU is the ‘nerve centre’ of the whole reform. It will
need a mix of public and private sector as well as local and
international skill sets.
158. The PDU will monitor progress toward the program
objectives, component by component. It will collect and
analyze relevant data, coordinate with implementers to ensure
that results are on track, solve problems early and rigorously,
and when necessary, escalate issues to the PSC for corrective
action to achieve aspirations.
159. The PDU will provide on demand technical assistance to the
states in specific areas by troubleshooting delivery challenges
and through capability building. The PDU will also support the
Steering Committee in driving the Initiative and report regularly
to the Chair of the PSC.
160. The PDU will also have functional expertise that states can
draw on to drive execution. This functional expertise will
include problem solving and analytical skills, strategy, demand
generation, procurement, supply chain management, training,
communication and data management and analysis.
161. The PDU will incorporate a team of 10-15 data analysts. This
team will define a list of KPIs to be collected on weekly and
monthly bases and getting the system into the habit of
collecting them. As data becomes available, it will be
analyzed to create managerial reports that can be used to
prioritize interventions and resolve performance issues.
162. A key element of the PDU is to coordinate the building of
capabilities to drive and manage delivery at the State and
Local Government levels and in the Primary Health facilities.
The capability being build will cover both technical and
managerial elements. On the technical side, the PDU will
support scaling up of existing training and capability
enhancing initiatives. It will focus enhancing competencies as
will be monitored through improvement in performance.
163. On the managerial or systemic side the PDU will tailor
training and capability building at multiple levels in the system
on topics relevant to day to day management of health
service delivery. Building on the success of the Middle-level
management training organized by the NPHCDA, but with an
expanded scope and range of participants, this will include;
formal executive and leadership training for key leaders at the
State level.
164. The PDU functions are in two major categories: the
Administrative/Strategic staff and the Implementation Units.
The Secretariat would be based in the Federal Capital Territory
(FCT) and managed by the Project Coordinator/Adviser and
Deputy Coordinator/Adviser.
165. The Strategy and Operations unit which consists of core staff
like:
a. Project Coordinator/Adviser: to drive the planning,
implementation and eventual success of the Saving One
Million Lives Program. He/She will also serve as the secretariat
to the PSC
b. Deputy Coordinator/ Adviser: provides support to and
deputizes for the Project Coordinator.
c. Performance Management Adviser: responsible for
monitoring and evaluation of the Programme. He will report
directly to the Program Director and Deputy Director and will
be based at the PDU Secretariat.
d. Procurement Advisor: This person will report directly to the
PDU secretariat.
e. Financial Management Adviser: will ensure compliance with
standard internal (e.g., audit) and external (e.g.,
disbursement) processes. He/She will also maintain
adequate financial M&E and prepare quarterly reports for
delivery unit and work with the Local Funding Agents and
Project accountants for the relevant programs.
f. Supply Chain Advisor: an expert in the supply chain
management procurement, storage and distribution. He will
report directly to the PDU Secretariat. He will coordinate a
complementary supply chain system all implementation
activities and managing SLA’s with private sector and other
partners.
166. The implementation unit is responsible for the core activities
of the program components, monitoring and evaluation
exercises. This unit will consist of:
a. Six Regional Coordinators (RC): the RCs will report directly to
the PDU Secretariat and will be responsible for liasing with
state data agents to pursue, collect and review weekly data.
In addition, they will conduct training exercises for State
Agents in proper data collection and management
b. Data analysts: works with the Regional Coordinator at the
Federal level to review, analyze reports in preparation for
presentations to the Steering Committee. They will be
located within the PDU Secretariat in the FCT.
c. State Liaison Agents: Two State liaison persons/agents
present in 36 states and the FCT. The State Agents will report
to the Regional Coordinators and will be responsible for
pursuing facility data and providing monthly data reports to
their respective Regional Coordinators. These agents will also
maintain a comprehensive database of facilities, which will
include location, mobile number of key contacts, HR staffing
and other relevant information.
d. Technical Advisers: within each intervention area, a
technical adviser will provide on-demand problem-solving
expertise to regional data coordinators /state liaison officers
and engage with relevant focus-area partners and
implementing partners to ensure alignment with targets.
e. Administrative staff: responsible for the day to day
administrative activities of the secretariat.
167. This multiphase program over 1-2 years will reach the 37
Permanent Secretaries and other key positions at the state and
local government levels.
168. It is anticipated that some DPs will support the GON’s Saving
One Million Lives initiative Program through a Sub -Sector Wide
Program Approach. Some of this support would be financial.
There will be a Joint Financing Arrangement (JFA) between the
GON and these DPs. The JFA will guide both the pooled and
non-pooled fund contributions of the DPs as well as provide
detailed arrangements for disbursing, managing and reporting
on the use of funds.
169. In addition, there will be a coherent multi-year integrated
and consolidated TA plan of the Program, to support the
Program implementation, strengthen institutional capacity at
different levels, increase focus on achieving results as well as
carrying out the agreed upon reforms. The GON will carry out
the Project in accordance with the Environment Management
Plan (EMP) and the Social Management Framework (SMF).
FINANCIAL MANAGEMENT, DISBURSEMENTS AND PROCUREMENT
170. Given the SOML program is not designing new policies or
new programs per se, but rather, a new approach to delivery,
a lot of the outcomes can be achieved using existing
resources more effectively. Therefore, the financing approach
for the program will be one whereby available resources will
be used to purchase specific results. The combination of
existing and ongoing federal government budgetary provisions
(MDG-DRG funded MSS, Polio, Routine Immunization, SURE-P
MCH), existing and ongoing development partner funds (World
Bank PBF, Malaria Booster, Polio Program Buy Down, US PEPFAR,
USAID, US CDC, DFID and CIDA) will be used to start the
program.
171. However, additional resources to be mobilized (through
World Bank, Global Fund, USAID, DFID and others will be
required to fill any financing gaps as outlined in the program
budgets and gap analysis. This section outlines the financial
management architecture for the additional resources
required to achieve the outcome targets.
172. Pooled funding approaches will be explored with willing
partners, including Multi-Donor Trust Fund or Basket Fund. As
implementation progress is made, additional resources will be
mobilized to close any remaining funding gaps.
173. The funding sources will come from the government
(existing and new commitments) as well as from development
partners (DPs). It is anticipated that there will be three possible
pools for financing the SOML program. These include (i) Parallel
financing of specific projects currently under implementation
by development partners for whom pooling is not an option.
However, the expectation is that there will be significant
alignment in approach and strategy and link to results. (ii)
Pooling of funds by DPs through a Multi-Donor Trust Fund
(MDTF). These funds could be managed by a third party such
as the World Bank or through a reputable local fund agent.
The pooled funding arrangement will be developed with
assistance with the World Bank to ensure highest fiduciary
standards are applied. An external, competitively recruited
private sector fund manager will administer the pooled fund
for attainment of the program objectives. (iii) Resources
channeled through the GON Treasury system.
DISBURSEMENT
174. Disbursement of funds will be based on quarterly Interim
Unaudited Financial Management Reports (IUFRs), which
include quarterly expenditures, and these are compared to
the annual budgets. The IUFRs will include revenue expenditure,
parallel/direct expenditure financed by non-pooling DPs
thereby ensuring a comprehensive picture covering all
expenditures of the health sector. Based on the project
features the following arrangements can be agreed upon for
financial management and disbursements under the Project:
175. Planning and Budgeting: Linkages will be maintained
between project budget and the annual resource envelope
for the program, which is a sub-sector program. As part of the
implementation support, the PDU will share the annual
program budget with the PSC. The DPs who are part of the
MDTF will input into the annual budget. Others will share their
annual contributions to their respective projects accordingly.
This will give a more robust picture of the funding available for
the program for the year.
176. Accounting and Reporting: For GON funds, and IDA and
pooled funds channelled through the government Treasury
System, accounting will follow the existing government system.
Under this system, a central Financial Management unit will
continue receiving and recording financial information for
GON, IDA Credit and pooled funds and will be responsible for
maintaining the sector accounts. For the MDTF, the local fund
agent will be responsible for this, whereas with DPs using
parallel financing mechanisms, this will follow their own
reporting mechanisms
177. Internal Control: Government’s General Financial Rules will
be followed. There are clear guidelines for authorization and
approval of financial transactions at various level/tiers of
government.
178. Internal Audit: An outsourced private firm will carry out
internal audits of the Project under an agreed TOR. The
Internal Audit report, together with the management response
and follow up action will be shared with the PSC within 15 days
from date of the receipt of the report.
179. Fund Flow, Disbursement and Release procedures: An
acceptable institute/donor will administer the funds
channelled through the Multi Donor Trust Fund (MDTF). The
MDTF resources will flow to a pooled FOREX Account
maintained as a sub account of the GON treasury account.
Figure 1 below depicts the arrangement of the flow of funds
for the Program.
180. The first advance by DPs to the pooled Designated Account
will be in an amount equivalent to its share of six months’
estimated eligible expenditures of the Project. Consolidated
Financial Statements will be generated– including a statement
on funds required for the next six months so as to facilitate
replenishment of DA (Treasury Account).
181. Project Reporting: Appropriate formats of the periodic
financial reports (IUFRs) shall be agreed. A dedicated FM Unit
(for government and IDA funds) or the LFA (For the MDTF) will
support consolidation of financial data from the treasury
system and direct payments through special commitment etc.
Records evidencing eligible expenditures (e.g., contracts) will
support the requests for direct payments. The Central FM Unit
where the Withdrawal Application will be prepared and sent
for reimbursement will consolidate these requests and
documentation.
182. External Audit: The annual financial statement under the
Project will be prepared by the GON and will be audited by
CAG who is considered as an independent auditor to carry
out annual audits. The audits will be conducted following
country procedures and in accordance with an agreed
“TOR/Statement of Audit Needs” which will specify essential
elements of audit coverage under the Project. Throughout
Project implementation, audit coverage, focus and steps for
effective and timely follow up of audit observations will be
driven by the Audit Strategy.
183. The figure below outlines possible financing options
EXHIBIT 1
Possible flow of funds for the Program
Parallel
financing
Development
partners
Development
partners
IDA Credit GoN
Parallel
financing
Pooling of
funds
Separate
funding pool
DP
designated
account
Designated
account in
CBN
Local Fund
manager
Source of
revenue
Resource
allocation
Financial
mgt
Mechanism
Public Sector
Funding
Projects ProjectsProjects Projects Projects Projects
Multi Donor
Trust Fund
PROCUREMENT
184. For the pooled funding (MTDF or basket fund), a detailed
procurement plan for the first two years of the program will be
developed for the program. A reputable procurement
firm/Agent may be engaged to handle procurement for the
respective projects in compliance with standards of public
procurement. To avoid undue interference in the procurement
process, the general procurement manual, developed for IDA-
financed projects in Nigeria and the World Bank’s standard
bidding documents will be adapted for use by this program.
185. Inputs required to achieve the results will be procured using
national procedures consistent with World Bank guidelines.
Consultancy, goods and minor works, will be procured in
accordance with the World Bank‘s Guidelines. Particular
Methods of Procurement of Goods, Works, consultancy and
Non-consultancy services will be determined during project
preparation.
186. The operating costs include staff, travel expenditures and
other travel-related allowances; vehicles rental; vehicle fuelling;
utilities and communication expenses; and bank charges.
Operating costs will be managed using the implementing
agency‘s administrative procedures and for the PDU, using
procedures consistent with Government of Nigeria Financial
Regulations and applicable partner guidelines.
187. In addition, the following steps will be followed as part of
procurement and implementation arrangements: (a) raise
awareness among entities’ officials/staff about fraud &
corruption issues; (b) make bidders generally aware about
fraud & corruption issues; (c) the multiple dropping of bids will
not be permissible for all procurement under the donor
financed Project; (d) award of contracts within the initial bid
validity period, and closely monitor the timing; (e) take action
against corrupt bidders in accordance with Section I of the
World Bank’s Procurement/Consultant Guidelines; (f) preserve
records and all documents regarding public procurement, in
accordance with World Bank Guidelines; (g) publish contract
award information in dgMarket/UNDB online and entities’
website within two weeks of contract award; and (h) ensure
timely payments to the suppliers/ contractors/consultants and
impose liquidated damages for delayed completion.
SUSTAINABILITY PLAN
188. This program is a Federal intervention program aimed at
accelerating Nigeria’s progress towards achieving MDG goals
by 2015. Upon completion of the program, it is expected that
the focus on improving access to basic services and life-saving
interventions will continue.
189. In the National Health Bill under development, a primary
healthcare fund will be established. It is expected that this
program, with the focus on results, better coordination among
development partners and government, and with an effective
performance management, and with transparent fiduciary
systems in place will serve as a platform for effectively
channelling the resources from government (through the
Primary Health care fund) and from development partners.
ECONOMIC ANALYSIS
190. The program supports evidence-based cost-effective
interventions: By supporting the delivery of FMOH‘s Minimum
Package of primary and first-referral services, the program is supporting a highly cost-effective measure with a well documented
impact on averting maternal and neo-natal deaths. In addition, the
bulk of the services are to be provided at the primary and outreach
levels. PHC services have the advantage over hospital care in that
they are more accessible to the community. Because of their
staffing and organization, they are less costly, and more easily able
to provide comprehensive and integrated care.
191. A review of service delivery in Nigeria shows significant
inequities in access to basic services with the poorest
population quintiles and the rural dwellers significantly
disadvantaged. This program, by targeting poor rural and
urban communities, with a large concentration of the poor,
this program addresses inequities in access to services in the
country.
192. In addition, given the strong in-built monitoring and
evaluation tools and systems, the program could also help
establish a culture of systematic data collection, analysis and
use in decision making, as well as accountability for expected
results of spending decisions, all areas that currently are
extremely weak.
193. The cost effectiveness of the specific interventions have
been outlined in the program documents that have been
developed for the respective programs.
194. For example, Malaria is responsible for an estimated 300,000
child deaths each year. The economic and social burden is
substantial. At the macroeconomic level, the economic
growth penalty of malaria endemicity over the 15 year period
1980 - 1995 was estimated at US$17 billion, representing a per
capita loss of US$156, or 18 percent of actual 1995 income.
Market failures and the poverty dimensions of malaria control
are a strong justification for public sector involvement.
195. Malaria control interventions have proven to be highly cost-
effective in many settings and studies, exhibiting cost-
effectiveness ratios lower than US$ 100 per Disability Adjusted
Life Year (DALY) saved. Estimation of the Project potential
impact, using the Marginal Budgeting for Bottleneck tool,
showed that we can expect substantial reduction in child and
maternal mortality at impressive cost-effectiveness ratios if the
project reaches its coverage targets. Delivering malaria-
specific interventions, along with other effective health
interventions that can be delivered through the same mode,
and are already present in the country, will have a higher
impact but at a negligible increase in cost, when compared to
combinations of pure malaria-specific interventions.
196. HIV/AIDS affects an economy through (a) reducing
productivity, domestic savings and economic growth, and (b)
increasing costs of treatment and care for both affected
households and the society as a whole. AIDS strikes people in
their most productive age, reducing both the size and growth
of the nation's labor force. Care and treatment for AIDS
impose enormous costs on households and the society at large.
Households with AIDS patients are likely to lose the income of
PLWHAs (often the main breadwinner) in addition to facing an
increase in medical expenses. Some households are forced to
withdraw their children from school in order to save money.
197. The economic benefits of the interventions are multifold. First,
since this project aims to assist with scaling up interventions in
HIV/AIDS control and mitigation, the majority of Nigerians will
directly and indirectly benefit from increased access to
HIV/AIDS prevention, treatment, care and mitigation activities.
Secondly, new HIV infections in children will be reduced, due
to an expansion in coverage of the package of HIV/AIDS
prevention activities supported by the project.
198. Pneumonia and Diarrhoea contribute to the cycle of
poverty. It poses a significant economic burden for families
and communities. The financial costs of pneumonia include
hospital stays and medications, transportation to health
centers, and the caretakers’ inability to work or take care of
other family members while they are caring for a sick child.
199. In India an increase in coverage of diarrhoa interventions to
60% was associated with an 11% mortality reduction as well as
significant improvements in health outcomes. The cost per
DALY averted was US$0.24 ($0.21-$0.34) per DALY averted and
US$6.68 ($5. 58-$9.19) per death averted relative to the control
arm per 10,000 children 1-59 months. (LeFevre, 2011).
200. Malnutrition remains a significant problem in Nigeria. The
contribution of CMAM to child mortality and loss of healthy life
years is now well quantified (Collins 2006a; Bhutta et al.2008a),
and the urgent need to scale up effective interventions to
both prevent and treat undernutrition can no longer be
ignored (Bhutta et al. 2008b). While CMAM’s effectiveness has
been recognized globally for some time (Collins et al. 2006a;
WHO et al. 2007), its cost-effectiveness was evaluated recently
in a study by Bachmann in Lusaka (Bachmann 2009). The
results clearly indicate that CMAM was cost-effective within
the studies’ respective rural and urban contexts in southern
Africa.
201. APPENDIX: Programmatic targets and costs
ANNEX 1: ESTIMATED BREAKDOWN OF NUMBER OF LIVES SAVED BY
PROGRAM COMPONENT
ANNEX 2: LIST OF PERSONS CONSULTED OR INTERVIEWED
Program area Organisation Contact person
Routine
Immunization
NPHCDA Dr. Joseph Oteri
NPHCDA Mrs Hassan
MCH NPHCDA - MSS Dr Abdullahi
NPHCDA - MSS Dr. Urua
SURE-P Dr. Ugo Okoli
SURE-P Dr. Tokunbo Oshin
Nutrition FMOH Mrs. Roselyn Gabriel
NPHCDA Dr. Nnenna Ihebuzor
UNICEF Mr. Stanley Chitekwe
UNICEF Mr Omotola
UNICEF Ms. Angela Kangori
Malaria Program NMCP Dr. Timothy Obot
NMCP Dr. Femi Ajumobi
NMCP Dr. Omede
NMCP Dr. Sola Oresanya
PMTCT NASCP Dr. Azeez Aderemi
NACA Dr. Akudo Ikpeazu
NACA Dr Uzoma Ene
NASCP Dr. Anyaike
NASCP Mrs. Jolaoso
NASCP Dr Debbie Odoh
NPHCDA Mr. Seye Abimbola
PEPFAR
MDG Health Alliance Anna Levine
Essential
Medicines
CHAI Mr. Jason Houdek
NPHCDA Dr. Nnenna Ihebuzor
Implementation
and Finance
arrangement
World Bank Mr Dinesh Nair
Supply chain and
logistics
USAID Ms Kelly Badiane
JSI Mr. Peter Hauslohner
JSI Ms. Elizabeth Obaje
JSI Mr Chuks Okoh
JSI Mr Emmanuel Sokpo
SCMS Mr Bernard Fabre
Department of Food and
Drugs (FMOH)
Pharm. Joy Ugwu
State Designation Name
Kogi State Permanent Secretary Adamu Ahmed
Kogi State DPHC Dr. J.F. Olorunfemi
Taraba DDPHC John D. Mboli
Enugu State Hon. Commissioner Dr. Fidelia N. Akpa
Yobe DPHC Dr. Hauwa L. Goni
Anambra State DPHC Dr. C.J. Okoye
Kaduna State DPHC Dr. Ado Zakari
Benue Permanent Secretary Dr. J. Kwaghtsule
Niger State Hon. Commissioner Dr. Ibrahim B. Sulemni
Niger DPH Dr. M.B. Usman
Ekiti State Hon. Commissioner Prof. O.B. Fasubaa
Ekiti State DPHC Dr. Ayodele Seluba
Kwara State Hon. Commissioner Alhaji Kayode Issa
Kwara State DPHC Dr. A.P. Folorunso
Ebonyi State Hon. Commissioner Dr. Sunday Nwangele
Ebonyi State DPHC/DC Dr. Achi E.C.
Ondo State Permanent Secretary Dr. E.T. Oni
Ondo State DDPHC Dr. Adelusi
Gombe State Hon. Commissioner Dr. Kennedy Ishaya
Abia State DPHC Dr. Oluoha C.N.
Abia State Hon. Commissioner Dr. O.S. Ogah
Delta State Senior Medical Officer Dr. Anibor
Nasarawa State Hon. Commissioner Dr. E. Akabe
Nasarawa State DPHC Dr. Z.T. Umar
Ogun State Hon. Commissioner Dr. Olaokun Soyinka
Borno State Hon. Commissioner Sr. S.A. Kolo
Borno State DPHC Baba Gana Abiso
Cross River State HOD for the Comm. Ekanlu Comfort
Adamawa State DDC/ DPHC Dr. L.C. Bakar
Organization Position Name
NACA Director General Prof. John Idoko
NPHCDA Executive Director Dr. Ado Muhammed
NHIS DG Ab Okauru
Governors Forum Health Policy Consultant Dr. Dale Ogunbayo
NHIS GM Uweja Hope
NHIS Ag. ES Dr. Abdulrahman Sambo
PM Ajuoli N. N.
Organization Position Name
USAID MCH Manager Folake Olayinka
UNICEF Consultant Dr. Anante
USAID/DELIVER Snr Logistics Advisor Elizabeth Obaje
USAID/DELIVER Assoc. Dir. Pub. Health Elizabeth Ighano
CIDA Second Secretary
Development
Lisa Demoor
UNICEF Chief of Health Naawa Sipliyambe
DFID Health Advisor Susan Elden
USAID-TSHIP MCHS Dr. Sadahi Ringim
ANNEX 3: OVERVIEW OF COSTING AND FUNDING GAP
Programme Total Cost Probable Funding Funding Gap
Malaria 2,198,787,844$ 380,270,790$ 1,818,517,055$
MNCH 783,201,759$ 581,006,986$ 202,194,773$
PMTCT 665,719,546$ 373,600,000$ 292,119,546$
Essential Meds 146,851,698$ -$ 146,851,698$
Immunization 1,452,880,483$ 841,807,612$ 611,072,871$
Nutrition 515,458,030$ 69,252,228$ 446,205,802$
Delivery Unit 24,289,819$ -$ 24,289,819$
Infrastructure
Improvement212,370,782$ -$ 212,370,782$
Total ($) 5,787,189,179 2,245,937,616 3,541,251,563
UNFPA
World Bank Senior Health Specialist Dinesh Nair
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