#1A case study of Nigeria Evidence-based Health System Initiative (NEHSI) In Bauchi State Presentation made to the Joint Planning Board (JPB) Meeting By Aminu Hammayo, Secretary to the State Government At Zarandah Hotel, Bauchi 23 April 2014#2Introduction The objective of this presentation is to share with participants the achievements of the NEHSI project in Bauchi State and its impact in Planning and Resource Allocation. This is particularly in relation to the need to address the unacceptable levels of maternal & child mortalities.#3Background • Information is the cornerstone to plan and better services and improve deliver development outcomes This requires a major improvement in the Information systems, especially the capacity to generate, analyse and use evidence for planning and resource allocation#4Background (Cont'd) Government Since 2009, the Federal working with the Canadian Government had initiated a model of evidence based planning in the health sector in Bauchi and Cross River States The five year project which started in 2008 was funded by CIDA through IDRC and ended in December 2013#5• Social Scope of the Initiative Audits: Population based benchmarks for evidence based planning Modelling Strategies to socialise evidence for participatory action (SEPA) Community Surveillance Strengthening community based HMIS • Human System: for Capital development Institutionalisation and sustainability#6Multi Stakeholder Information System (MSS) Social Audit • Since 2009, under the auspices of the SMOH and with the support of the SPHCDA, the MSS component of NEHSI has established and implemented three rounds of social audit • The State Government had decided the priorities for the social audits The first (2009-10) focused on maternal health outcomes#7Multi Stakeholder Information System (MSS) Social Audit (Cont'd) The second covered child healthcare within the the context of the Integrated Management of childhood illnesses (IMCI) The third was on primary healthcare Millennium development goals which consolidated the two priority areas • The social audits had initially used paper based data collection system but later shifted to a geo-referenced electronic data gathering and transmission system#8Modelling Strategies to socialise evidence for participatory action (SEPA) • Under this initiative, the evidence generated from the surveys were shared with all major stakeholders at the state and local government levels using scorecards • At the community and household levels, a documentary drama was used to share the evidence to help generate community and individual action plans to improve the situation#9Findings from the first social audit A woman was more likely to suffer from complications during pregnancy or child birth if she: • had four or more pregnancies • was exposed to physical Intimate Partner violence (IPV) ⚫ was not discussing pregnancy with the husband had insufficient food during the week prior to survey ⚫ had female genital mutilation (FGM) • had less than four Antenatal checkups was delivered by an un-skilled birth attendant#10Follow-up evidence based actions Need to Implement a structured strategy for social mobilisation to: ● • Increase awareness on danger signs during pregnancy/child birth Reduce heavy workload during pregnancy Encourage women and their husbands to discuss about pregnancy Ensure at least four home visits to pregnant women by a trained worker Prevent intimate partner and domestic violence during pregnancy Improving availability of skilled health workers#11Health seeking for illness/experience at health facility • Health seeking behaviour (children 0-36 months) • 3% had mothers involved in deciding where to go • 49% taken to a qualified health facility for treatment • 46% taken to a government health facility (map) Experience at government health facility • 56% waited less than 30 minutes to be seen • 45% received full explanation about child's condition • 66% paid for treatment at the health facility 27% paid for medicines or tests outside the facility#12Social Audit on PHC MDGs -Scope of data collection Units 2009 2011 2013 Households (all LGAs) 5709 5535 6230 Women 14-49 years 11486 8881 Mothers/caregivers 6933 7775 Children 0-59 months* 11277 12331 Children 6-59 months (MUAC) Focus groups 7183 9355 180 180 TBD **#13Indicator Maternal health Knowledge on danger signs 2009 2013 during pregnancy 50% 88% during childbirth 50% 80% ANC coverage (4 visits) 40% 47% BP checked on every visit 35% 44% Urine tested on every visit 8% 4%#14Maternal health Indicator 2009 2013 Delivery at a health facility 19% 21% By a skilled heath worker 20% 22% Post natal checkup within 6 weeks 14% 28% Paid unofficial charges for ANC 50% 57%#15Child health Nutrition and immunisation* 2011 2013 Exclusively breastfed into 6 months. 9% 6% Malnourished (MUAC) 12% 9% Received measles vaccine 42% 29% Received all vaccines 12% 7% Received polio vaccine Had measles like symptoms. 85% 92% 30% 23% * Vaccine coverage reported among children aged 12-23 months#16Child health Personal hygiene 2011 2013 Households with access to improved water source 42% 47% a formal toilet within 62% no garbage, sewage or excrete 24% 15% water container clean/covered/raised 31% 17%#17Child health Bed nets and Malaria 2011 2013 Households with treated bed nets 87% 78% Children 0-59 sleeping under a net 52% 49% Had high fever* 28% 37% Taken to a qualified facility 40% 44% Received anti-malarial medicines 16% 40% * Last two weeks prior to survey as a proxy to malaria#18Child health Quality of care at health facilities* 2011 2013 waited for 30 minutes or less 57% 53% given full explanation about illness 45% 62% received all prescribed medicine 63% 69% paid unofficial charges for treatment 66% 79% * For children taken to a govt. facility for treatment during last one year#19CSS: Implementation framework • Initiated as a pilot in Oct 2010 in Giade LGA, Bauchi • Involved training of health workers to visit 400-600 households Identify pregnant women; screen all women of child bearing age. The pregnant woman is visited every two months to identify her risk status • Based on her situation, a plan for managing the risk as identified is made. A male worker discusses with the husband of the pregnant woman for a plan to address the risk#20CSS: Implementation framework • Work divided into three distinct phases Phase 1: paper instruments, Bhopal books, 10 communities Phase 2: e-data gathering with NDG, Nokia handsets, universal coverage Phase 3: e-data gathering with ODK, android tablets, universal coverage#21Coverage so far..... 39,426 households registered • 22,745 pregnancies registered and followed • 3,264 new born registered and followed during the period Jun-Dec 2013...... • 7,176 home visits • 23,646 visits to pregnant women 13,379 visits to husbands#22Preliminary trends in maternal mortality Contrast among three phases Mat deaths Live births MMR Phase 1 12 1359 883 Phase 2 28 4488 624 Phase 3 29 5126 566#23Planning Concerns Improvements in maternal health indicators but... Quality of care still a concern More people paying unofficial charges at facilities Low indices on hygiene and child care practices Most importantly..... Polio coverage improves but routine goes down#24SMOH Action Implications review free treatment policy/quality of care. improve upon governance and system checks bring in community for local accountability SPHCDA advocates donors allocate more on routine immunisation use home visits as a means to reach non- adopters of PHC services#25BACATMA Action Implications implements awareness package on use of bed nets SOCIAL AUDIT TEAM helps SPHCDA & BACATMA to produce video clips on key messages uses third cycle focus groups to identity contents for knowledge translation#26Human Capital development Information can only become useful evidence if capacities are present to analyse, interpret and use the information • With NEHSI, there has been capacity building/training of a pool of human resources with specific set of skills to carry out different components of social audit These include those at policy level within MDAs, institutions & LGA Councils#27Human Capital development Continuous involvement of State/LGA stakeholders 18 state officials trained in basic data analysis 13 trainers/supervisors/128 workers trained in home visit methods 9 participants to the eight week course completed the draft publication - under review for submission#28Sustainability strategies Skill transfer • training and supervision • field data collection including electronic • basic analysis and interpretation - scorecards • come from state as well as LGAs • both from government as well as NGOs Domestication - CSS unit in SPHCDA Expansion - Beyond the Health Sector (Multi sectoral)#29Sustainability strategies Financial sustainability • Estimate minimum costs - SMOH • Line-up existing resources - SMOH/SPHCDA (human, space, vehicles) • Establish permanent budget lines - MOB&P#30Benefits of social audit Information has provided useful context to the MOB&EP to evaluate progress against key indicators not just in health but other sectors SMOH and its agencies as well as LGAs have leveraged on social audit evidence to develop their strategic plans The social audit evidence has also been used as a justification for budget allocations It also provided a basis to source for resources and support from donor agencies. Having access to the same evidence, the SPC has found it easy to evaluate justifications for proposed allocations from other MDAS#31● Benefits of social audit Though health sector driven, the evidences have been used beyond the Health related MDAs. It has provided useful guide for some other MDAs, for example: Drawing up plans for portable water accessibility (MWR); Addressing socio-cultural practices that are inimical to gender rights (MOWA); Making plans for Promotion and Protection of Child Rights (MOWA); Designing strategies for Mass mobilisation, Sensitisation and Public Enlightenment (MOI) etc.#32THANK YOU & GOD BLESS