Understanding PHC Reviews and the Nigeria planning and implementation framework- Dr Eboreime Ejemai

7/28/2019 Understanding PHC Reviews and the Nigeria planning and implementation framework- Dr Eboreime Ejemai

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Rational

Primary Health Care delivery is acore contribution to NSHDPimplementation. Over 90% of inputs in the Health

services delivery and Humanresources for health SDAs ofNHSDP(Leadership & Governance,Health financing, NHIS, Communityparticipation & Ownership,Partnership for health, Research forhealth).

In order to improve participationand ownership by the servicedelivery points , the PHC reviewsshould focus on the operationalunit which is the LGAs.

NHSDP Costing Analysis, 2010


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Challenges of NHSDP operational planning

The 2011 State Operational Plans were not consistent with the level of ambition of theSSHDPs, costed activities were mainly based on lower level inputs and that budgetsare not consistent with the NHSDP allocation criteria. More funding still allocated forclinical services and capital costs.

The 2011 Operational Plans showed no prioritization to focus on Primary Health Careas the anchor of Service Delivery and Human Resources for health and there was nolink of the planning process and actual budget allocation.

There was no logical framework for reviewing the data inputs and linkages with theon-going work on developing the M&E Framework for results-based monitoring.

There are multiple systems for data collection and reporting that are unrelatedleading to duplication with no feedback to the Service Delivery Points (States andLGAs).

Despite several processes that have been put in place including 1) incorporating the

ATM indicators into HMIS and the 2) development of the Integration andDecentralisation Guidelines; Programs and Partners still collect and manage theirown M&E systems.

There is no current system to develop capacity for the LGAs to fully own andimplement PHC programs.

There was no systematic process for quantifying the bottlenecks and no outline forassigning roles and responsibilities in managing the identified corrective actions.


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Process of PHC Review

Harmonize indicators, collect and validate existing data fromdifferent sources (Progs + NHMIS) in order to inform PHCreviews.

Use PHCs reviews to identify, remove & follow up bottlenecksto improve service delivery.

Develop LGA PHC action plans to address bottlenecks throughcoordinated actions of all stakeholders.

Support development of LGA annual Operational plans thatderives from and contributes to the SSHDPs.

Provide feedback to inform State and Federal planning andreview.

D.I.V.A methodology for PHCUOR


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Framework

Improved Health Plan Results

Conduct PHC Reviews

Using DIVA methodology

Implement PHCUOR and Minimum Standards


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The 4 steps of DIVA

Identify disparities and analyze barriers to

access of services (Diagnose)

Prioritize and implement solutions to

overcome identified barriers (Intervene)

In real-time, monitor progress in reducing

barriers (Verify)

Adjust solutions and strategies during

implementation as needed (Adjust)


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What is D-I-V-A?

A systematic, flexible, outcome-based

approach to equitable programming and real-

time monitoring that strengthens the ward

health system, complementing and building

on what exists.


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Prioritization of interventions

Main causes of morbidity and mortalityidentified and linked to poverty.

Core package of intervention determined by

service delivery point. Clinical , Population based and

Community/Households.

Coverage of interventions varies by state andLGAs.

Need for context specificity in planning.


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Increasing No. of Interventions and Skilled Staff

9

Burden

of

Disease

Increasing Resources Required

MalariaVPDDiarrheaetc

MaternalNewbornChild Health

etc

HypertensionCanceretc

Canceretc


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Neonatal, 37%

Pneumonia, 19%

Diarrhea, 17%

Malaria, 8%

Measles, 4%

HIV/AIDs, 3%

Injuries, 3%

Other, 10%

Under-nutrition

(underlying cause)

Major Causes of U-5 Deaths in Nigeria

Up to 1 million

children die

before the age of

five.

50% underlying

cause is under

nutrition.

36% are neonatal

deaths (284,000).


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Equity & Impact : High Burden diseases in Q1 have known,

very effective, low cost interventions

40.726.9

50

11

56.3

22.1

6.6

1.6

36.7

13.9

4.9

1.6

21.6

8.8

0

50

100

150

200

250

Nigeria: Nigeria Q1 Nigeria: Nigeria Q5 (richest)

(Under Five Mortality Rate per 1000 Live Births)

Others

Injuries

AIDS

Pneumonia

Measles

Malaria

Diarrhea

Neonatal

Examples of using a Bottleneck Analysis


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8 Tracer Interventions for PHC ReviewsDefined National priority Tracer interventions

1. PMTCT and ARV prophylaxis

2. Immunization

3. Childhood Illnesses Malaria

4. Ante Natal Care

5. Skilled Birth Attendance & Community based NewBorn Care

6. Infant and Young Child Feeding

7. Vitamin A Supplementation

8. Community Management of Acute malnutritionIdentify the most deprived LGAs

Adapt to the existing health system and ongoing processes


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D-I-V-A approach:

scope and applicability

Health

WASH

Nutrition

HIV/

AIDSHealthSystem


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BOTTLENECK ANALYSIS

CONCEPT


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A health system bottleneck can be defined as

a constraint, problem, barrier that hinders

the health performance

A bottleneck is a loss of system efficiency


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Using a bottleneck analysis to

investigate low coverage

There are many interventions that are known tobe effective at reducing maternal and childmortality

Most of these interventions are already includedin Nigeria National HSDP

These interventions do not always reach thepeople that need them most, due to bottlenecks

within the health system Resolving problems causing bottlenecks requires

both evidence-based interventions AND evidence-based strategies at federal, State and LGA levels

16

I d i B l k A l i


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Tanahashi: a bottleneck constrains the flow of

resources through a health system, limiting the

output; i.e. coverage of an intervention

Multiple

interventions

Introduction to Bottleneck Analysis

I t d ti t B ttl k A l i


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Bottleneck analysis is a horizontal approach

18

Nutrition HIV EPI

Facility-Based services

Population oriented

outreach services

Community based services

(Family oriented )

FamilyPlanning TB SocialservicesWASH

Effective Quality coverage for specific target populations

I t d ti t B ttl k A l i


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Six coverage determinants, from supply to demand side,

analyze where health system bottlenecks exist.

A bottleneck is a loss of system efficiency

19Adapted from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2)

http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf

Availabilityessential health commodities

Adequate coveragecontinuity/completion

Initial utilizationfirst contact of

multi-contact services

Accessibilityphysical access of services

Effective coverage quality/impact

Target Population

Availabilityhuman resources




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We look for bottlenecks between

the determinants of coverage

Determinants are major health system functionsthat DETERMINE the level of coverage possiblefor an intervention.

Supply-side determinants:1. Availability of essential commodities.

2. Availability of human resources.

3. Geographical accessibility.

Demand-side determinants:4. Initial use: the first contact

5. Adequate and complete use

6. Effective, or Quality, Coverage that gets IMPACT

20




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The Tanahashi Model to assess system bottlenecks

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% District withLLITN's or nets +

insecticide in stock

% villages with HRproviding LLITNs

% villages selling ordistribution LLITN or

nets + insecticide

% householdshaving at least one

bed net

% pregnant womenusing MN last night

% pregnant womenusing ITMN

Nigeriaapplication2006

21

Adapted by T. OConnell from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2)

http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf

TargetPopula

tion

GAP




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0%

25%

50%

75%

100%

COMMODITIES: %

health facilities

with no Essential

Meds stock-out

HUMAN RES: %

PHC facilities with

sufficient

professionals

ACCESS: %

families living

near health

facility with

sufficient staff

UTILISATION: % 0-

59 mos

w/pneumonia

taken to trained

provider

CONTINUITY: % 0-

59 mos ARI/fever

cases Tx

w/antibiotics by

trained worker

EFFECTIVE COV: %

0-59 mos. ARI and

fever cases

treated by IMCI-

trained worker

Clinical management of U5 pneumonia

Coverage Determinants and Bottlenecks:

improving coverage of Quality treatment of ARI


22



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Commodities

A

vailabilityofthec

orrecthuman

resources

Points

ofaccess/distribution

Initia

luseofproducto

r

service

Con

tinuoususeof

pro

ductorservice

QUALITY0%

10%

20%

30%

40%

50%

60%

70%

Stock of

antibiotics in

district

# of fully

trained VHTs

vs. national

target

% villages with

complete VHT

Child with

ARI seen by

VHT

Child given

antibioticsChild

completes full

antibiotic

treatment < 24

hrs

1 Bottleneck is

too few access

points for CHWs

w/antibiotics

A 2nd major

bottleneck is

QUALITY: few

children finish

antibiotic course

Too much $$ (so

Moms save

antibiotics for nexttime); thus quality is

low

23



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Identify bottlenecks in the Tracer Interventions

0%

25%

50%

75%

100%

ITN in

district

HEWs Families

with Net

Using net Using

treated

net

36%

20% 16%

4% 1%

We do not

have enough

bednets!

And we do nothave enough

people to give

them out!

And few

people are

sleeping

under them!

And they are

not treated: we

are not getting

IMPACT!!!Example:

Removing

coverage

bottlenecks

to scale up

ITNs

Identify the main supply, demand, and quality bottlenecks




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0%

25%

50%

75%

100%

ITN in

district

HEWs Families

with Net

Using net Using

treated

net

36%

20% 16%

4%1%

80% 80%75%

72%65%

Trained and

deployed

HEWs in the

LGAs

Behavioralchange

communication

campaign

Policy decision:

long lasting ITN

20072005

Procured

>200,000 ITN

Corrective measures identified

Example:

Removing

coverage

bottlenecks

to scale up

ITNs




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83 %

33 % 33 % 25 %

6 %

0 %

10 %

20 %

30 %

40 %

50 %

60 %

70 %

80 %

90 %

100 %

Commodity Human Resources Geographical Access Utilization Continuity Quality

Example: PMTCT Bottleneck Analysis

Nigeria

Targ

etPopulation

GAP

26



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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Proportion of ANC

centers without

stock out of HIV test

kits over the last 3

months

Number of HF staff

trained for PMTCT

% of HFs that

provide ANC

services with HIV

counselling and

testing in PMTCT

% of pregnant

women who know

their HIV status

% of pregnant

women who

received ARVs to

reduce MTCT

% of infants born to

HIV+ women

receiving ARV

prophylaxy to

reduce MTCT

PMTCT (Ikeja, Lagos)

Bottleneck 2:

Pregnant W. not

attending ANC

Plausible Cause: Trained

staff concentrated in

model facilities

Corrective Action: Train

staff from other facilities

Plausible Cause: Lack of

awareness of available

services and benefits of ANC

Corrective Action: Increase

social mobilization/ social

marketing

Bottleneck 1: Only 4

out of 10 facilities

provide CT


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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of HFs without

stock out of SP in

the last 3 months

% of ANC

providers trained

on prevention of

Malaria in

Pregnancy

% of HFs

providing ANC

% of pregnant

women who

received IPT1

% of pregnant

women who

received IPT2

during the last

birth

% of pregnant

women who

received IPT2 in

3rd trimester

IPTp in Makurdi PHC, Benue State

Bottleneck 2: Apparent

dropout

Plausible Cause:Distance/financial barrier.

(+ Underreporting).

Corrective Action: Provision of

transportation OR stipend for

transportation

Bottleneck 2:

Insufficient trained

staff

Plausible Cause: No

recent training in 2011.

Small # trained due to $.

Corrective Action: Advocacywith State and partners to

release funds for training


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Analyze the bottlenecks and their

possible causes

Carried out by the existing Committees

State /LGAs with key stakeholders (including private sector,

civil society and community representatives) in collaboration

with regional/provincial health officers/supervisors

Includes these steps:

1. Analyze the root causes of identified bottlenecks

(Causality Analysis)2. Identify and prioritize context-specific and equityfocused solutions

3. Validate findings and recommended solutions through astakeholder consultation

A l t


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Analyze root causesa. Supply side causality analysis

Type of bottleneck Common bottlenecks Causes of common bottlenecks

Availability of

human resources

Lack of OR insufficient

availability

Lack of established positions

Ineffective recruitment Ineffective deployment

High vacancy rates and turn over

High absenteeism

Lack of OR Insufficient skills Lack of staff training opportunities

Lack of mentoring and supervision

Lack of OR Insufficient

motivation

Insufficient, inequitable, untimely salaries

Lack of performance-based incentives

Disruptive working environment

Lack of physical facilities and/or equipment

Geographic

accessibility

Lack of OR Insufficient health

facilities

Facilities are not functional

Lack of OR Insufficient outreach

sessions (not done, not of

sufficient scope and/or quality)

Ineffective planning

Infective implementation

Lack of OR Insufficient

community coverage (CHWs)

Community health workers are not carrying out designated

activities

Financial barriers (direct costs, indirect costs and insufficient

social protection mechanisms)


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Analyze root causes:b. Demand side causality analysis

Type of bottleneck Common bottlenecks Causes of common bottlenecks

Initial utilization

Financial barriers Family cannot afford to pay user fees or to travel long

distances to facilities

Socio-cultural barriers andgender dynamics

Mothers must obtain permission from others inhousehold prior to seeking care

Social norms are not supportive to specific

interventions

Belief that illness is caused

by factors that cannot be

addressed at health facility

(e.g witchcraft)

Limited information (for example on childhood illness

danger signs) available to families in deprived settings

Timely, continued

utilisation

Loss to follow-up/drop-outs Lack of active follow up systems

Negative experience with provider/facility


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Analyze root causes:b. Quality causality analysis

Type of

bottleneck

Common

bottlenecks

Causes of common bottlenecks

Initialutilization

Low quality

Timeliness

Completeness

Appropriateness

Regular standards: not developed,

not approved, and not used

Inadequate staffing and skills in

quality of care

Service organization: overload,

inadequate equipment and supply


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Identification of corrective

measures

Carried out by existing Committees

State /LGAs with key stakeholders (including private

sector, civil society and community representatives) in

collaboration with regional/provincial health

officers/supervisors

Includes these steps:1. Identify and prioritize context-specific and equityfocused solutions

2. Validate findings and recommended solutionsthrough a stakeholder consultation


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Summarize bottlenecks, solutions and strategies

INTERVENTION:. Quarter/Year:

Determinant

/ Indicator?

Baseline

as of:

_______

Main

Bneck?

(mark

X)

Plausible Causes

(indicate if further

investigation required)

Proposed Solutions Responsible

person &

partners

involved

Timeframe Target as

of:

_________


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Conclusion

The PHC Reviews will contribute to the successfulimplementation of the National Health Plan and theachievement of results in line with health-relatedMDGs.

Collective action and responsibilities are requiredfrom the Federal, State and LGAs levels for improvingthe delivery of services for children, women andother vulnerable populations.

Partners and Donors will require to fully buy-in andcontribute to the PHC Reviews.

Government leadership and ownership is cardinal.

Documents

Understanding PHC Reviews and the Nigeria planning and implementation framework- Dr Eboreime Ejemai