BACKGROUND AND HISTORY OF THE PHC/HEALTH PLANNING AND REVIEWS IN NIGERIA

1. BACKGROUND

The Federal Ministry of Health (FMOH) and the National Primary Health Care Development Agency (NPHCDA), with the support of development partners developed the National Strategic Health Development Plan (NSHDP) which was launched by President Goodluck Ebele Jonathan (GCON) on 16 December 2010.In line with the National Health Policy and the National Economic Empowerment and Development Strategy (NEEDS), Primary Health Care (PHC) service delivery is the Core of the NSHDP and Vision 20:2020. Most outcome and impact indicators of the Results Matrix of the NSHDP relate to PHC. Further, States were supported to develop State strategic Health Development Plan (SSHDP) for all States and Federal Capital Territory (FCT). The Minister of Health inaugurated four (4) Committees towards ensuring a comprehensive implementation of NSHDP. These and the corresponding lead agencies are Mobilization and Ownership Committee (FMOH-PRS); Monitoring and Evaluation Committee (FMOH-PRS); Implementation and Alignment Committee (NPHCDA-PRS); Health Financing Committee (NHIS). In furtherance of its role in the implementation of the NSHDP, the Implementation and Alignment Group (NPHCDA and Stakeholders) initiated the strategy of PHC/Health Plan Review for implementation in all States and LGAs throughout the country, as a strategy for ensuring a nationwide comprehensive implementation of NSHDP, the core of which is PHC. The following are the components of PHC/Health Review initiative, for implementation at LGAs/state levels;
a) b) c) d) e) Capacity-building. Operational Planning/Budgeting. Implementation & Progress Review. Monitoring & Evaluation; Data/Information Management Advocacy.

2. METHODOLOGY/APPROACH & RESULTS

2. 0 Implementation of this strategy involves supporting States to develop operational or annual (implementation) plans from State strategic Health Development Plan (SSHDP); supporting LGAs to develop PHC programme implementation plan based on SSHDP, review implementation progress every quarter, identify and analyse implementation challenges/bottlenecks using LGA/health facility data and develop Plans of Action (POA) for addressing the challenges/bottlenecks 2.1. Methodology/Approach A Concept Note was developed, circulated and finalized with inputs by various stakeholders. Implementation is being managed through a Workshop mode at zonal and State levels, while learning

components include lectures, plenary interactive discussion, group work exercises and group presentations. The strategy was implemented in 2 phases, namely Phase1 and Phase 2 (Revised PHC/Health Plan Review using Bottleneck analysis)

2.1.1 Phase 1. State level Workshop.

A 2-day Workshop was implemented with the purpose of supporting the states to develop annual plans from SSHDP, identify implementation challenges and develop corrective action plans. Participants included State Directors: PRS-SMOH, PHC (SMOH), PHC (SMOLG); Chairman SPHCB, State Epidemiologist, Programme Managers; LGAs PHC Coordinators; NPHCDA and Partners; and DPHC (MOH) of other states in the zone. The state fed into Zonal level Workshop.

2.1.2. Phase 1. Zonal level Workshop

A 4-day Workshop was implemented in each of the geopolitical zones. The purpose was to review and finalize the state annual plans as well as the plans of Action for addressing challenges/constraints. All states of each zone were involved. Participants included , management/senior officials of FMoH, NPHCDA (headquarters and zones), State Officials (DPRS-MOH, DPHC-MOH, DPHC-MoLG/State PHC Board/agencies), Selected Local Government health officials, (PHC Coordinator for 3 selected LGAs); NACA; NMCP; and development partners Health Partners (UNICEF, WHO, UNFPA, DFID-PATHS2, DFIDPRINN/MNCH, USAID, MSH, FHI and other health partners investing in health development in the States

2.1.3. Results (Phase 1)

At the end of the first phase, the following results were achieved; State annual Plans developed for 36 States and FCT; challenges identified and documented with regards to the implementation of the State health plans and PHC interventions; State plans of action (POA) for addressing identified bottlenecks/constraints developed; establishment of State PHC Board discussed and guidelines/policy document provided; a number of States (e.g. Kogi & Benue) supported LGAs to implement PHC/Health Plan review. 2.1.4 Challenges (Phase 1) These included funding; low level of awareness and ownership of SSHDPs in most States at, as at commencement of the initiative; apparent attractiveness of vertical programmes; Lack of funds at State/LGA level for planning and implementation at the State/LGA levels.

3. REVISED PHC/HEALTH PLAN REVIEW USING BOTTLENECK ANALYSIS

The PHC/Health Plan review strategy was reviewed, in a special mission conducted by government and development partners. The review aimed at refocusing on service delivery results at the LGA level through addressing bottlenecks and coverage determinants at the supply and demand-side, using LGA/health facility data with regards to agreed tracer interventions and corresponding indicators. Bottle-Neck Definition: A systemic (demand or supply) problem that is preventing target population from effective coverage. Coverage determinant: each of the critical conditions required for effective coverage (Enabling Environment, Supply of Services, Demand of Services, and Quality of services)

3.1 Special Mission Recommendations

These included the following; Collection and validation existing data from different sources (Programmes + NHMIS) in order to inform PHC reviews. Agree on key PHC tracer interventions Harmonization of indicators to assess PHC performance

Use of HF/LGA data to identify, & analyse bottleneck, plan & implement PHC service delivery programmes. Use PHCs reviews to identify, remove & follow up bottlenecks to improve service delivery. Develop LGA PHC action plans to address bottlenecks through coordinated actions of all stakeholders. Support development of LGA annual plans that derive from and contribute to the SSHDPs. Provide feedback to inform State and Federal planning and review strategies.

3.2 Objectives of PHC Review using Bottleneck Analysis Methodology. These were to; Address significant gaps (harmonization of indicators, coverage stagnation, inequity) Build the capacity of LGA Health Managers to identify, analyze, act and be accountable for equitable service delivery so as to strengthen decentralized health systems

monitor local data in real-time and implement timely correction Engage communities and stakeholders as key partners in improving the health of population (esp. children and women). Perform bottleneck and analysis to develop comprehensive situation analysis at LGA level (Diagnose) Define corrective strategies/action plans for bottleneck resolution at LGA level (Intervene) Assess and improve LGA bottleneck monitoring activities that focus on MNCH-related & other programmes (Verify). Strengthen assessment of current performance and progress and to lay the foundation for a new cycle (Adjust).

3.3 Expected Outcome of the Revised PHC/Health Plan Review. The Expected Outcome of the revised methodology, using bottleneck approach includes the following; Effective overage of PHC high impact interventions, particularly for underserved populations, improved. Effectiveness & efficiency in planning, implementation & monitoring improved. Alignment & integration into LGA & State Planning cycles achieved 7 local funds available. Effective progress tracking towards equity of access for the most underserved populations attained. Quality PHC service availability and utilization, based on Ward Minimum Health care package, improved.

3.4 Progress on Revised Methodology Significant progress has been achieved. Key areas include;
Harmonization, Verification and Validation of the tracer interventions (Benue and Lagos field assessment- Feb 2012) LGA profile Tool and the Bottleneck analysis Tool were developed (in a Workshop in EnuguMarch 2012)

National Training of Trainers (TOT) for resource persons on the Revised PHC review methodology using the Bottleneck analysis approach. Coverage determinants were developed and agreed by stakeholders. These are Commodities, Human Resources, Geographic access, Service Utilization, Continuity and Effective Coverage Key tracer interventions were identified and agreed, namely, Immunization, PMTCT, Integrated Management of Childhood illness, Antenatal Attendance, Skilled Birth Attendance, Infant & young child feeding, Vit A Supplementation and Community Management of Acute Malnutrition.

3.5 Results Achieved The following results were achieved, as a, as part of the nation-wide implementation; States 2012 annual plans developed for all states. LGAs Q1 2013 workplans developed for 420 LGAs. 297 Resource Persons trained in all states + FCT; 115 for North Central and South South zones; in Abuja 18-23 March 2012. 88 for South West and South East zones; in Enugu, 10-14 April 2012. 94 for North West and North East zones; in Minna 08-12 May 2012. 2,134 LGAs officers trained on the revised PHC review methodology. These include PHCC, M & E, Officers, Immunization Officers, HMIS officers from 420 LGAs. 3.6 LGA level key Activities Training of LGAs level implementation team (PHC Coordinators, M & E Officers, Local Immunization Officers; health programme officers, etc. LGAs level Training of Programme Officers, Ward Focal Persons & Officers in charge of HFs Development of LGA profiles. Quarterly PHC/Health Planning and review at LGA level using Health facility/programme data, using Bottleneck analysis and development of solutions action plans. 3-monthly implementation, monitoring and supervision; review and re-planning. Bi-annual PHC/Health Plan Review at State and Federal levels. Planning/Budgeting for following year.

4. National Council on Health and PHC/Health Planning and Review

The Hon. Minister of Health presented this initiative to the 55th National Council on Health with the purpose of briefing the Council on the above strategy and to seek the approval of the National

Council for Health for institutionalization of the methodology and concerted stakeholder support at all levels as a means of strengthening the capacities of LGAs to plan, implement and monitor the delivery of quality/equitable PHC services and resolving demand and supply-side bottlenecks for achievement of effective universal coverage. The council noted as follows;
4.1. That the PHC /health plan review using Bottleneck approach; a. Remains the 1st large-scale PHC initiative of FGN/NPHCDA & partners, by which the NSHDP is being systematically operationalised and implemented in States/LGAs throughout the country. b. Addresses Managerial, planning and technical capacities at the States and LGA levels for effective and equitable delivery of PHC services. c. Addresses both demand and supply side constraints or bottlenecks so as to proffers solutions. d. Increases State/LGA ownership & capacity e. Assures evidence-based planning; implementation; and Monitoring and Evaluation. 4. 2 That implementing the PHC /health plan review using Bottleneck approach in all LGAs every quarter will provide and enhance continuous improvements in the delivery of the Ward Minimum Health care package of interventions and programmes in all Wards of the Country. 4. 3 That Nation-wide institutionalization of the initiative/methodology would guarantee the much needed transformation of the Health sector; achievement of MDGs; and platform for post 2015 health initiatives.

4.4 The council thereby resolved as follows; a. Approved the implementation of Quarterly Primary Health Care/Health Plan Review as the main strategy for nationwide implementation National Health Plan and for service delivery improvements in the context of NSHDP, Transformation Agenda, MDGs and health Component of Vision 20:2020 b. Approved the quarterly PHC /health plan review using Bottleneck approach as a tool for assuring State/LGA ownership & capacity for quality and equitable health service delivery. c. Approved that all states, LGAs, development partners commit resources to the quarterly PHC /health plan review using Bottleneck approach as this enhances the delivery of PHC service delivery and systems strengthening interventions and programmes in an integrated manner, based on evidence.