L'vlemorandum July 21, 1983

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,," ~') ( ff DEP ..l.RT\lE:'H OF HEALTH & l-JU.\IAN SERVICES Public Health SerlJice Centers for Disease Control " \',," . -....~.., "" ,-' l'vlemorandum July 21, 1983

~lichael From E. Dalmat, Dr.P.H., Public Health Advisor, Program Evaluation Branch, Division of Reproductive Health (ORH), Center for Health Promotion and Education (CEPE)

Foreign Trip Report (AID/RSSA): Nigeria, June 4-19, 1983

Tu ltJ'illiam H. Foege, H.D. Director, Centers for Disease Control Through: Dennis D. Tolsma Acting Director, CHPE nO~

SUMMARY I. PLACES, DATES, AND PURPOSE OF TRAVEL II. PRINCIPAL CONTACTS III. PROGRAM DEVELOPHENT ACCOMPLISHHENTS A. Oyo State Community-Based Distribution Project B. Ogun State Family Planning Proposal C. Nigerian Army Family Planning Proposal D. Lagos CBD/cRS Project IV. CONTRIBUTIONS TO THE AID POPULATION ST~~TEGY A. Contraceptive Distribution System B. Projections of Commodity Requirements TABLES 1-12 FIGURES 1-2

SUMMARY

Technical assistance from the Division of Reproductive Health (DRR) was requested by the Pathfinder Fund and the AID representatives to Nigeria. Pathfinder asked for assistance (1) in reviewing the progress of the Dyo State community-based distribution (CBD) project that it suppor.ts and in formulating recommendations for the expansion of the project, and (2) in assisting Ogun State ~tlnistry of Health staff in developing the technical aspects of its proposal to incorporate family planning services into the operations of its primary health care clinics.

The AID representative asked for DRR input into the (1) design of a contraceptive distribution system to support existing and future family planning programs in Nigeria, and (2) projection of contraceptive requirements for Nigeria during the next 5 years.

Dr. Dalmat completed both tasks requested by the Pathfinder Fund. In addition, the CDC consultant identified the potential areas of technical assistance that DRR could offer to Pathfinder-supported programs in Nigeria: (1) developing commodity supply systems including requisitions, distribution, and inventory control; (2) designing and testing service statistics systeQs; (3) defining the roles, responsibilities, and techniques to be used by tech nical supervisors; and (4) analyzing and, when necessary, modifying staffing patterns, appoint:nent systems) the utilization of space and cornnodity storage facilities and procedures. \ Page 2 - W:llliam H. Focg e, ~-1. D.

DRH representatives will participate in a meeting with the AID representative from Nigeria, a representative of the Federal Ministry of Health of Nigeria, and representatives from several AID intermediary organizations from August 3-4, 1983, in Washington. During this meeting, the role that each organiza tion will play in support of new family planning programs in Nigeria will be clarified.

I. PLACES, DATES, AND PURPOSE Of TRAVEL

During the consultation (June 4-19, 1983), Dr. Dalmat assisted (1) the Pathfinder Fund in reviewing existing programs and developing new family planning project strategies with potential Nigerian grantees, and (2) AID in developing a strategy for the support of family planning population programs in Nigeri~. Assistance was provided in Lagos, Ibadan (Oyo State), and Abeokuta (Ogun State). This travel was in accordance with the Resource Support Services Agreement (RSSA) between CDC/CHPE/DRH and AID/S&T/POP/FPS.

II. PRINCIPAL CONTACTS u.s. Embassy 1. Mr. John Norris, Acting Deputy Ambassador 2. Hs. I(eys NacHanus, AID representative

The Pathfinder Fund 1. Dr. Dierdre Strachan, Chief, Fertility Services 2. Dr. Ayorinde (Ayo) Ajayi, Senior Program Officer, Africa

AID Consultants (American Public Health Association) 1. Dr. Elizabeth Connell, Department of Gynecola5Y and Obstetrics, Emory University School of Nedicine 2. Ms. Peggy Curlin, Center for Development and Population Activities (CEDPA) 3. Dr. Harald Pedersen, Private Consultant 4. Dr. Rocco Piotrow, Population Communications Services, Johns Hopkins University 5. Mr. Stephen Smith, Regional Program Coordinator, Population Communications Services, Johns Hopkins University 6. Dr. rmy Yacoob, African Studies and Research Center, Howard University

Federal ~linistry of Health Dr. A. B. Sulaiman, Director, National Health Planning and Research 2. Dr. O. A. Adelaja, Senior Consultant, Medical Statistics 1. Dr. J. A. Laole, Assistant Director, Health Education 4. Dr. P. Y. Odunsi, Senior Consultant, Epidemiology 5. Dr. A. O. Okunsanya, Senior Consultant, National Health Planning 6. Mrs. A. O. Payne, Deputy Chief Nursing Advisor

Oyo State 1. Dr. P. A. Ibeziako, Acting Head, Department of Obstetrics and Gynecology, University Hospital (UCH), Ibadan 2. Mrs. Grace Ebun Delano, Chief Coordinator, Fertility Research Unit/Clinical Training Program; Assistant Director, Community Based Distribution (CBD) Program, UCH, Ibadan Page 3 - William H. Foege, M.D.

3. Mrs. Alice Adekola, Project Administrator, CBD Program UCH, Ibadan 4. Hr. M. A. Adesiyun, Permanent Secretary, State Ministry of Health, Ibadan 5. Dr. Dejo Raimi, Chief Medical Officer, State Ministry of Health, Ibadan 6. Dr. Olapoju Taiwo, Secretary, State Health Council, Ibadan • 7. 11rs. o. o. Williams, Chief Nursing Sister, State Health Council, Coordinator, CBD Program, Ibadan 8. Mrs. E. F. O'Wwyer, CBD Program Officer, State Health Council "s. F. o. Fakunle, Chief Area Coordinator, Akinyele North, CBD Program .oniya 3. S. O. Areola, Nurse Hidwife-in-Charge, Ikereku Maternity, eBD Project Supervisor, Ikereku 11. Miss B. K. Oyelakin, Community Health Assistant, Ikereku ~~ternity, Assistant CnD Project Supervisor, Ikereku 12. Mrs. A. Oledere, Senior Ward l~id, Ikereku ~~ternity, Assistant CBD Supervisor, Ikereku 13. Mr. Timothy .Akinwale, Village Health Assistant, CBD Program, Ikereku

Ogun State 1. Mr. Odulano, Permanent Secretary, State ~tlnistry of Health, Abeokuta 2. Dr. S. A. Onadeko, Acting Secretary, Chief Medical Officer, State Health I'~nagement Board, Abeokuta 3. Hrs. V. E. Babalola, Chief, ~~trone for Hospitals, State Health ~~nagement Board, Abeokuta 4. Mrs. F. A. Olata, Chief Health Sister (Primary Health Care), State Health ~~nagement Board, Abeokuta 5. Hrs. I. V. Mako, Assistant Chief Health Sister, State Health Hanagement Board, Abeokuta 6. Dr. S. Ayodele Oni, Medical Officer of Health (Northern Zone), Abeokuta

Others 1. Professor Ransum-Kuti, Director, Institute of Child Health, University of Lagos, Lagos Dr. (Hrs.) Adepeju Olukoya, Institute of Child Health, Senior Consultant, Shomolu Comlnunity Health Project, Shomolu (Lagos) 3. Mrs. Babalola, Educationalist, Shomolu Clinic, Shomolu (Lagos) 4. Hrs. Gladys Olabisi, Family Health Assistant, Shomolu Community Health Project, Shomolu (Lagos) ~~jor General J. U. Ekong, Medical Director, Nigerian Army, Bonny Camp, Lagos 6. Colonel S. A. Majekodunmi, Chief of Medical Planning, Nigerian Army, Bonny Camp, Lagos 7. Colonel Simkaiyc, Batallion Hedical Director, Enduyo

III. PROGRAJ1 DEVELOp~mNT ACCOMPLISH}lliNTS

A. Oyo State Community-Based Distribution (CBD) Project In 1979, Columbia University began p~oviding financial and technical assist ance to the University College Hospital (UCH), Department of Obstetrics and Page 4 - HilHam H. Foege, H.D.

Gynecology, for the purposes of: (1) establishing a demonstration CBD program that would offer family planning, basic antenatal and childbirth services, as well as treatment or referral of common morbidity; and (2) conducting opera tions research to test alternative approaches to delivering these s~rvices.

(1) Catchment Area: During the demonstration phase of the project, service delivery has been established in one zone, Akinyele. In this zone, 164 village service pro viders (61 percent are female and are trained traditional birth attendants TBA's)), and 39 percent are male and are voluntary health workers (VHVl's) provide services to a catchment area population of 85,000 (see Table 1). Overall, village workers serve communities with 518 inhabitants.

(2) Supervision: Supervision is provided by three tiers of health workers:

Site of Supervisory Supervisors Personnel No. Cadre

UCH, Ibadan 2-4 Senior Nurse-~tldwives

Akinyele Zonal 1 Ex:erienced Registered Headquarters, Moniya Midwife

Each Area with the 1 Nurse-Midwife and/or Zone (from ~~ternity 1 Community Health or Health Center) Assistant (CRA) and/or 1 '..lard Maiden

Reportedly, each village service provider is supervised in the village once every 4-6 weeks. During these visits, the supervisor (nurse-midwife, ca~, or wardmaid) visits three-to seven families with the TBA or Vill~. Further, the supervisor (1) inspects TBA/VHW kits, (2) assists in solving problems that arise, (3) inspects the TBA's/Vln~'s home to make sure that it can serve as a community model, and (4) reviews the TBA's/VHW's supplies and tally shp.ets (record of services provided a~d referrals made).

In addition to being supervised in the village, all TBA's and vm~'s attend two meetings each month. During the first meeting with the area supervisor(s), the TBA's/~fH's (1) receive new supplies (contraceptives, dr~gs, recordkeeping forms), (2) discuss problems related to their I.,ork, including the use of the tally sheets, and (3) review hOloT a.nd when to administer drugs and I"hen and where to refer complicated patients. The zonal supervisor, Mrs. Fakunle, and UCH supervisors attend the second monthly meeting. T!-ese meetings are used (1) to identify and help solve problems encountered by TBA's/VHW's in their work and (2) to provide continuing education to the TBA's/VH\~'s.

L'lI Page 5 - William H. Foege, M.D.

(3) Services Provided: The services provided by TBA's/Vln~'s fall into four categories: treatment of common illnesses, antenatal care, childbirth, and family planning services (refer to Table 2). From January-~~y 1983, 70 percent of all clients I~ere treated for common illnesses, 5 percent received antenatal care, 1 perGent childbirth-related assistance, and 24 percent family planning services. (For mora details about each type of service provided, see Tables 3-5.) For ,?overy person receiving a reproductive health service (antenatal, childbirth, family planning), 2.3 were treated for an illness. Of those treated, 50 percent were adults, 28 percent were school-aged children, and 22 percent were children under 5 years of age (see Table 3).

Unfortunately, reporting of service statistics does not permit one to assess the proportion of adults treated who are women, or more specifically, women of reproductive age. Nonetheless, making the conservative assumption that half of the adults treated are women in their childbearing years, we can estimate the fo11o\-1ing:

Women Children (January-;'~y 1983) 15-45 0-4 Total

Treatment 629 547 1,176 Antenatal care 169 N/A 169 Childbirth 50 N/A 50 Family planning 872 N/A 872 1,720 547 2,267

If these figures are ac~urate, 2,26, of 3,595 services offered per month (63 percent) \~ere provided to IJomen of r~p:coductive age and children under 5.

On the average, each CRD \~orker. provicies famIly planning services to 5.3 clIents per month (see Table 6). Overall, the TBA/VHW assists 22 people each month.

(4) Contraceptive Prevalence: Assuming that 21 percent of the catchment area population (see Table 1) con sists of women of reproductive age, \~e can estimate that there are 17,850 women who are potential users of family planning services. Based on the Page 6 - William q. Foege, M.D. service statistics provided in Table 5, a projection of the number of active family planning users that will be served by the CBD program by December 31, 1983 , has been made in Table 7: 2,480 users. If these optlmistic projections hold true, a level of 16 percent contraceptive prevalence could be achieved by year-end. This estimate does not take into consideration contraceptive users from alternative sources of services I~hich can be estimated at 1-2 percent prevalence.

Caution shuuld be used in relying on these projections. Based on a review of monthly tally sheets filled out by TBA's/VHlv's, I suspect that there is con fusion in the '~ay "new cases" and "old cases" are recorded. This could strongly influence the ass~~ed ~ate of growth in new acceptors as well as the program continuation rates.

(5) Cost-Effectiveness: ~~o measures of cost-effectiveness have been calculated: (1) cost per client contact and (2) cost per active family planning user-year. Neither takes into consideration the quality or effectiveness of the service provided. Both calculations exclude all costs associated with research.

(a) Cost Per Client Contact 3,928* Average number of client contacts provided per month (all CBO (~orker s) x12 Months per year 47,136 Total client contacts per year

$ 87,550** Total program cost

$1.86 Cost per client contact

(b) Cost Per Active Family Planning User-Year 2,480 Projected number of active users by year-end

$ 87,550 Total program cost

$35.30 Cost active family planning user-year

(6) Self-Help Projects: Given the alternatives of investing the monthly incentives (Naira 10 per CBO worker) collectively to start self-help projects or keeping the money individ ually, the TBA's/VHW's elected to implement self-help projects. Ei6ht projects have been started, one in each CBD area within the Akinyele Zone:

*Includes home vi~its. **Reported by Gene Weiss, Project Monitor, Columbia University. Page 7 - William H. Foege, M.D.

Number Type of Area CBD l~orkers Project

Ikereku 31 Farming Ijaiye 30 Piggery/Farming Alade 18 Poultry/Farming Moniya 16 Poultry/Farming Aroro 20 Poultry/Farming Mele 19 Poultry/Farming Iroko 16 Poultry/Farming Akinyele 14 Poultry/Farming

Formal proposals were developed for each area and have resulted in an agree ment with the Project Authority (UCH). The CBD workers work at the project site on a rotating basis. The present treasurer and/or secretary records the quantity of goods taken to market by each worker and how much money each is to turn over after the sale for deposit in a bank account. Reportedly, the amounts of money being deposited have been increasing, particularly after control of the finances was left entirely to the CBD workers of each area. Savings are to be used for reinvestment in the projects. By way of editorial, Dr. Dalmat was very impressed with the project that ne visited in Ikereku.

(7) Commodities and Eq~ipment: (a) Along with a few medicines, Noriday 1+50, NeoSampoon, and condoms are scpplied by UGH to the zonal headquarters at Moniya, to each area supervisor, and finally, to the CBO workers.

(b) No stockouts were reported at the area or zonal headquarters within the last 5 months.

(c) The area supervisors, working in the maternities that serve as area headquarters, themselves provide contraceptives directly to clients of the maternity but do not record these cases along with the rest of the CBD service statistics.

(d) Commodities are requisitioned by CBD workers as part of a consolidated request from the area supervisor to the zonal headquarters. Area requests are then consolidated into a zonal requisition. This approach, a str.ictly "pull" system, is cumbersome. A combination "push-pull" system that maintains a 50 percent reserve throughout the "pipeline" should be considered (refer, to Figure 1).

(e) IUCD insertion kits are needed at the maternities, including the zonal headquarters. Presently, village referrals for IUCD's are sent on from the area supervisors to UCH, whereas the supervisors (nurses, nurse-midwives, CHArs) have been trained and are capable of inserting IUCD's themselves.

(f) Oralyte packets to be supplied from UNICEF are to be used for oral rehydration in the CBD program. The project staff has experienced a long delay in receiving the first shipment of Oralyte. Page 8 - William H. Foege, ~.D.

(8) Expansion 0f CBD Program: UCH CBD staff members are providing assistance to the State Health Council in expanding the CBD program to new zones. Coordinators for five new zones have been named in addition to the ongoing, demonstration zone, Akinyele (North).

Coordinator Zone

Mrs. F. O. Fakunle Akinyele North Mrs. A. A. Fadakunsi Ibadan/Ibarapa Mrs. F. B. Jaiyeoba Oyo Hrs. O. O. O~olodimilehin Osun Mrs. I. B. A. Ladipo Ijesha Nrs. J. A.. Amoo Ije

Implementation of the CBD program is at different stages in each of the zones. For example, in Osun Zone a presurvey has been conducted. Also, the training of supervisors is in process. The zonal supervisor in Dyo Zone is completing the selection of the TBA's/VHW's to be trained as CBD workers. Dr. Dalmat was not informed about the status of the other expansion zones.

There are a number of questions raised as a result of Dr. Dalmat's brief obser vat:on of the Akinyele North CBD program that might profitably be addressed before proceding too much further with the expansion of CBD to new zones:

(1) Selection of Areas Hithin Each Zone (a) IVhat are the criteria for selecting an area within a zone? Is proximity to the zonal headquarters a consideration?

(b) Are there villages between selected areas that are not served by the program? These decisions influence the costs of supervision profoundly: feasible ratio of supe~visors to CBD workers, transport, frequency of supervisory visits, etc.

(2) Supervision (a) Can the number of supervisors that are in contact with TBA's/CHW's and the number of contacts between supervisor and village worker be reduced without alterin'. the quality and quantity of TBA/VHW work?

(b) Could first-line supervisors be trained to provide on-the-job training to TBA's/VHW's in a way that would reduce the need for large group meetings with senior staff without compromising the learning motiva tion, and development of CBD workers?

(c) Can one full-time supervisor be used to supervise all TBA's/VHW's in an area better than two to three part-time supervisors? What are the implications for cost, new acceptor and program continuation rates, and quality of service?

(d) How can the costs associated with supervision and transportation be reduced without jeopardizing the program?

(e) If necessary, can the self-help projects be used to reduce the cost of supervision to the funding agencies? Page 9 - William H. Foege, M.D.

(3) Tally Sheets and Recordkeeping (a) Are TBA's7vffi~'s accurately recording new versus old cases? If not, can these sheets be modified to improve recording?

(b) Is there a simple way of monitoring program continuation Irlthout overburdening TBA's/VHW's?

(4) Supply System Can a "push" system (standard order list and schedule) be adapted to (1) simplify the current resupply system, (2) guarantee a reserve of 50 percent at all levels of the supply system, and (3) reduce the cost and time involved in distributing supplies?

(5) Oral Rehydration Therapy What are the risks and benefits of using oral rehydration solutions mixed by mothers in their homes versus prepackaged Oralyte?

B. Oyo State FamHy Planning Proposal Ogun State operates 19 basic health service clinics in its 4 zones:

Family Primary Comprehen Health Health sive Health Zone Center1 Center2 Center3 Total Northern 1 4 5 Western 1 2 1 4 Eastern 2 3 2 7 Central 1 1 1 3 TOTAL "5 10 "4 IT

IFamily health centers offer MCH, antenatal, post-partum, and childbirth care and have four-six beds. 2primary health centers offer the same services and have 14-20 beds. 3Comprehensive health centers provide the same services and have 25-30 beds.

Currently, family planning services are not provided in these State-run clinics or the 200 local Government-run clinics. The Ogun State Health Management Board has submitted a proposal to Pathfinder to obtain support for family planning training, equipment, and supplies in order to integrate family planning into the 19 State-run clinics. This assistance is tentatively scheduled to begin this fall.

To date, Mrs. Grace Delano and her staff (UCH Ibadan) have trained 86 Ogun State staff members to provide family planning services, including the insertion of IUCD's:

9 Public Health Nurses 19 Comunity Health Assistants 19 Community Health Hidwives 39 Community Aids 86 TOTAL Page 10 - William H. Foege, M.D.

A summary that matches up the category of health worker by category with each State-run clinic is available from the Pathfinder Fund Nairobi Office.

This fall, a subset of those already trained will begin providing family plan ning services in their clinics. As the caseload of family planning clients builds up, training of untrained colleagues in the 19 clinics "ill begin. An adequate caseload is necessary as staff will be trained by observing presenta tions and demonstrations, practicing their new skills, and being closely supervised. Individuals from each zone will receive further training in the supervision of family planni.ng services. Others will be selected and further trained as family planning trainees.

Generally speaking, the clinics that Dr. Dalmat visited are large, well staffed, and underutilized (see Tables 8-10). Adding family planning should pose little strain on existing clinic staff members.

It is likely that the Pathfinder Fund will calIon CDC to provide technical assistance in:

1. developing and testing a State supply system for fmuily planning commodities; 2. designing and testing client records and service statistics forms and report formats; 3. establishing an approach to monitoring and evaluating clinic performance and progress; and 4. training Ogun State employees on-the-job in order to develop and operate the systems outlined in points 1-3 above.

C. Nigerian Army Family Planning Proposal The Nigerian Army is anxious to begin providing family planning services from all of its medical facilities in each of the four national divisions plus Lagos*. To this end, the Army has submitted a proposal to the Pathfinder Fund. In this proposal the Army has asked for training of service providers, family planning commodities, equipment, and technical assistance.

Five senior Army nurses have already been trained by UCH, Ibadan. A core of trainers will be trained at UCH. They will go back to their facilities and begin providing family planning services. Once their caseloads are high enough, the trainers will be assisted in training the providers of family planning services in all 62-67 facilities.

A crude estimate of the population of women of reproductive age suggests that there are approximately 80,000 people in the group targeted to receive family planning services. Senior Army staff members have discussed setting a goal of

*7 military hospitals, 20 thirty-bed medical reception stations (M1~S), and 35-40 medical posts (outpatient services only). Page 11 - William H. Foege, M.D.

12.5 percent contraceptive prevalence at the eri of the full year of providing services and 25 percent at the end of the secoud year. If the proposal is accepted, Pathfinder will probably call on CDC to provide technical assistance in:

1. developing and testing a recorillteeping system; 2. establishing efficient staffing patterns; 3. implementing a reliable system for supplying contraceptives to distri bution points; and 4. designing and testing a system for monitorinc progress toward achiev ing family planning goals to be set by the Army.

IV. CONTRIBUTIONS TO AID POPULATION STRATEGY

Dr. llara1d Pedersen was primarily responsible for developing:

1. guidelines for the procurement and distribution of contraceptives, and 2. estimates of contraceptive requirements.

Dr. Da1mat reviewed Dr. Pedersen's proposals and provided input. A copy of these proposals is available from the AID representative in Nigeria.

A. Highlights of Procurement and Distribution Proposal

1. The Nigerian Federal Ministry of Health, under the Health Planning Board, should procure and distribute contraceptives to regional warehouses (see Figure 2).

2. Each State l1inistry of Health, through its Health Hanagement Boards, should be responsible for picking up the contraceptives at the appropriate regional warehouse and for distributing them to the service delivery points within the State (see Figure 2).

3. Uniform client record, service statistics, inventory control, and requisi tion systems should be used by all States and the Federal UOH to enable management to monitor overall utilization levels, changes in contracep tive preferences, changes in characteristics of users, and changes in acceptance rates. In this way, reasonably accurate projections can be made in Nigeria once a "track record" has been established.

4. A centralized procurement and distribution system should serve all new State programs as well as existing and future local projects. This will hopefully reduce the overhead costs of supplying contraceptives and reduce overstocking in some sites and stockouts or u~dersupply in others.

5. An intermediary organization will be responsible for deve10pins the logis tic management system and for supplying the Federal MOH. Page 12 - William R. Foege, M.D.

6. The intermediary organization should consider establishing a distribution system that operates independently of the existing Federal MaR medical stores system.

7. !~hile five regional or zonal warehouses may eventually be established to serve the entire country, initially one "test zone" warehouse should be put into operation first to serve existing and new programs while debugging the distribution system.

8. To expedite matters initially, the intermediary should consider renting '.Y'arehouse space and employing local warehousing staff for the "test zone."

B. Estimates of Contraceptive Requirements In estimating initial contraceptive requirements, Dr. Pedersen (1) assumed that contraceptive prevalence will increase from the current level of approximately 2 percent to 10 percent, and (2) proposed that the "pipeline" throughout Nigeria needs to be filled. Based on these assertions, Dr. Pedersen estimated the requirements for a population of 1 million women and subsequently the 16 million Nigerian women 15-44 years old (see Table 12) given the following ~ix of methods:

Percent* Oral contraceptives 35 Depo-Provera 10 ruCD's 35 Condoms 15 NeoSampoon 5 TOTAL 100

*These proportion~ were arrived at in consultation with MaR personnel in Ogun, Oyo, Niger, Ondo, Lagos, and Plateau States.

After detailed discussions with State HOR personnel in Ogun State, Dr. Dalmat estimated contraceptive requirements based on the expected rate at which family planning services can be introduced to primary health care facilities during the next 5 years. These projections and similar projections for the Nigerian Army are presented in Table 13. Using this approach, Dr. Dalmat estimates that in Ogun State, the State-run program will have built up to providing family planning services to 6-8 percent of the State's women of reproductive age within 5 years. ~~ ' .. _...... () .', /' 'J . J t>·.. ·t 7/ I, Y oIt..... l..t~~-<.r J-/-'). ,....(.:._._... "-. ..v \ Michael E. Dalmat, Dr.P.R. ~, TABLE 1

Service Providers and Catchment Populations by Health Center Area, Akinyele Zone, Oyo State CBD Demonstration Project

Catchment Catchment Service Population per Health Center Area Population Providers Service Provider

Alade 9,600 18 533 Moniya 15,400 16 963 Ikereku 12,700 31 410 Ijaiye 15,800 30 527 Aroro 10,500 20 525 Mele 9,000 19 474 Iroko/Akinyele 12,000 30 400

TOTAL 85,000 164 518

,1 11/ • \ I' TABLE 2

Reproductive and Other Health Services Provided by CBn \o1orkers January-May 1983

Honth1y A.v. Jan. Feb. March April i1ay No. %

Treatment of commo.' illnesses 2204 2618 2474 2667 2560 2504 70 Antenatal care 155 158 149 203 183 169 5 Childbirth 48 39 39 58 62 50 1 Family planning 666 819 617 1149 1103 872 24 TOTAL 3073 3634 3279 3472 3908 3585 100

Ratio of Treatment to Reproductive Health Services

Treatment of common illnesses 2204 2618 2474 2667 2560 2504 Reproductive Health Services* 869 1016 805 1410 1348 1091 Ratio 2.5 2.6 3.1 1.9 1.9 2.3

*Reproductive Health Services = Antenatal Care + Childbirth + Family Planning.

. \ \ \ TABLE 3

Morbidity-Related Services Provided by Akinyele Zone CBD Horkers (Treatment, Referral, Home Visits) January-May 1983

I. Category of Honthly Av. Treatment Jan. Feb. Harch April L1ay No. %

Malaria 992 1035 1019 936 1006 998 40 Cough 321 506 481 517 482 461 19 Diarrhea 260 262 265 245 257 258 10 l~o .. ms 241 274 239 354 343 290 12 Dressing 197 195 198 282 209 216 9 Anemia 157 238 217 176 177 193 8 Other 46 105 59 102 44 71 3 TOTAL 100

II. Recipients of Treatments

Adults 1116 1299 1224 1380 1271 1258 50 School Child 622 726 6/+0 764 744 699 28 Under 5 466 593 610 523 545 547 22

III. Total Treatments 2204 2618 2474 2667 2560 2504 100

IV. Referrals 9 6 6 1 4 V. Home Visits 324 358 294 303 368 329

VI. Total Contacts 2537 2976 2774 2976 2929 2837 TABLE 4

Antenatal and Childbirth Services Provided by Akinyele Zone CBD Ivorkers January-Hay 1983

Monthly Av. Antenatal Jan. Feb. March April Hay No. %

New cases 125 131 122 128 141 129 76 Old cases 26 26 23 59 41 35 21 New referral maternity 4 1 4 16 1 5 3

TOTAL G·\SES 155 158 149 203 183 169 100

Childbirth

Delivery I; 7 36 37 43 60 45 90 Referral 6 2 2 4 Post-natal visit 1 3 2 9 3 6

TOTAL 48 39 39 58 62 50 100

\! "\ \ TABLE 5

Family Planning Users Served According to CBD Tally Sheet Monthly Reports, January-Hay 1983

Honthly Av. Users by Method Jan. Feb. Narch April ~1ay No. %

Pill 211 257 251 346 378 289 33 Condom 287 372 230 544 460 379 43 Foam 148 159 136 233 242 184 21 Referral for IUCD 1 27 26 15 14 2 Referral for Infertility 19 4 8 6 1

TOTAL 666 819 617 1,149 1,103 872 100

% Distribution

New Cases 92 81 83 80 75 81 Old Cases 8 19 17 20 25 19

{\ TABLE 6

Average Number of Services Provided Per Month by CBD Workers January-May 1983

Total Nwnber Average Monthly of CBD Per CBD Average* lolorkers lolorker/Ho.

Treatment of common illnesses 2,504 164 15.3 Antenatal care 169 164 1.0 Childbirth 50 103** 0.5 Family planning 872 164 5.3

TOTAL 3,595 164 22.1

*Taken from Table 2. **TBA's only.

\Lb TABLE 7

Projection of Active Family Planning Users Served by CBD Program by December 31, 1983

Active Users by 12/31/83 Monthly ~ew Cases/ From New From Old Average Month (81%) Cases Cases Total

Pill 289 234 5622 222 584 Condom 379 307 737 2 43 2 780 Foam 184 74 4442 142 458 rUCD Referral 14 11 3 66 5924 6584

TOTAL 2,480

1Based on providing three cycles during resupply visits. 2Assuming 40 percent program continuaton rate. 3Assuming 75 percent of referrals actually go for the referral, are seen, and accept an rUCD. 4Assumeing same level of referral since start of project with a 90 percent rate pf rUCD retention. TABLE 8

Three Ogun State Clinics: Staffing, June 1983

Clinic Abeokuta Iberekodo 1£0 Category FHC PHC PHC

Physician 2 2 3 Nurses 101 24 282 Community health assts. 21 5 3 Community aides 21 2 4

TOTAL 16 33 38

1Numbers must be confirmed. 2Twelve are student nurses, 6-week shift. TABLE 9

Three Ogun State Clinics: May 1983 Service Statistics

Clinic Abeokuta Iberekodo 1£0 Services Provided FHC PHC PRC

Antenatal 385 39 594 Child ~o1e1fare 194 56 1,210 Births 41 * 57 Home Visits 3 30 * Postnatal 10 * 30 Norbidity 1,192 Infant 1,300 4,565 Adults 440 5,018 Immunizations 1,700 1,560 400

*Information was not provided. TABLE 10

Ogun State: Estimate of Daily Workload per Staff Member, May 1983

Clinic Abeokuta Iberekodo Ifo MCR Services FRC PRC PRC

No. of nursing staff 10 24 28 No. MCR services provided 2,333 1,655 2,291 No. MCR services provided per month per nursing staff member 233 69 82 No. MOR services provided per nursing staff member day (22 workdays) 11 3 4

Morbidity

No. physicians + 25% of nurses 2+3=5 2+6==8 3+7=10 No. of cases 1,740 1,192 9,583 No. of cases per staff member month 348 149 958 No. cases per staff member day 16 7 44 TABLE 11

Examples of Service Delivery-Based Calculations of Commodity Requirements

1984 1985 Pill IUCD Condom Foam (Cycles) (Units) (Pieces) (Tablets) Pill IUCD Condom Foam OGUN STATE Phases 2-3: Service delivery, 19 State clinics and train ing of additional workers 41,000 5,500 569,100 47,400

Phase 4: Extend services to 38 local Government clinics 132,700 8,200 1,904,300 158,700

Phase 5: Clinic outreach -2 field workers @ of 19 clinics

-2 field workers @ of 57 clinics

NIGERIAN ARMY Phases 1-3: Train trainers of clinic providers, provide services (hospital t-IRS' s) 24,100 3,200 342,100 31,100

Phase 4 Training of medical post personnel; extend services to medical posts and all MRS's 65,700 3,700 1,392,800 88,700

~ Continue providing ...... --~ services TABLE 11

Examples of Service Delivery-Based Calculations of Commodity Requirements (Continued)

1986 1987 Pill rUCD Condom Foam (Cycles) (Units) (Pieces) (Tablets) Pill IUCD Condom Foam OGUN STATE Phases 2-3: Service delivery, 19 State clinics and train ing of additional workers

Phase 4: Extend services to 38 local Government clinics 222,300 5,000 3,338,000 278,200

Phase 5: Clinic outreach -2 field workers @ of 19 clinics 292,500 4,600 4,651,200 387,600

-2 field workers @ of 57 clinics

NIGERIAN ARMY Phases 1-3: Train trainers of clinic providers, provide services (hospital }IRS's)

Phase 4 Training of medical post personnel; extend services to medical --.. posts and all MRS's ~ /'".-- Continue providing services 83,200 1,000 1,267,200 115,200 83,200 1,000 1,267,200 115,200

TABLE 12

Estimated Supply Requirements for a Population Uith 1 ~ 11ion Uomen (Ages 15-44), Assuming Coverage for 10 Percent for 1 Year as a Start-up Supply Level

Quantity Required Distribution Quantity Required for all of Nigeria, of Users for 1,000,000 WRA 16,000,000 WRA Contraceptive % Number (10% Prevalence) (10% Prevalence)

Orals 35 35,000 455,000* 7,280,000* Depo-Provera 10 10,000 40,000 640,000 rUCD's 35 35,000 35,000· 560,000 Condoms 15 15,000 1,500,000 24,000,000 NeoSampoon 5 5,000 500,000 8,000,000

TOTAL 100 100,000

*Recommended ratio of 40% = 1 + 50 60% = .50-35

Assuming that the low-dose pill is the initial method issued to new users.

, II ...f". ~l FIGURE 1

Push-Pull CBD Resupply System Dyo State

UCH Store

Standard Order Adjust Standard Order to sent to each maintain 50% reserve Zonal Headqua rters " Zonal Headquarters Store

Standard Orde r Adjust Standard Order to sent to each maintain 50% reserve Maternity Cen ter ,~

Maternity Center Store ~ Resupply ",hi!e Adjust individual TBA/VHW attending mon thly 4 supplies to meet (expanding) meeting at Ce nter Idemand and maintain 50% reserve

Midwives TBA's/VHW's Working in Maternity Center

l' FIGURE 2

COMMODITY SUPPLY SYSTEM (DISCUSSION DRAFT)

REG IONJIL STORE HOUSES ZONE 1 ENTRAL STO r---- -, r- -, (TEST ZONE) r- --, r- --, I ZONE 2 I I ZONE 3 I I ZONE 4 I I ZONE 5 I : STORE : I STORE I : STORE STORE : .. .I IL JI I , • I 1. ..1 L .I

.....---.".... -~' ...... ---" PHASE 2 PHASE-_ 2

S1,ATE AREA 2 AREA 3 AREA 4 H~~QUARTERS CLINIC STORE STORE STORE

S~ATE OR LOCAL CLINICS

OUTREACH WORKERS

URBAN/RURAL COMMUNITY WORKERS