Strengthening Health Systems in Kaduna State: Investing in the Health Workforce and Partnership for Eye Health by Taitos Matafeni with Sunday Isiyaku

ISSN 2044-7191

insightno.1 June 2009 Strengthening health systems in Kaduna State: Investing in the health workforce and partnership for eye health By Taitos Matafeni with Sunday Isiyaku

Thanks to the eye care programme supported it supported “medical and surgical treatment of by Sightsavers in Kaduna State, Nigeria, services ocular conditions”, as part of an onchocerciasis delivered by trained health workers can now be research programme. accessed by the majority of the population and KSECP has gone through three phases. Phase are affordable for even the poorest people. one (1991-1998) focused on building the capacity Spanning two decades and based on the World of Kaduna State Ministry of Health (KSMoH). Health Oranization (WHO) framework to improve Teams from the National Eye Centre Kaduna the performance of health systems, the Kaduna shadowed the KSMoH staff during this phase. State Eye Care Programme (KSECP) has seen a The second phase (1999-2003) saw KSMoH significant improvement in the delivery and quality taking on bigger implementation roles in eye of services. Human resources for health have care delivery in the state. been trained and deployed across the state, whilst Having put in place some basic capacities for essential medical products and technologies have service delivery, the third phase (2004 -2008) been provided. focused on LGAs and the integration of the Today, VISION 2020: the Right to Sight strategies programme into KSMoH decision making and are being implemented in more than 70% of the state’s local government Figure 1: 5 year examination and treatment areas. In a recent evaluation statistics (2004-2008) conducted by a team of external 200000 120% consultants, the team concluded that the time is now ripe for the 100% Kaduna State government to take full 150000 ownership of the programme. 80% This briefing paper summarises the key findings and recommendations 100000 60%

arising from this KSECP review. . of people

no 40% Background 50000 20% Kaduna State is one of 36 states in Nigeria and has an estimated 0 0% population of 6.07 million1 spread over 23 administrative or local government Target Examined Treated areas (LGAs). Sightsavers’ relationship No. of people 155000 128751 108679 with Kaduna State dates as far back as 1987, when, in partnership with WHO, Percent 100% 83% 70% 1National Bureau of Statistics, 2006 Census Available from http://www.nigerianstat.gov.ng/Connections/Pop2006.pdf www.sightsavers.org Registered charity numbers 207544 & SC038110 resource allocation systems and cycles. The team visited three primary health care KSECP has managed to increase access to centres. It held focus group discussions and services for the rural poor by establishing eye patient examinations in two locations. To assess care service centres, manned by an ophthalmic the quality of surgical outcomes, the team held nurse, in 80% of LGAs. This surpassed the 70% conversations with post-operative cataract target set in the project document. patients. Key informant interviews were used to triangulate the field findings as well as request Over 108,000 people received treatment (70% additional information where necessary. All of the target set for the period) and a total of geographic locations covered by the project 7,708 cataract surgeries were performed over were included in the sampling frame, with all but this period (77% of the target). Figure 1 above the focus group discussions being applied in presents the surgical statistics for phase three these localities. of KSECP. Key Findings Evaluation Objectives KSECP is the oldest Sightsavers intervention The KSECP evaluation was designed to draw in Nigeria. Designed to ensure integration of out key learning from the implementation of the the programme into MoH decision making and 2 third phase. Using “effectiveness ” as the main resource allocation systems and cycles, the last evaluation criterion, the following questions five year phase (2004-2008) drew on all six WHO guided the exercise: health systems building blocks. i. Is service delivery accessible, affordable, The evaluation team concluded that delivery acceptable, appropriate and available, with of services are significantly improved and high quality eye care services in at least 70% generally of good quality. Health workers have of the state by end 2008? been trained and deployed at various levels, and ii. Have human resources been developed to essential medical products and technologies ensure eye care teams are in place at each have been provided. level in at least 70% of LGAs? There has been strong advocacy with iii. Are there physical infrastructures in place, with stakeholders at all levels and this has led to at least 50% coverage of the state and 70% of more collaborative work and an increase in facilities appropriately equipped and supplied both the uptake of services and support for the at all levels (state, zone, LGA, and district)? programme. However, there is a need to improve iv. How efficient and effective are management linkages between tertiary, secondary and primary structures and systems at all levels? levels, the onchocerciasis control programme team and the zonal eye care team. v. Has advocacy resulted in linkages between primary, secondary and tertiary eye care Service Delivery levels, and between eye care, rehabilitation and onchocerciasis? The programme has surpassed its target for reach and treatment of blinding conditions in the state. At its inception, the programme set Methodology out to ensure that accessible, affordable and appropriate eye care services were in place in at A five person team, headed by a consultant least 70% of Kaduna state by the end of 2008. ophthalmologist, undertook this study with support from key KSECP personnel. In order to address the key evaluation questions, the team ‘I was not able to sell grains anymore employed a range of methods for data collection: but after the surgery I am now back in business. I am grateful to the staff of this v Focus group discussions programme’ v Conversations with recipients of services Yarima Ango, 60-year-old grain seller in Saminaka (post-operative patients)

v Field visits to programme partners These services are now available in 80% of LGAs and, over the phase, 83% of the projects target v Review of official records and project documents population were examined. Of those examined, 84% (108,679 people) were treated for various v Key informant interviews 2Effectiveness as an evaluation criteria looks at the extent to which the intervention objectives have been achieved (or how likely they are to be achieved). www.sightsavers.org purchased. Though technology has been deployed based on service needs, there is still no clear outline for equipment packages at each level of service. Financing As a result of advocacy following the programme mid term review, the Kaduna State government managed to meet their financial commitments to the programme in the last two years of the phase. Satisfactory accountability measures for these funds have been established in the programme. However, the Guinness Ophthalmic Unit, the School of Post-Basic Ophthalmic Nursing (both part of Ahmadu Bello University Teaching Hospital), and the National Eye Centre have not met their commitments. As federal institutions, they cited that they could not be expected to

Zul Mukhida/Sightsavers Zul budget funds for a state activity, though the technical support they provide is within their Hafsatu Shuaieu farming in Kajuru, Kaduna, following a mandate. cataract operation User fees for cataract surgery and optical blinding conditions. 77% of the targeted cataract services have produced over £53,000 surgeries were completed during this period. (N13million). There are instances where some poor citizens have been deprived of services as From interviews with post-operative patients, a result of these fees, but some LGAs (Birnin the majority were satisfied with their visual Gwari, Jaba and Lere) have allocated subsidies improvements and many had even resumed their for such cases. occupations. Despite these positive gains, the team noted Health workforce that, in all but one of the hospitals visited (Hajiya In 80% of LGAs, there is at least one eye care Gambo Sawaba hospital in Zaria), surgical service centre manned by an ophthalmic nurse. service provision was intermittent, thus affecting Most of the training targets for eye health productivity. There was also more attention by cadres were above 80% attainment rate, which programme staff to quantity of service provided, exceeded the target set for the period. almost to the exclusion of quality of service. However, the provision and management of Technologies and Infrastructure eye care services is being compromised by the duality of the role of ophthalmologists, who have There are positive signs from the Kaduna to perform additional duties as medical directors State government, who have met their or general services doctors. partnership commitment of renovating the health infrastructure. At the secondary level, Although over 1,200 primary health workers infrastructures were found to be adequate. (community health extension workers, community directed distributors, and teachers) Most base hospitals visited during the evaluation have been trained, their participation in the had adequate diagnostic and surgical equipment. programme is disappointing in many LGAs. This Inventory lists were clearly displayed on the walls low participation can be traced to inadequate in the majority of the centres, though they did not follow-up support and monitoring from the include the functionality of the equipment and secondary level as well as failure to refresh their had not been updated regularly. In all facilities at skills through appropriate training. Kaduna, Zaria and Kafanchan, the optical centres had been equipped for the provision of low cost Information spectacles. The generation and strategic use of information, There are still some issues with record keeping intelligence and research on health and health and data integrity, making it difficult to clearly systems is an integral part of the leadership identify gaps and recommend what is to be and governance function (WHO, 2007:18). In ophthalmologists’ role compromises the KSECP, eye diseases are not fully included in the provision and management of eye care national health management information system, services. even though ear, nose and throat diseases are c. Advocacy with state partners has been included. In cases where information is collected, effective in ensuring they meet their such as ophthalmic neonatorum, onchocerciasis contractual commitments. and trachoma, it is very sketchy and there is no electronic copy. d. Subsidies are still required for poorer citizens if service provision is to be equitable. Information, Education and Communication (IEC) materials are inadequate and the programme has not developed its own. Consequently, Recommendations outdated materials are being used, which do not 1. Leadership and governance needs to be cover issues identified in the recent Nigerian addressed through the appointment of a state national blindness survey. eye care coordinator. Leadership and Governance 2. Linkages between eye care teams and service levels needs to be revisited and strengthened At the state level, a project office and to ensure continuous service provision. management team has been established and is responsible for the day to day running 3. Serious attention needs to be paid to the of the programme. All partners have a clear information component of the health systems understanding of their roles and cooperate building blocks, in order for benefits made in effectively in the implementation of the the other blocks to be maintained. programme. 4. Community ownership of the programme is Despite the above achievements, effective still lacking and can be enhanced through oversight of strategic policy frameworks is supporting community participation and the compromised in the programme. Firstly, the inclusion of local government and primary appointment of a state programme coordinator, health care workers in programme planning. as recommended by the mid term review, has not been carried out. The post was meant to have responsibility for the eye health of Kaduna References State and provide, amongst other things, National Bureau of Statistics, 2006 Census. technical leadership and an effective link with the Available from http://www.nigerianstat.gov.ng/ MoH. Secondly, the Blindness Prevention/ Vision Connections/Pop2006.pdf 2020 Committee is still not in place in the state. World Health Organization, 2007. Everybody’s Last but not least, key personnel do not attend business: Strengthening Health Systems to the monthly state implementation committee improve Health Outcomes. WHO’s framework meetings. for action. WHO Document Production Services, Geneva, Switzerland Lessons Learnt a. Zoning of Kaduna State has allowed for Contacts effective state coverage, and was made For more information on this programme and possible due to the partnership between other Sightsavers activities in Nigeria, contact: Kaduna State government, federal tertiary institutions and Sightsavers, Sightsavers, 1 Golf Course Road, P.O. Box 503, Kaduna State, Nigeria. [email protected] b. The dual or triple nature of the

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