Lessons Learned and Impacts of the CPH Experience in Nigeria
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Lessons Learned and Impacts of the CPH Experience in Nigeria by William R. Brieger African Regional Health Education Centre Department of Health Promotion and Education College of Medicine, University of Ibadan Ibadan, Nigeria <[email protected]> and Peter Bolade Ogunlade Department of Sociology University of Lagos Yaba/Bariga, Lagos, Nigeria for the Basic Support for Institutionalizing Child Survival (BASICS) Project U.S. Agency for International Development Draft, December 2001 ACKNOWLEDGMENTS The help of Samuel Akinyemi Orisasona in the Lagos office of BASICS was invaluable for ensuring that both logistical and administrative arraignments were made for the actual data collection in Lagos and for liaison with the staff in Aba and Kano. His strong relationship with each of the Lagos Community Partners for Health (CPHs) coalitions ensured that all CPHs were ready and willing to share their concerns and opinions with the interviewers. Dr. John Oluropo Ayodele, Ene Obi and Hezekiah Adesina provided information on specific programs and activities as well as general overviews of the CPHs. Kayode Adewale and the financial staff guaranteed that necessary support was available to conduct the field work. Field office support in Kano and Aba was exceptional. Staff, including Ibrahim Bebeji, Salamatu Bako, Uchechukwu E. Eze, and Kenneth Obialor undertook the needed groundwork to ensure successful interviews and assisted with transport, interviewer recruitment and other administrative arrangements. Kabiru Salami, a core research assistant from the University of Ibadan, oversaw quality control in the field, conducted interviews, reviewed transcripts and assisted in typing of transcripts. Secretarial staff at the Department of Sociology, University of Lagos provided typing services. Lagos interviewers included Pius Adejo, Folusho Apantaku, and Ebun Afilaka with assistance from Lanre Ajoboye. Kano interviewers comprised Maimuna Mani Yan’gora, Zakariya M. Zakari, Hadiza Gidado, Idowu Biao and Hauwa Bala. Aba staff recruited the following interviewers: Charles Dibia, Bukola Adenikinju, Joy Ijeoma Onyeagba, Ogechi H. Mba and David Ike Ahuchaogu, Marilyn Rice and Bob Lennox from the Arlington office of BASICS gave guidance and advice for organizing the data collection and provided feedback on findings from the field. December 2001 draft Lessons for CPH Independence - 2 CONTENTS COVER ACKNOWLEDGMENTS CONTENTS EXECUTIVE SUMMARY 1. BACKGROUND 1.1 The Social and Political Context of CPH Development 1.2 Coalition Building Processes 1.3 Overview of CPH Development and Growth 1.4 Preparation for Independence 2. METHODS 2.1 In-depth Interviews 2.2 Survey Data 3. SUSTAINABILITY PROCESSES 3.1 Governance 3.1a The Constitution 3.1b Dyads and Triads 3.1c Leadership and Elections 3.1d Conflict Management 3.2 Membership and Involvement 3.2a Membership Changes 3.2b CBO Involvement 3.3 Program Planning and Management 3.3a Program Planning 3.3b Training Capacity 3.4 Fundraising and Resource Management 3.4a Sources of Income 3.4b Dues 3.5 Establishing Linkages and Collaboration 3.5a Local Government 3.5b NGOs and Donors 3.5c The Media 4. PERCEPTIONS OF IMPACT - QUALITATIVE DATA 4.1 Perceptions of Health Program Achievement 4.1a Immunization 4.1b Environmental Sanitation December 2001 draft Lessons for CPH Independence - 3 4.1c Breastfeeding Promotion 4.1d Health Care Access 4.1e Other Health Concerns 4.2 Perceptions of Social Action Achievements 4.2a Democracy and Governance 4.2b Cooperatives and Microcredit 4.2c Other Social and Development Issues 4.3 Medical Staff Perceptions of the Impact on Their Health Facilities 4.3a Perceived Benefits 4.3b Perceived Costs 4.4 Perceptions of Local Government Officials 4.4a Health Department Staff 4.4b Political Leaders 5. QUANTITATIVE DATA 5.1 Secondary Analysis of Survey Data 5.2 Other Quantitative Data 5.2a Health Facility Data 5.2b National Immunization Days 5.2c Capacity Building Exercise 5.2d Other Available Data 5.3 Comparison of Findings from Different Sources 6. TRANSITION TO INDEPENDENCE 6.1 Efforts Made by CPHs 6.2 Prospects for Sustainability 7. CONCLUSIONS AND LESSONS 8. RECOMMENDATIONS 9. REFERENCES 10. APPENDICES A. Indepth Interview Guide for CPH/CBO Members B. Interview Guide for LGA Staff C. TextBase Beta Node (Coding) Tree D. Aba CPH Start-up Inputs from Basics December 2001 draft Lessons for CPH Independence - 4 EXECUTIVE SUMMARY The political reality that BASICS I confronted in setting up its programs in Nigeria required innovative approaches to child survival that involved the community and the private health care sector, since the military dictatorship precluded work with government agencies at all levels. Thus, strategy of community based health coalitions was introduced in 1994, starting with an inventory of community based organizations (CBOs) and private health care facilities (HCFs) in poor communities in Lagos that were potentially interested in promoting child survival. This resulted in the formation of six Community Partnerships for Health (CPHs) in late 1995. A similar process resulted in five CPHs in Kano, the largest city in northern Nigeria, in 1997, and five more CPHs in Aba, a large commercial city in the eastern part of the country. Although Nigeria has started down the road to Democracy again, with an elected civilian government taking office in 1999, the CPHs are still relevant today as the CPHs contribute to the building of civil society and hopefully an environment more conducive to child health, development and survival. One of the consequences of the Nigeria’s return to the path of democracy was that the BASICS II project was designed to work with Local Government Area (LGA) Primary health Care Departments in the three states where the CPHs are located, Lagos, Kano and Abia. In the process, the CPHs that were developed under BASICS I programming, are slated to become independent non-governmental organizations (NGOs) by the end of 2001. BASICS made no secret of the fact that the CPHs were to become independent organizations from the beginning, and as reported in the 1997 Documentation Exercise, CPH leaders were well aware of this direction. BASICS I provided a variety of technical inputs and resources for CPH development including training workshops on both managerial and health issues and simple equipment needed for environmental sanitation and maintaining the immunization cold chain. BASICS I also guided the CPHs in developing their ow constitutions and using these as a basis for registering with the Nigerian Government as full fledged NGOs. Over the years between 1995 and 2001, the CPHs engaged in numerous health and development activities, most of which were suggested and coordinated by BASICS staff, but many that were started on the initiative of the CPHs themselves as a response to community needs. Central activities included establishing regular immunization services at CPH HCFs as well as participation in the local manifestations of the National Immunization Days (NIDs) campaigns. CPHs also focused on health education for oral rehydration therapy (ORT) and exclusive breastfeeding (EBF). CPHs set up youth wings on their own initiatives, and these groups spearheaded community awareness and education about HIV/AIDS prevention. CPHs realized that a mother’s ability to protect her child’s health depended on her own economic well being and therefore initiated cooperative thrift and credit associations for their own members. BASICS later introduced a microcredit system for the Lagos CPHs. Using the shovels, rakes and wheelbarrows provided by BASICS, CPHs organized their membership to conduct regular environmental cleanup, initially as part of a monthly national environmental sanitation day, but later after national sponsorship of the event stopped, CPHs continued to work toward maintaining their environments. Individual CPH activities included adult education and skill training for women members in Kano and advocacy and mobilization to address community infrastructure problems such as roads and drainage. The key questions that led to the final documentation/process evaluation found in this report were first, are the CPHs at this stage in their development capable of sustaining their health and development activities, and secondly, what lessons can be learned from the CPH process that can be applied to fostering community involvement in other health projects? In-depth interview with CPH members was the main tool for answering these questions. A minimum of 10 interviews with CPH leads, CBO members and CF representatives were conducted, ensuring that men, women and youth were included. There were also interviews with LGA health staff and political leaders. These interviews yielded descriptions of essential sustainability processes including organizational development, leadership capacity, linkages with outside resources and ability to raise funds, among others. These qualitative reports were supplemented with secondary analysis of available quantitative sources including a baseline survey conduced in the three sites in preparation for BASICS II activities. Major conclusions from the data were grouped according to short and long term benchmark indicators. Lessons concerning the sort term indicators of organizational development and sustainability were generally positive. The process of developing a constitution and running an organization by its laws and norms has been a December 2001 draft Lessons for CPH Independence - 5 positive and essential experience in all CPHs. It is