MATERNAL AND CHILD SURVIVAL PROGRAM NIGERIA – ROUTINE IMMUNIZATION Quarterly Report Program Year 2 Third Quarter

Agreement Number: AID-OAA-A-14-00028 Activity Start Date and End Date: September 1, 2014 – December 31, 2018 Activity Manager: Dr. Yakubu Joel Cherima

Submitted by: Dr. Femi Oyewole, National Immunization Technical Advisor John Snow, Inc. (JSI) Plot 1015 Fria Close Off Coree Bay Crescent Wuse II, Abuja, Nigeria

July 2008 1 PROGRAM SUMMARY

Maternal and Child Survival Program Nigeria - Routine Program Name: Immunization

Activity Start Date and End Date: September 1, 2014 – December 31, 2018

Name of Prime Implementing John Snow, Inc. (JSI) Partner: Agreement Number: AID-OAA-A-14-00028 National Primary Health Care Development Agency (NPHCDA), Expanded Programme on Immunization (EPI), The Bill & Melinda Gates Foundation, Dangote Foundation, Solina Health, World Health Organization (WHO), United Nations Children’s Fund (UNICEF), US Centers for Disease Control and Prevention N-STOP Project (CDC-NSTOP), Major Counterpart Organizations: European Union-funded Support Immunization Governance in Nigeria (EU-SIGN), Bauchi and Sokoto State Primary Health Care Development Agencies (BSPHCDA and SSPHCDA, respectively), Ministries of Local Government (MoLGs), Local Government Authorities (LGAs), Northern Traditional and Religious Leaders’ Council, Ward Development Committees (WDCs), Community-Based Health Volunteers (CBHVs) Geographic Coverage (cities and or countries) Abuja FCT, Bauchi and Sokoto states, Nigeria Reporting Period Program Year 2, Quarter 3: April 1 to June 30, 2016

ACRONYMS AND ABBREVIATIONS bOPV Bivalent Oral Polio Vaccine BMGF The Bill and Melinda Gates Foundation BSPHCDA Bauchi State Primary Health Care Development Agency CCE Cold Chain Equipment CDC N-STOP U.S. Centers for Disease Control and Prevention N-STOP Project cMYP Comprehensive EPI Multi Year Plan DF Dangote Foundation DHIS-2 District Health Information System version 2 DVD-MT District Vaccine Device-Management Tool DQS Data Quality Self-Assessment EOC Emergency Operations Center EU-SIGN European Union-funded Support Immunization Governance in Nigeria HF Health Facility HMIS Health Management Information System HW Health Worker IPD Immunization Plus Day IPV Inactivated Polio Vaccine LGA Local Government Area LIO LGA Immunization Officer M&E Monitoring and Evaluation MCSP Maternal and Child Survival Program MMR Measles, Mumps, and Rubella vaccine MOU Memorandum of Understanding NITA National Immunization Technical Advisor NPHCDA National Primary Health Care Development Agency NVI New Vaccine Introduction OPV Oral Polio Vaccine PCV Pneumococcal Conjugate Vaccine PHC Primary Health Care PHCUOR Primary Health Care Under One Roof PY Program Year REW Reaching Every Ward RI Routine Immunization SITA State Immunization Technical Advisor SITO State Immunization Technical Officer SPHCDA State Primary Health Care Development Agency SSPHCDA Sokoto State Primary Health Care Development Agency STTA Short-Term Technical Assistance TFI Task Force on Immunization tOPV Trivalent Oral Polio Vaccine TSHIP Targeted States Health Impact Project UNICEF United Nations Children’s Fund USAID United States Agency for International Development VDC Village Development Committee WHO World Health Organization

1 | Page

TABLE OF CONTENTS

PROGRAM SUMMARY...... 1

ACRONYMS AND ABBREVIATIONS ...... 1

1. pROGRAM OVERVIEW ...... 3

1.1 Introduction ...... 3 The MCSP/Nigeria RI program’s life of program objectives in Bauchi and Sokoto states are as follows: ...... 3

1.2 Quarterly Achievement Highlights (April to June, 2016) ...... 5

ACTIVITY IMPLEMENTATION PROGRESS ...... 10 2.1 Progress Summary ...... 10 2.2 MOU Thematic Area 1: Governance and Accountability ...... 13 2.3 MOU Thematic Area 2: Improving Accessibility and Utilization ...... 14 Sokoto: ...... 17 2.4 MOU Thematic Area 3: Vaccine Security, Cold Chain, and Logistics ...... 18 2.5 MOU Thematic Area 4: Monitoring and Evaluation/Supportive Supervision...... 19 2.6 MOU Thematic Area 5: Community Partnership ...... 20 2.7 MOU Thematic Area 6: Capacity Building and Training ...... 23 3. National-Level Program Support ...... 25

5. IMPLEMENTATION CHALLENGES ...... 26

5. MANAGEMENT AND ADMINISTRATION ...... 27

1. ACTIVITIES PLANNED NEXT QUARTER ...... 29 Appendix A: Indicator Reporting Matrix* ...... 31 Appendix B: Success Story 1 ...... 38

2 | Page

1. PROGRAM OVERVIEW

1.1 Introduction

The Maternal and Child Survival Program (MSCP) is a global U.S. Agency for International Development (USAID) cooperative agreement to introduce and support high-impact health interventions in 24 priority countries, including Nigeria, with the ultimate goal of ending preventable maternal and child deaths (EPCMD) within a generation. MCSP engages governments, policymakers, private sector leaders, health care providers, civil society, faith-based organizations, and communities in adopting and accelerating proven approaches to address the major causes of maternal, newborn, and child mortality such as postpartum hemorrhage (PPH), birth asphyxia, and diarrhea, respectively, and to improve the quality of health services from the household to the hospital. The program will tackle these issues through approaches that focus on health systems strengthening, household, and community mobilization, gender integration, and eHealth, among others.

MCSP has launched multiple activities in Nigeria. These include a routine immunization (RI) technical assistance program in Bauchi and Sokoto states, a project aimed at reducing neonatal and maternal deaths in Kogi and Ebonyi states, a public-private partnership through the Mobile Alliance for Maternal Action (MAMA), and a child health program that is currently under development. In line with MCSP’s contractual agreement with USAID and close partnership with the State Primary Health Care Development Agency (SPHCDA) and other public and private partners, MCSP-RI program assistance aims to strengthen the RI system to increase and sustain RI coverage and reduce childhood illness and death. USAID MCSP’s RI program is now fully operational at the national level (in Abuja), and in Bauchi and Sokoto states.

The MCSP/Nigeria RI program’s life of program objectives in Bauchi and Sokoto states are as follows: Bauchi • Objective 1: Support State-led and State-owned efforts to achieve >50% RI coverage in every ward of Bauchi State by the end of December 2016, and >80% RI coverage in every ward of Bauchi State by the end of December 2017. • Objective 2: Support State-led and State-owned efforts to expand the availability and quality of RI services by providing technical assistance in the areas of capacity building and training, supportive supervision, monitoring and use of data, supply/cold chain, and community engagement. • Objective 3: Promote the transition of all responsibility for sustaining and building on these gains to Bauchi State by January 2018, by improving capacity to promote, deliver, and monitor RI services at the State, Local Government Area (LGA), health facility (health facility), and community levels.

Sokoto In close coordination and collaboration with state and other RI partners, MCSP will: • Objective 1: Support state-led and state-owned efforts to achieve >80 percent RI coverage in every ward by the end of December 2018. • Objective 2: Support state-led and state-owned efforts to expand the availability and quality of RI services by providing technical assistance in the areas of capacity building and training, supportive supervision, monitoring and use of data, supply/cold chain, and community partnership.

3 | Page

• Objective 3: Promote the transition of all responsibility for sustaining and building on these gains to the State by January 2019, by improving capacity to promote, deliver, and monitor RI services at the state, LGA, health facility, and community levels.

MCSP has been supporting implementation of the Bauchi State Primary Health Care Development Agency’s (SPHCDA’s) quadripartite RI strengthening memorandum of understanding (MOU) since January 2015, and of the Sokoto SPHCDA’s quadripartite RI strengthening MOU since October 2015. The program has been tasked by each state’s SPHCDA, and by the three remaining MOU signatories—USAID, the Bill & Melinda Gates Foundation (BMGF), and the Dangote Foundation—to focus on providing four areas of technical assistance: • Monitoring and use of data • Supportive supervision • Community partnership • Capacity building and training

The following report covers the period from April 1 to June 30, 2016, or third quarter (Q3) of Program Year 2 (PY2). Included in this report is a summary of achievements for the quarter, planned activities for the following quarter, challenges, opportunities, and recommendations.

4 | Page

1.2 Quarterly Achievement Highlights (April to June, 2016)

BAUCHI MOU Thematic Area 1 – Governance and Accountability During the reporting quarter, BSPHCDA has released additional sum of 40 million Naira into the RI Basket fund. The total amount of money so far contributed by the state is now 120 million Naira (being 75% of the amount pledged by the state), per government’s commitment to taking increasing lead over financing of the RI MOU Workplan. RI micro-plans in 531(54%) out of 984 health facilities that are currently regularly providing RI services during the quarter were reviewed and updated using target population projections for 2006. MCSP actively participated in the review process along with other MOU partners and provided technical support to service providers to review their immunization session plans and determine the appropriate number of immunization sessions needed (both fixed and outreach strategy) to maximize their RI services. In close collaboration with other RI MO partners, MCSP continued to actively participate and provide technical support to LGAs to plan and convene monthly LGA review meetings; 47 out of 60 monthly LGA TFI meetings planned, and 57 out of 60 monthly LGA-level RI review meetings planned were held with MCSP support across the 20 LGAs. Updates on key RI performance indicators including progress on action points developed during health facility supportive supervision were shared among LGA Immunization Officers (LIOs) and RI partners during these meetings. Three State level RI working groups and 4 sub-working group (Training, SS/M&E, Finance and Supply and Logistics) meetings conducted as planned with MCSP support. Action points are now being followed up by state and partners as required. These meetings continue to serve as an opportunity to strengthen plans and coordination of RI activities in the state, review performance progress, identify and proffer solution to challenges. MOU Thematic Area 2 – Improving Accessibility and Utilization Currently 984 (87%) of all 1,090 health facilities in Bauchi state are offering RI services.*1 Of the state’s 106 remaining 106 health facilities that do not yet provide RI services, MCSP assessed 39 health facility with the potential to initiate RI services—22 of which were selected as qualified to initiate RI sessions. 82 health facilities already providing RI services were also assessed for their potential to increase the number of RI fixed sessions they offer per month; of these, 26 health facilities were selected as qualified to do so. health facility This quarter 67,921 (26%) of the 261,235 children less than 12 months of age in Bauchi received DPT3 containing vaccine, a marginal increase with respect to the 66,982 (25%) eligible children who received penta3 last quarter. A total of 23,481 RI sessions (11,507 fixed and 11,974 outreach sessions) were planned across 984 health facility currently providing RI for PY2/Q3 in Bauchi. 95% of this total [11,441 (99.4%) fixed and 11,162 (93.2%) outreach sessions] were conducted as planned in Q3, a marginal increase with respect to 94%% reported last quarter for both type of sessions.

1 “Providing RI services” is defined by a health facility providing at least one fixed RI session and or one outreach RI session per month.

5 | Page

MOU Thematic Area 3 – Vaccine Security, Cold Chain, & Logistics MCSP supported a monitoring visits by state-led team through the Supply and Logistics working group to 144 ward level cold chain equipped (CCE) health facilities and another 127 non-CCE equipped health facilities for consistency between quantities of vaccines recorded in ledgers and physical count. Issues of stock-outs observed in 48 health facilities were reported and later resolved by the LGA cold chain officers. MCSP supported LGA cold chain officers in the 20 LGAs across the state in checking and reporting functionality of CCEs in 160 wards level health facilities equipped with CCEs. 38 non-functional CCEs were observed and reported to the state. State is currently processing the procurement of new CCEs to replace faulty and obsolete ones. The State has achieved 75% stock adequacy, stock-outs stood at 15% since the beginning of Vaccine Direct Delivery (VDD) as evidenced in the state vaccine stock performance monitoring dashboard. In close collaboration with SOLINA, and through the state Supply and Logistics Working Group, MCSP has assisted the state in monitoring vaccine stockouts using the vaccine monitoring dashboard and also assist RI providers in proper filling of their vaccine ledgers, reporting issues of stockouts and calculating vaccine stock requirements. As recommended during the RI Working Group meeting in March, the Supply Chain and Logistics Working Group printed job aids for reporting of faulty solar direct drive vaccine refrigerators from health facility to LGA and the entire state team. MCSP will continue to collaborate with other MOU partners in providing support to the LGAs in applying the guidelines to monitor functionality of cold chain equipment and monitoring the vaccine stock performance using the vaccine monitoring dashboard as well as reporting findings to the State. MOU Thematic Area 4 – Monitoring and Evaluation/Supportive Supervision For the quarter under review, all the planned 60 (100%) state –to- LGA RI SS visits were conducted. At the LGA to health facility level, 2,802 (95%) out of 2952 planned RI SS visits across all 984 health facilities offering RI were conducted. MCSP supported SS from the state to LGA level in 8 of Bauchi’s 20 LGAs, and from LGA to health facility level in 433 of the 884 health facilities supervised. Some issues such as not updated micro-plans and monitoring charts were identified and addressed. Routine RI data for the months of April, May, and June 2016 were collated and entered into the National DHIS 2.0 database. Data entry was carried out by LGA M&E/HMIS officers across the state. Timeliness of RI reporting from health facilities to LGAs in Bauchi was 87%, a decrease in performance when compared with 92% timeliness reported last quarter. Health facilities in the hard-to-reach areas and those with poor access road were among the ones that submitted their report late – perhaps, as a result of the raining season. An excel based LGA level RI SS monitoring dashboard to provide visibility into the supervision process at the LGA level has been developed and pilot tested in 2 LGAs. State-wide rollout of this dashboard will begin in Q4. MCSP is currently supporting in planning for this rollout. In an effort to increase quality of RI data and reporting and as a follow-up to the previous DQA that was conducted in PY2/Q1, DQA were conducted in all 20 LGAs and in 120 health randomly selected facilities. MCSP actively participated and supported the DQAs in 11 out of 20 LGAs and 66 out of the 120 health facilities. Analysis of results is ongoing at the state EOC with the support of MCSP. Preliminary findings revealed gaps in data accuracy and management at the health facility level. Detailed analysis of findings is underway, and a report will be shared in July to inform the development of data quality action plans.

6 | Page

MOU Thematic Area 5 – Community Partnership The Social Mobilization Working Group (SSMWG) finalized the RI Community Engagement Strategy (CES) with MCSP support, including by engaging a consultant to support the development the strategy. This Strategy, which is the first of its kind to be developed by the state, will be printed and disseminated early next quarter. Out of the 889 RI community meetings with health facility planned during the quarter, 746 health facilities (84%) conducted their meetings, a 48 percentage point increase compare to last quarter. Meetings are used as a platform to review progress in newborn tracking and other community mobilization activities. MCSP supported 3 LGAs in developing a dashboard to track number of newborns referred by the traditional barber and number of referred children immunized. MCSP supported the state to track newborns referred by traditional barbers. 3,419 newborns were referred by traditional barbers from all 20 LGAs for immunization, 3,377 of whom were immunized with appropriate antigens. MOU Thematic Area 6 – Capacity Building and Training During the quarter, 100 (97M 3F) LGA PHC team members, and 2,019 (1617M, 402F) health facility staff, for a total of 2,119 (1714M and 409F), were trained by the state in preparation for anticipated PCV introduction in _____. MCSP actively supported the facilitation of the training across the 20 LGAs. tOPV to bOPV was switch conducted in Bauchi. All activities leading to the switch, including state and LGA level trainings, were fully supported by MCSP. SOKOTO MOU Thematic Area 1 – Governance and Accountability All 23 LGAs and 482 health facilities providing RI in the state have received all of their RI MOU basket funds for the quarter as planned. In close collaboration with other MOU partners, and through the Finance Working Group, MCSP supported the state to monitor and track disbursement of RI fund, ensure utilization and timely retirement of RI funds. All the 21 planned RI working group and the sub working groups meetings for the quarter (April to June) were convened and documented at state level. Meeting of the minutes with action points were disseminated at state level. This represent an improvement over the previous quarter where only 11 meetings (55%) were convened. All the 482 health facilities in the state have updated their RI Micro-Plans for the quarter under review with MCSP support. Supported 23 LGAs to conduct monthly RI review meetings with service providers and RI focal persons. During the review MCSP collaborated with other partners and provided technical support to ward focal persons and service providers on Micro Planning protocol. 23 LGAs Task Force on Immunization meetings held with MCSP support. MCSP technically supported the documentation and follow-up of action points. MCSP continued to actively participate as a member of SS Working Group and provided technical support to state and LGA teams to conduct supportive supervision visits to 23 LGAs and 482 health facilities. MOU Thematic Area 2 – Improving Accessibility and Utilization In close collaboration with other RI MOU partners, MCSP supported the state to develop RI outreach plan for 482 health facilities currently providing RI services across the 23 LGAs. The plans aimed at covering the catchment areas especially underserved communities.

7 | Page

As requested by SSPHCDA, MCSP supported the 23 LGAs to validate outreach RI services in 40 selected communities, with a view to track utilization of RI services and serve as an avenue for sensitizing the community/mothers. Findings indicated high numbers of partially immunized children, especially in underserved communities. A total of 3,856 fixed and 3,866 outreach sessions were planned for the quarter in Sokoto. Of this total, 3,680 (95%) fixed and 3,720 (96%) outreach sessions were conducted as planned in Q3, representing a steady maintenance of good performance compare to 95% fixed and 96% outreach sessions conducted last quarter. Provided technical support to 23 LGA and service providers in 482 health facilities during health facility supportive supervision as well as follow-up visits to address outstanding issues such as Service delivery, capacity building, RI session not conducted and CCE maintenance. MCSP supported the 23 LGAs during April IPDs by conducting supportive supervision, training of RI service providers in 120 health facilities on data and vaccine management.

MOU Thematic Area 3 – Vaccine Security, Cold Chain, & Logistics MCSP team actively participated in both state and LGAs planning meetings for tOPV switch. MCSP provided post Implementation follow up and reporting. During the planning stage MCSP supported the state to document findings during planning and review meetings. MCSP provided technical assistance to CCOs in 23 LGAs and 64 health facilities on the preventive maintenance of CCE and orient the service providers on monitoring and charting temperature of vaccines according to standard. MOU Thematic Area 4 – Monitoring and Evaluation/Supportive Supervision MCSP participated in planning and implementation of state and LGA supportive supervision for RI services through orientation and mentoring of state and LGA staff SS checklist, and following up identified action points. 23 LGAs Through the SS sub-working group, MCSP supported the 23 LGAS to Conduct on the job training for RI service providers in 120 health facilities on data management, and vaccine administration, and interpreting immunization monitoring charts in order to ensure sessions are conducted as planned for both fixed and outreach RI sessions. MOU Thematic Area 5 – Community Partnership Supported state to conduct quarterly review meetings with 85 district heads, aimed at providing updates, accomplishments, challenges and development of action points for the next quarter. Through the state community engagement and social mobilization working group, MCSP supported the SSPHCDA to conduct community sensitization activities in 11 communities. These activities mobilized and engaged community structures in planning for fixed and outreach sessions, as well as mothers to support the vaccination of their children for improved coverage. The communities are; Hurumi in Gande ward, Tungar Isa in Silame LGA, Marabawa and Kalalawa in Kware LGA; Warankai in Goronyo LGA; Alasan community in Tambuwal LGA; Soro in Soro Gabas ward, Birnin Wari in Soron Yamma Ward of Binji LGA; Kelenjeni in Tangaza LGA, Magaci in Dagawa ward, Shiyar Gareji, and Rugar Yamma in Yabo LGA.

MCSP supported the 2 LGAs to reactivate VDCs in two communities which were selected based on low number of unimmunized children. The VDCs will facilitate community participation in RI sessions planning, scheduling of outreach sessions to all settlements far away to the health facility in order to increase

8 | Page demand. This activity was conducted in Muza settlement of Yabo LGA and Alasan settlement of Tambuwal LGA.

MOU Thematic Area 6 – Capacity Building and Training Through the State Training Working Group, MCSP actively participated and provided technical and logistic support for the orientation of state 17 RI supervisors and 8 members of SSWG on planning, application and analysis of SS protocols. MCSP supported 22 LGAs to train RI service providers, Ward focal persons and RI focal persons on revised RI data collection tools across the 3 zones. 785 participants were trained: 605 male and 180 female. MCSP supported 23 LGA teams in conducting post training follow up to health facilities to support the service providers in effective use of the data tools and effect corrections where necessary As requested by SPHCDA, MCSP trained 12 SPHCDA M&E department staff (5 Female and 7 Male) on the use and application of DHIS2. This is to enable the agency staff to be monitoring timeliness and completeness of RI monthly data reporting from the health facilities, analysis and provision of feedback. Through the State Training Working Group, MCSP actively participated and provided technical support in training of 23 LIOs and CCOs on task identification and standard setting for RI service management and delivery, cold chain management and maintenance. In close collaboration with CDC, and through the Training sub-Working group, MCSP provided technical support to the State in training 23 LIOs, CCOs and health education officers on demand creation and supportive supervision. Participants were trained on how to conduct an immunization sessions, reducing missed opportunities and dropouts etc. MCSP supported the state to conduct cold chain management training for RI service providers and LGA CCOs drawn from public and private health facilities, where a total number of 276 staff participated, 222 male and 54 female were trained on cold chain management.

9 | Page

ACTIVITY IMPLEMENTATION PROGRESS

2.1 Progress Summary This report covers the MCSP/Nigeria RI program’s PY2 Q3 implementation progress and results. Results presented in this report primarily rely on service statistics from Bauchi and Sokoto states’ routine health management information systems (HMIS), including DHIS2 and DVD-MT, state RI Working Group and Sub-Working Group reports and program records. In both states, Ministries of Health (MOHs) and State Primary Health Care Development Agencies (SPHCDAs) continued to record important progress in strengthening the RI system to contribute to reductions in vaccine preventable childhood morbidity and mortality.

Largely based on administrative data, Bauchi and Sokoto states continued to record consistent improvements based on key RI indicators while focusing on accelerating most promising interventions for greater impact. Between October 2015 and June 2016, a total of 347,200 (75% of estimated target population) infants in Bauchi (201,151) and Sokoto (146,049) received three doses of DPT containing vaccine, representing an achievement of 77 percentage coverage in Bauchi and 72 percentage coverage in Sokoto. During the reporting period, 114,576 infants received three doses of DPT containing vaccine in Bauchi (67,921 out of 261,235 annual target population) and Sokoto (46,655 out of 202,846 annual target population). Cumulative drop-out rate stood at 11% for Bauchi and 8% for Sokoto. Also noted was the steady improvement in percentage of RI sessions conducted since PY2Q1, where 99% of planned fixed and 93% of planned outreach sessions in Bauchi and 96% of planned fixed and 95% of planned outreach sessions were conducted in Sokoto. MCSP continued to work closely with each state PHCDA and other RI MOU partners to target stronger-performing and “higher-yielding” health facilities for added support to further boost the number and session sizes of fixed and outreach services. In line with this, 78 health facilities in Bauchi state were visited and their RI session plans were reviewed based on criteria that each RI provider should immunize an average of 15 children per session.

During the quarter, the Bauchi State Government released the sum of 40 million Naira as per the state commitment to financing RI activities in the approved Harmonized RI MOU Workplan. From October 2015 to date, the state has released 120 million Naira (75%) into the RI MOU Basket Fund. The MCSP/Nigeria RI program continued to actively participate and provide technical assistance in routine planning, coordination, and review meetings of the EOC, State and LGA TFIs, state RI Working Group and sub-working groups as well as other coordinating bodies at states and LGA levels. In Bauchi, a total of 47 out of 60 LGA TFI and 57 out of 60 LGA RI review meetings were conducted as planned. Updates on RI fund disbursements and use, RI and post IPDs campaign activities were shared among LIO and RI partners. In Sokoto, all meetings of RI coordinating bodies (State TFI, RI working groups and all the sub- working groups) were conducted as planned. These meetings continue to serve as an opportunity to promote proper data collection, collation, analysis and use at the LGA and health facility levels. With respect to RI fund disbursement, a total of 958 (99%) health facilities in Bauchi received their RI funds during the reporting period. Similarly in Sokoto, a total of 482 health facilities (99%) have received their RI funds during the period under review. While 482 (99%) health facilities providing RI in Sokoto have successfully retired the RI funds they received during the reporting period, 958 health facilities (99%) in Bauchi are retiring funds on time.

10 | Page

There have been notable improvements in the number of health facilities offering RI services in Bauchi. MCSP collaborated with other RI MOU partners and supported the state to effectively expand RI services to an additional 26 health facilities across the state during the quarter. All the 26 health facilities have initiated fixed RI sessions. Ten of these health facilities have started receiving RI funds and consequently initiated RI outreach sessions, 16 have not started receiving RI fund for conducting outreach sessions;. Next quarter, MCSP will follow up with the state to open bank accounts for the remaining 16 health facilities to commence outreach sessions.

In close collaboration with UNICEF and SOLINA, MCSP continues to provide technical support to Bauchi and Sokoto states for the effective distribution of vaccines to service delivery points. As of June, 2016, a total of 285 (88%) out of 323 ward level satellite cold stores in Bauchi had functional cold chain equipment, with 75% vaccine stock adequacy. A total of 160 cold chain-equipped health facilities received monitoring visits from the program team during the quarter. Issues of stock-outs observed in 48 health facilities were reported and later resolved by the LGA cold chain officers. 38 CCEs were found faulty and findings were shared with the respective LGA officer responsible. While the State is currently processing the procurement of new CCEs to replace faulty ones, 3 out of the 38 faulty solar refrigerators were repaired. In Sokoto, MCSP team provided support to 67 CCE-equipped health facilities to track and report faulty cold chain equipment, five solar refrigerators were installed in Tureta, Kware, Gwadabawa, Tangaza and Gudu LGAs; 12 LGA cold chain staff were also provided with on-the-job training on cold chain management in Tureta, Kware, Gwadabawa, Tangaza, Gudu and Isa. Additionally, MCSP provided on-the job training to three service providers at Dange Shuni and Tureta LGA on CCE preventive maintenance, which included repair of faulty solar refrigerator.

Routine RI data for the months of April, May, and June 2016 were collated and entered into the National DHIS 2.0 database (for Bauchi) and DVD-MT (for Sokoto). Data entry is carried out by LGA M&E/HMIS officers across the two states. Timeliness of RI reporting from health facilities to LGAs in Bauchi and Sokoto were 87% and 99%, respectively. Health facilities that submitted their RI monthly report on or before 15th of every month are considered as those with timely reporting. In terms of data quality audits and supportive supervision, MCSP collaborated with other RI MOU partners and provided technical support to the state SS/M&E working group and LGA M&E officers to conduct data quality assessment to 120 health facilities in 20 LGAs in Bauchi. The DQA was aimed at mentoring and strengthening the capacity of LGA technical teams on data quality emanating from their health facilities. Preliminary findings from the DQS showed transcription errors from facility registers to monthly summary forms and DHIS2.0 database platform. The outcomes of the DQA exercise will be presented next quarter at State and LGA level review meetings. Subsequently, LGA teams will be supported to develop and implement corrective actions. Sokoto will roll out their DQA in Q4.

During the reporting period, MCSP in close collaboration with other MOU partners, and through the RI working groups and sub working groups equally strengthened the capacity of state and LGA staff to intensify and improve provision of supportive supervision with a view to improving the quality of RI services. RI providers were trained to determine the appropriate number of immunization sessions needed to maximize their RI services for optimal services. Out of the 984 health facilities visited for supportive supervision in Bauchi, 531 (54%) had an updated RI micro-plan while 623(64%) had updated

11 | Page

their RI coverage/drop-out monitoring charts with MCSP support. In Sokoto, 482 health facilities health providing RI received supportive supervision during the reporting period. All the 482 health facilities’ micro-plans were successfully reviewed and updated with MCSP and other RI MOU partner support.

In preparation for the MOU Mid-Year review, MCSP collaborated with other RI MOU partners and provided technical support to the state in preparing slides presentation on key achievements of the MOU from January to June 2016. During the meeting, MCSP and other partners supported the state to highlight progress made so far with core indicators such as number of health facility providing RI services, proportion of planned fixed and outreach sessions, penta3 coverage, dropout rate, supportive supervision, and financial management.

MCSP collaborated with other RI MOU partners and provided technical support to Bauchi PHCDA to finalize the Community Engagement Strategy (CES). Following the finalization of the strategy, a validation workshop with traditional and religious leaders was held under the leadership of state PHCDA. The purpose of the CES is to further strengthen the linkage between community and health facilities providing RI services through the engagement of traditional leaders and other community resource groups. Also in line with the CES, the Bauchi State Emirate Committee on Health (BASECOH) was inaugurated with the aim to sensitize and mobilize communities to access and utilize and sustain routine immunization services in the community. Furthermore, MCSP supported the conduct of quarterly review meeting with 85 district heads in Sokoto. The meeting aimed at providing updates, accomplishments, challenges and development of action points for next quarter. It also serves as an opportunity to re-train the district heads on their role in ensuring effective and sustainable platforms that will link communities with RI services. Action points were agreed upon based on the challenges and gaps identified by the district heads during the discussion. Furthermore, MCSP in Bauchi provided technical support to 746 (76%) health facilities to conduct review meetings with village and ward development committees on RI session planning, session monitoring and child tracking activities. About 3,419 children have been referred from their communities to health facilities immunization services by the traditional barbers across the 20 LGAs in Bauchi. Of the 3419, 3,377 (98%) newborns were immunized during the quarter. Out of the 984 health facilities providing RI, 746 (76%) have had meetings with their catchment communities during the reporting period.

MCSP and other RI MOU partners continued to support the states to build the capacity of service providers to expand and deliver quality RI services. 446 health facilities were supported in post REW training monitoring for compliance across 20 LGAs in Bauchi. Ongoing support will be provided in this aspect through SS visits. During the exercise, health facilities with outdated micro-plans were supported to review and update their micro-plans including the importance of communicating the six key messages with the caregivers was emphasized in health facilities that were not communicating properly with caregivers. In a related development, MCSP supported PCV introduction in Bauchi State during the reporting quarter. A total of 100 (97M, 3F) LGA PHC staff, and 2019 (1617 M, 402F) health facility staff have been trained on PCV. Sokoto has introduced PCV vaccine in PY2/Q1.

In close collaboration with other MOU partners and through the state RI working group, MCSP provided technical support to both Bauchi and Sokoto states to implement the tOPV to bOPV switch. The global withdrawal of tOPV, specifically its type 2 component, will represent a substantial milestone in the effort

12 | Page

to eradicate polio, because it will mark the eradication of Wild Polio Virus (WPV2) and, in the long-term, should lead to the elimination of type 2 of Vaccine Derived Polio Virus (VDPV) s. MCSP’s support included supervision of switch activities at every stage of implementation. During the activity a total number of 24, 306 and 13,999 tOPV vials (representing 98% of total expected vials) were retrieved and destroyed in Bauchi and Sokoto State respectively.

MCSP’s national-level RI technical support during the quarter continued to include technical contributions to quarterly Expanded Program on Immunization (EPI) reviews, as well as sharing ongoing experiences and lessons learned from Bauchi and Sokoto RI MOU implementation.

2.2 MOU Thematic Area 1: Governance and Accountability

Bauchi During the past quarter, the Bauchi State Government has released the sum of 40 million naira as per the state commitment to fund RI activities in the approved Harmonized RI MOU workplan. From January 2016 to date, the state has released 120 million naira (75%) into the RI MOU Basket fund. MCSP/Nigeria RI continued to actively participate and provide technical assistance in routine planning coordination and review meetings of the EOC, State and LGA TFIs, state RI Working Group and sub-working groups as well as other coordinating bodies at states and LGA levels. In Bauchi, a total of 47 out of 60 LGA TFI and 57 out of 60 LGA RI review meetings were conducted as planned. Updates on RI fund disbursements and use, RI and post IPDs campaign activities was shared among LIO and RI partners. Also during these meetings activities and challenges around the MOU implementation were discussed, including issues around data quality such as higher number of immunization sessions reported against the number planned.

MCSP provided technical support to 531 health facilities (55%) in Bauchi to review and update their RI micro-plans, including immunization session plans, to determine the appropriate number of immunization sessions needed to maximize their RI services.

The MOU mid-Year Review (MYR) for the period of January to June 2016 highlighting the progress made so far was successfully conducted in July 2016 in Bauchi state. Some of the strengths observed during the review included: increased ownership and accountability by the State, increased frequency of meetings by state partners and all working groups and increased SS from the State to LGA level. Weak areas needing improvement included: data quality: using data for action, demand creation within the community and proper tracking finances and linking it to outcomes. Key priorities for July to December 2016 were highlighted and all the stakeholders affirmed their continued support to the state. Identified areas of weakness were quality of data and demand creation in the communities. Strategies to improving the quality of technical assistance specifically in session planning, demand creation, data quality and supportive supervision provided from state to LGA level and LGA to health facility level are being developed. Priorities for the program’s technical assistance in Bauchi across all MOU thematic areas for the rest of the year includes: prioritizing and concentrating level of effort on reaching the most children, intensifying capacity building support for supportive supervision from the LGA to health facility level, supporting improvement quality of RI services provided by the state especially at the lower levels.

13 | Page

Sokoto: During the period under review, all the 23 LGAs in the state have received funds for conducting supportive supervision to health facilities. All the 482 health facilities (100%) have received the funds for the period under review. This clearly shows an increase in the financial disbursement to the health facilities conducting RI in the state between Q2 (29%) and Q3 (100%). This increase is as a result of collaborative effort between SPHCDA and MOU partners including MCSP through the commitment and continued advocacy by ensuring that all the health facilities conducting RI in the state open a bank account so that RI funds can be transferred directly. The fund was meant for supportive supervision, outreach, and conducting monthly review meetings with service providers at the health facility and LGA level, respectively.

All the RI working group and the sub working groups meetings were held as planned in the quarter. MCSP actively participated in planning and coordination of the working group meetings and ensured the implementation of action points. One of the key highlights during the M&E working group meetings was the need to train state M&E staff on the use and application of DHIS2 software for monthly health facility RI data monitoring, analysis and provision of feedback. Accordingly, and as requested by SSPHCDA, a total of 12 SPHCDA HMIS/M&E staff were trained by MCSP on DHIS platform to generate and analyze RI data.

Sokoto state had initially been applying supportive checklist without a standard guide on how each question should be applied and this practice had led to inconsistency in scoring LGAs or health facilities by different supervisors. To help the state address this challenge, MCSP collaborated with other MOU partners and supported the state through the SS working group to adapt the supportive supervision checklist guide used in Bauchi. Subsequently, MCSP organized an orientation for the supervisors and thought them how to apply the SS checklist as well as the verification criteria which the state adopted for use. Also during the meetings, MCSP supported the LGAs to review and document reasons for health facilities’ failure to conduct immunization sessions and subsequently work with the service providers to review and update their RI session plans for subsequent months.

MCSP actively participated and supported SSPHCDA to convene the three meetings for the State Task Force on Immunization (STFI) which were all chaired by the H.E. the Deputy Governor. The meeting was meant to review immunization-related operations on Polio Eradication Initiative (PEI) and RI, progress, challenges, and to solicit for government support to strengthen commitment and coordination especially at LGAs and sub- LGA levels. MCSP contributed to planning of the Task Force meeting through the EOC, including by sharing critical RI issues as observed in the field and offering suggestions for corrective actions.

2.3 MOU Thematic Area 2: Improving Accessibility and Utilization Between October 2015 and June 2016, a total of 347,200 (75%) infants in Bauchi (201,151) and Sokoto (146,049) received three doses of DPT vaccine, representing an achievement of 77% estimated coverage in Bauchi and 72% estimated coverage in Sokoto. During the past quarter, 114,576 infants received three doses of DPT containing vaccine in Bauchi (67,921 out of 261,235 annual target population) and

14 | Page

Sokoto (46,655 out of 202,846 annual target population). Cumulative drop-out rate for Bauchi and Sokoto have been reported this quarter at 9% and 8% respectively. The low dropout rates may be attributed to underreporting on the one hand, but also to increased regularity of vaccine delivery to RI service delivery points, including regular outreach immunization services to underserved communities, through RI MOU implementation in both states. A total of 11,507 fixed and 11,974 outreach RI sessions were planned for the quarter in Bauchi. Of these, 11,441 fixed RI sessions (99.4%) and 11,162 outreach RI sessions (93.2%) were conducted, representing a two percentage point increase for both types of RI sessions with respect to the previous quarter. Similarly, 3,856 fixed and 3,866 outreach sessions were planned during the quarter in Sokoto. Of this total, 3,680 (93 percent) fixed and 3,720 (95 percent) outreach sessions were conducted as planned

Bauchi During the reporting period, 26% of the estimated 464,170 children under 12-months targeted annually received three doses of DPT-containing vaccine in Bauchi (67,921 children). This represents an achievement of 77% of children who received penta3 by 12 months of age during the month of April, as compared to March. MCSP continued to mentor state and LGA staff to analyze and interpret immunization coverage data and provide meaningful feedback on RI performance, and RI service management to LGAs. For example, vaccination coverage of the 20 LGAs in Bauchi, as illustrated in Figure 1, shows that 10 LGAs (50 percent) achieved the state’s penta3 MOU target of ≥50 percent that was set for June 2016. The proportion of LGAs that met coverage targets varied between senatorial zones, ranging from five out of seven LGAs (71 percent) within the south zone, four out of six LGAs (66 percent) in the central zone and only one LGA (Jama’are) within the North zone. Shira, Alkaleri, Ningi, Shira and Gamawa were the LGAs with highest number of unimmunized children in the state. Also, Alkaleri, Ningi, Darazo, Katagum and Zaki were the LGAs with highest dropout rate. One of the major reasons for the variations in immunization coverage among the senatorial zones is the disparity in average number of qualified health personnel working in the health facilities across this zones, with Northern zone LGAs (like Shira, Zaki and Itas) having the lowest.

A total of 11,507 fixed and 11,974 outreach sessions were planned for the quarter in Bauchi. Of this total, about 11,441 (99%) fixed and 11,162 (93%) outreach sessions were conducted as planned, representing an increase of 6% for both type of sessions over the previous quarter. Improved planning of immunization sessions and continuous referral of new born and tracking of drop-out infants by traditional barbers in their communities may have contributed to these performance improvement, including by decreasing the proportion of drop-outs and left-outs. The program team continued to work closely with State and other RI MOU partners to target stronger-performing and “higher-yielding” health facilities for added support to further boost the number and session sizes of fixed and outreach services. In line with this goal, 78 health facilities in Bauchi state were visited and their RI session plans reviewed by LGA teams, based on the requirement that each RI provider would immunize an average of 15 children per session. As an outcome of this exercise, 53 of these 78 health facilities are now set to provide minimum of four fixed sessions per month.

15 | Page

Figure 1: Cumulative Percentage Coverage of Children <1 yrs old who received Penta 3 Vaccine, as well as Dropout Rates, January - June 2016, Bauchi State 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Source: HMIS records, SPHCDA, Bauchi PENTA3 Cumm Cov Dropout Rate MOU Target

In close collaboration with other MOU partners, MCSP supported the switch from tOPV to bOPV in all the 20 LGAs of the zone. The tOPV switch started following the successful training of LGA and RI service providers at various levels with support from the MCSP and other MOU RI partners, including NPHCDA and TFI members who were part of the switch committees. MCSP supported the supervision and monitoring of activities including retrieval of tOPV and distribution of bOPV to health facilities as well as helping the state to document the whole process. A total of 24,306 vials were retrieved, stocked and labeled in special bag. All retrieved tOPV vials were assembled at the State cold store and recorded, and transported for disposal using the boil and bury method. About 184,404 bOPV vials were supplied to health facilities. During the activity, MCSP played the following roles to ensure the success of the switch;

1. Supported the LGAs in the planning and monitoring of the switch activities. 2. Supported the LGAs in Data Collection from WFPs. 3. Supported the LGAs in the distribution of bOPV to health facilities. 4. Supported the LGAs in mopping out all health facility to ensure no single Vial of tOPV (empty or unopened) was left at the facility and LGA cold stores.

Continuous validation of the exercise and community sensitization for ongoing PEI activities and post switch pre-certification efforts as well as Intensifying AFP surveillance are ongoing in the state.

MCSP facilitated the PCV training at the state and LGA levels. Topics facilitated by MCSP staff includes Key facts about pneumococcal disease, introduction to PCV handling, storage and administration, data tools for monitoring REW implementation, creating immunization demand within the community and improving coverage of underutilized vaccines the participants were able to understand the key facts about PCV which are-: 1. PCV comes in 2 doses per vial 2. The VVM is on the top of the vaccine vial. 3. Any unused PCV dose at the end of the session or after six hours must be discarded.

16 | Page

4. Do not return open vial of PCV to the refrigerator.

Sokoto: A total of 3,856 fixed and 3,866 outreach sessions were planned during the quarter in Sokoto. Of this total, 3,680 (93 percent) fixed and 3,720 (95 percent) outreach sessions were conducted as planned. As of the end of June, 487 of Sokoto’s 780 health facilities, or 62 percent, are conducting at least one RI session per month. However, this number has dropped to 482 (61 percent) due to security challenges that affected five health facilities. The State Ministry of Health is working with other government agencies to address the problem.

Vaccination coverage of the 23 LGAs in Sokoto state, as illustrated in Figure 2, below shows that only two (Kware and Wamakko) out of the 23 LGAs (9 percent) achieved the state penta3 MOU target of ≥50 percent that was set for January through June 2016. Gada, Goronyo, Kebe, Rabah, Sokoto North and Wurno were the LGAs with lowest coverage. Also, Gada, Goronyo, Gudu, Silame and Tureta happened to be the LGAs with the highest dropout rates. Given the added value of outreach RI sessions to increase coverage, MCSP continues to work with the state and LGAs in ensuring that all the targeted outreach and planned sessions are conducted. In line with this, MCSP supported 60 health facilities (20 per zone) to provide RI services focusing on 1-4-3 strategy. The 1.4.3 strategy stands for 1 fixed session per week, 4 outreach per month regardless of interval and 3 supportive supervision. Sokoto adopted the strategy looking at existing number of underserve communities, low coverage and maximizing the utilization of the available facilities providing RI services around 60% of the existing HFs in the state. Out of the 482 health facilities in the state, about 360, or 74%, are currently implementing 1-4-3 strategy. The 1-4-3 strategy also aim at increase the number of sessions and ability to reach more children. MCSP continued to work closely with other partners to follow up with the state government as needed to ensure the timely release of RI funds to LGAs and health facility bank accounts for routine supportive supervision

Cummulative Percentage Coverage of Children <1 yrs old who received PENTA 3 Vaccine and Dropout Rate From January to June 2016, Sokoto State. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Source: HMIS records, SPHCDA, Sokoto Penta 3 Cov Dropout Rate State target and outreach immunization sessions, respectively.

17 | Page

Through its LGA immunization consultants, MCSP continues to collaborate with other partners working at the LGA level (like UNICEF and WHO) to provide technical support to LGAs and service providers during supportive supervision and follow-up visits to address issues around service delivery, data management, and RI session planning. MCSP actively participate in April IPDs campaign and supported the state led-led effort in in supervision vaccination teams. During the supervision, service providers received training on data management and vaccine management.

MCSP actively participated and supported the state level training of STF on IPDs as well as the ward level training for RI service providers to facilitate the immunization activities during the IPDs campaigns. LGA Immunization Consultants supported LGAs to train fixed post and health camp teams in LGA level training during IPDs. Additionally, MCSP program staff supported LGA teams to monitor and supervise the fixed post and health camp during the IPDs implementation where RI antigens were administered to children under 1 year. Also MCSP participated in the daily evening review meeting to discuss issues observed during field visits. MCSP supported the Surveillance update of AFP on monthly basis through documentation, accessing immunization status of the targeted children and follow up the record of RI of the affected children.

In a related development, MCSP join other partners to support the State and LGAs to train vaccinators for CSM re-active vaccination campaign. During the campaign MCSP also monitored and supervised CSM campaign implementation in the affected wards in the zone. The campaigned was conducted in the followings wards and LGAs: 1. Giyawa, Boye Kai and Kojiyo wards in Goronyo LGA 2. Sarkin Adar ward in Sokoto South LGA, 3. Jekanadu ward in Silame LGA 4. Kalenjeni, Sakkwai and Tangaza wards in Tangaza LGA 5. Tambuwal (FGGC) 6. Rabah (Goddodi and Rara) 7. Dange-Shuni (Shuni Ward)

2.4 MOU Thematic Area 3: Vaccine Security, Cold Chain, and Logistics Bauchi During the quarter, the program team provided support to 160 wards/health facilities to track and report faulty cold chain equipment. This activity is performed in order to sustain the increased availability of vaccines in health facilities observed in the previous quarter. 38 CCEs out of the 323 wards equipped with functional CCEs were found faulty and 45 were obsolete, findings were reported to the respective LGA officer responsible. However, three out of the 38 CCEs were repaired. Bauchi State is currently processing the procurement of 85 new CCEs to replace faulty and obsolete CCEs. State Logistics Working Group (SLWG) has agreed to print out job aids for reporting of faulty CCEs from health facility to LGA and the state. In close collaboration with UNICEF, MCSP also provided technical support to 20 LGA cold chain officers in conducting basic preventive maintenance and tracking bi-weekly vaccine stock availability at ward level health facility cold stores. Bauchi State has achieved 75% stock adequacy, and stock outs stood at 15%, a decrease compare to 5% stock out reported last quarter. This happened

18 | Page

as a result of the broken down CCEs reported during the reporting quarter, however, vaccines were shifted from the health facilities with non-functional CCEs to neighbouring health facilities with functional CCEs. The program team continued to support the state Supply and Logistics Working Group to carefully review vaccine stock performance data and adjust health facilities’ maximum vaccine stock levels. Follow up on action points was promised by the LGA teams.

Sokoto: IN close collaboration with Solina and other RI MOU Partners, MCSP provided technical assistance to LGAs and health facilities on CCE preventive maintenance, installation and repairs of faulty solar refrigerators, and on the job training. Five solar refrigerators were installed in Tureta, Kware, Gwadabawa, Tangaza, and Gudu LGAs and also 12 LGA cold chain staff were provided with on the job training on cold chain management in Tureta, Kware, Gwadabawa, Tangaza, Gudu, and Isa. The program team supported LGA teams to monitor the availability and functionality of cold chain equipment through the development and rollout of a planned preventive maintenance plan. During the past quarter, technical assistance was provided to cold chain officers on how to use temperature charts to monitor vaccine temperatures twice daily, including by checking and updating the vaccine stock performance of dashboard. Furthermore, MCSP supported the state to implement the tOPV to bOPV switch, from planning to the implementation process at the state and LGA levels. MCSP and other RI MOU partners are now working with the state to conduct post-switch follow-up at the LGA and health facility levels, and to ensure strict compliance and application of bOPV in both routine and supplemental immunization activities. A total of 13,999 vials were retrieved and destroyed in Sokoto State during switch activities.

2.5 MOU Thematic Area 4: Monitoring and Evaluation/Supportive Supervision Bauchi Routine RI data for the months of April, May and June 2016 were collated and entered into the National DHIS 2.0 database. Data entry was carried out by LGA M&E officers across the states. Timeliness of RI reporting through the HMIS from health facility to LGAs in the state is 85%. In terms of data quality audits and supportive supervision. In close collaboration with WHO and MOU partners, MCSP supported the Bauchi SPHCDA through the SS/M&E working group to conduct a state wide data quality self- assessment (DQS) in all the 20 LGAs, with six health facilities randomly selected per LGA. Data is being analyzed and preliminary findings indicated poor-quality RI data and discrepancies between health facility-level and LGA-level immunization data, with cases of over-reporting and under reporting of data received from health facilities and poor data management skills observed among LGA and health facility staff. Detail of the assessment findings including report will be shared with the mission in Q4. In the meantime MCSP will work with the state M&E/SS working group to disseminate the findings and facilitate the development and implementation of action plans across all levels for improved data quality.

The GIS model is being considered as a complement to census data and as a means of improving health facility micro planning by improving health facility catchment area estimate. MCSP has examined the GIS data for Bauchi state to determine ways to use and validate RI data. Analysis of Vaccination Tracking

19 | Page

System (VTS) population and polio micro-plan data was performed in effort to validate the GIS data. Discussions about using GIS data to improve microplanning processes is ongoing, and MCSP developed and submitted a concept note around learning from this activity to USAID during the quarter.

For the quarter under review, all the planned 60 (100%) state –to- LGA RI SS visits were conducted. At the LGA to health facility level, 2,802 (95%) out of 2952 planned RI SS visits across all 984 health facilities offering RI were conducted. MCSP supported SS from the state to LGA level in 8 of Bauchi’s 20 LGAs, and from LGA to health facility level in 433 of the 884 health facilities supervised. Some issues such as not updated micro-plans and monitoring charts were identified and addressed.

Sokoto: During the past quarter, MCSP provided technical support state- wide, SSPHCDA-led RI supportive supervision visits to 23 LGAs. State teams made 69 LGA supportive supervision visits to the state’s 23 LGAs, and LGA teams made 1,215 supportive supervision visits to 482 health facilities across the state. As the usual practice, MCSP staff were assigned by SSPHCDA through the SS working group to contribute focused support to four LGAs, namely Silame, Gudu, Sokoto North and Ilela. LGA staff supported by MCSP Consultant to plot an Technical support included clinical observation immunization chart during supportive supervision in Silame LGA. followed by on-the job training, supporting the LGA and health facility staff to develop action plans.

As the state prepares to launch the use of the RI module of DHIS2, MCSP supported the state-level training and co-facilitated the LGA level step-down training for 430 service providers at the LGA level.

2.6 MOU Thematic Area 5: Community Partnership Bauchi One of the major achievement in the past quarter was the finalization of Bauchi state RI Community Engagement Strategy (CES). Consensus and validation meetings were held in May 2016 with all RI MOU partners present. MCSP is now working through the state SMWG to print and disseminate copies of the strategy to all relevant stakeholders. Next quarter, the strategy will be used for develop a detailed operational plan for community engagement around RI. MCSP will provide technical support to the SPHCDA to develop the monitoring and evaluation (M&E) framework that will be used to measure progress achieving expected outputs outcomes of the community engagement strategy. In line with the community engagement strategy, Bauchi State Emirate Committee on Health (BASECOH) being the first of its kind, was inaugurated with the aim to sensitize and mobilize communities to access and utilize as well as sustain routine immunization services in the community. They monitor demand of vaccines in the community and supply of vaccines from the state. Chigari foundation is assigned by

20 | Page

SSMWG to orient traditional leaders on the CES in 3 phases starting with 7 LGAs in the first phase to 4209 persons consisting of 81 district heads, 425 village head and 3709 settlement heads. The orientation will be done after dissemination of community engagement strategy and will focus on both bottom-up and top-bottom approaches involving various sectors and stakeholders in the community with the aim of building consensus, popular support and shared responsibilities towards increasing and sustaining uptake of routine immunization services. In order to engage and partner effectively with the community, the strategy will leverage on the platform of traditional and religious leaders and other, Community Resource Groups (CRGs) such as WDCs/VDCs, Community volunteers, the traditional barbers, youth groups, women groups and community professional associations. The level of engagement of these structures span from Bauchi State Emirate Committee on Health (BASECOH) at state level to LGAs, Wards, Community and Household levels enlisting the relevant stakeholders at all the levels.

MCSP team worked closely with BSPHCDA, through the state social mobilization working group and distributed additional 470 color coded RI referral cards across LGAs in the state. As at the end of June, 2016, a total of 3,418 newborns have been referred from their communities to health facilities for immunization services by the traditional barbers. Of this total, 3377 (98%) have been immunized across the state. MCSP consultant supported 746 health facilities to conduct MCSP Consultant during WDC review meeting at Misau T/Maternity. Photo: JSI. meetings with VDCs and traditional barbers around their catchment communities. The meetings were meant to review progress in child tracking activities by providing feedback to the community structures and develop plans to address challenges. As part of the action plans from these meetings, three LGAs namely Dass, Darazo and Bogoro were supported by MCSP to initiate the use of child tracking dash board indicating number of children referred by the traditional barber and number that were immunized. This practice is expected to be scale up to other LGAs in Q4. WDC/VDC supported 17 health facilities in the management of waste disposal process, this include provision of 7 burn and buried site and training on the process of evacuation and burning through general sanitation activity in the facility.

MCSP supported the Social Mobilization Working Group (SMWG) to select five civil society organizations—the federation of Muslim women association of Nigeria (FOMWAN), syndicate in supporting women and children (SISWACHI), African Community for Environmental and Health Initiative (ACE-HE), FAHIMTA and RAHAMA to be engaged in and granted by EU-Sign to support the state in demand creation for RI services. Their roles is to support the traditional leaders and health workers to ensure that sessions are conducted as planned and actively mobilize communities to access RI services.

Sokoto:

21 | Page

During the period under review, MCSP actively participated and provided technical supported the state to convene quarterly review meetings with 85 district heads. The District heads are senior traditional leaders; mandated by the Sultanate Council, to be responsible for supporting the Sultanate Council and their respective LGAs to manage community affairs across wards. They are also expected to play a vital role in awareness-raising, advocacy, resource mobilization, around health. MCSP technical support includes, helping the state to develop meeting agenda, prepare feedback on RI performance and document minutes of meeting. The meeting aimed at providing updates, accomplishments, challenges and development of action points for subsequent quarter. It also serves as an opportunity to re-orient the district heads on their roles in ensuring effective and sustainable platforms that will link communities with RI services. Action points were agreed upon based on the challenges and gaps identified by the district heads.

In close collaboration with UNICEF, MCSP supported service providers in 120 health facilities during the reporting period to conduct review meetings with village and ward development committees on RI sessions planning and sessions monitoring. This particular intervention has further strengthened the community linkages with health facilities on RI service provision.

Through the state community engagement and social mobilization working group, MCSP supported the SSPHCDA to conduct community sensitization activities in 11 communities. These activities mobilized and engaged community structures in planning for fixed and outreach sessions, as well as mothers to support the vaccination of their children for improved coverage. The communities are; Hurumi in Gande ward, Tungar Isa in Silame LGA, Marabawa and Kalalawa in Kware LGA; Warankai in Goronyo LGA; Alasan community in Tambuwal LGA; Soro in Soro Gabas ward, Birnin Wari in Soron Yamma Ward of Binji LGA; Kelenjeni in Tangaza LGA, Magaci in Dagawa ward, Shiyar Gareji, and Rugar Yamma in Yabo LGA.

Moreover, during the reporting period, MCSP supported the SPHCDA through the community engagement and social mobilization working group in collaborate with UNICEF/VCMs and FOMWAN volunteers to refer newborn babies and track defaulters. Volunteers were train to sensitize mothers and caregivers on the importance of bringing their children to the health facilities for routine immunization. Other effort includes targeting mothers and caregiver’s with messages on ensuring their children are fully immunized and cards are retain. Furthermore, Village Development Committees were revived in Muza settlement of Torankawa ward of Yabo LGA, and in the Alasan community of Tambuwal LGA to encourage community participation in Routine Immunization’s session planning and scheduling of outreach for settlements far away from health facilities.

22 | Page

2.7 MOU Thematic Area 6: Capacity Building and Training Bauchi MCSP continues to work closely with other RI MOU partners to design and implement diverse strategies to build the capacity of service providers to expand and deliver quality RI services. During the reporting quarter, MCSP supported 20 LGAs to conduct training on PCV introduction, and to cascade this training to RI service providers and health facility in-charges. A total of 2,119 individuals, including 100 LGA PHC team members and 2,019 health facility staff, completed this training. The training included content on adult PCV training session in progress at Misau Photo: JSI. learning principles and facilitation skills, proper use of data tools to record PCV vaccinations, and coordinated group exercises on administration of PCV vaccine. MCSP supported the state to conduct post-training follow-up visits to 446 health facilities to monitor compliance and re-enforce knowledge. Ongoing support will be provided in this aspect through SS visits. During the exercise, health facilities without updated micro plans were supported in updating their micro plans. The importance of communicating the six key messages with caregivers was also emphasized in health facilities needing additional coaching support.

Sokoto: In the reporting quarter, MCSP and other RI MOU partners supported the orientation of 20 state supervisors on supportive supervision checklist and verification criteria. Supervisors were oriented on the process of conducting supportive supervision at the LGA and health facility levels, using checklists and verification criteria. Participants included members of the state Supportive Supervision Working Group, state supervisors, LGA immunization consultants, and partners. Feedback on the January to March SS cycle revealed that the SS checklist was being administered without a guide. The participants were taken through the LGA checklist and verification criteria as a guide, it was discussed extensively and questions raised by participants were answered. On-site trainings were held with supervisors at Sokoto South LGA cold store, where each supervisor assessed the cold room using the LGA SS checklist and verification criteria as a guide. MCSP facilitated the session, and state supervisors were encouraged to apply the checklist and use the verification criteria as guide for subsequent supportive supervision cycles.

As part of the state plan to fully roll out DHIS-2, MCSP actively participated in the LIOs training on DHIS-2 organized by NPHCDA through the CDC at the state level and also co-facilitated the step down training at LGA level for RI service providers which followed immediately. MCSP supported the capacity building of 12 SPHCDA M&E department staff (5 Female and 7 Male) on the use and application of DHIS2. This is

23 | Page

to enable the agency staff to be monitoring timeliness and completeness of RI monthly data reporting from the health facilities performing analysis and provide feedback to the concerned LGAs and health facilities. Post training follow-up visits was conducted by the state team including MCSP staff to all LGAs in order to support the service providers in effective use of the data tools and made correction where necessary.

MCSP supported 2 days Training for Task identification on cold chain management and maintenance plan organized for 23 LGA CCO and 23 LGA LIOs of the state. A total number of 46 participants participated in the training.

MCSP facilitated a two-day training for State and LGA teams on demand creation and supportive supervision organized by CDC. The training aimed at looking at how to conduct an immunization session, how to reduce missed opportunities and dropouts. A total number of LGA Participants during Task Identification and training for 69 participants participated in the training. 23 LGAstask LIOs, Identification 23 LGAs. Photo:CCOs JSI. and ACCO’s all of them male

participated in the training.

Also as part of the state plan to deploy CCEs to 157 satellite health facilities, MCSP in close collaboration with other MOU partners and through the state Training Working group organized a one-day cold chain management training where a total number 276 service providers were trained on cold chain management. Subsequently, MCSP supported a two-day training on vaccine management where 223 participants where trained by MCSP on vaccine management.

24 | Page

3. National-Level Program Support MCSP continues to play a valuable role at the national level by bringing practical field experience and an operational lens to the discourse at the national level, influencing policy formulation and implementation. MCSP RI continued to support NPHCDA and other implementing partners to improve RI systems and policies.

MCSP RI participated in the USAID town hall meeting and the HPN retreat. Both meetings provided an avenue for MCSP RI to further understand the USAID/Nigeria Country Development Cooperative Strategy (2015 – 2019), get feedback from the Nigeria mission, learn best practices from other Implementing Partners and update the Mission on status of MOU implementation in Bauchi and Sokoto States.

MCSP RI participated in a meeting on piloting cold chain equipment maintenance and ensuring vaccine security through NPHCDA and Project Last Mile (PLM) partnership - a Coca-Cola funded initiative that provides support to governments in some African countries get essential medicines and supplies to the last mile, particularly in hard to reach communities. This partnership was brought about in a bid to ensure vaccine security though regular cold chain equipment maintenance. Discussions are still ongoing .

MCSP RI, as an active member of RI Core Group, supported the development of the Groups terms of reference (which clearly states its roles and its relationship with ICC and NITAG) of the Core Group to be presented to the ICC; supported the finalization of the application for Rota Vaccine introduction to the ICC for endorsement and participated in the discussions around the RI performance framework.

MCSP participated in all RI Working Group meetings and ensured meeting notes were shared with Sokoto and Bauchi State government officials as needed. As a member of the RI working group, MCSP RI contributed to the planning process of PCV introduction to the states and the finalization of the basic guide for RI service providers.

MCSP continues to be part of the National Logistics Working Group and participate in their meetings. In the quarter under review; the National Logistics Working Group received the Manufacturing group of the Manufacturers Association of Nigeria, which made a presentation on the potential of producing child survival medicines including infusions, antibiotics, Amox DT and Zinc. Sure-chill Technologies attended one of the meetings and made a presentation on the Sure-Chill vaccine refrigerator technology which keeps vaccines safe at the required 2oC to 8oC on as little as 2½ hours of electricity per day, and can maintain this temperature for a month. These refrigerators are being explored for broader procurement in Nigeria.

MCSP RI received the Honorable Commissioner of Health for Sokoto State in company of the AOR at their offices in Abuja. During the meeting, the USAID paradigm shift and the principles of MCSP’s technical support were discussed. MCSP programs activities at state and national levels were also shared with the commissioner. At the end of the meeting, the Commissioner assured MCSP of his full support and collaboration with the program for the successful implementation of the MOU.

25 | Page

MCSP worked closely with Solina to make a joint presentation during the directors briefing on program implementation progress and also participated in the MoU directors briefing on the progress being made in the MoU States. Two of the major take away from the meeting is the need to finalist on a community engagement strategy to improve demand for RI and the need for a coverage survey probably in Bauchi and Kano States.

5. IMPLEMENTATION CHALLENGES Bauchi 1. Some health facilities visited during supportive supervision in the past quarter were found not have updated their REW micro plan, health facilities catchment area maps, temperature and monitoring charts. Reasons behind this include lack of adequate copies of the templates at the LGA level. Not all facility staff are able to make photocopies of these templates especially in the rural areas where photocopying is expensive. In some health facilities the only RI provider and facility in charge are present and at the same time engaged with other consultations and treatment of clients. Another reason is that the LGA teams do not follow up with the health facilities on meeting deadlines for submission of the updated micro plan to the LGA. This makes some health workers deprioritize the micro plan updating. Issues observed are usually resolved by MCSP staff during on-the job training

2. TFI and RI meetings were not fully conducted as planned due to weak coordination at the part of state and LGA teams. This presents challenge to the progress of our achievements as these meetings serve as an avenue for all RI stakeholders at the LGA level to develop strategies on how to best tackle obstacles and resolve issues

3. The discrepancy between the DHIS2 and DVD-MT continue to exist despite ongoing technical support provided. The challenges in the discrepancies between the DHIS2 and DVD-MT was due to the fact that the two data tools are handled by two different persons, DVD-MT by the WHO, and DHIS2 by the LGA M/E Officer. RI data source from the health facility is reported into two templates with the RI provider and the health facility in charge each submitting to different bodies. RI provider submits to WHO DVD-MT while health facility in charge submits to DHIS2.

4. Some health facilities experienced stock out of some antigens because of their failures to come to the LGAs to collect from the 25% buffer stock. With issue of running out of stock by some health facilities despite the availability of the 25% buffer stock at the LGA level. The reason for this might be a lack of proper stock checking and planning. When stock are check frequently, SP will be able to know what vaccines are trying be out of stock and that will enable him to source the vaccines from the LGA in time. Secondly lack of commitment by the service providers to collect the vaccines from the LGA buffer stock despite the fact they are aware of the availability of the buffer stock contributes to the challenge.

26 | Page

5. Security threat was a challenge during the reporting period. It was addressed by complying with security update from the security advisor and collaborating with the LGA Teams for every movement.

6. Lack of Child Immunization Cards were reported in some LGAs. MCSP supported the transportation of cards from LGAs to the health facilities for use by the traditional barbers. Documentation of newborn/defaulter tracking/tracing cards was also a challenge at the Communities and health facilities. Capacity building was carried out on the Job to the Traditional Barbers and service providers, which is continuous. There is weak knowledge on how some of the community structures work among the MOU partners and some members of the community structures. Weak WDCS/VDCS in some Wards serve also a challenge in Community Linkage. It is expected that rolling out of the CES in the next quarter will help in resolving the issue.

7. Competing activities at state/LGAs resulting in lesser MCSP planned activities for this month. (TFI Review meetings for LGAS/health facilities).

Sokoto: 1. Within past quarter, Sokoto state experienced stock out of 3 antigens namely Measles, BCG and Hepatitis B in the first week of May, 2016. Also, the state exhausted quarterly RI vaccines supplies, hence making it challenging for children to have BCG and HBV0 vaccines at birth and clients wishing to complete their immunization measles and yellow fever vaccination will end up missing measles due to current shortage. MCSP is currently working together with the partners in analyzing the affected LGAs and health facilities.

2. Slow process of transferring staff and facilities for implementation of PHC under one roof. This is seriously affecting the implementation of proposed activities by partners within the state. 3. Disruption of planned field activities due to competing activities. 4. Low level of commitment of the LGA team in monitoring outreaches and lack of adequate sanction mechanism against service providers who defaulted in carrying out sessions

5. MANAGEMENT AND ADMINISTRATION The Finance and Administration team has continued to ensure that the implementation of program activities are efficiently supported both administratively and financially to ensure efficiency, accountability and effective delivery of program objectives. In addition to ensuring that financial deadlines and donor requirements are met, MCSP ensures that all of JSI’s procedures and policies are implemented and applied correctly in all function levels.

Staffing At the close of the quarter, the MCSP/Nigeria RI program had 33 staff on board—two based in Abuja, 12 in Sokoto, and 19 in Bauchi. The program’s technical support team also includes 24 long-term LGA immunization officer consultants, 13 in Bauchi and 11 in Sokoto. Pending confirmation from USAID, the program also plans to hire additional long-term LGA immunization officer consultants in both Bauchi and Sokoto.

27 | Page

Security Security in the northeast is still a challenge , though there have been recent advances in the fight against the insurgency. Bauchi and especially Sokoto have remained relatively calm, with minimal pockets of reported incidences ranging from cattle rustling, kidnappings, and robbery on local market days in some LGAs in some parts of Ganjuwa, Toro, and Nigi LGAs in Bauchi. The program’s Security Officer provides staff and consultants with daily local security tips and prepares weekly intelligence reports which have helped program staff avoid specific areas. Over the past quarter, the program reported once incidence of robbery among one Bauchi staff member who was returning from a personal trip along Gombe Bauchi Road: the robbers snatched his personal vehicle, which was later recovered along Saminaka- Kaduna Road. The MCSP team has a security and safety manual aimed at helping to ensure the safety of both staff’s lives and program property.

Inventory MCSP has been fortunate to acquire six vehicles from other, recently closed out USAID projects, four from Bauchi and two from Sokoto, closed TSHIP with 2 generators were transferred to MCSP. All vehicles and generators are currently in working condition; given the number of years these vehicles and generators have been put to use by previous projects, and now by MCSP, however, as well as the intermittent power supply in Nigeria that has required the generators to run for long hours each day, MCSP is now consulting with DELIVER, as the project prepares to close at the end of August, to request their transfer of additional generators to MCSP to support program operatioons in Bauchi and Sokoto.

28 | Page

1. ACTIVITIES PLANNED NEXT QUARTER

Bauchi Support the Social Mobilization Working Group to finalize and disseminate the RI Community Engagement Strategy. In close coordination with State and other RI MOU partners, support ongoing efforts to increase the number of health facilities providing RI services from 984 health facilities to 1,077 health facilities. Participate through the Financial Working Group in monthly financial monitoring visits and SS spot- checks to LGAs led by State staff, using updated financial/basket fund tracking tools. In close partnership with the State, join State and LGA teams in conducting joint monthly SS visits to LGAs and two health facilities per LGA in all 20 LGAs. Contribute to coordinated MOU work planning, implementation, monitoring, and reviews through regular, active participation in State and LGA TFI, RI Working Group, sub-group, and sub-committee meetings led by BSPHCDA. Continue to contribute to targeted monitoring and coaching support during state- and LGA-level monthly RI review meetings. Support will include gathering observations and feedback, to improve the agenda format to encourage on-the-job learning and dedicate time for targeted, participatory discussion on specific challenges (e.g., data completeness/inconsistencies, completing and interpreting immunization monitoring charts, and proper vaccine storage). Provide ongoing technical support to the BSPHCDA, in close collaboration with CDC N-STOP, UNICEF, and WHO, to monitor quarterly updating of REW micro plans at LGA and health facility levels. Support the BSPHCDA to use existing GIS population estimates to update health facility catchment area maps in all LGAs. Provide continued technical and capacity building support to the BSPHCDA, through Logistics Working Group and working closely with Solina, to monitor weekly stock and vaccination reporting at LGA and health facility levels via the vaccine stock performance dashboard. Contribute to State-led process documentation and learning around rollout of the vaccine push system in Bauchi and the phased transition of the vaccine distribution cycle from bi-weekly to monthly. Through the Data/M&E Working Group, contribute to quarterly reviews/updates to joint SS plan, and to track SS visits, especially follow up visit on agreed action points (e.g., visits conducted vs. planned, checklists) at the LGA level. Support ongoing documentation, dissemination, and follow-up of quarterly DQAs at state and LGA levels. Provide ongoing technical support at state and LGA levels, working closely with WHO, to strengthen the quality and completeness of RI data in DHIS-2 and the ongoing transition from DVD-MT platform. In line with the state effort to establish EPI Training Unit, collaborate with World Bank funded STEP- IN project to conduct training of master trainers on EPI modules. Support roll out of the community engagement strategy with traditional and religious leaders, via the Bauchi State Emirates Committee on Health [BASECOH], with support from Chigari Foundation. Submit concept note to USAID on the use of traditional barbers for newborn tracking. Support the roll out of PCV introduction in July 2016 across all LGAs. Sokoto Support SSPHCDA in conducting RI partner mapping exercise

29 | Page

Synthesize and document findings from RI partner mapping exercise Provide ongoing, technical support and orientation of SPHCDA official and new staff on PHCUOR Provide technical and logistics support to assist assigned LGAs and health facilities to implement RI sessions per their micro plans Provide technical support to SSPHCDA to use GIS mapping for RI micro planning in selected, targeted LGAs and wards by the end of next quarter Support community structures and actors to participate in planning, monitoring, and tracking of drop outs and left outs Provide technical support to all 23 LGAs in implementation of vaccine stock monitoring dashboard

Support SS visits and on-the- job training in selected LGAs and health facilities Provide technical support in convening quarterly RI review meetings with traditional leaders from all 23 LGAs Conduct state-wide sensitization and orientation of district heads on RI services. support orientations and monthly review meetings with town announcers across all 244 wards, identified local barbers, and relevant community structures to sensitize and mobilize community members to promote increased demand for and utilization of RI services Provide support to adaption, development, dissemination, and orientation on targeted IEC materials/messages by engaging a consultant to facilitate the process Support SSPHCDA, with other partners, to use findings from training needs assessment to inform development of RI capacity development plan Support SSPHCDA, through Training Working Group, to develop TORs for establishment of an RI Training Unit and ensuring that a functional RI training unit is available Provide technical and logistics support for biannual REW training and orientation of RI service providers Support training of RI service providers on new vaccines introduced into RI schedule Provide technical support for training and retraining of the remaining 280 RI service providers not trained in Q4 on cold chain management and vaccine push system Provide technical support for on-the-job trainings to service providers who have received procured CCE across the state Support Training Working Group to engage pre-service education institutions to incorporate RI into final year of training curriculum for nursing, midwifery, and CHEW students in order to identify existing gaps in training curriculum and methodology as well as identifying immediate means of providing up to date training on immunization services. National Level Support the review and adoption of MLM and IIP revised modules and training at State and LGA levels

30 | Page

Appendix A: Indicator Reporting Matrix*

Cumulative PY2 Q1 PY2 Q2 PY2 Q3 Performance PMP MOU targets Achievement Achievement Achievement Achieved from Indicator Indicator State by Dec. 31, Comments (Oct.-Dec. (Jan.-Mar. (Apr-June, January to # 2016 2015) 2016) 2016) December 2016

Percentage of Bauchi - 25% This indicator is measured through household survey. No 1 children who survey data was obtained during the period under review. received DPT3 by 12 MCSP is planning to roll-out a survey in both states in months of age Sokoto - 15% October 2016.

Overall, 114,576 infants received three doses of DPT Bauchi 25% 26% 26% 52% 70% containing vaccine during the reporting period in Bauchi Percentage of (67,921 out of 261,235 annual target population) and children less than 12 Sokoto (46,655 out of 202,846 annual target population). months of age who 2 Cumulatively from January to June 2016, 347,200 (52%) received DPT 3 from infants in Bauchi (135,842) and Sokoto (111, 565) received USG-supported Sokoto 23% 26% 23% 49% 57% three doses of DPT vaccine, representing an achievement programs of 49% in Bauchi and 49% in Sokoto.

Cumulative dropout rate as at June 2016 for Bauchi have Bauchi 14% 11% 9% 9% 10% been reported as 9% while that of Sokoto is 8%. The on- DPT1 - DPT3 dropout 27 going newborn and defaulter tracking by traditional rate Sokoto 8% 7% 8% 8% 18% barbers in Bauchi as well as outreach immunization activities might contribute to the drop in the dropout rate. 11,441 (99%) of 11,507 planned fixed RI sessions were Bauchi 88% 93% 99% 97% 75% conducted in Bauchi during the quarter. Similarly, 3,680 Percentage of RI fixed (95%) out of the 3,856 planned fixed sessions were 6 sessions conducted conducted in Sokoto. Cumulative from January to June as planned Sokoto 94% 98% 95% 96% 65% 2016, 97% and 96% of planned RI Fixed services were conducted in Bauchi and Sokoto respectively.

Percentage of RI Bauchi 92% 94% 93% 94% 75% 11162 (93.2%) of 11,974 planned RI outreach sessions outreach sessions were conducted in Bauchi during the reporting quarter. 7 conducted as Accordingly, 3,720 (96%) of the 3,866 planned RI outreach planned Sokoto 91% 97% 96% 95% 55% in Sokoto were conducted. Cumulative from January to

31 | Page Cumulative PY2 Q1 PY2 Q2 PY2 Q3 Performance PMP MOU targets Achievement Achievement Achievement Achieved from Indicator Indicator State by Dec. 31, Comments (Oct.-Dec. (Jan.-Mar. (Apr-June, January to # 2016 2015) 2016) 2016) December 2016 June 2016, 94% and 95% of planned RI outreach services were conducted in Bauchi and Sokoto respectively. Health facilities providing >1 fixed RI session and >1 outreach session per month, for all 3 months of the Bauchi 88% 88% 90% 90% 88% quarter, are counted for this indicator. Of Bauchi’s total 1,090 functional HFs, 984 HFs are currently providing RI services per this definition. During the reporting quarter, MCSP in collaboration with other MOU partners supported Percentage of health the SPHCDA to trained health workers from additional 26 12 facilities offering RI HFs in REW which have started providing RI services as services defined above. In Sokoto, 5 out of the 487 HFs providing RI Sokoto 62% 62% 61% 61% 92% in the state have closed due to security challenges that affected their catchment communities. As a result, only 61% (482 HFs) of all 785 HFs in the state are currently provide RI services. The state has collaborated with security agencies and working to resolve the issues.

Target not Earlier phases of RI MOU implementation in both Bauchi Bauchi N/A N/A N/A N/A specified in and Sokoto states will first prioritize increasing the number Percentage of planned 2016 workplan and improving the quality and tracking of fixed RI sessions, 8 RI mobile sessions because state then outreach sessions, then mobile sessions, as conducted didn’t plan for appropriate and as health facilities are ready. In Sokoto N/A N/A N/A N/A mobile September 2016, the BSPHCDA plans to initiate mobile outreaches. sessions where appropriate.

According to joint RI SS plans in the two states, each health Bauchi 89% 94% 90% 90% 63% facility is expected to receive at least 1 SS visit per month. Percentage of health 884 (90%) of Bauchi’s 984 health facilities that are now facilities receiving at providing RI services were visited during the reporting 13 least one SS visit for quarter in Bauchi. Of the 884 visited, only 167 (17%) RI within a quarter received more than once. Similarly, of all the 487 health Sokoto N/A 57% 99% 99% 72% facilities in Sokoto, only 482 received one or more Supportive Supervision visits for RI during the quarter.

32 | Page Cumulative PY2 Q1 PY2 Q2 PY2 Q3 Performance PMP MOU targets Achievement Achievement Achievement Achieved from Indicator Indicator State by Dec. 31, Comments (Oct.-Dec. (Jan.-Mar. (Apr-June, January to # 2016 2015) 2016) 2016) December 2016 According to RI SS plans in Bauchi, each health facility is Percentage of SS Bauchi 50% 91% 95% 95% 50% expected to receive >1 SS visit every month. In Bauchi, 95% visits conducted to 14 (2,802) of all 2,952 expected SS visits planned for the health facilities quarter were made as planned. In Sokoto State 84% providing RI services Sokoto N/A 19% 95% 38% 70% (1,215) of 1,446 expected SS visits were conducted. Percentage of health Bauchi N/A 36% 84%% 84% 25% facilities holding In Bauchi, 746 health facilities (84%) conducted meetings monthly review with community structures (Ward Focal Persons, 17 meetings with Traditional Baber and VDCs/WDCs]) as evidenced by community Sokoto N/A N/A N/A N/A 25% minutes of meetings during SS visits. structures as planned A total of 3419 newborns have been referred from their Bauchi N/A 1,383 3419 4,802 110,000 Number of children communities to health facilities for immunization services referred from by the traditional barbers across the state. Of this number, community to health 3377 (84%) were immunized. Newborn tracking is yet to 18 facility for start in Sokoto as MCSP is currently supporting the state immunization Sokoto N/A N/A N/A N/A 80,000 Social Mobilization Working group to develop plans for services engaging community health volunteers whose monthly stipend was approved by the Governor in June 2016. In Bauchi, 88% (285) of the 323 satellite cold store health Bauchi 99% 99% 88% 82% 70% facilities have functional CCEs. 38 CCEs broke down during Percentage of the reporting quarter. The state is in the process of satellite cold store procuring and replacing the faulty CCEs. Similarly, Sokoto 19 health facilities with state is in the process of procuring and installing new CCEs functional CCE Sokoto 34% 27% 27% 29% 60% in 177 wards across the state, consequently, only 67 (27%) wards have functional CCEs in the state. The new CCEs are expected to be installed in September 2016.

Percentage of health In Bauchi, vaccine stocks at the satellite cold store health 10 facilities with no Bauchi 99% 99% 75% 75% 70% facility level are monitored on a weekly basis via the state- stock out of vaccines owned vaccine stock monitoring dashboard. While the

33 | Page Cumulative PY2 Q1 PY2 Q2 PY2 Q3 Performance PMP MOU targets Achievement Achievement Achievement Achieved from Indicator Indicator State by Dec. 31, Comments (Oct.-Dec. (Jan.-Mar. (Apr-June, January to # 2016 2015) 2016) 2016) December 2016 for 30 days state has achieved 75% stock adequacy in Q3, stock-outs is recorded as 15% (38 of the 323 ward-level satellite cold stores that broke down during the reporting quarter). In Sokoto N/A N/A 25% 25% 70% Sokoto, 17 out of the 67 ward level satellite cold stores have experienced vaccine stock during the reporting quarter. Vaccine consumption data from 285 out of 323 satellite cold store health facilities with functional CCEs across the Percentage of health Bauchi 99% 99% 88% 88% TBD state was obtained and analyzed during the reporting facilities using period using the vaccine monitoring dashboard. Sokoto is 11 vaccine monitoring in the process of introducing the vaccine direct delivery dashboard on a N/A N/A N/A system across 244 wards and tracking using the vaccine weekly basis Sokoto N/A TBD dashboard will commence following the installation of the new CCEs. Figures reflect state-led trainings supported by MCSP. In 2,119 (M1714, 2,119 (M1714, Bauchi 902 (M822, 80F 1,202 832 Bauchi, MCSP supported the BSPHCDA to train 2,119 (100 F405) F 405) LGA staff and 2019 health facility staff) individuals on PCV Number of people introduction. This included, under this indicator 1714 male, trained in Child 405 female. In Sokoto, MCSP collaborated with CDC and Health and nutrition 3 supported the state to train 785 individuals on revised through USG HMIS tools that included the RI modules. This included 605 supported health 797(M617, 450 (390M, male and 180 female. MCSP also organized and trained 12 area programs Sokoto 235 17 400 F180) 60F) SPHCDA staff on DHIS2 software. In Sokoto, MCSP supported the SSPHCDA to train 450 individuals on Polio- supplemental immunization (IPDs). 2,119 (M1714, 2,119 (M1714, Figures reflect state-led trainings that included MCSP's Bauchi 902 (M822, 80F) 840 832 F405) F405) technical support (not a subset of Indicator 3). In Bauchi, Number of health MCSP-supported PCV Introduction trainings (per the above workers trained on indicator) for 2,119 LGA staff and health workers that 4 updated RI data 797 (M617, 797 (M617, included a module on revised RI data management and Sokoto 100 17 488 management tools F180) F180) tools. In Sokoto, MCSP collaborated with CDC and supported the state to train 785 individuals on revised HMIS tools that included the RI modules. This included 605 34 | Page Cumulative PY2 Q1 PY2 Q2 PY2 Q3 Performance PMP MOU targets Achievement Achievement Achievement Achieved from Indicator Indicator State by Dec. 31, Comments (Oct.-Dec. (Jan.-Mar. (Apr-June, January to # 2016 2015) 2016) 2016) December 2016 male and 180 female. MCSP also organized and trained 12 SPHCDA staff on DHIS2 software. In Bauchi, Out of the facilities visited during the quarter, Percentage of health Bauchi 0% 46% 55% 55% 78% 531 (55%) have an updated their micro-plan. In Sokoto, facilities providing RI 5 482health facilities out of the 487 (5 closed down due to services with up-to- security challenges) conducting RI have reviewed and date RI micro plans Sokoto 0% 0% 99% 99% 65% updated their RI micro plans. In both states, the State PHCDA must disburse RI basket Bauchi 99% 100% 99% 99% 80% funds to health facilities at the beginning of every quarter. In Bauchi, 98% (968) of the total health facilities (984) Percentage of health offering RI are receiving their RI funds. The remaining 16 facilities receiving RI 24 health facilities are currently opening their RI basket fund basket funds on a account and were scheduled to start receiving fund in Q4. monthly basis Sokoto N/A 29% 100% 100% 80% In Sokoto, all the 482 health facilities (100%) providing RI have received funds from the RI basket fund during the reporting period. In both states, bank account statements and EOC SS Bauchi 99% 100% 100% 100% 80% reports are used to verify fund utilization. All the 968 Monthly RI basket health facilities that received their RI basket fund Fund budget disbursements for the quarter in Bauchi have submitted 25 execution rate at their account statements. Similarly, In Sokoto 482 out of health facility level Sokoto N/A 100% 99% 99% 80% 487 health facilities currently offering RI services in the state have used the basket fund for the execution of RI activities as evidence by the records in the state MCSP has supported Bauchi State to develop an LGA Bauchi N/A N/A N/A N/A 20 Number of LGA performance review dashboard, which is expected to be 18 performance reviews finalized and rolled out in Q4. Training of LGA teams will conducted Sokoto N/A N/A N/A N/A 23 commence in July 2016. MCSP therefore anticipates beginning to report on this indicator in Q4.

35 | Page Cumulative PY2 Q1 PY2 Q2 PY2 Q3 Performance PMP MOU targets Achievement Achievement Achievement Achieved from Indicator Indicator State by Dec. 31, Comments (Oct.-Dec. (Jan.-Mar. (Apr-June, January to # 2016 2015) 2016) 2016) December 2016 In Bauchi, 89% of meetings of key, state-level RI coordinating bodies (including the state TFI meeting) were Bauchi 73% 71% 89% 56% 70% convened as planned during the quarter, as evidenced by meeting minutes. Other key coordinating bodies reflected Percentage of routine here include the RI, Financial, SS/M&E, Logistics, and meetings of RI 15 Training Working Groups. 14/15 meetings were convened coordinating bodies as planned. In Sokoto, all the meetings of State level RI convened as planned Sokoto N/A 55% 100% 50% 70% coordinating bodies including the monthly state TFI meetings and all the monthly RI working group/sub working group meetings were convened as evidenced by minutes of meeting documented in the EOC. LGA = 100% LGA = 100% LGA = 100% In Bauchi, all 20 LGAs were observed to have an up-to date Percentage of LGAs Bauchi N/A health facility= health facility = health 80% immunization monitoring chart displayed. Up-to date and health facilities 63% 65% facility=64% charts were observed displayed in 623 of 984 health with up-to-date 20 facilities providing RI services. In Sokoto State all the 23 immunization LGA = N/A LGA = 100% LGA = 100% LGAs were observed to have an updated RI monitoring monitoring charts Sokoto N/A health facility = health facility = health facility = 80% charts displayed in all the 169 health facilities providing RI visible on their walls N/A 100% 35% in the state. In Bauchi, 856/984 (87%) of health facilities providing RI Bauchi 93% 92% 87% 87% 90% services submitted their monthly RI reports on a timely Percentage of health basis during the quarter. This indicator reflects data facilities submitting 21 completeness only, not quality. In Sokoto, 482/487 (99%) monthly RI reports on of health facilities providing RI services submitted their a timely basis Sokoto 75% 91% 99% 99% N/A monthly RI reports on a timely basis during the quarter (Apr-Jun, 2016) State = 100% State = 100% State = 100% State = 100% In Bauchi, all the 3 state-level RI review meetings and 57 Bauchi 75% Percentage of LGA=90% LGA = 93% LGA= 95% LGA= 47% out of the 60 planned LGA-level RI review meetings were monthly RI review conducted during the quarter. Similarly, in Sokoto State all 16 State =100% meetings held as State=100% State=100% State = 100% the 3 planned state-level RI review meetings and the 69 Sokoto LGA=100% 75% planned LGA=0% LGA=33% LGA= 33% LGA-level RI review meetings were convened as planned during the reporting quarter.

36 | Page Cumulative PY2 Q1 PY2 Q2 PY2 Q3 Performance PMP MOU targets Achievement Achievement Achievement Achieved from Indicator Indicator State by Dec. 31, Comments (Oct.-Dec. (Jan.-Mar. (Apr-June, January to # 2016 2015) 2016) 2016) December 2016 Number of (national) Bauchi 1 N/A 0 1 TBD policies drafted with National Policy review or adaption is spear headed by the 22 USG (MCSP) support. NPHCDA updating of MLM and IIP modules anticipated to MCSP Global PMP Sokoto N/A 1 0 1 TBD begin in Q4. Indicator Number of RI-related National N/A 0 0 0 TBD technical guidelines, training curricula, Bauchi RI community partnership strategy has been plans, strategies, and Bauchi N/A N/A 1 1 TBD developed, reviewed and finalized. Dissemination of the 23 policies implemented strategy and training of community structures is with MCSP support anticipated in Q4. for RI system Sokoto N/A N/A N/A N/A TBD strengthening/learnin g N/A N/A N/A MCSP is developing a protocol and guide for assessing Number of people Bauchi N/A TBD improvement in capacity among RI managers in the two with increased 26 states. The tool will be used to form baseline in Q4 and capacity for training N/A N/A N/A another follow-up in Q2PY3. MCSP expected to start and advocacy Sokoto N/A TBD reporting this indicator in PY3.

37 | Page Appendix B: Success Story 1

Vaccines Work; a story of Vaccinated Children during Measles Out-beak in Sokoto

Early this year in Sokoto, around the months of February and March; there were about 300 serious measles cases in around 18 local government areas, with no fewer than 50 cases of death due to the epidemic as reported. Recent WHO estimates indicate that close to a million children (868,000 children) under the age of five years die in Nigeria each year. This places Nigeria in the second position in terms of global annual childhood deaths after India. Many of these deaths are caused by vaccine-preventable diseases. Disease such as measles has been almost eliminated in several countries, including some African countries, but still The district head of Gigane (Left), Alhaji Abbas (Middle) and Mallam A. Okene, has high incidences and mortality rates in Nigeria. MCSP LGA consultant (Right)

Measles is a highly contagious viral disease. It remains an important cause of death among young children globally, despite the availability of a safe and effective vaccine. Measles is one of the most infectious diseases known to humankind and an important cause of death and disability among children worldwide. Those unvaccinated against the disease are at risk of severe health complications. A sudden outbreak came as a shock to many in the state, though some people were not surprised due to the low immunization coverage as people don’t take their children to access routine immunization services. Gigane a small community in Gwadabawa local government area was not left behind during the outbreak. There were many confirmed and unconfirmed cases all over including those of deaths. People were crying for help from left, center and right.

A magic happened along the line. In the residence of Alhaji Abbas, a large compound with different household there were about four recorded cases where one child (his nephew) lost his life. To everyone surprise, none among Alhaji Abbas children is infected, people were asking questions about it. He narrated that; it is miracle due to the vaccination status of his children. Alhaji Abbas (Magajin Shiyar Baichi) is a hamlet head in Gigane community. A father to about seventeen children is one of strongest and respected figures in his community. His traditional title makes him among those that usually mobilize the community to access health and social services for the development of his community. It is along this line that he learnt the significance and importance of routine immunization to the health and wellbeing of children. He uses the opportunity to make sure all of his newborn children were fully vaccinated. Though he has managed to complete only primary school education, he gave open-exit permission to his two wives when it comes to their health or that of their children. So, they frequently access health services and that contributed to the status of his children

38 | Page