GOVERNMENT OF ABIA STATE OF NIGERIA

OPERATIONAL GUIDELINES

OF ABIA STATE PRIMARY HEALTH CARE DEVELOPMENT AGENCY (ABSPHCDA) FOR THE IMPLEMENTATION OF PRIMARY HEALTH CARE UNDER ONE ROOF (PHCUOR) March 2019

TABLE OF CONTENTS

Table of Contents 2 List of Tables 4 List of Figures 5 Acronyms 6 Foreword 7 Acknowledgements 8 Executive summary 9 Chapter 1: Introduction 10 1.1 Overview 10 1.2 Principles for Bringing PHC under one Roof 10 1.3 The SPHCDA Operation Guidelines 11 Chapter 2: Governance structures and ownership 12 2.1 Overview 12 2.2 Membership of various governance bodies 12 2.2.1 Governance Structure at the State Level: (State PHCDA) 12 2.2.2 Governance Structure at the LG Level: (LGHA) 13 2.2.3 Governance Structure at the Ward Level: (WDC) 13 2.3 Roles and Responsibilities 14 2.3.1 State Primary Health Care Development Agency (SPHCDA) 14 2.3.2 The Executive Secretary 14 2.3.3 Local Government Primary Health Care Authority (LGHA) 14 2.3.4 Ward Development Committee 15 2.4 Organogram of the SPHCDA 15 2.5 Organogram of the LGHA 16 2.6 Linkage of the SPHCDA with other governance structure 17 2.7 Choosing a functional health facility per ward for the BHCPF 17 2.7.1 Criteria for accreditation of a functional health facility per ward 18 Chapter 3: Legislation 19 3.1 Overview 19 3.2. Abia State Primary Health Care Development Agency (Establishment) 19 Law 2015. Chapter 4: Human Resource For Health 21 4.1 Overview 21 4.2 Human Resource Requirement 22 4.3 Staff Mix 28 4.4 Office set-up 29 Chapter 5: Capacity Building and Mentorship 30 5.1 Overview 30 5.2Capacity Building Needs for SPHCB workers 30 5.2.1 Medical Officers of Health 30 5.2.2 Pharmacist/Pharmacy Technician 31 5.2.3 Community Health Officer 31 5.2.4 CHEW and JCHEW 31

24 5.2.5 Nurses and Midwives 31 5.2.6 Nutritionist/Nutrition Officers/Dieticians 31 5.2.7 Medical Laboratory Scientist, Technicians, Science Laboratory 32 Technologist/technicians 5.2.8 Dental Therapist/Technician 32 5.2.9 Environmental Health Officer 32 5.2.10 Medical Record Officer 32 32 5.2.11 Administrative and Account Staff 33 5.2.12 Cross cutting training needs for PHC program 33 Chapter 6: Funds Management System 34 6.1 Overview 34 6.2 Guiding Principles 34 6.3 Budget Processes 35 6.4 Resource Mobilization 36 6.5 Funds Disbursement and tracking 37 6.6 Results-based Financing 38 6.7 Funds Tracking 38 6.8 Accounting 38 6.9 Role of Auditors 39 6.10 Financial Reporting 39 Chapter 7: Materials Management 40 7.1 Overview 40 7.2 Strategic procurement systems 40 7.3 Reporting Channels 41 7.4 Strategic Purchasing System 41 7.5 Store Management 43 7.6 Asset Management 43 Chapter 8: Integrated Supportive Supervision, Monitoring And 44 Evaluation 8.1 Integrated Supportive supervision and mentorship 44 8.2 Transparent independent oversight role 46 8.3 Data management 46 8.4 Transparent reporting 48 8.5 Monitoring and Evaluation 48 Annex 1: Names of Chosen facility for the BHCPF per ward 51 Annex 2: Participant’s list 61

LIST OF TABLES

Pag e Tables Table 1: Sections of the Abia State PHCDA Establishment Law 2015 19

24 Table 2: Schedules of the Abia State PHCDA Establishment Law 2015 20

Table 3: Human Resource requirement 22

Table 4: Staff mix for each health center 28

Table 5: Staff mix for each health Clinic 29

Table 6: Staff mix for each health post 29

Table 7: Resource Management 37

Table 8: Minimum Standards for Store Management 43

Table 9: Integrated Supportive Supervisory Schedule 45

Table 10: Work plan for solving problems after supportive supervision 46

Table 11: Work plan for Monitoring and Evaluation Framework 49

Table 12: Template for M&E Framework For SPHCDA 50

LIST OF FIGURES

Figure Page Figure 1: Organogram of the SPHCDA 15

24 Figure 2: Organogram of the LGHA 16

Figure 3: Linkage of the SPHCDA with other Governance structure 17

Figure 4: Flow chart showing supply of commodities and reporting 41 channels

Figure 5: Strategic purchasing system process 42 Figure 6: Flow of information in HMIS 47

24 ACRONYMS

ABSHIS Abia Health Insurance Scheme ABSPHCDA Abia State Primary Health Care Development Agency BOEC Basic Obstetrics Emergency Care BHCPF Basic Health Care Provision Fund CB Capacity Building CHEW Community Health Extension Worker CHIP Community Health Influencer and Promoter CHO Community Health Officer DHIS District Health Information System DPRS Department Planning Research and Statistics DVEA Departmental Vote Allocation Expenditure Book EHO Environmental Health Officer EHT Environmental Health Technician FMF Federal Ministry of Finance FMOH Federal Ministry of Health GoN Government of Nigeria HF Health Facility HFG Health Financing Group HMIS Health Management Information System HR Human Resources HRIS Human Resources Information System ICT Information, Communication Technology IMCI Integrated Management of Child Illness IPC Interpersonal Communication JCHEW Junior Community Health Extension Worker LGA Local Government Authority LGHA Local Government Health Authority LGSC Local Government Service Commission MOLG Ministry of Local Government MOJ Ministry of Justice MCH Mother and Child Health M&E Mother and Child Health MLSS Modified Life Saving Skills MSP Minimum Service Package MTRF Medium Term Revenue Framework MTSS Medium Term Sector Strategy NTD Neglected Tropical Disease NHAct National Health Act NPHCDA National Primary Health Care Development Agency OIC Officer in Charge PFM Public Financial Management PHC Primary Health Care PHCDA Primary Health Care Development AGENCY PHCUOR Primary Health Care Under One Roof PHF Primary Health Facilities SHMB State Health Management AGENCY SMOH State Ministry of Health SPHCDA State PHC Development AGENCY UHC Universal Health Coverage USAID United States UNICEF United Nations Children Fund WDC Ward Development Committee WHO World Health Organization

FOREWORD

24 Operational Guideline for the implementation of Primary Health Care Under One Roof is in line with the ongoing revitalization of Primary Health Care. This publication was developed against a background of continuing efforts to reform the Health Sector in Nigeria.

Indeed remarkable progress has been made in bringing Primary Health Care Under One Roof in Abia State. It is instructive to state here that in Abia State, the state Primary Health Care Development Agency and Local Government Health Authority Law was innacted in 2015, the Governing Board is equally in place and the complete transfer of Local Government Health Workers and Primary Health staff of the state Ministry of Health has been achieved, there is an urgent need to develop an operational guideline that will help in the full implementation of PHCUOR at the state, Local Government, Ward and Health Facility levels.

Consequently, the state Primary Health Care Development Agency, the Local Government Health Authority, Official Development Partners, Civil Society Groups and other relevant MDAs undertook a comprehensive review of relevant manuals, legal frameworks and equally received inputs from stakeholders.

The result of the reviews and brainstorming sessions was the development of this scientific document which contains the Roles, and Responsibilities of Primary Health Care Teams at various levels and of course highlighted the measures and activities to achieve PHCUOR and a seamless implementation.

It is obvious that Abia is at an advanced state of implementation of PHCUOR, I am confident that this Operational Guidelines will be of immense value to all and serve as a catalyst for the achievement of the deserved health targets and expectations

Dr. Chinagozi Adindu Executive Secretary

ACKNOWLEDGEMENT

The Governing Board of Abia State Primary Health Care Development Agency is very grateful to all those within and outside the state who contributed to the

24 development, review, finalization and production of the Operational Guidelines of Abia State Primary Health Care Development Agency for the implementation of Primary Health Care Under One Roof.

We profusely thank all individuals, partners, stakeholders who provided the Technical Assistance and funds neede. We are grateful to Dr. Okezie Ikpeazu, the Executive Governor of Abia State, Dr. John Ahukannah, the Commissioner for Health, History and posterity will not forgive us for wrong doing if we fail to pay glowing tribute to the Health Policy Plus (HP+) for facilitating this activity and in making sure that this publication saw the light of the day.

We appreciate the leadership of the National Primary Health Care Development Agency especially the Technical Support Unit (TSU) for coming to our rescue.

Finally we are grateful to the Abia State Primary Health Care Development Agency Management Team, the Local Government Health Authority Secretaries for making refreshing lucid contribution which further enriched this document. We thank you all

Dr. Madu Awa Board Chairman

EXECUTIVE SUMMARY

The Operational Guidelines as a comprehensive publication that encompasses the process, procedures and policies that guides the activities of staff, operators and stakeholders in the delivery of primary health care sector and proper implementation

24 of Primary Health Care Under One Roof the Guidelines provides detailed information on how the Abia State Primary Health Care Development Agency and Local Government Health Authority will be administered in accordance with the provision of the Abia SPHCDA and LGHA Law of 2015.

The publication took a critical look at the Governance Structure and Ownership of the Agency, Legislation, Human Resource Management, Capacity Building and Mentorship for the Human Resource, Funds Management System, Material Management, Integrated Supportive Supervision as well as Monitoring and Evaluation.

Indeed the Operational Guidelines will certainly assist stakeholders, health policy advisors, legislators, governing bodies and managers establish the key elements of the state primary health care institutions, programmes, activities and sustainability arrangement.

This work made frantic efforts to explain in details the principles of Primary Health Care Under One Roof, the membership of various governance bodies such as SPHCDA, LGHA, WDC, VDC and FMC. The Operational Guidelines highlights the roles and responsibilities of key personnel at various levels. The organogram and overview of the Agency Law was made.

A sizeable section of the work was devoted to Human Resources for Health, Overview, Requirement, Staff Mix and Office Setup. The work equally considered the Fund Management System, with emphasis on Budgeting, Fund Tracking, Account, Role of Auditors and Financial Reporting.

While considering material management, reporting channels and asset management, the book devoted final chapter to the imperatives of supportive supervision, monitoring and evaluation, data management and transparent reporting.

The Operational Guidelines will certainly help to fill the gap in the apparent death of books in use for the proper implementation of the Law and PHCUOR. It is a must read for all PHC staff, Ward Development Committee Members, Board Members and other relevant stakeholders in the area of Primary Health Care.

Dr. John Gozie Ahukannah Hon. Commissioner for Health

CHAPTER 1

INTRODUCTION

1.0 Overview

24 Primary Health Care Under One Roof was introduced in Nigeria by 2004 but was approved by the National Council on Health in 2010.

It is in response to evidence-based studies depicting the PHC system in Nigeria as weak due to Fragmentation, Leadership Conflicts, Wide span of control, Duplication of roles / wastage of resources, Weak collaboration and coordination, Poor structure and organization.

It is aimed to harmonize the PHC sub-system (in order to overcome structural constraints and improve coordination with one management body, one plan and one Monitoring & Evaluation System as core principles), establish a unitary, integrated and decentralised management structures and sub-systems, reposition States for successful Implementation of Health Act and Achieve effective service delivery for improved health outcomes.

Abia State government established the State Primary Health Care Development Agency (SPHCDA) in 2012 with an enabling Law enacted in 2015. The ABSPHCDA is the Agency of Government in charge of the 768 Primary Health Care Facilities (both public and private) distributed across 292 political wards in the 17 Local Government Areas (LGAs) of the state.

1.1 Principles for “Bringing PHC under One Roof”

"Bringing PHC under One Roof" is modelled on guidelines developed by the World Health Organization for integrated district-based service delivery and is based on the following key principles: • Integration of all PHC services delivered under one authority, at a minimum consisting of health education and promotion, maternal and child health, family planning, immunisation, disease control, essential drugs, nutrition and treatment of common ailments.

• A single management body with adequate capacity to control services and resources, especially human and financial resources. As this is implemented, it will require repositioning of existing bodies.

• Decentralized authority, responsibility and accountability with an appropriate “span of control” at all levels. Roles and responsibilities at the different levels will need to be clearly defined.

• Principle of “three ones”: one management, one plan and one monitoring and evaluation (M&E) system.

• An integrated supportive supervisory system managed from a single source.

• An effective referral system between/across the different levels of care.

• Enabling legislation and concomitant regulations which incorporate these key principles.

24 1.2 The ABSPHCDA Operation Guidelines

Operational guidelines describe the processes and procedures that staff and other operators/stakeholders of the Agency follow when carrying out their work especially in implementation of PHCUOR. The Guidelines provides detailed information on how ABSPHCDA and LGHA will be administered in accordance with the provision of the enabling Laws. The main objective of the operation guidelines is to provide a clear direction to policy makers and programme managers on the day-to-day activities of the ABSPHCDA and LGHA to ensure efficient delivery of PHC services.

The guideline encompasses the governance structures and ownership of the ABSPHCDA, legislation, human resource management, capacity building and mentorship for the human resource, funds management system, materials management, Integrated Supportive Supervision, Monitoring and Evaluation.

This operational manual for the ABSPHCDA has been developed to assist with the operationalization of the ABSPHCDA and PHCUOR. It is intended to help stakeholders, health policy advisors, legislators, governing bodies and managers establish the key elements of state PHC institutions that can take root and thrive and it encompass all the tasks required to sustain the development of Primary Health Care (PHC) in the long term.

Chapter 2:

Governance structures and ownership

2.1. Overview

The governing body is saddled with the responsibility of setting the PHC vision, winning resources, and holding implementers accountable. The ABSPHCDA is to oversee and ensure the implementation of the state's approach to primary health

24 care. The various governing bodies have been developed through stakeholder engagement that agreed on the scope, mandate, membership and design of the PHC Agency governing body. To ensure that women and community members were adequately represented on the governing structures at state, LGA, Ward and Facility levels, clear criteria were drawn up in conjunction with community members, leaders and groups. The Agency was also established based on the guidelines set out by the National Primary Health Care Development Agency (NPHCDA) and the ABSPHCDA establishment Law No. 5 of 2015.

2.2. Membership of various governance bodies a. A part-time Chairman b. An Executive Secretary who shall provide secretariat services to the Agency; c. The Abia State ALGON Chairman; d. One representative from:

i. Nigerian Medical Association (State Branch). ii. Association of Private Healthcare Practitioners (State Branch). iii. National Association of Nigerian Nurses and Midwives (State Branch). iv. National Association of Community Health Extension Workers (State Branch) v. State Council of Traditional Rulers. vi. Pharmaceutical Society of Nigeria (State Branch). vii. Ministry of Health. viii. Ministry of Education. ix. Ministry of Women Affairs and Social Development. x. Ministry of Information. xi. Ministry of Environment xii. Ministry of Local Government and Chieftaincy Affairs. xiii. Ministry of Finance. xiv. Hospitals Management Board. xv. Association of Alternative Medicine Practitioners. xvi. Association of Environmental Health Officers xvii. Women Group xviii. State Ministry of Justice xix. College of Health Sciences, Aba xx. Two Ex-Officio members

2.2.1 Governance Structure at the State Level: (ABSPHCDA)

1. The Executive Secretary 2. All Directors :  Administration and Human Resources  Finance and Accounts  Reproductive Health and Rights  Immunization and Disease Control

24  Primary Curative Care & Essential Medicines/ Equipment  Community Health Services and Linkages  Advocacy Communication & Social Mobilization  Planning, Research and Statistics 3. Program Officers  Immunization Services  Reproductive Health Services  Family Planning  Nutrition Services  Health Education  Malaria control  HIV/AIDS  NTDs  Tuberculosis/ Leprosy  Nutrition/Maternal, Newborn, Child health services  Cold Chain Services  Community Eye Services  Ear, Nose and Throat care  Technical Support Unit (Desk officer)  Community Mental Health  Community Dental Health  Logistics and Supply Chain Management  Health Promotion  Disease Surveillance and Notification  Monitoring and Evaluation  School Health Services  Baby Friendly Initiative  Growth Monitoring  Adolescent Reproductive Health  Reproductive Health Cancer  Non- Communicable Diseases

4. NPHCDA and Development Partners 5. 3 Representatives of the LGHA secretaries (One from each Senatorial Zone) 6. Representatives from other ministries e.g Agriculture, Works, Water, Environment, Education, Women Affairs 2.2.2 Governance Structure at the Local Government Level: Local Government Health Authority (LGHA)

1. LGA Chairman shall serve as Chairman of the LGHA Adversary Committee 2. Health Authority Secretary 3. Medical Officer

24 4. Heads of Department - Nursing, Community Health, Pharmacy, Disease surveillance, Monitoring and Evaluation, Laboratory services 5. Officers in Charge of WPHCs 6. Officers in Charge of other HCs 7. All program officers (Same as ABSPHCDA) 8. Finance Officers 9. Administrative Officers 10.Representatives from other sectors e.g Agriculture, Works, Water, Education 11.Representative of the patent medicine vendors 12.Civil society organizations

2.2.3 Governance Structure at the Ward Level: Ward Development Committee (WDC)

 Members shall elect the head of the committee (Chairperson)  Clan Head (Patron), but where no such person exists, the most respectable village head or any other person so elected may serve as Committee Patron.  The WDC consist of representatives from each Village Development Committee (VDC) in the villages.  The OIC shall be the secretary of the committee  The Wards Community Development Officer  The committee can where necessary co-opt members of health related sectors such as Secondary School Principals and Primary School Heads, Agric-Extension Workers, EEDC/Water-Works Staff, NGOs. At least 40% of membership will be women and they should be given effective post.  Heads of Health facilities within the ward  National Council of Women Society (NCWS) or its equivalent  Representatives of the Religious Groups  Representatives of CSOs

2.3 Roles and Responsibilities

2.3.1 State Primary Health Care Development Agency (SPHCDA)

(1) The Agency shall provide integrated strategic health planning and development for the delivery of primary health care services, including but not limited to the Ward Minimum Health Care Package, in the State and oversee the implementation of all strategic plans.

(2) The Agency shall be responsible for overseeing the integration, allocation and disbursement of resources and ensure their equitable delivery in the State and Local Government Primary Health Care Authorities.

24 (3) The Agency shall ensure coordination of planning, budgetary provisions, monitoring, supervision as well as implementation of primary health care programmes and services in the State and undertake capital projects.

(4) The Agency shall make appropriate recommendations to the Ministry of Health with respect to:

(a) The nature and scope of delivery of and all matters affecting primary health care services, including but not limited to:

(i) The development, adoption and implementation of policies on primary health care services; and

(ii) The Ward Minimum Health Care Package to be provided by each LGHA;

(b) The demarcation of boundaries of Local Government Health Authorities; and

(c) Any other matter related to the effective functioning of LGHA and health care service delivery. (5) The Agency shall collaborate with the Ministry of Health: (a) On developing policies, Guidelines and Regulations on matters related to and affecting Primary Health Care in the State.

(b) On the development of individual LGHA annual plans and proposed global and individual annual Primary Health Care Fund Account Allocations to the Local Government Health Authority in the Councils; and

(c) To establish a fee structure for health care services, including but not limited to health care services to be provided at no cost;

(d) Related matters.

(6) The Agency shall collaborate with the Ministry of Health and Ministry of Local Government and Chieftaincy Affairs to develop, maintain and continuously update the Health Management Information System.

(7) The Agency shall:

(a) Submit Yearly State of Primary Health Care Report to the Board with copy to the Commissioner for Health not later than the 30th day of June of the succeeding year; and specify levels of primary health care service delivery, including but not limited to the Ward Minimum Health Care Package, and related standards;

(b) Establish its annual performance targets, together with annual performance targets for LGHA, Local Government Technical Health Teams, Health Facility Management Teams and Ward Development Committees;

24 (c) Revise annual performance targets contemplated in clause (b) to accommodate financial and other constraints as they arise and specify realistic targets taking into cognizance constraints;

(d) Promote collaboration among public, private and non-governmental health care providers and major stakeholders, including but not limited to donors and CSOs;

(e) Oversee and manage the integration, allocation and disbursement of resources for primary health care services generally and the Ward Minimum Health Care Package specifically to Local Government Health Authorities; including but not limited to Ward Committees; with the supervision of the Ministry of Health;

(f) Incorporate and assign health care personnel responsible for the delivery of primary health care services and Ward Minimum Health Care Package specifically employed by it or through the Ministry of Local Government and a Local Government Council to relevant Local Government Health Authorities;

(g) Be responsible, as of the date of assignment of health care medical supplies;

(h) The development and implementation of a written policy on all matters relating to procurement by Local Government Health Authorities; and

(i) Coordinate the purchase and distribution of all medical supplies and equipment to Health Facilities;

(j) Support the supervision, monitoring and evaluation of all Primary Health Care Programmes at LGA and health facility levels and using such data for planning, management and decision making.

(9) The Agency shall adopt a Patients Charter in English, Igbo and any other relevant language specifying health user rights and obligations and;

(i) Require the Patients Charter to be visibly displayed at all Health Facilities in the State; and

(ii)Develop and implement a grievance procedure to ensure that a health user has effective recourse in the event their rights as stated in the patients Charter are breached or health users have other complaints requiring redress.

(10) The Agency shall with respect to the referral system:

(a) In consultation with Secondary and Tertiary hospitals and Federal Medical Centre Management, develop and implement an effective referral system from Primary Health Care Facilities to Secondary and Tertiary Health care service levels;

(b) Assess the effectiveness of the referral system from time to time and implement revisions to the referral system as required;

24 (c) Support the development of strategies to strengthen the referral system and encourage, at all times, its utilization.

(11) The Agency shall with respect to planning:

(a) Specify the format to be used by Local Government Health Authorities; and Health Authority Teams for annual plans, including business plans and detailed budgets; and

(b) review Local Government Health Authorities annual plans, including business plans and detailed budget:

(i) May approve, modify or reject an annual plan; and

(ii) Shall, in the event of approving an annual plan, advise the relevant council in writing of its approval; or

(iii) Shall, in the event of modifying or rejecting an annual plan, promptly submit its decision, including written comments and advice to the relevant Authority for amendment;

(iv) Ensure that annual reports are rendered by primary health care facilities in the Local Government Areas Authorities which culminate to the Authority report.

(12) The Agency shall, in consonance with the Public Service Rules:

(a) recruit, promote, post, transfer, train and discipline all Staff of the Agency and the Health Authorities;

(b) Pay salaries and allowances of all Staff in the Agency;

(c) Determine staffing and managerial requirements, categories of staff and required staff qualifications for each Health Management Team and develop job descriptions for each category of Staff;

(d) Determine and implement terms and conditions of service pursuant to public service rules and regulations for all levels of Agency employees, including remunerations, allowances and benefits at the time of transfers, allowances and benefits thereafter;

(e) Monitor activities of Local Government Primary Health Authorities on appointments, discipline and promotions of employees GL 01-06 in order to ensure that the guidelines are strictly and uniformly adhered to;

(f) Consider and approve promotions for Primary Health Care employees on GL 01 to 06 as recommended by each Local Government Health Authority and Serve as the appellate body for all dismissals, retirement and petitions from aggrieved Primary Health Care employees on GL 01 to 06;

24 (g) Appoint Health secretaries for each Health Authority, who shall be a person not below the rank of a Deputy Director;

(h) Process the selection and appointment of Health Authority Management Team staff;

(i) Determine and implement mechanisms to provide for the oversight and supervision of each Health Authority and Health Authority Management Team;

(j) Establish an evidence-based performance monitoring system for all categories of staff, programs and activities;

(k) Develop incentives to reward staff performances and sanctions to address improvement of Staff performances

(l) Ensure appropriate external and on-the-job training for each category of staff for the continuous upgrading of staff capacity with proper re-orientation to community participation and development; and

(m) Collaborate with the College of Health Technology, School of Nursing and Midwifery and any other health training institution that may be established in the State for the development of human resources for health.

(13.) The Agency shall, with respect to accounting and financial management systems:

(a) Establish and maintain accounting and financial management systems to be used by the Agency, Local Government Health Authorities;

(b) Assist each Local Government Health Authority in establishing and maintaining proper accounting and financial records in accordance with the highest financial standards;

(c) Ensure annual auditing of accounts of primary healthcare facilities in the Local government Authorities;

(d) Assist Health Authority Management Teams with planning and budgetary processes to implement and maintain financial management and accounting systems;

(e) The Agency shall encourage and assist Local Government Health Authorities; with the development of funding mechanisms to increase available funding for primary health care services generally and the Ward Minimum Health Care Package specifically and assist Local Government Health Authorities in resource mobilization.

(14.) The Agency shall with respect to general administrative support:

(a) Provide general administrative support including developing a performance monitoring system for each Local Government Health Authorities;

24 (b) Supervise and monitor the activities and outputs of each Local Government Health Authority, Local Government Technical Health Team, Health Facility Management Team and Ward Committees;

(c) Work with Local Government Health Authorities to establish their headquarters and physical infrastructure;

(d) Establish minimum requirements for Health Facilities and oversee the acquisition and renovation of Health Facilities by each Local Government Health Authority;

(e) Establish minimum equipment requirements and oversee the acquisition and maintenance of equipment by each Local Government Health Authority; and

(f) Establish minimum vehicle requirements and oversee the acquisition and maintenance of vehicles by each Local Government Health Authority.

24 24

(15) The Agency shall in collaboration with the Ministry of Health;

(a) Develop a written policy on all matters affecting the delivery of primary health care services generally and the Ward Minimum Health Care Package specifically, including but not limited to minimum standards for community participation;

(b) Domesticate and disseminate National policies, Guidelines and standard operating procedures to all Local Government Health Authorities for distribution to the relevant Health Authority Management Team and Ward Committees; and formulate State Primary Health Care Policy;

(c) Ensure that Councils and Ward Committees implement the policy contemplated in Sub section (a).

(16.) The Agency shall receive report from all Local Government Health Authorities on their performance and financial management and meet as required with Councils.

(17.) The Agency shall submit annual report on the State of Primary Health Care in the State to the Commissioners for Health and Local Government.

(18.) The Agency shall coordinate activities with and in relation to other health care stakeholders, including but not limited to donor partners.

(19.) The Agency shall undertake any other action reasonably required to implement the objectives of the Law.

(20.) (a) The Agency may enact or amend rules for the operation of Local Government Health Authorities, Local Government Technical Health Teams, Health Facility Management Teams and Ward Committees in line with its Guidelines and Public Service Rules.

(b) The Agency shall promptly distribute any rules contemplated in Sub section (a)

(c) The Agency shall oversee the implementation of all rules.

2.3.2 The Executive Secretary

(1) The Executive Secretary shall be responsible for the day to day execution of the Agency’s policy, general management of the business of the Agency and other functions as may be directed from time to time by the Board. He/She shall also be responsible for the following:

(a) Making arrangement for the meetings of the Board of the Agency;

(b) Preparing the agenda and minutes of such meetings;

24 (c.) Executing of the decisions of the Board of the Agency;

(d.) Keeping proper records of the proceedings of the Board of the Agency;

(e.) Signing all contractual documents/agreements of the Agency;

(f.) Arranging for the payment of fees and allowances of members of the Board; and

(g.) Performing such other functions as the Board may from time to time direct.

(2.) The Executive Secretary shall report to the Agency Governing Board.

2.3.3 Local Government Primary Health Care Authority (LGHA)

(a) Coordinate and ensure the planning for and the provision and delivery of Primary Health Care Services generally and the Ward Minimum Health Care Package specifically, including equitable access to and a defined quality of the Minimum Package of Primary Health Care Services, as specified by the Agency.

(b) Integrate, as directed by the Agency, State and Local Government Health Care Service providers, management, staff, health facilities, equipment and vehicles into Local Government Health Authority;

(c) Collaborate with all relevant agencies responsible for other sectors that impact on health to achieve common objectives;

(d) Establish its Health Authority Management Team, which shall consist of departments, as may be established by the Agency;

(e) Establish in consultation with relevant Local Government Chairmen, Ward Committees under Section 63 of the Law;

(f) Implement health care delivery in line with Agency guidelines;

(g) Manage and monitor the performance and quality of health care provided by the Health Facility Management Team as well as Ward Development Committee to ensure that Ward Minimum Health Care Package is routinely provided in the LGA.

(h) Ensure that health services information are available in the health facilities and communities in English, Igbo and any other relevant language.

(i) Ensure that the Patients Charter is prominently displayed at all Health Facilities;

(j) Provide general administrative support to the Health Authority Management Team and Oversight for Health Facilities;

24 (k) Maintain and manage land, buildings, equipment, vehicles and medical supplies pursuant to Agency guidelines or requirements.

(l) Establish and maintain financial and accounting systems pursuant to Agency requirements;

(m) Assist Communities with Health Facilities in the Ward with the development of annual operational work plan, in line with the format specified by the Agency;

(n) Amalgamate all Ward committee/Health Facility plans into the Local Government Health Authority annual Operational Work plan, including a costed budget and submit the annual plan to the Agency on the prescribed date;

(o) Operate and maintain the Health Management Information System prescribed by the Agency;

(p) Implement the referral system as prescribed by the Agency;

(q) Promote collaboration among all health care providers at all levels of health care service delivery within the LGA;

(r) Coordinate activities with and in relation to stakeholders, including but not limited to Local Government Health Authority, Health Authority Management Teams, Local Government Health Technical Teams, Health Facility Management Teams and Ward Development committees;

(s) Collaborate with other Local Government Health Authority to ensure effective coverage in service delivery with no gaps, duplication or wastage;

(t) Monitor and evaluate activities and outputs of the Local Government Health Authority Management Team;

(u) Report as required on Local Government Health Authority financial management and Health Authority Management Team performance;

(v) Ensure compliance with the performance monitoring system prescribed by the Agency;

(w) Meet with the Agency as required;

(x) Submit yearly state of Local Government Area Primary Health Care Report to the Agency with copy to the LGA Chairman not later than 31st day of March of the succeeding year; and

(y) Take any other steps the Agency reasonably requires to implement the objectives of the Law.

2.3.4 Ward Development Committee

24  Identify health and social needs and plan for them:  Supervise the implementation of developed work plans,  Identify local human and material resources to meet these needs;  Forward all health/community development plans (village, facility and Wards levels to LGA)  Mobilize and stimulate active involvement of prominent and other local people in the planning. implementation, and evaluation of projects  Take active role in the supervision and monitoring of the Wards Drug Revolving Fund  Raise funds for community programmes when necessary at village, facilities and Wards levels;  Provide feedback to the rest of the community on how funds raised are disbursed:  Liaise with government and other voluntary agencies in finding solution to health, social and other related problems in the Wards;  Supervise the activities of the VHWs  Monitor activities at both the health facilities in the Wards:  Provide necessary support to VHWs  Ensure that a Bank account is opened with a reliable commercial bank. The signatories will be as given by the ABSPHCDA guidelines on the Ward Health Systems document.

2.4 Organogram of the SPHCDA. ABIA SPHCDA ORGANOGRAM GOV HC H BOARD Procurement Servicom & Anti-

corruption and Supplies

Internal Audit

& Protocol Unit Protocol & mgt mgt Legal EXECUTIVE SECRETARY PR/Information/Knowledge Board Matters PHC system Development &

Resource Mobilization Stakeholder Dep Engagement Immuart Repr Primary nizati Commu Planni Fina me o Curative onnts & nity ng, Care & nce Admin Heal Health Resear Essential & & Services ACSM Medicin Disea th& ch & Acco Program & es/ HRH se Righ Statisti unts mes/Contr Linkages cs Equipme interven ts ol nts tionsFigure 1: Organogram of the ABSPHCDA LGHA Figure 1 shows the organogram of the ABSPHCDA. On the whole, there are 8 directorates each headed by a director to take care of several services including general administration, human resource and training; finance and accounts; reproductive health, family planning, disease control, immunization, disease surveillance, non communicable disease, maternal & child Health; policy planning, research, monitoring and evaluation, capital projects, operations research; laboratory

24 services; essential drugs, logistics, community health services, home visits, Health promotion, nutrition, advocacy, communication, social mobilization

2.5 Organogram of the LGHA Figure 2, shows the organogram of the LGHA. The LGHA has 8 directorates consisting of pharmaceutical services; community health services; laboratory services as well as monitoring and evaluation, Logistics & Drug Revolving

LGHA ORGANOGRAM

ES, ABSPHCDA

Executive Chairman Servicom & Anti- corruption LGHA Advisory Procurement and Supplies Legal BOARD

LGHA Advisory Internal Audit

Matters

mgt & Protocol Unit Protocol & mgt Resource PR/Information/Knowledge Mobilization Health Authority Secretary

PHC system Development & Stakeholder Engagement dep art men t HOD Disease HOD Environmental HOD HOD MCH/ Control HOD Health HOD Health Sanitation Education/Comm FINANCE/ACC /Immunizatio HOD PRS Services Admin RH unity Mobilization ONT n

WPHC WDC

HEALTH CLINIC VDC

HEALTH POST CDC/CHIPS

Figure 2: Organogram of the LGHA

2.6 Linkage of the ABSPHCDA with other Governance structure

Figure 3, shows the linkages with other sectors and governing bodies depicting inter sectoral collaboration

24

SMOH (Policy Formulation)

Ministry of Local Works Government Service SPHCDBABSPHCDA OABSHIA’HIS Commission Ministry of

(Policy implementation) Finance NPHCDA

Zonal office Ministry of Women Affairs

HumanMinistry of Ministry of Ministry of ResourcesLG&CA MinistryMinistry of water of Agriculture Education andEnvironment Environmental

Sanitation

Figure 3: Linkage of the ABSPHCDA with other Governance structure

2.7 Choosing a functional health facility per ward for the BHCPF

To ensure a minimum of one functional primary Health centre in every political ward, the ABSPHCDA and the LGHA is required to identify one primary health centre in their various political wards and ensure that they meet the minimum standards for PHC in Nigeria which defines Human Resource for health, service delivery, infrastructure, medicines, consumable commodities and equipment. States and L.G.A shall conduct the needs assessment and baseline surveys for the health facilities, which will identify investment options and potential areas of development.

The proposals from the states and LGAs should be in line with the National Health Act, which stipulates that from the 45% BHCPF to the NPHCDA, 20% of the Fund shall be used to provide essential drugs, vaccines and consumables for eligible primary health care facilities; 15% of the Fund shall be used for the provision and maintenance of facilities, equipment and transport); and 10% of the Fund shall be used for the development of human resources for primary health care.

2.7.1 Criteria for accreditation of a functional health facility per ward

The criteria employed for the accreditation of a functional health facility is as shown in box 1 below

1. Client flow 2. Manpower

24 3. Type of services rendered e.g Immunization, delivery services 4. Facilities available - water, toilet, electricity supply 5. Availability of drugs and basic equipment(As contained in BHCPF Operational Guideline) 6. Befitting structure in terms of space and aesthetic value 7. Accessibility

Box 1: Criteria employed for the accreditation of a functional health facility

CHAPTER 3

LEGISLATION

3.1 Overview

Legislation is one of the most important instruments of government in organising society and protecting citizens. It determines amongst others the rights and responsibilities of individuals and authorities to whom the legislation applies.

Without legislation, managers in the public sector have no framework to guide them in the performance of their duties and no legal footing to backstop their actions. A law to provide for the establishment of the Abia State Primary Health Care Development AGENCY and matters connected therewith has been passed. The Law

24 is cited as the Abia State Primary Health Care Development agency and Local Government Health Authority (Establishment) Law No. 5 of 2015.

In developing the bill, there was strong consensus among all stakeholders including government structures, for example the State Ministry of Health, State Ministry of Local Government & Chieftaincy Affairs, Local Government Service Commission, State Ministry of Finance, State Ministry of Justice, State Civil Service Commission and State Ministry of Women Affairs; Legislators; LGA council chairmen, council and management; PHC co-ordinators (now Health Authority Secretaries); partners, community-based organisations, professional groups; traditional and religious leaders; private health professionals. It is important that this Law is widely disseminated to relevant stakeholders

3.2. Abia State Primary Health Care Development Agency and Local Government Health Authority (Establishment) Law No. 5 of 2015

The Law has 23 part, 106 sections and 8 schedules. The various sections are shown in table 1

Table 1: Sections of the ABSPHCDA and LGHA Establishment Law 2015

S/ Description N 1 Preliminary 2 Agency, Establishment, Composition and Tenure of Office 3 Board Proceedings 4 Board Committees 5 Functions, Duties and Powers of the Agency 6 Executive Secretary 7 Agency Departments and Staffing 8 Agency Funding, Bank Account and Expenditure 9 Establishment and Composition of Local Government Health Authority (L G H A) 10 Local Government Health Authority Proceedings 11 Powers, Functions and Duties Specific to Local Government Health Authorities 12 Local Government Health Authority Committees and Sub-Committees 13 Miscellaneous Powers of Local Government Health Authorities 14 Local Government Health Authority Technical Teams 15 Ward Development Committees 16 Health Facility Management Team 17 Primary Health Care Fund Account 18 General Financial Provisions 19 Rectification Measures 20 Audit 21 Transitional Provisions 22 Legal Proceedings 23 Miscellaneous

24 Table 2: Schedules of the ABSPHCDA and LGHA Establishment Law No. 5 of 2015

S/N Schedule 1 Resignation 2 Standing Orders 3 Voting 4 Meetings 5 Committees 6 Seal of the AGENCY 7 Validity of proceedings 8 Disclosure of interest

CHAPTER 4

HUMAN RESOURCES FOR HEALTH

4.1 Overview

Human Resource for Health (HRH) development will support the states to aspire to achieve the minimum HRH standards for PHC service delivery. In keeping with the ‘PHC under one Roof’ Policy, HRH for PHC will be managed and governed by the SPHCDA. Human Resource for ABSPHCDA should have the capacity to deliver the services defined in the minimum service package for the State.

Human resource management is one of the key challenges that will face new structures such as the SPHCDA. These challenges include the size, distribution, and skill mix of the health workforce, inadequate training of number of required health

24 workers, mal-distribution of the trained personnel, high attrition rate, the movement of staff from the existing bodies to the new Agency, the appointment of management staff at state and LGA levels and the inherited problems of misdistribution of staff between urban and rural areas, ghost workers and imbalance between professional and non-professional cadres.

In tackling these problems it is recommended:

a) Establishment of a human resource unit or department in the ABSPHCDA and LGHA b) Establishment of a human resource information system (HRIS) database of existing staff to ensure the right number of staff with the right skills are in the right place carrying out the right services. c) Establishment of a high profile Human Resource (HR) committee with clear terms of reference to deal with the issues of HR misdistribution, ghost workers and the balance between types of staff. This is important as most HR issues have a governance or political dimension. d) Use the developed MSP to determine HR needs at all facilities, mix and numbers of staff required for each facility. e) Appointment of LGHA HR management team with adequate HRH planning and management capacity

Human resource management for ABSPHCDA should consists of deployment of staff, staff duty records, Staff appraisal, Job Description, time sheet, Staff performance sheets, output sheets and Staff compliance with HR policies

4.2 Human Resource Requirement Based on stakeholder consensus, the following cadre and quantity has been recommended. For the recruitment guideline (refer to the law establishing the AGENCY). This is shown in table 3.

Table 3: Human Resource requirement Cadre Qualification Present Expected Gaps S/ N 1 Executive Bachelor of Medicine, Bachelor 1 1 0 Secretary of Surgery (MBBS) degree, or its equivalent, recognized by the Medical and Dental Council of Nigeria; Registration with the Medical and Dental Council of Nigeria; Possession of the current license to practice, issued by the Medical and Dental Council of Nigeria (MDCN).

24 Relevant qualification in public health (i.e. M.com, MPH, Medical Fellowship & minimum of 15 years work experience).OR Health personnel with vast experience in Public Health 2 LGHA Bachelor of Medicine, Bachelor 17 17 0 Health of Surgery (MBBS) degree, or its Authority equivalent, recognized by the Secretary Medical and Dental Council of (HAS) Nigeria; Registration with the Medical and Dental Council of Nigeria; Possession of the current license to practice, issued by the Medical and Dental Council of Nigeria (MDCN). Or Nurse/Midwife/Public Health Nurse/Community Health Officer/ Environmental Health Officer with Health related Degree and at least 15 years experience in Public Health programes and service delivery. 3 Medical Bachelor of Medicine, Bachelor 7 294 287 Officer of Surgery (MBBS) degree, or its equivalent, recognized by the Medical and Dental Council of Nigeria; Registration with the Medical and Dental Council of Nigeria; Possession of the current license to practice, issued by the Medical and Dental Council of Nigeria (MDCN). 4 Pharmacist Bachelor of Pharmacy (B. 0 17 17 Pharm) degree or equivalent qualification, recognized by the Pharmacists Council of Nigeria (PCN); Registration with PCN; Possession of the professional license to practice, issued by PCN 5 Pharmacy Pharmacy technician certificate 66 294 228 technician/As issued by the sistant school of health technology accredited and recognized by the Pharmacists Council of Nigeria (PCN); Registration with the PCN; Possession of current annual permit to practice, issued

24 by PCN. 6 Community Must have completed a 24-month 56 294 238 Health Officer course for 2Community (CHO) Health Officer Course in an approved University Teaching Hospital or College of Health Technology; Must be registered by Community Health Practitioners Registration AGENCY of Nigeria (CHPRBN); Possession of a current license to practice by the CHPRBN

7 Nurse/ BNSc/or RN/RM or its equivalent, 396 1336 940 Midwives or other specialized areas of Nursing) ; Registration by the Nursing and Midwifery Council of Nigeria(NMCN) ; Possession of the current license to practice, issued by the NMCN 8 Community Ordinary National Diploma; Must 1059 1202 143 Health have completed a 36-month Extension course for Community Workers Health Extension Worker in an (CHEWs) approved Health Institution or; Must be registered by Community Health Practitioners Registration AGENCY of Nigeria (CHPRBN); Possession of a current license to practice by the CHPRBN 9 Junior JCHEW Certificate. Must have 338 2157 1819 Community completed a 24-month course for Health Junior Community Health Extension Extension Worker in an approved Workers Health Institution; Must be (JCHEWs) registered by CHPRBN; Possession of a current license to practice by the CHPRBN 10 Health WASCE/GCE O/L 833 908 75 Attendant/ Assistant 11 Dental Certificate, BSc. Or HND in 0 292 292 technician Dental Technology or equivalent qualification from accredited Schools or institution; Possession of current license issued by the relevant regulatory body. 12 Medical Possession of the relevant 136 294 158

24 Record bachelor’s degree , HND or Officers equivalent qualification; National Certificates and OND in Health Information; Management; Possession of required Practicing license; Possession of postgraduate degree and or relevant professional qualifications 16 Medical Lab. Bachelor of Medical Laboratory 0 34 34 Scientist Science (BMLS) degree or equivalent qualification, recognized by the Medical Laboratory Science Council of Nigeria (MLSCN); Registration with the MLSCN; Possession of the current license to practice, issued by the MLSCN 17 Nutrition HND/BSC 3 37 34 Officer 18 Scientific HND/BSC Biological and medical 15 49 34 Officer sciences 19 Environmenta HND/BSC in Environmental 538 l Health Health, Environmental Sciences Technicians/ Officers 20 Medical Certificate issued by the Medical 185 294 109 Laboratory Laboratory Technician Science Council of Nigeria (MLSCN); Registration with the MLS; Possession of current annual tag issued by MLSCN 21 Ambulance JSS3 certificate/TT3 0 292 292 driver 22 Drivers JSS3 certificate/TT3 0 34 34 23 Security Primary 6 certificate 39 908 869 guard

4.3 Staff Mix

The staff mix for each facility as recommended by WHO is as follows:

Table 4: Staff mix for each PHC

Cadre Number Community Health Officer 1 Nurse/Midwife 4 CHEWs 3 JCHEWs 6 Health Technician 2

24 Pharmacy technician 1 Health Attendant/Assistant 2 Medical Officer 1 Environmental Health Officer 1 Laboratory technician 1 Medical Record Officer 1 Security Personnel 2

Table 5: Staff mix for each health Clinic

Cadre Number Nurse/Midwife 2 CHEW (must work with standing 2 order) JCHEW 4 Health Attendant/Assistant 2 Security personnel 2

Table 6: Staff mix for each health post

Cadre Number JCHEW 1 CHIPS 1 Security personnel 1 Functional community/VDC

4.4 Office set-up A conducive work environment is important for optimal productivity. It is necessary that suitable office accommodation should be provided for both ABSPHCDA and LGHA. In selection of office, it important to draw up clear criteria to guide the process and this should be used by the team looking for offices. It is equally important that appropriate offices, in terms of location and space are chosen to enable the Agency function effectively. The requirements needed to operationalize these offices should be clearly stated and included in the start-up budget proposal and subsequent costed annual operational plans of both the Agency and various LGHA.

To make the office functional, there should be adequate tools to work with. For example vehicles, equipment, computers, laptops, photocopiers, printers, scanners, internet facilities, furniture etc should be made available to enable the ABSPHCDA and LGHA to perform their duties. It is important to maintain inventories of these items.

The building for the offices must have a clean water supply system (public water supply or from a motorized borehole), functional toilet facilities, office connected to the national grid and other regular alternative power source.

24 These have been achieved in Abia State

24 CHAPTER 5 Capacity Building and Mentorship

5.1 Overview

Many capacity building programmes for managers are theoretical in nature and remove the health workers from their sites of work in order to train them. Health workers need a work-based programme and need to be coached and mentored. These are all key elements in the design of a capacity building programme.

Evidence-based learning allows training participants to be immersed in their learning environment, to learn by doing, and to instantly plough back lessons learned into future work because it involves practical and hands-on learning. Therefore a structured management capacity building programme needs to be developed. There are several models currently operational in Nigeria. It is proposed to use an on-the- job coaching and mentoring approach with minimal time away from work. The capacity building programme should be tailored to state specific circumstances that can be adjusted according to the budget available and could be linked to a certificated programme through a tertiary institution, if needed.

It is also important to make sure that participants in training are able to step down their knowledge to their peers and subordinates who were not opportuned to attend the training within four weeks after the training. This is an important aspect of health training programs that those who design training should take into consideration. This allows participants to fully embrace the training programme and prepare to guide others once they are back in their work environments.

The capacity building programmes should start with managers (ES, HAS, HoDs, Programme Officers), especially those managers in the new structures. They, in turn, will lead the managerial and technical development of staff throughout the PHC system. It is also important that capacity building plan is developed and that it has a budget line in the ABSPHCDA annual budget.

5.2 Capacity Building Needs for ABSPHCDA workers

The following are capacity building needs for the ABSPHCDA workers

5.2.1 Medical Officers of Health

1. Leadership and management for health

2. Refresher courses on clinical or case management of diseases

24 3. Training on ISS and M&E

4. Training on Information, Communication Technology (ICT)

5. Interpersonal Communication (IPC)

6. Expanded Life Saving Skills

7. Logistics Management information System

8. Comprehensive Emergency Obstetric Care

9. Annual professional conferences/seminars/workshops

10. New trends in PHC/Public Health/Medicine as it presents

11. Research and Report writing

5.2.2 Pharmacist/Pharmacy Technician 1. Logistic management training for public health and Nutrition commodities 2. Training on Information, Communication Technology (ICT), Procurement, Essential Drug List, Quantification, Inventory control & Distribution etc 3. Logistics Management information System 4. Leadership & Management training 5. Annual professional conferences/seminars/workshops 6. New trends in PHC/Public Health/Medicine as it presents 7. Research and Report writing

5.2.3 Community Health Officer 1. Leadership and Health management training

24 2. Life Saving Skills 3. Training on Information, Communication Technology (ICT) 4. IPC & Counselling Skills 5. Logistics Management information System 6. Case management of diseases including IMCI 7. Basic Emergency Obstetric Care (BEOC) 8. Annual professional conferences/seminars/workshops 9. New trends in PHC/Public Health/Medicine as it presents 10.Report writing

5.2.4 CHEW and JCHEW 1. Patients intake and assessment 2. Refresher course on Protocol delivery 3. Interpersonal Communication and Counselling skills 4. Health promotion 5. Training on Information, Communication Technology (ICT) 6. Modified Live Saving Skills (MLSS) & Modified Essential newborn care 7. Logistics Management information System 8. Case management of diseases including IMCI 9. Basic Obstetric Emergency Care (BOEC)

5.2.5 Nurses and Midwives 1. Training on Information, Communication Technology (ICT) and data management 2. IPC & Counselling skills 3. Life Saving Skills & Essential newborn care 4. Leadership and Health Management training 5. Logistics Management information System 6. Case management of diseases including IMCI 7. Basic Emergency Obstetric Care (BEOC) 8. Family planning counselling, education and services 9. Refresher courses 10.Annual professional conferences/seminars/workshops 11.New trends in PHC/Public Health/Medicine as it presents 12.Report writing

5.2.6 Nutritionist/Nutrition Officers/Dieticians 1. Training on Information, Communication Technology (ICT) 2. IPC & Counselling skills 3. Refresher training on new and emerging nutrition issues 4. Leadership & Management training 5. Nutrition Information System 6. New trends in PHC/Public Health/Medicine as it presents 7. Annual professional conferences/seminars/workshops 8. Research and Report writing

24 5.2.7 Medical Laboratory Scientist, Technicians, Science Laboratory Technologist/technicians 1. ICT and data management 2. Laboratory quality management system essentials 3. Update training on HIV diagnosis, malaria and TBL diseases 4. New trends in medical laboratory sciences 5. Logistics Management information System 6. IPC & Counselling skills 7. Leadership & Management training 8. Logistics Management information System 9. Annual professional conferences/seminars/workshops 10.Research and Report writing

5.2.8 Dental Therapist/Technician 1. ICT and data management 2. IPC & Counselling skills 3. Refresher courses 4. Logistics Management information System 5. Annual professional conferences/seminars/workshops 6. Research and Report writing

24 5.2.9 Environmental Health Officer 1. ICT and data management 2. IPC & Counselling skills 3. Refresher courses 4. Leadership and management skills 5. Annual professional conferences/seminars/workshops 6. New trends in PHC/Public Health/Environmental Health as it presents 7. Disease Surveillance and Notification 8. Research and Report writing

5.2.10 Medical Record Officer 1. ICT and data management including HMIS 2. Disease Surveillance & Notification 3. Refresher courses 4. Annual professional conferences/seminars/workshops 5. Report Writing 6. Record keeping

5.2.11 Administrative 1. Training on Information, Communication Technology (ICT) 2. IPC 3. Logistics management and information system 4. Leadership and management training 5. Human Resource/ personnel management training 6. Refresher courses 7. Report writing

5.2.12 Account Staff 1. Training on Information, Communication Technology (ICT) 2. Audit 3. IPC 4. Logistics management and information system 5. Leadership and management training 6. Refresher courses 7. New trends in accounting and auditing system 8. Annual professional conferences/seminars/workshops 9. Report writing

5.2.13 Scientific Officer 1. ICT and data management 2. Refresher courses 3. Logistics Management information System 4. Annual professional conferences/seminars/workshops 5. Research and Report writing

5.2.14 Cross cutting training needs for PHC program

24 1. Integrated supportive supervision for programme implementation 2. Capacity building for optimum financial management and efficiency of spending 3. Maternal Perinatal Death Surveillance Response for health workers (Doctors, Nurses/midwives, Surveillance Officers, CHO/CHEW, Medical Lab scientist, Medical Record etc) 4. Management of Severe Acute Malnutrition (Doctors, Nutrition Officers, Nurses/Midwives, CHO/CHEW, Pharmacist) 5. Mass administration of preventive chemotherapy NTD Drugs and Case management for facility based health workers 6. Early identification of emergency cases and referral 7. Early detection, screening and management of non communicable diseases and appropriate referral 8. Health promotion, hygiene education and WASH 9. Health & Safety at Workplace 10.Environmental sanitation and vector management 11.Primary Health Care Under One Roof 12.Basic Health Care Provision Fund 13.Training on the Operational Guidelines 14.Training and re-training of OICs and WDCs 15.Training for the ABSPHCDA and LGHA management team on governance and general oversight in policy formulation and direction 16.Training for the ABSPHCDA and LGHA management team on the use of the Minimum Service Package and operational guideline

24 CHAPTER 6

FUNDS MANAGEMENT SYSTEM 6.1 Overview

Financial resources are a key ingredient in ensuring the success of “Bringing PHC under one roof”. SPHCDAs by virtue of the Law establishing ABSPHCDA is empowered to acquire, utilize as well as disburse funds from and to relevant organizations, LGHA and health facilities for health care delivery. Statutorily, the ABSPHCDA would create a funds management unit and appoint an appropriately skilled officer (Accountant) as the Funds Manager for the AGENCY with clearly defined terms of reference. Such persons must have the skills to closely monitor the costs and risks of the cash and assets flows to the ABSPHCDA. This unit will also be tasked with supporting budgeting process within the organization as well as tracking revenue and expenditure procedure with the organization.

The unit designs the internal order which is used periodically to allocate budgeted funds to support different or specific strategic initiatives within the system including the account hierarchy and sources of funds. It is the role of the funds management unit to keep on monthly or quarterly basis reports for each type of account as well as review the status of all existing funds and rate of spending. Depending on the account type and source of funding, the unit also has the role of defining the procedure for retiring or closing the accounts as the case maybe. It is the role of the unit to ensure that funds are utilized for their original intent to reduce to barest minimum any form of inefficiency. Financial Management in any health care setting requires exceptional insights and skills to ensure efficiency.

6.2 Guiding Principles

To ensure the smooth operations of the Funds management unit within the SPHCDA, there is need to clearly set out its guiding principles as follows:

a. Develop mechanisms for joint (Basket or Pool) funding for implementing MSP. This allows the state, local government and development partners to contribute to the management and running of services provided by the ABSPHCDA and LGHA b. Develop the capacity to plan, budget and track release of funds c. Maintain a focus on accountability and transparency on budgeting process, the utilization and disbursement of all funds for the smooth running of the ABSPHCDA , LGHA and the State Health system d. Facilitate and promote a strong and effective strategic coordination that will generate results for informed decision making in terms of resource allocation. e. Put in place strategies to ensure release of funds. Deduct from source as first line charge. If the State adopts the direct facility financing models such as

24 Results Based Financing (RBF) or for the BHCPF, releases should be made directly to points of utilization. f. Ensure disbursement of operational and programmatic funds aligned with relevant legislation, policies and set guidelines. g. Ensure that expenditures are appropriately tracked, performance is reviewed and amendment made where and when necessary.

a. Budget Processes

The promising initiatives of the PHCUOR can only be implemented if their underlying priorities and strategies are reflected in the annual budget of the Ministry of Health , ABSPHCDA and LGHA. Over the years, there has been clear disconnect between health policies and annual budgets due to lack of clarity in translating funding to activity. Outlined below are clear budgeting strategies to mitigate the challenges identified as per budgeting for health. Activity #1: Initial steps and processes for developing the budget for the SPHCDA

 The Executive Secretary of ABSPHCDA, all directors, deputy directors and program officers should drive the budget process  The State budgeting template which consists of recurrent, overhead, capital costs should be used. And relevant staff should be trained on the use of the template.  ABSPHCDA should also ensure that the main components of the State PHC budget are annual budget, mid-term budget (2-3 yrs) and long term budget (5- 10yrs).  The ABSPHCDA as first step must identify its strategic objectives for the year and work with that to set goals and targets  ABSPHCDA should draw up an annual budget calendar (both internal and external calendar)  Identify at what time in the year, the Ministry of Budget and Planning sends out the call circular for budget preparation and submission  In developing the budget, the following factors should be considered: (Operational plans, program need, target population, funds available, revenue accruable, areas of priority and available current health indices)  The ABSPHCDA team must understand the Ministry of Finance’s Medium Term Revenue Framework (MTRF) – A retreat can be held to fast track this process.  Also work to understand the Medium Term Sector Strategy (MTSS), how it fits into a programmatic budget and how it ultimately translates into a detailed annual budget.  ABSPHCDA must ensure that its budget reflects its strategic objectives and priorities for the year

24 Activity #2: Identifying opportunities in the budget process for improved execution.  Once budget is created, it needs to be executed which, especially in the case of investment in health through capital expenditure, often involves complicated fiscal transfers.  The SPHCDA can leverage the support of local implementing partners to identify some of these opportunities  These opportunities will likely span many aspects of budget execution, including improved monitoring of funds and emphasis on strategic purchasing of health goods/services.  This process of improving Public Financial Management (PFM) is especially pertinent in light of the BHCPF pilot.  The SPHCDA will need to ensure that money is distributed successfully to the PHCs identified in each ward and, once it gets there, that the PHCs use it well.

6.4 Resource Mobilization (RM)

Resource mix at the disposal of the ABSPHCDA to meet her obligations is limited and so this will necessitate both domestic and international resource mobilization. There are international best practices on resources mobilization that the ABSPHCDA can leverage to initiate resource mobilization.

The SPHCDA will outline all sources of funding available to it in order to strategize on how to harness these funds. Sources of funds available to the SPHCDA will include allocations from the State Government through the State Ministry of Health, Contract Taxes, Donor Contributions to the SPHCDA by UNICEF, WHO, USAID, HFG, PSI, Philanthropy, and transfers from NPHCDA and funds from any other source. These contributions should go into the basket funds

To ensure the sustainability of these funding streams, ABSPHCDA will need to be strategic; this entails the generation of results and evidence to substantiate the impact of funds utilized. These evidences can be used to develop advocacy briefs for resource mobilization both for domestic resources and from other sources. An in- depth analysis of the resource outlay and environment including resource needs is key to a successful RM exercise with potential resource partners participating in the initial stages of the design. Resource partner’s interests should be identified and they must match ABSPHCDA’s objectives.

RM is central to the success of any program delivery and for effectiveness and efficiency can be disaggregated into the following:

With the above well-articulated, ABSPHCDA is ready to plan, implement her strategies and initiatives as well as provide for reflecting and documenting lessons learned.

24 Table 7 is resource mobilization outlay of financial, human resources and goods and services.

24 Table 7: Resource Mobilization

Financial resources Human resources Goods and Services 1. Government budget 1. Seconded from 1. Vehicles, Ministries of Computers, health, Economic equipment, office Planning etc space, office furniture 2. Grants from 2. Recruited by State 2. IEC materials international donors Government donated 3. Loans from financial 3. Recruited by 3. IEC materials institutions International printed by donors government 4. Donations private 4. Volunteers 4. Communication Philanthropists tools 5. Donations from town 5. Interns 5. Job aids unions and other private individuals 6. Others 6. Others

6.5 Funds Disbursement

Funds will be disbursed through dedicated accounts with appropriate signatories as long as they align with the current health priorities of the State. On a quarterly basis, health facilities are encouraged to develop their quality improvement plans through their LGHA in line with stated priorities of the state in the health sector through writing of proposal via the Executive Secretary to the Honourable Commissioner for Health and to the Governor. Upon approval, this is transmitted to ABSPHCDA via due process and upon verification by the funds management team at ABSPHCDA, funds are disbursed using the quality improvement plans submitted. This method for release of funds is said to be effective in terms of timeliness, authority, completeness and agreed channels as it is devoid of bureaucratic bottle neck

ABSPHCDA can leverage the funds disbursement strategies being articulated for operationalization of the Basic Health care Provision Fund whereby funds are channelled to health facilities on quarterly basis through dedicated accounts to eligible health facilities.

For the Banking System, the following are recommended a) At each level (ABSPHCDA, LGHA, Ward PHCs), accounts should be opened with reputable commercial banks. The health Posts and Clinics will only receive imprest. b) All payments must pass through the banking system i.e there shall be no cash payment c) All payments shall be by electronic-payment system d) Monthly bank reconciliation statements shall be prepared along with the monthly certificates of cash and bank balances e) Preparation of monthly receipt and payment accounts

24 f) All payments shall conform to approved expenditure heads g) All payments shall be based on approved payment vouchers h) All payments shall follow the approved authorization procedures i) All expenditures shall be based on approved annual workplan. j) The use of electronic and bank payments for transactions between consumers and service providers would make the system more transparent by eliminating the middlemen who jeopardize the whole system, and promote good record keeping. It would also improve trust and accountability in managing the Fund and hence reduce corruption. The community banking process at PHC level should be initiated so as to keep a record of fund management at this level”

Accounting for Receipts and Payments For each bank account, a cash book shall be kept by the accounts staff to record all receipts and payments on a daily basis.

1. Receipts shall be banked intact on a daily basis and not later than the morning of the working day following the date of receipt; 2. All cheques/transfer instructions shall be signed only by the authorized signatories, 3. The cash books shall be reconciled with the bank statements monthly and the bank reconciliation statement reviewed and approved by the Director of Finance/Heads of Accounts. 4. After having closed and balanced all subsidiary books, the General ledger will be posted and a monthly Trial Balance extracted from the General Ledger; 5. When the Trial balance is agreed, the Final Accounts is prepared for the ABSPHCDA, and Health Facilities with all the supporting schedules 6. Approval must be sought from appropriate authority before payment processes must commence in all circumstances. 7. Payment vouchers (PVs) dully processed and passed by internal audit must be coupled with supporting documents. 8. Payment Vouchers must be stamped Paid and Dated after payment processes are concluded. 9. Cash Book maintained for each fund accounts must have certificate of balance at the end of each month. 10.Codification of non-current assets i.e property, plants and equipment’s (PPE) must be done for accountability and security.

11.Retirement of any advance granted to programme officer and other staff becomes due after completion of the purpose for which that advance was granted. 12.Any beneficiary of cash advance must retire the advance granted before he will be eligible for further cash advance.

6.7 Results-based Financing

24 The SPHCDA should institutionalize the practice of results-based financing both as a reward system and as an accountability system. Here, new disbursements are conditional on the results of previous disbursements and these results could be monitored using some performance indicators. This should be developed at the State level and implemented at the LGA and PHC frontline.

6.8 Funds Tracking

Concerning funds tracking for the ABSPHCDA, the main steps in the documentation process for retirement of PHC funds are writing report of implementation, making available receipts and vouchers, pooling of reiterate retirement documents, auditioning of retired document, periodic internal and external auditioning. And to ensure transparency during fund retirement auditioning following due process in procurement should be mandatory. However, the FMOH National Health Accounts team has developed a template for funds tracking; this template can be used at the SPHCDA level to track expenditure flow. It outlines the items to be tracked both in the primary and secondary health facilities including private health facilities and can be adapted to suit the needs of the Agency.

Furthermore, budgeted funds often go unreleased and thus unspent, resulting in the frustration of PHC development plans. ABSPHCDA needs to develop the capacity to track and measure, and to ensure that budget performance gets proper attention by the governing body and management team.

6.9 Accounting

All necessary books of accounts and records shall be maintained in a manner that will allow for adequate control and measurement of income, expenses, assets and liabilities in the management of any grants received by ABSPHCDA. The minimum books of accounts and records to be maintained by ABSPHCDA and each of the LGHA and Health Facilities include:

a) Cheque books b) General account ledger c) Cash Book d) Departmental Vote Allocation Expenditure Book (DVEA Book) e) Receipt Vouchers f) Payment Vouchers g) Receipt Voucher Register h) Payment Voucher Register i) Mandate register j) Ledger Accounts k) Trial Balance l) Fixed assets register

24 These accounting books and records must be kept for at least seven (7) years after such books of accounts and records have been audited by the external auditors.

6.10 Role of Auditors

With reference to the BHCPF, internal / external auditors should monitor and evaluate financial activities across State, LGA and frontline levels, and publish financial reports about the BHCPF on their websites for ease of access. The Agency is obliged to have and equip an Internal Audit for proper checks and balance of her operations.

1.1 Imprest Float system of ABSPHCDA/LGHA The Agency shall maintain an Imprest account to facilitate the purchase of minor items. The Agency shall maintain an imprest float for the day to day running of its mandate. For the sake of clarity and accountability, monthly imprest are as detailed below:

Imprest Holders Imprest Float ES PHCA - N100, 000 Directors - N50, 000 Deputy Directors - N20, 000 Programme Officer/Unit Heads - N10, 000

LGA Imprest Holders Imprest Float HAS - N50, 000 Where there is justifiable need, an officer maybe granted additional imprest twice in a quarter (FR).

1.2 Special Imprest The Agency shall maintain a special imprest of N500,000 to address exigencies not envisaged in the quarterly imprest. When cash on hand has depleted to N50,000, the imprest holder must commence reimbursement. An imprest holder is expected to maintain imprest register and cash book. Prompt retirement of any advance is required as a condition for replenishment. In utilization of the imprest, there should be due diligence and prudence.

1.3 Progress Report by Internal Auditor The internal auditor in charge will maintain under him a register to record the progress of the audit. The register will have columns not less than 13 in number, to record in the first column the specific tasks to be taken in the course of the internal audit and the officer in charge of each task for each month.

1.4 Internal Audit and Internal Control system 1. The accounting officer of the Agency will ensure that subject to the availability of staff, an internal audit unit is established to provide a complete

24 and continuous audit of the accounts and records of revenue. Expenditure plants, allocated stores and all unallocated stores. The existence of an internal audit unit will not divest any member of the Agency and the individual responsibility placed upon him, neither will it obviate the necessity for normal departmental checks. 2. The Executive Secretary of Abia State Primary Health Development Care Agency (ABSPHCA) and the Accountant General of the state will ensure that a suitable competent accountant or auditor is placed directly in charge. 3. The internal auditor in charge will be directly responsible to the Executive Secretary of the ABSPHCA for a detailed audit of the accounts and records and for the examination of the systems and procedures enforce. The auditor shall report monthly to the Executive Secretary progress report of the audit. He will also issue special reports, if necessary, when, in his opinion, the attention of the Executive Secretary to check some accounting irregularities. He will also assume the control of the stock verification staff and direct their programme of inspection. 4. The internal auditor in charge will ensure that the programme of the audit will extend to cover all the records of the Agency, departments or units in other to ascertain that; a. The safe guards introduced for the prompt detection of fraud and loss of cash and other items are adequate. b. The system for the control and collection of revenue is adequate vis a vis money brought in the system are under the correct heading and subheads. c. System for the control of expenditure is adequate and that all payments made are fully authorized. - d. The system for the control of the issue and consumption of stores is adequate and that all issues are properly authorized and correct, that issues are made to the right person and are used for the purpose for which that are authorized. e. That there are adequate means for the verification by him of all cash, stores and plant head. f. That the accounting records are accurate.

6.12 Financial Reporting

A financial reporting format and structure should be developed to monitor PHC finances across all levels (State, LGHAs, WPHCs, HFs). This should involve income and expenditure; periodic auditing; check and balance reconciliation using state revenue reconciliation document. The AGENCY must monitor this process quarterly and yearly.

24 24 CHAPTER 7

SUPPLY CHAIN MANAGEMENT

7.1 Overview

Supply chain management refers to the effective management of essential medicines and other health commodities for the Agency. This involves the rational selection, quantification, procurement, storage and distribution of essential medicines and health commodities. The availability of essential medicines and commodities in primary health centers is critical to the success of most healthcare interventions. Therefore, selection of essential medicines and commodities for optimal use is important not only from a medical point of view but also to optimize use of funds for pharmaceuticals. An efficient procurement and distribution system of health commodities will always ensure the absence of logistics failure. Essential medicines and commodities should therefore be available at the right quantity, quality, time and place. These medicines should be affordable, accessible and available to the end users. Procurement and distribution of essential medicines and health commodities should be in strict compliance with the Agency’s procurement policy. This is to ensure that substandard medicines are not supplied while wastages arising from over stocking will be eliminated.

7.2 Current Situation The prevailing scenario in the management of Essential Medicines is characterised by the following Challenges:

 Out of Stock Syndrome  Non-availability of Essential medicines  Lack of storage facilities  Non-Sustainability of the DRF due to decapitalisation as a result of diversion of DRF.  Lack of capacity and personnel to provide the right counselling and information to patients.  Irrational drug prescription.

7.3 Guideline for Essential Medicines 7.3.1 Funding for the Department of Pharmaceutical Services in ABSPHCDA The Agency should establish a Department of Pharmaceutical Services whose funding should be in line with the National guideline on Funding with regards to sources of funding and budgetary allocation.

In order to achieve favourable health outcomes in patients who come to PHCs, Essential Medicines are needed to treat the Patients ailments.

Consequently, Funds should be readily available to procure essential medicines; otherwise the PHCs will be mere consulting clinics.

24 7.3.2 Coordination The Department of Pharmaceutical services should coordinate all activities of Procurement, Distribution, Pricing, Pharmacovigilance, and Logistics.

The department should also ensure the availability of quality and affordable drugs in all PHCs.

The department should monitor and supervise DRF activities at the PHCs (Facilities) to identify challenges and proffer solutions for the smooth operation of DRF.

7.3.3 Procurement Currently procurement is handled at both the Agency and the Local Government Health Authorities. This responsibility should be transferred to the procurement Committee of the Agency which is composed of the Following:

i) The Executive Secretary – As Chairman ii) The Director Pharmaceutical Services iii) The Director Admin iv) The Director of Finance v) Head Procurement – as Secretary

All essential medicines should be procured in generic names as contained in the state Essential Medicines List and in compliance with the National Drug Policy.

7.3.4 Quality Assessment/Assurance Quality Assurance and Assessment of medicines procured must be carried out before distribution to the facilities. This is to ensure delivery of potent and safe medicines.

7.3.5 Standard Drug Storage Facilities There should be provision of Standard Storage facilities at the PHCs to maintain the potency and accessibility of medicines stored.

7.3.6 Drugs Distribution The PULL system of distribution should be adopted to prevent expiration and wastages of medicines as against the PUSH which dumps medicines that are not needed at the facilities.

Medicines should be supplied in conformity with the Minimum Service Package (MSP)

Medicines should be distributed in Pharma Grade Vehicles.

7.4 Strategic procurement systems

24 The use of strategic procurement systems in the purchase of essential medicines and commodities is being suggested as a means of achieving better value for money. Procurement systems are often weak, or may be poorly understood by new managers. Managers may need training to understand the steps and time required to order supplies and equipment. This will also enhance internal accountability and minimize corruption. Based on the above considerations, the core principles of pharmaceutical procurements to be followed are:

1. Procurement of the most cost-effective drugs in the right quantities. 2. Selection of reliable suppliers of quality products. 3. Assurance of timely delivery. 4. Use of the lowest possible cost.

Therefore, recognised local pharmaceutical industries, community pharmacies, retail/ distribution outlets will be certified by the Agency for health facilities to directly purchase essential medicines and health facilities shall procure consumables locally within their LGAs.

Flow of drugs and commodities

The chart below shows recommended flow of drugs and commodities

 Commodities come from Federal medical store directly to the State Central Medical Store/Agency to the LGHA down to the Health Facilities at the ward levels E.g ITNs, Anti-malaria Drugs etc  Commodities procured at the Health Facility after verification and approval by LGHA/ABSPHCDA.  Commodities come from federal medical store to the state for onward transmission to the health facillties.eg family planning, vitamin A, tuberculosis,antimalarial, mectizan etc

24 SCMS/ABSPHCDA

Figure 4: Flow chart showing supply of commodities and reporting channels

7.5 Reporting Channels The reporting channels will take this form: a) State will provide the list of accredited supplies to the Health Facility through LGHA b) Health facility sends report of procured items to the LGHA mgt team who in turn will send to the State for upward transmission to the federal (NPHCDA) c) Health facility sends report to the LGHA ,to state then to federal (NPHCDA) d) Partners offer technical support fund and equipment to health facility.

7.6 Strategic Purchasing System

The Agency will be required to identify and certify the drug distribution retailers around the state and L.G.As for easy procurement of Essential drugs and commodities. The process of the strategic purchasing system is made up of: Process of choosing accredited suppliers, the procurement process and the audit process, as

24 shown in fig

Figure 5: Strategic purchasing system process

To choose the accredited suppliers, this should be advertised, tenders submitted, prices compared and approval given to eligible suppliers to supply the items. This process should be reviewed annually. The procurement process should start with demand generation by health facility procurement committee, then verification exercise will be carried out by LGHA and ABSPHCDA. Approval for procurement is given by LGHA and ABSPHCDA for the purchase of needed items by the facilities. Thereafter, supplies to health facilities are made, the quality control committee LGHA management team/ABSPHCDA will check what has been supplied. Then audit of the supplied items should be conducted weekly by the health facility, monthly by the LGHA and quarterly by ABSPHCDA.

Composition of Procurement sub-committee (Health Facility Level)

The procurement sub-committee should be made up of:

1. OIC – Chairman 2. Pharmacy Technician –Secretary 3. Chairman WDC – Member

24 4. Treasurer WDC –Member

7.7 Store Management

Essential medicines, commodities and medical supplies require adequate care because of their susceptibility to deterioration, pilferage and expiry. Therefore, the focus of stores administration shall be geared towards eliminating the risks of deterioration, pilferage, expiry, overstocking, stock out, etc and thus instilling confidence in the Primary Health Care delivery system throughout the State. In this regard, the following minimum standards shall be maintained at all stores locations in the State, LGHA and health facility levels:

Table 8: Minimum Standards for Store Management

Stores a) Adequate and secured accommodation with a good roof and floor space Layout sufficient enough to allow for free movement of persons and goods b) Adequate ventilation c) Drug cupboard d) Drug shelf e) The stores space must be kept clean at all time f) Goods must be carefully arranged on shelves and appropriately labeled Stock a) Stock Bin card/Tally Sheet must be maintained for each item of stock Managemen b) Stores Ledger Cards shall be maintained t c) Stores Receipt Vouchers shall be used to account for items of stock received d) Stores Issued Vouchers shall be used to record the issuance of stock items e) Stock adjustment vouchers shall be used to record variation in stocks during stock count Minimum stock, Maximum Stock and reorder levels as well as average usage and reorder quantity shall be established for each category of stock f) Quarterly stock count shall be conducted and any discrepancies reported for appropriate management action.

7.8 Asset Management This will entail periodic facility maintenance, safety and security, introduction of fixed asset register and fleet management (Drivers log book, maintenance and repairs, fuel vouchers, vehicle tracking and transportation for services)

24 CHAPTER 8

INTEGRATED SUPPORTIVE SUPERVISION, MONITORING AND EVALUATION

8.1 Integrated Supportive Supervision and Mentorship

Integrated supportive supervision is a harmonized supervisory system that uses a common tool and reporting format based on a collection of indicators from several initiatives/programmes, driven by a common supervisory team and ensures that managers are in the field on a regular basis ( monthly or quarterly).The Nigerian national strategic health development plan recognises the need to establish and institutionalize a framework for an integrated supportive supervision with adequate committed resources for all types and levels of care providers across public and private sectors. This could be leveraged by the Agency.

Integrated Supportive supervision is important:

 To make sure that operational objectives are appropriate  Health workers’ practice are usually at variance with standards  There is disconnect between practitioners, policy makers and users  To help staff to identify and solve problems  To motivate the staff  To improve knowledge and skills of health staff.  To tracks and assess the result of the interventions.  To improve current and future management of outputs, outcomes and impact.

Integrated Supportive Supervision (ISS) is an approach aimed at eliminating most of the short comings associated with parallel supervisory processes. ISS is a harmonized supervisory system which uses a common tool and reporting format based on a collection of indicators from as many initiatives/programs as possible. It is driven by a common supervisory team which ensures that health managers are in the field on a regular basis (monthly or quarterly) checking the performance of subordinates and helping them to progressively improve on their competencies

Objectives of Integrated Supportive Supervision (ISS)

The objectives of ISS include:

 Motivating people/health workers at the lower level – interaction and sharing of information  Encouraging/promoting team work  Assessing the functioning of different systems at facility and other levels  Mentoring and re-enforce skills of health workers to improve quality of health services  Jointly identifying and solving problems  Measuring level of implementation of activities in work plans

24  Measuring the quality of services from client’s perspective to jointly improve services  Maintaining good linkage and communication between levels of the health care  Providing regular and statutory report to State council on Health  Using the data for Health research and planning  Promoting effective coordination and collaboration between MNCH programmes

Integrated Supportive monitoring and supervision for health workers at the facility by the LGA would guard against waste and prevent health workers in the facilities from managing the facilities in the ways they deem fit. It is also likely to address and promote compliance. Thus, the State will supervise the LGA and the LGA will supervise the PHC frontline. The institutionalized mentorship is likely to give workers a sense of fulfilment while strengthened supervision and monitoring of activities will be able to detect staff who are derailing and put them back on track.

MENTORING:

The process in which an experienced person affects the Professional life of others by fostering insight, and Knowledge through advise, and guidance that Expands their growth opportunities

The use of reward and mentorship-based monitoring and evaluation system comprising of different levels of participants, including community members, would increase community participation, ensure good facility management and compliance as well as improve accountability. This system would be such that health facilities that are not doing so well are mentored and trained on how to go about addressing their specific challenges.

The ISS will be done for the entire year. A supervision checklist will be used as the assessment tool. A copy of the supervision checklist should be left with the supervisee for follow-up actions on the recommendations. The supervision checklists will provide information for the preparation of a supervisory report that documents the completion of the exercise and serves as a feedback for decision making. Opportunity to customize the ISS checklist in an electronic data collection format (ODK) will be explored. ABSPHCDA and LGHA will institutionalize ISS into PHC Program activities with the M&E divisions participating regularly in the ISS exercises.

Table 9: Integrated Supportive Supervisory Schedule

Supervisors Supervisees Frequency

24 State Team LGAs and other lower levels Quarterly

LGA Team Wards and other lower levels Monthly

For integrated supportive supervision, there should be problem-solving and feedback mechanism. It is therefore important that the supervisor develops a field visit schedule and an action-plan for solving problems identified. An example of an action plan for solving identified problems is shown in table 10 and is recommended for use

Name of HF Problem Cause Action Point Person Responsible/ Due Dates Designation

Adelabu Stock-out of Lack of order Facility head completes Ngozi/OIC Same day clinic BCG forms emergency requisition (24/7/2016) Vaccines External supervisor carries Comfort Same day request to ward pharmacy (24/7/2018) Facility head confirms BCG Biola 1 week later Arrives (2/8/2018) Obtain sufficient supply Samuel (2/8/2018) order forms (Pharmacy Manager) Proceed with usual Samuel (16/8/2018) ordering (Pharmacy Manager) procedure Table 10: Action-plan template example for solving problems after supportive supervision

8.2 Transparent independent oversight role

With respect to the BHCPF of the SPHCDA, the oversight of the fund recognizes the huge investment by the Government of Nigeria (GoN) towards the improvement of PHC. It further recognizes the need to ensure that there is ‘value for money’ and most important that Nigerian communities, the primary beneficiaries, derive the expected benefits from the Fund. Therefore effective systems for oversight of the implementation of the Fund is proposed to be put in place to ensure periodic accountability and progress reporting to the federal government. The objective is to provide independent oversight and validation at State, local government and PHC

24 frontline, of the Fund’s implementation, monitor progress and ensure delivery on the targets. This oversight function should be carried out by development partners, CSOs and community members.

Having an independent and unbiased partner in the BHCPF’s success will give leadership valuable insight into potential risks, areas for improvement and even “blind spots” in the internal governance and management of the Fund. It will also ensure accountability. The involvement of Community members, through the ward development Committees, in decisions regarding how health facility revenue is spent is also important.

8.3 Data management

8.3.1 Data Sources: The ABSPHCDA data shall be sourced from the following: Routine data from health facilities (Public and Private) and NGOs for routine programs and other sources such as (National surveys, SMART survey, special studies, operational research, Health Facility Surveys, National Health Management information system reporting tools (HMIS) and DHIS. 8.3.2 Use of Information Technology in M & E: Information Technology shall play a substantial role in the collection, collation, analysing harmonized data and in the dissemination of Information needed in order to support M&E/ HMIS both at LGA and state. The use of a developed and well-designed website in collection and storage of routine health information will be employed for efficiency in data collection and management. 8.3.3 Reporting Levels and Data flow: The Agency shall adopt the following data flow as explained in the chart below. Data on health related indicators shall originate from health facilities (Public and Private) in the communities, and transmitted to the state and National through the LGA.

NATIONAL NPHCDA/FMOH HDGC

SMOH- DPRS (HMIS) HDCC SMOH

ABSPHCDA DPRS/M&E HDCC ABSPHCDA Level

DHIS28.4 Dashboard Tools for M&E Reporting LGHA/ M &E Unit HDCC LGHA Level The following tools are used for effective M&E activities at various levels  NHMIS Version 2013 tools

Health Facility/ CHIPS

(Private /Public) 24  All the registers example General Register, General Attendance Register, Out-Patient Register,In-patient Register, ANC, Post-Natal, Nutrition, Growth Monitoring, Delivery, Immunization, HIV, PMTCT, Malaria, Family Planning, Monthly Summary Forms, Tally Sheets, Monthly Immunization Summary Forms, Labour and Delivery, Child Immunization, and all other data capturing forms.  Referral Form  Quality Integrated Supportive Supervision (QISS) monitoring check list.

8.4.1 Coordination of data collection The ABSPHCDA will work closely with various stakeholders at both state and local government levels to coordinate the collection of data that will be used to generate information. This strategy entails data collection from the community, health facility (public and private), local Government and state levels.

8.4.2 Data Ownership: The state has full ownership and control of all data generated at all levels of health care in the state and no partner/ Agency will have the right to by-pass the state and collect any data from any source.

8.4.3 Steps in data management For appropriate data management, the following steps shall be followed;  Collection - This shall consist the process of gathering and measuring information on variables of interest, in an established systematic fashion that enables one to answer stated research questions, test hypotheses, and evaluate outcomes.  Collation – It shall be assembling of collected data into a standard order  Cleaning – This shall consist the process of detecting and correcting (or removing) corrupt or inaccurate records from a record set, table, or database and refers to identifying incomplete, incorrect, inaccurate or irrelevant parts of the data and then replacing, modifying, or deleting the dirty or coarse data.  Analysis- Analysis shall be done at the state and national levels for decision making  Storage- An adequate storage technology which implements a system with the appropriate configuration shall be in place for data storage and backup. Automated backups systems should be developed to make every day data- back-up possible for easy recovery purpose (Hardware). For the majority part of the software that will be used, free and open source software are more preferred not only because they are free but because they enjoy a wide range of support community which makes it easier to get help should there be need for one.  Data Security – Security of some document shall be discussed on how they shall be addressed or handled. Example- personal medical records tagged confidential who shall have access and when it shall be destroyed.

8.5 Information Dissemination: Monitoring and evaluation at all levels shall not end with the production of reports. The reports shall be adequately shared and disseminated to all relevant

24 stakeholders and partners, so that M&E can serve as an instrument for ensuring the achievement of state and national health goals. Besides the dissemination as stated above, any documents that help improve understanding, planning and management of health services should be disseminated as widely as possible, using modern technology. E.g functional website, SMS, Emails etc

8.6 Data Quality Assessment (DQA): M&E and Research Unit of ABSPHCDA is Charged with the responsibility of ensuring that data collected and reported on State indicators are of high quality and can be assessed and verified. The State M&E and Research Unit should also work with all program M&E Units in coordinating the assessment of their programs’ data quality. The assessment and verification of data can be done through a developed data quality assessment (DQA) tool—a single integrated tool that ensures that standards are harmonized and allows for joint implementation.

8.6.1 Essentials of Quality Data Data are of quality when it contains the following features Features Description Completeness Data exhibits completeness if nothing needs to be added, e.g. no blank space is left Accuracy The degree to which data correctly reflect the real world of an event being described Reliability The degree to which the same result can be obtained by repeating the same data capture process Timeliness Data are current and information is on time. Reporting as per schedule Confidentiality Interviewees/clients are assured that whatever data collected are kept private or secret according to national and international standards Integrity This dimension protects data from deliberate bias or manipulation for political or personal reason(s) Precision Data have sufficient details ,e.g. disaggregated by age, sex etc.

Periodic Data quality checks shall be carried out at the end of every month by the state Monitoring & Evaluation Unit and more frequently at the LGHA and Facility level

8.6.2 Guiding principles and methodology of data verification The following activities shall be carried out to verify quality of data: Methodology Activities Determine the level Carry out periodic survey on a sample size to validate of input sources/quality of data. Select indicators for set of indicators to verified, using the national or state Evaluation program-related standards, e.g. Skilled Birth Attendance, No of Under 5 Sleeping under LLINs, No of women of Child Bearing age using modern contraceptive etc Carry out NEED Carry out Periodic NEED assessment identifying areas of assessments need. Select source of Primary records:

24 documents Registers, tally sheets, medical records of people reached, distribution log sheets, inventory statements, commodities distributed (e.g. drugs, Vaccine etc) attendance sheets, community based records (e.g. ICCM reporting form, VHW form etc).

Referral Forms and Registers.

Check summary reports at different administrative levels- service delivery points, LGA, State and national. Perform the Bottom-top audit trail----from primary source to summary verification report Cross verification---cross verification of programmatic outcome with other data sources

On the Spot assessment of actual service delivery Report Production Production of report will be carried out by M&E and Research/HMIS Unit and submitted to ABSPHCDA and the state M&E Units for their programs.

8.7 The Roles of the State Monitoring & Evaluation and Research Unit  Develop comprehensive and effective collaboration with partners and public and private sectors  Develop and implement various standard monitoring mentoring protocols (including questionnaire and survey designs) for different programs, research studies and third party assignment.  Manage field based data collection of PHC activities in the state  Develop proposals for conducting baseline studies, process review monitoring and evaluation studies and impact assessment studies for various partners/donors organisation.  Supervise data management and analysis in the required areas of need.  Design and produce standardized data management tools for use at various levels within the State with collaboration amongst partners/stakeholders.  Coordinate, supervise, and provide technical assistance to track progress of the program activities at all levels.  Coordinate and support capacity building and training at state and LGA levels to ensure that the M&E systems at the state level are functional and capacity enhanced.  Organize periodic Integrated Supportive Supervision visits and reviews of state based M&E system and develop capacity building plans.

24 8.8 KEY COMPONENTS OF M&E SYSTEM Monitoring and Evaluation System require twelve main components in order to function effectively and efficiently to achieve the desired results. These twelve M&E components are:  Organizational Structure with M&E functions  Human Capacity for M&E  Partnership for Planning, Coordinating and Managing the M&E System  M&E Frameworks/Logical Framework  M&E Work Plan and Costs  Communication, Advocacy and Culture for M&E  Routine Programme Monitoring  Surveys and Surveillance  National and Sub-national database  Supportive Supervisions and data Auditing  Evaluation and Research  Data Dissemination and use

8.9 STRENGTHENING M&E SYSTEMS 8.9.1 Capacity development for M&E at all levels: The goal is to enhance the knowledge and skills of M&E persons at all levels to effectively coordinate, conduct data collection and analysis. The specific activities include the following:  Development of the M&E training program/manual in collaboration with the partners and other relevant agencies  Training of the M&E focal persons in relevant M&E/modem data management technology  Organizing state and LGA level seminars and workshops for cross-fertilization of ideas on emerging and re-emerging M&E concepts.

8.9.2 Governance structures for Data Quality Assurance The existing governance structures of the Department of Planning, Research & Statistics of the ABSPHCDA as stipulated in the MSP will oversee performance of the LGHA M&E unit and at the Health Facility level to ensure qualitative and reliable data.

8.9.3 The coordinating review committee is as follows: State Level: HDGC The membership is made up of the following: HCH – Chairman PS SMOH - Member ES ABSPHCDA – Member CE HMB – Member ES ABHIA – Member CMD ABSUTH - Member CMD FMC - Member ES/PM ABSACA - Member Rector Abia State Collage of Health and Management Sciences Aba - Member PRSD – Secretary

24 HDCC DPRS – Chairman Programs M&E Officers- Member ABSPHCDA M&E Member – Member ABSHIA M&E - Member State HMIS Officer – Secretary ABSPHCDA Level HDCC ES ABSPHCDA – Chairman Program Officers – Members ABSPHCDA M&E Officers – Members ABSPHCDA DPRS – Secretary LGHA Level HDCC HAS – Chairman Program Officers – Members LGHA M&E Officer – Member LGHA DPRS – Secretary

8.9.4 Roles of HDGC at State  Assure that data standards are followed  Ensure data documentation is written and maintained  Set goals for future state of data management capabilities  Advocate for governance and improved data management  Identify and prioritize data governance projects (e.g., data quality, data security, etc.)  Resolve issues escalated by data stewards  Track data quality by profiling/reviewing data and monitoring metrics on data quality  Shall approve the data for use

8.9.5 Roles of HDCC at State Shall harmonize the data from the ABSPHCDA Shall validate the data from the ABSPHCDA

8.9.6 Roles of HDCC at ABSPHCDA Shall harmonize the data from the LGHA Shall validate the data from the LGHA

8.9.7 Roles of HDCC at LGAH Shall harmonize the data from the facilities (Public and Private) Shall validate the data from the facilities (Public and Private)

24 8.9.8 The uses of Data The Data Collected, Collated, cleaned and analyzed shall be used for the following purposes:  to manage the health care of individual consumers and ensure continuity of care  to streamline health care service delivery at all levels  to manage and administer hospital and health care service delivery  to keep track of healthcare costs including billing for goods and services delivered  to inform health system policy  to ensure reliable and consistently high quality of care.  to be used for research and policy making

8.10 Transparent reporting A good reporting system would be essential for better accountability, and reporting tools and aids should be developed and made easily accessible to implementers. At State, LGA and facility level, quarterly reports should be generated based on all the activities including financial and activity reports. The report should include successes and identifying obstacles to progress and limitations for all the proposed timeliness with corrective actions attributable to named individuals, utilization updates on drugs, vaccines, immunization etc.

8.11 Monitoring and Evaluation

8.11.1 MONITORING:

Process of continuous observation and collection of data on the Health program to ensure that the program is progressing as planned it can be (Daily, weekly, monthly, quarterly etc) or Closely related to supervision all aimed at improving quality and effective implementation of programme.

8.11.2 EVALUATION:

Systematic analysis of the adequacy, efficiency and effectiveness of the program can be Long, mid-term and annual analysis of performance in relation to the goals, objectives and targets set.

Ethical and research committee shall be tasked with the responsibility for reviewing and giving approval for all health research

8.12 The M&E of ABSPHCDA should be done at the following levels: 8.12.1 State Level: The ABSPHCDA DPRS with data officers shall coordinate M&E activities in the Agency, local Government and Health facilities and also partners. The M&E unit will be under the department of Planning Research and statistics of the Agency, who transmits the data to the DHIS/HMIS Unit of Department Planning Research and Statistics (DPRS) of State Ministry of Health and also uses same data after analysis for research, decision making and planning.

8.12.2 LGHA: The LGA should have a functional M&E Unit headed by the LGHA M&E officer which must be well empowered to monitor and evaluate health programs

24 implementation of different units at the LGA and Health facilities (Public and Private). They are also in-charge of collecting, collating, harmonization from both private and public facilities and submitting program activity data to the ABSPHCDA M&E unit who transmits the data to the office of DPRS HMIS Unit State Ministry of Health and with feedback from the state to the LGHA.

8.12.3 Health Facility: All primary health facilities both public and private should have a designated data focal person who shall be responsible for the day to day recording of health activities using the acceptable NHMIS tools for data collection, collation and reporting. The data focal person in conjunction with the officer in- charge (OIC) should harmonize the data for accuracy and completeness and ensure timely reporting and submission of the data to the LGHA M&E Unit.

8.12.4 NGOs & the Private Sector Level: The LGHA M&E shall ensure that private health facilities and NGOs who render PHC interventions in their Health facilities shall designate one of their staff who should be responsible for their Monthly data collection, collation and timely submission of same LGHA M&E Unit. However, the LGHA M&E shall also go for their data in the case of delay in submission.

8.13 MONITORING AND EVALUATION STRATEGY: There shall be in place, a state harmonized mechanism for performance monitoring and impact evaluation with an established sets of input, process, output, and outcome indicators for tracking implementation progress over a period of time. (1st - 14th of the preceding month) 8.13.1 Data integration/harmonization at all levels: In order to ensure good quality of data, there shall be an instituted data integration/harmonization team at all level. There shall be harmonization meeting coordinated by the LGHA M&E units with the HAS at the LGA and the state data team at the state level. Also, there will be an agreed date for data harmonization with all partners working in the state. Among the data to be harmonized include the following: i. Weekly data at the HF ii. Monthly service data at the LGHA and state iii. Quarterly Service data at the LGHA and state iv. LGA and state Annual data 8.13.2 Weekly Monitoring at all Service Delivery Points: All health facilities (Public and Private) starting from health post to primary health care will be monitoring their outputs on weekly basis. Such weekly monitoring should help service providers detect the problems at an early stage and take corrective measures so that the monthly targets of the program are met. 8.13.3 Monthly Monitoring at all Service Delivery Points: All health facilities (Public and Private) in the LGA shall be monitoring their outputs on a monthly basis. Such monthly monitoring will help service providers detect the problems at an early stage and take corrective measures so that the annual targets of the program are met. 8.13.4 Quarterly monitoring at all Management Levels: State (MOH/PHCDA) shall carry out quarterly monitoring to ensure that programme results are produced as planned. Such monitoring will trigger supportive supervision and follow-up visits by the stakeholders to the health facilities.

Frequency and participation in Monitoring and Evaluation: Frequency Level Responsibility/ Timing / Deadline

24 Leadership Health facilities (Public Data focal person/ Every Monday of each Weekly and Private Officer In-charge week Facility (Public and LGHA M&E team First week of the following Monthly Private and OIC month LGHA M&E team Quarterly LGHA April, July, Sept, January and HAS ABSPHCDA/State Quarterly STATE April, July, Sept, January team Annual LGHA M&E team LGHA March Review and HAS Annual ABSPHCDA/State State March Review team ABSPHCDA/State Evaluation State Frequently team

The main purpose of the Monitoring and Evaluation (M & E) framework is to provide guidance for carrying out M & E activities for PHC across all levels aimed at providing accurate, reliable and timely information on progress made in the implementation of PHC.

Therefore, there will be routine monitoring and periodic evaluation of activities by ABSPHCDA, LGHA and NPHCDA. The project reports will include successes, challenges and limitations for all the proposed activities in the guidelines. It is necessary to develop a work plan for M & E activities as shown in table 11 and the suggested template for M&E is shown in table 12

The M & E system is necessary to track progress, measure success and identify challenges. The information generated will also guide the review of the strategic and annual operational health plans.

Table 11: Work plan for Monitoring and Evaluation Framework

Themes Activities/ Expected Indicator/ Timeline Required Responsible Tasks Results/De Performance s tools/logisti Persons liverables Measure cs

Monitoring Development M&E tools Number of M&E Fund DPRS and of M&E tools developed tools developed

24 Evaluation for the monitoring of the PHCUOR activities NHMIS Tools Printing of M&E tools Numbers of M&E Fund DPRS M&E tools printed tools printed

Capacity Training of Trained Numbers of Staff Training DPRS Building Staff on the Staff on trained materials M&E tools M&E tools developed Proportion of training Conducted

Integrated Conduct Improved Proportion of ISS ISS Checklist DPRS Supportive Integrated Service visit conducted SMOH,SPH Supervision Supportive delivery at CDA & Supervision Facility SHMB level Conduct Conduct HF Survey Report on Client Fund DPRS SMOH, Surveys survey (HRH). conducted satisfaction SPHCDA & available SHMB

Health Upgrading of Increased Proportion of HFs Fund Infrastructur health facilities access to with adequate DPRS O’HIS e health health DPRS/ care infrastructure SPHCDA delivery

Table 12: Template for M&E Framework For SPHCDA

Themes Activities Outpu Indicato Definition Baseline Targe Data Frequenc Who is Reportin (MSP) t r t sources y responsibl g Time e Maternal Health

Newborn And Child Health

Sexual And Reproductive Health For Adolescent

Nutrition

Control Of Communicable diseases Control Of non Communicable diseases Treatment Of Minor Ailment and Injuries

24 Emergency Medical And Hospital Services Public Health Emergencies Preparedness And Response Health Education & Promotion Food Safety And Hygiene Water Sanitation And Hygiene Environment Chemical Products And Medical Waste Support Services And Resources Human Resource For Health Health Infrastructure Development

Annex 1: Names of Chosen facility for the BHCPF per ward

S/N LGA WARD WARD HEALTH CENTRE 1 ABA NORTH ARIARIA UMUNNE-ATO HP 2 ABA NORTH ASAOKPUAJA ASAOKPUAJA HP 3 ABA NORTH ASAOKPULOR ASAOKPULOR 1 PHC 4 ABA NORTH EZIAMA EZIAMA PHC 5 ABA NORTH INDUSTRIAL RAILWAY HC 6 ABA NORTH OGBOR 1 OGBOR 1 7 ABA NORTH OGBOR 2 OGBOR 2 CLINIC 8 ABA NORTH OLD GRA OLD GRA HC 9 ABA NORTH OSUSU 1 OSUSU I PHC 10 ABA NORTH OSUSU 2 OSUSU 2 HP 11 ABA NORTH ST EUGENE ST EUGENE HP 12 ABA NORTH UMUOGOR UMUOGOR PHC 13 ABA NORTH UMUOLA UMUOLA EGBELU PHC 14 ABA NORTH URATTA URATTA PHC 15 ABA SOUTH ABA RIVER NGWA ROAD CLINIC 16 ABA SOUTH ABA TOWN HALL MCH HEALTH OFFICE 17 ABA SOUTH ASA ASA CLINIC 18 ABA SOUTH COLLEGE COLLEGE OF HEALTH 19 ABA SOUTH EKEOHA EKEOHA HC

24 20 ABA SOUTH ELUOHAZU ASAEME 21 ABA SOUTH ENYIMBA ABA UKWU 22 ABA SOUTH EZIUKWU 1 EZIUKWU PHC 23 ABA SOUTH EZIUKWU 2 ASAOKPUAJA CLINIC 24 ABA SOUTH GLOCESTER ABSUTH PHC 25 ABA SOUTH IGWEBUIKE AMAUFURU 26 ABA SOUTH IHEORJI IHEORJI PHC 27 ABA SOUTH NGWA 1 IGWEBUIKE HP 28 ABA SOUTH NGWA 2 OZUITEM HC 29 ABA SOUTH OKPOROENYI NNENTU HC 30 ABA SOUTH UMUOGELE UMUOGELE PHC 31 AROCHUKWU ARO WARD 1 HEALTH OFFICE 32 AROCHUKWU ARO WARD 2 OBINKITA 33 AROCHUKWU ARO WARD 3 AMUVI 34 AROCHUKWU ARO WARD 4 IBOM HC 35 AROCHUKWU EBEM OHA WARD NDI AGWU ABAM 36 AROCHUKWU ELEOHA IHE 1 ADUANU HC 37 AROCHUKWU ELEOHA IHE 2 ACHARA HC 38 AROCHUKWU ELEOHA IHE 3 OKPO HC 39 AROCHUKWU ETITI ABAM NDI OKORIE ABAM HC 40 AROCHUKWU IKWUN 1 NDI OKPO 41 AROCHUKWU IKWUN 2 UMUZOMGBO HC 42 AROCHUKWU ISU WARD IKE ISU HC 43 AROCHUKWU OHAEKE WARD IDIMA ABAM HC 44 AROCHUKWU OHAFOR 1 OZU ABAM 45 AROCHUKWU OHAFOR 2 AMAEKE HC 46 AROCHUKWU OVUKWU NDI OJI ABAM 47 AROCHUKWU UTUTU WARD UKWUAKWU HC 48 AROCHUKWU UTUTU WARD ABUMA HEALTH CENTER 49 AROCHUKWU UTUTU WARD ELEOHA UTUTU 50 BENDE ALAYI ALAYI MATERNITY 51 BENDE ALAYI 2 AMANKALU ALAYI 52 BENDE BENDE BENDE MATERNITY 53 BENDE IGBERE AMAIYI IGBERE PHC 54 BENDE IGBERE 1 IGBERE PHC 55 BENDE IGBERE 3 UMUISI 56 BENDE ITEM 2 OKOKO MATERNITY 57 BENDE ITEM 3 AKANU ITEM MPHC 58 BENDE ITEM 4 AMOKWE MATERNITY 59 BENDE ITEM1 UMUNNATO PHC 60 BENDE ITUMBAUZO 1 NDIWO PHC 61 BENDE ITUMBUZO 2 NTALAKWU HC 62 BENDE NKPA 2 AMAEGBUATO NKPA PHC 63 BENDE OKPUHU NKPA 1 OKPUHU NKPA PHC 64 BENDE OZUITEM ISIEGBU OZUITEM PHC 65 BENDE UGWUEKE AMABA UGWUEKE

24 66 BENDE UMUHU UMUHU PHC 67 BENDE UMUIMEYI AKOLI PHC 68 BENDE UZUAKOLI 1 NGWU PHC 69 BENDE UZUAKOLI 2 UZUAKOLI PHC 70 IKWUANO AGBALUOZU UMUGBALU HC 71 IKWUANO AJATANAIGU UMUIGU PHC 72 IKWUANO ARIAM ARIAM 1 HC 73 IKWUANO ARIAM 2 ARIAM 2 PHC 74 IKWUANO AZUIYI AZUIYI HC 75 IKWUANO EKPIRI EKPIRI HC 76 IKWUANO IBERE AHIAORIE HC 77 IKWUANO IBERE ITUNTA 78 IKWUANO IKEMBA IKEMBA HC 79 IKWUANO OBORO 1 AMAWOM HC 80 IKWUANO OBORO 2 AMAOBA HC 81 IKWUANO OBORO 3 OBORO MATERNITY 82 IKWUANO OBORO 4 ISIALA CLINIC 83 IKWUANO OLOKO 1 OLOKO PHC 84 IKWUANO OLOKO 2 OBUOHIA OKIKE HC 85 IKWUANO UGWUEGBU OBUGWU HC 86 IKWUANO UHALAUDA/ ORUKWE NNONO HC 87 IKWUANO UMUDIKE UMUDIKE HC 88 IKWUANO USAKA USAKA HC 89 ISIALA NGWA NORTH ABAYI/ AMAORJI ABAYI HC 90 ISIALA NGWA NORTH ACHI UDO USAKA UMUOFOR 91 ISIALA NGWA NORTH AGBURUEZEUKWU AGBURUEZEUKWU PHC 92 ISIALA NGWA NORTH AHIABA UBI/ UMUCHIMA AHIABA UBI HC 93 ISIALA NGWA NORTH AMANO NSULU IKPUTU 94 ISIALA NGWA NORTH AMAPU NTIGHA UMUOGELE PHC 95 ISIALA NGWA NORTH AMASA NSULU UMUAKWU PHC 96 ISIALA NGWA NORTH AMASAA NTIGHA NTIGHA PHC 97 ISIALA NGWA NORTH EZIAMA NTIGHA OBINGWA 98 ISIALA NGWA NORTH IHIE IHIE PHC 99 ISIALA NGWA NORTH ISIALA AMAPU APU NA EKPU 100 ISIALA NGWA NORTH ISIALA ENYIALA IMEREM HP 101 ISIALA NGWA NORTH ISIALA NSULU EZIALA HC 102 ISIALA NGWA NORTH NGWA UKWU 1 OKPUALA NGWA PHC 103 ISIALA NGWA NORTH NGWA UKWU 2 AHIABA OKPUALA 104 ISIALA NGWA NORTH ORIA NA UGAA UMUOGWOKA 105 ISIALA NGWA NORTH UMUELEMOHA UMUELEMOHA HP 106 ISIALA NGWA NORTH UMUNNA NSULU UMUOSU PHC 107 ISIALA NGWA NORTH UMUOMAINTA BASIC HF 108 ISIALA NGWA NORTH URATTA URATTA PHC 109 ISIALA NGWA SOUTH AKUNAEKPU AMAKU HC 110 ISIALA NGWA SOUTH ALAUKWU PHC ALAUKWU PHC 111 ISIALA NGWA SOUTH AMAISE UMUEKENE

24 112 ISIALA NGWA SOUTH AMAISE AHABA UGBA 113 ISIALA NGWA SOUTH AMAITOLU UMUOTIRI PHC 114 ISIALA NGWA SOUTH ANYA MBUTU ANYA MBUTU 115 ISIALA NGWA SOUTH EHI NA UGURU AMAIYI PHC 116 ISIALA NGWA SOUTH IKEALA MBUTU IKEALA MBUTU HP 117 ISIALA NGWA SOUTH MBUTU NGWA MBUTU NGWA HC 118 ISIALA NGWA SOUTH MBUTU UKWU MBUTU UKWU 119 ISIALA NGWA SOUTH NGWAOBI NGWAOBI 120 ISIALA NGWA SOUTH OBINTU MBUTU OBINTU MBUTU 121 ISIALA NGWA SOUTH OKPOROAHABA UMUHIE 122 ISIALA NGWA SOUTH OMOBA OMOBA 123 ISIALA NGWA SOUTH OSOKWA UMUABALI 124 ISIALA NGWA SOUTH OVNKWU AFRICARE 125 ISIALA NGWA SOUTH OVUKWU EKETA 126 ISIALA NGWA SOUTH OWERRE NA OCHE OWERRINTA PHC 127 ISUIKWUATO ACHA AMACHARA ACHA PHC 128 ISUIKWUATO ACHARA ACHARA HC 129 ISUIKWUATO AMIYIOBILOHIA/ NUNYA AMAIYIOBILOHIA PHC 130 ISUIKWUATO ELUAMA ELUAMA PHC 131 ISUIKWUATO EZERE EZERE HC 132 ISUIKWUATO IKEAGHA 1 ONUAKU PHC 133 ISUIKWUATO IKEAGHA 2 NVURUNVU 134 ISUIKWUATO IMENYI 1 OHIYINTA 135 ISUIKWUATO IMENYI 2 AHABA PHC 136 ISUIKWUATO ISIALA ECHIELE HC 137 ISUIKWUATO ISUNABO UTURU PHC 138 ISUIKWUATO NDUNDU NDUNDU PHC 139 ISUIKWUATO NGODO/ UGWUELE NGODO HC 140 ISUIKWUATO OBIALAUGO UMUOBIALA PHC 141 ISUIKWUATO OGUDUASA AMAIYI UHU PHC 142 ISUIKWUATO OVIM AMANGELEUKWU HC 143 ISUIKWUATO UMUANYI/ ABSU MBAUGWU PHC 144 ISUIKWUATO UMUASUA UMUASUA HC 145 ISUIKWUATO UMUNNEKWU I AGBO UMUNNEKWU 146 ISUIKWUATO UMUNNEKWU II MGBELU PHC 147 OBINGWA ABALA IBEME ABALA PHC 148 OBINGWA ABAYI 1 OSUSU AMAUKWA 149 OBINGWA ABAYI 2 EHERE 150 OBINGWA AHIABA UMUAGU PHC 151 OBINGWA AKPAA MBATO AKPAA MBATO 152 OBINGWA AKUMAIMO AKUMAIMO PHC 153 OBINGWA ALAUKWU OHANZE UMUEZIGBE PHC 154 OBINGWA ISIALA ITU ISIALA ITU 155 OBINGWA MGBOKO AMAIRI MGBOKO AMAIRI PHC 156 OBINGWA MGBOKO ITUNGWA ITUNGWA 157 OBINGWA MGBOKO-UMUANUNU 1 NENU PHC

24 158 OBINGWA MGBOKO-UMUANUNU 2 MGBOKO OKENGWA 159 OBINGWA NDIAKATA NDIAKATA PHC 160 OBINGWA NTIGHAUZOR MBANO NTIGHAUZOR 161 OHAFIA AGBOJI AGBOJI 162 OHAFIA AKANUKWU ANIA PHC 163 OHAFIA AMAOGUDU 1 AMOGUDU PHC 164 OHAFIA AMAOGUDU 2 AMAMBA HC 165 OHAFIA AMEKE 1 AMEKE HC 166 OHAFIA AMEKE 2 EKPANKUMA PHC 167 OHAFIA AMIBEZIOKE AMUKE HC 168 OHAFIA AMIYIUMUOKWURU AMURIE HC 169 OHAFIA ANIA ABIA HC 170 OHAFIA EBEMOHA EZIUKWU PHC 171 OHAFIA ISIALA PHC ISIAMA PHC 172 OHAFIA NDI ETITI NKPORO PHC 173 OHAFIA NDIAGBOR BASIC H/C 174 OHAFIA NDIELU ETITIAMA PHC 175 OHAFIA OHAFOR ASAGA MODEL HC 176 OHAFIA OKAMU OKON -AKU PHC 177 OHAFIA OWUWANYANWU OKAGWE PHC 178 OHAFIA UDUMA NDIUDUMA -AWOKE HC 179 OHAFIA UGWUFIE UGWUFIE PHC 180 OSISIOMA AMAISE AMAPUIFE PHC 181 OSISIOMA AMAITOLU ABAYI ARIARIA HP 182 OSISIOMA AMASAA UMUOBASI PHC 183 OSISIOMA AMASATOR UMUOCHAM PHC 184 OSISIOMA AMATOR UMUOYORO PHC 185 OSISIOMA AMAVO AMAVO TANK PHC 186 OSISIOMA AMAVOR NKWUOGU AMAVOR NKWUOGU 187 OSISIOMA ARO NGWA EKEARO PHC 188 OSISIOMA ISIALA OKPU ISIALA OKPU HP 189 OSISIOMA MBUTU OMA MBUTU OMA PHC 190 OSISIOMA MBUTU- UMUOJIMA UMUOJIMA OKEREKE 191 OSISIOMA ODE UKWU UMUODE 192 OSISIOMA OKPU UMUOBO OKPU UMUOBO PHC 193 OSISIOMA OSOKWA OSOKWA PHC 194 OSISIOMA OTUOBI OTUOBI PHC 195 OSISIOMA UMUNNEISE OKPUALOR UMUGWUOR LGA HEALTH OFFICE 196 OSISIOMA URATTA (HEALTH POST) 197 OSISIOMA URATTA AMAISE UMJUAGBARA PHC 198 UGWUNAGBO ABAYI MBASAA ABAYI NCHOKORO 199 UGWUNAGBO AMAPU IDEOBIA UMUAJA 200 UGWUNAGBO ASA UMUNKA ASA UMUNKA PHC 201 UGWUNAGBO IHIE OBEAKU ISIALA IHIE HC 202 UGWUNAGBO IHIE UKWU IHIE UKWU

24 203 UGWUNAGBO NGWAIYIEKWE NGWAIYIEKWE PHC 204 UGWUNAGBO NKPUKPUEVULA AZA PHC 205 UGWUNAGBO OBEAJA UGWUNAGBO PHC 206 UGWUNAGBO OBEGU OBEGU PHC 207 UGWUNAGBO OWERRI ABA UMUNKAMA 208 UGWUNAGBO OWERRI ABA OWERRI ABA 209 UGWUNAGBO UMUADA AKANU MODEL 210 UGWUNAGBO UMUARUKWU ASA- UMUAKWA 211 UGWUNAGBO UMUCHIMA UKEBE 212 UGWUNAGBO UMUGO UMUGO 213 UKWA EAST AKWUETE OHANDU AKWETE OHANDU 214 UKWA EAST AMAKAM AKWETTE AMAKAM 215 UKWA EAST AZUMINI AZUMINI 216 UKWA EAST IKWUEKE EAST AKANU 217 UKWA EAST IKWUORIE OHANKU 218 UKWA EAST IKWURIATO WEST ABAKI 219 UKWA EAST MBAM ABUO OBOHIA 220 UKWA EAST MKPUKPUAJA OGBUAGU MKPUKPUAJA 221 UKWA EAST OBEAKU OBEAKU 222 UKWA EAST OBOHIA OBOHIA 223 UKWA EAST OBUNKU OBUNKU 224 UKWA EAST OHAMBELE OHAMBELE 225 UKWA EAST OHURU MKPOROEBE OHURU 226 UKWA EAST UMUIGUEGBE ACHARA AKIRIKA OBU 227 UKWA WEST ASA NORTH OMUMA -UZOR PHC 228 UKWA WEST ASA SOUTH 1 UMUAKA PHC 229 UKWA WEST ASA SOUTH 2 UGWATI PHC 230 UKWA WEST IPU SOUTH IMO RIVER 231 UKWA WEST IPU-EAST OBEHIE PHC 232 UKWA WEST IPU-WEST OWAZA 233 UKWA WEST OBOKWE 1 OBOKWE HC 234 UKWA WEST OBOKWE 2 UMUAKWA 235 UKWA WEST OBUZOR UMUELECHI PHC 236 UKWA WEST OGWE OGWE PHC 237 UKWA WEST OZAR UKWU 1 UMUADIENWE PHC 238 UKWA WEST OZAR UKWU 2 UMUEBULUNGWU PHC 239 UKWA WEST OZAR WSET UMUORIE PHC 240 UKWA WEST UMUIKU ISI ASA UMUIKUKOR 241 UMUAHIA NORTH AFARAUKWU OKWULAGA 242 UMUAHIA NORTH AFUGIRI 1 UMUEGWU OKPUALA 243 UMUAHIA NORTH AFUGIRI 2 EKEOKWURU 244 UMUAHIA NORTH AZUEKE AHIAEKE 245 UMUAHIA NORTH IBEKU EAST 1 NKATA HC 246 UMUAHIA NORTH IBEKU EAST 2 EZIAMA OSSAH 247 UMUAHIA NORTH IBEKU WEST AJATA 248 UMUAHIA NORTH ISINGWU UMUDA PHC

24 249 UMUAHIA NORTH MBAOCHA MBAOCHA HC 250 UMUAHIA NORTH NDUME UMUANA NDUME 251 UMUAHIA NORTH NKWOACHARA UMUAWA ALAOCHA 252 UMUAHIA NORTH NKWOEGWU NKWOEGWU PHC 253 UMUAHIA NORTH OKAIUGA ALAIKE UMUKABIA HC 254 UMUAHIA NORTH ORIENDU EKEOBA HC 255 UMUAHIA NORTH UMUHU AMAOGWUGWU 256 UMUAHIA NORTH URBAN 1 ISIAMA AFARA 257 UMUAHIA NORTH URBAN 2 AMUZUKWU 258 UMUAHIA NORTH URBAN 3 HEALTH OFFICE 259 UMUAHIA NORTH URBAN 5 WORLD BANK PHC 260 UMUAHIA NORTH URBAN UGBA 4 INFANT WELFARE CLINIC 261 UMUAHIA SOUTH AHAIAUKWU A UMUTOWE PHC 262 UMUAHIA SOUTH AHIAUKWU B UMUOPARAOZARA PHC 263 UMUAHIA SOUTH AMAKAMA AMAKAMA PHC 264 UMUAHIA SOUTH AUU AMANGWO 265 UMUAHIA SOUTH EZELEKE EZELEKE PHC 266 UMUAHIA SOUTH EZIAMA EZIAMA PHC 267 UMUAHIA SOUTH NSIRIMO NSIRIMO PHC 268 UMUAHIA SOUTH OGBIDIUKWU OGODIUWKU PHC 269 UMUAHIA SOUTH OHIAOCHA UMUNWANWA PHC 270 UMUAHIA SOUTH OLD UMUAHIA OLD UMUAHIA 271 UMUAHIA SOUTH OMAEGWU DIKEUKWU PHC 272 UMUAHIA SOUTH UBAKALA A UBAKALA PHC 273 UMUAHIA SOUTH UBAKALA B AMUZU PHC 274 UMUNNEOCHI AMAUBA / UMUOGBUELE OBULO PHC 275 UMUNNEOCHI AMORIE UMUELEM PHC 276 UMUNNEOCHI AMUDA ISUOCHI PHC 277 UMUNNEOCHI ARO IKPA ARO IKPA PHC 278 UMUNNEOCHI EZIAMA AGBO EZIAMA NNEATO PHC 279 UMUNNEOCHI EZIAMA UGWU EZIOBA PHC 280 UMUNNEOCHI EZINGODO EZINGODO PHC 281 UMUNNEOCHI LEKWESI AMORJI PHC 282 UMUNNEOCHI LERU LERU PHC 283 UMUNNEOCHI LOKPANTA LOKPANTA PHC 284 UMUNNEOCHI LOKPAUKWU UMUCHIEZE PHC 285 UMUNNEOCHI MBALA /ACHARA MBALA PHC 286 UMUNNEOCHI OB/OB/LOMARA OBINOLU HC OBINULO/UHUDE/ 287 UMUNNEOCHI UMUOGBOKOCHA NGODO PHC 288 UMUNNEOCHI UBAHA AKAWA NNEATO PHC 289 UMUNNEOCHI UMUAKU 1 UMUAKU PHC 290 UMUNNEOCHI UMUAKU 2 AMAKPOWE HC 291 UMUNNEOCHI UMUDIM/ UHUOLUGHU UHUOLUGHU 292 UMUNNEOCHI UMUOBASI UMUOBASI PHC

24 24 LIST OF CONTRIBUTORS S/N NAME DESIGNATION/ORGANIZATION 1 Dr. John Ahukannah Hon. Commissioner/ Ministry of Health 2 Dr. Chinagozi Adindu Executive Secretary/ Abia SPHCDA 3 Dr.Elvina Nkemjika Orji HOD PCC/ Abia SPHCDA 4 Harbor Ijeoma HOD Administration/ Abia SPHCDA 5 Dr. Godwin Okezue HOD RHR/ Abia SPHCDA 6 Nmerechi Ofoegbu State Nutrition Officer/ Abia SPHCDA 7 Comrd Ugonma Obioma-Anosike Health Secretary, Ukwa West LGHA 8 Onwuka Chinyere Mang Health Secretary, Ohafia LGHA 9 Obioma Chikezie Health Secretary, Isiala Ngwa North LGHA 10 Dr Obioma Nwogwugwu Rep. Abia SHIA 11 Pharm.Nnaemeka Kanu-Oji Director Pharmacy/SMOH 12 Meg Onwu Director Health Education/ Abia SPHCDA 13 Onwuka Toyin State Immunization Officer/Abia SPHCDA 14 Eke Chinwe BFI Coordinator/ Abia SPHCDA 15 Cmrd. Onyeabor Chinedum HOD PRS/ Abia SPHCDA 16 Ehilegbu Caroline U. NHMIS Unit/SMOH 17 Ugo Precious Uma Asst SIO/ Abia SPHCDA 18 Elvis Nwosu FP iCCM/ Abia SPHCDA 19 Eric Nmecha HOD Accounts/ Abia SPHCDA 20 Chijioke Onyebuchi Udensi Senior Accountant/ Abia SPHCDA 21 Solomon Oge Kalu Planning Officer/ Abia SPHCDA 22 Ononogbu Juliet Rep.FP Coord/ Abia SPHCDA 23 Emeka Sopuruchi SDO/ Abia SPHCDA 24 Ukonu Victor C. M&E/ Abia SPHCDA 25 Chijioke Akpala ZTO NPHCDA 26 Ndifreke Mbaba Health Policy Plus (HP+)

24 27 Maxwell Ahunanya Health Policy Plus (HP+) 28 Queen Asuquo Health Policy Plus (HP+) 29 Dr Okechukwu Madukwe Health Policy Plus (HP+) 30 Sabastine Ikejide Health Policy Plus (HP+) 31 Felix Ogaga Oderoha Health Policy Plus (HP+)

24