ESMPIN Expanded Social Marketing Project in Nigeria

ESMPIN Integrated Health Implementation Report ESMPIN  Integrated Health Implementation Report SECTION 01

Acknowledgement

The ESMPIN Project is a social marketing project implemented by Society  for Family Health (SFH) along with the Association for Reproductive and Family This document is a product of Expanded Social Health (ARFH), BBC Media Action (BBCMA) and Population Services International FOREWORD Marketing Project in Nigeria (ESMPIN) consortium (PSI). The goal of the project is to improve the health of women and children in Nigeria partners led by Society for Family Health (SFH). by increasing use of modern family planning methods and child health. To achieve The Federal Ministry of Health (FMoH), along with this, the team worked to increase access to family planning (FP), reproductive health the various State Ministries of Health (where ESMPIN (RH) and child health products; increase use of health products and practice of health was implemented), was resourceful in providing behaviors; generate support from all sectors for social marketing as an important part of support and access to relevant stakeholders and sharing relevant information and data that informed the a total market approach; and improve the viability of local manufacturing of key health strategy design. These efforts are much appreciated. products. Local government departments of health were As an integrated project, ESMPIN had quality and scale as its implementation beneficial and physically available to support actual field focuses. The project therefore used several distinct channels to promote healthy interventions. We are grateful for all their guidance and practices among separate target groups in the areas of family planning, malaria, active involvement during the project implementation. diarrhea and nutrition. The intervention strategies were implemented one at a time or We acknowledge the effort and contribution of together over a period of time with the aim of changing behavior. The project also used the staff of SFH, BBC Media Action (BBCMA), the Association of Reproductive and Family Health (ARFH) approaches proven over time to design and deliver these messages to the target groups. and Population Services International (PSI) for their To achieve scale, ESMPIN designed and implemented several approaches, some relentless drive to achieving impacting results and also with a nationwide spread, while others focused on 22 states in Nigeria (including for taking time to document the processes involved. the Federal Capital Territory). This document therefore provides a brief outline of Finally, we acknowledge the technical support specific approaches used by ESMPIN as well as some program outcomes recorded received from PSI as well as content input from SFH, during and after field implementation. BBCMA and ARFH staff (both field and program).

 SIR BRIGHT EKWEREMADU, Managing Director, Society for Family Health  DR. JENNIFER ANYANTI, Chief of Party, ESMPIN Project 02 ESMPIN  Integrated Health Implementation Report SECTION SECTION Integrated Health Implementation Report  ESMPIN 03

Although family planning remained the focus for the ESMPIN project, other INTRODUCTION major objective components were the promotion of child survival interventions. It paid particular attention to nutrition (exclusive breastfeeding), malaria prevention and treatment and diarrheal management (point of use water treatment, hand washing with soap and water and diarrhea treatment with oral rehydration salts and Zinc) in an integrated manner and specifically for the wholesome benefit of women and children.

The project’s key objectives were: The different activities designed to achieve  To significantly expand access these objectives under and availability to family planning the ESMPIN project and child survival products are classified under the following subsections:  Improve knowledge, attitudes, perception and practices towards  Capacity-Building child spacing and survival  Demand Creation  Engender a sustainable partnership with key stakeholders  Service Provision

 Enhance the capability of the  Advocacy & Collaboration commercial sector in Nigeria to provide maternal and child health products  ORS & Zinc Promotion SECTION 1 Integrated Health Implementation Report  ESMPIN 05

CAPACITY BUILDING STRATEGY

The ESMPIN capacity building activities PPMV training sessions are instruction contacts to change or adopt positive behavior.  focused on providers and field agents. classes for PPMVs on ESMPIN health areas. It For the CBDAs, the training curriculum included Capacity building activities were designed to was either a one-day training on FP, malaria and learning sales skills designed to better persuade bridge the knowledge gap and address myths diarrhea or a six-day iCCM training on malaria, contacts to make an immediate purchase of non-eth- and misconceptions around child spacing diarrhea or pneumonia. Both had curricula ical products. In addition, the CHEWs training and survival health areas of ESMPIN. In developed in line with the FMoH guidelines. The included an additional two days on short and some cases, the activities addressed Family trainings improved their capability to better intermediate acting FP method service provisions. Planning (FP), malaria, diarrhea and nutrition handle (diagnose, treat or refer) health cases Various radio stations partnered with the program objectives at a sitting or separate meetings. commonly seen by these cadre of health staff. and their staff also received training to develop The objectives of these activities were to Clinical presentations under the ESMPIN pro- ESMPIN programs. In return, the stations received empower agents and providers with adequate gram were typically aimed at professional healthcare donations of work tools to aid their services. knowledge and skills. For agents, capacity providers (physicians, nurses and pharmacists) Furthermore, the ESMPIN project held building activities helped persuade specific and focused on one or more specific child spacing monthly review meetings with its field agents target groups to adopt ESMPIN health behaviors. or child survival products at a time. These sessions (IPCAs and CBDAs) to build capacity and For providers, it helped them provide a wide reviewed these products with the aim of motivat- address other administrative and logistic issues. “The balanced counseling sessions conducted by ESMPIN have helped range of FP and Maternal and Child Health ing the providers to offer quality services. The BCS Generally observed gaps from the field (both my providers to have a better insight to what method the client should (MCH) services in line with quality standards. updates, on the other hand, built the counseling knowledge and skills) were addressed during these take. ... and the client goes home more aware of what experiences Types of capacity building activities for skills of providers in offering quality FP services. meetings. Similarly, the project hosted quarterly they may go through with the method they have chosen. This makes providers (such as PPMVs, nurses, pharmacists The ESMPIN IPCA and CBDA training were three- provider meetings where informational and the client feel safer using an FP method and stay longer on it.” and physicians) included PPMV training, clinical day trainings where agents learned how to create administrative issues were addressed based on presentations, BCS updates and provider quarterly demand on ESMPIN objectives. The agents learned unique gaps observed during implementation.  MRS. AROGUNDADE FP coordinator, Epe LGA, Lagos State. meetings. For agents (such as IPCAs, CBDAs and the correct information on the ESMPIN health radio station personnel) it included IPCA training, areas, ways to dispel myths and misconceptions CBDA training and monthly review meetings. around these areas and requisite skills to motivate → CAPACITY BUILDING STRATEGY Integrated Health Implementation Report  ESMPIN 07 Statistics As a result of these capacity building sessions, health care providers were able to improve stocking practices for essential health commodities. SUCCESS STORY GOLD CIRCLE RECORDED AN 81% Empowered to Shelf Presence Across SDPs Take FP to the People Surveyed in Nigeria

COMBINATION 3 RECORDED 82% STOCKING Hamzat Kikelomo is a CHEW employed had this to say at the end of the cycle: “I was NORISTERAT 74%  by the ESMPIN project as an interpersonal unemployed for three years since I finished my DEPO-PROVERA 74% communication agent (IPCA) in the Odorangushin health education training. ESMPIN came and community of Epe LGA in Lagos State where the trained me to better practice my profession. I’m CYCLEBEADS 72% implementation of the Cycle 10 IPC program so excited that I was introduced to house-to-house POSTINOR 2 66% Total Number of Providers and Agents (between July–December 2016) took place. FP service provision. Our LGA FP Coordinator FEMALE CONDOM 74% The Mojoda PHC is one of the only health for Epe worked together with our SFH supervisor with Capacity Built Under the ESMPIN Project: facilities in the community which offers quality in training us to confidently talk to people. They The stocking findings for child and discounted FP services. Nevertheless, the worked with us all the time in the community while survival products recorded were: S/N CAPACITY BUILDING ACTIVITY FREQUENCY FEMALE MALE TOTAL facility had recorded relatively low patronage we provided these services and corrected us with due to proximity. Additionally, community love. I’ve gathered a customer base through the 31% FOR ORS/ZINC 1 PPMV Training Monthly 21,580 32,167 53,747 members were mostly civil servants or traders work period as well as all the prospective customers (Chi Co-packed ORS/Zinc) and had little time to seek FP services. I’m yet to meet. I hope to continue in this business 2 Clinical Presentations Hamzat and her colleagues created demand for a long time until I can get a formal hospital job.” 52% FOR P&G WATER PURIFIER & BCS Updates Monthly 10,240 6,570 16,810 for FP and other ESMPIN child survival objectives within the community by offering injections OF ALL OUTLETS SURVEYED 3 IPCA Training 6-Monthly 3,044 1,668 4,703 and pills to those who were unable to access FP due to distance and time constraints. I was unemployed for three years 4 CBD Training Twice in LOP 1,454 726 2,180 During the implementation phase, Hamzat’s since I finished my health education motivation for work was her monthly allowance, 49.4% training. ESMPIN came and trained me Sell other brands of MCH 5 CHEW Training Once (in Cycle 10) 433 123 556 the mark-up on sales of products and her passion products (2016 MAPS) for helping her community members. Hamzat to better practice my profession.” 08 ESMPIN  Integrated Health Implementation Report CAPACITY BUILDING STRATEGY ESMPIN  MARKETING BROCHURE 09

SUCCESS STORY Building Local Community Distribution Networks

Aisha Hassan was a house wife in Gwaram colleagues have formed a cooperative called CBD   LGA of Jigawa State before she was selected as networks. These are formally registered networks a community-based distribution agent (CBDA). with bank accounts, office accommodations Sustainability ESMPIN built her capacity to conduct one-on- and a constitution/policies. With Aisha Element one and group interpersonal communication serving as the treasurer of her CBD network, (IPC) sessions on child spacing and child survival she has further built her capacity to source The ESMPIN project products. She was also taught how best to resupply commodities and continue to better empower developed training curricula and sell the non-ethical products as well as how to herself, her network and her community. that partners or stakeholders refer persons to the ethical methods and services. can leverage. In addition, While creating and meeting these demands there are leave-behind within her community, she was soon regarded reference materials for as a ‘community doctor.’ The knowledge LESSONS LEARNED providers which will remain gained from the CBD training also elevated her in circulation. Some of these social standing among her peers. She received materials can also be made A major lesson learned for the capacity building of providers and field agents was the supportive supervisory visits both from program available on request or put staff as well as select community members need to work closely with relevant stakeholders (such as policy makers, community on the online public domain. (such as members of the ward development leaders, and leaders of relevant health associations) for support in seeking approvals, committee, WDC). The visits strengthened the delivery of qualitative information and selecting participants and participating in the actual capacity building exercise. Other provision of services. She also participated in the ESMPIN monthly review meetings which lessons included: more group work, games and field practice sessions, an objective served the dual purpose of product restock approach to screening participants nominated by community stakeholders as prospective and skills and knowledge improvement. Currently, Aisha and her other CBDA field agents, and uncovering provider concerns before engaging them in groups. 10 ESMPIN  Integrated Health Implementation Report SECTION SECTION 2 Integrated Health Implementation Report  ESMPIN 11

DEMAND CREATION ACTIVITIES

Demand creation activities under the ESMPIN project focused on providers  and men/women of reproductive age (MWRA). Activities were designed to address all ESMPIN health themes, either one at a time or altogether. Several factors were considered in developing the nature and content of activities, such as length of sessions, important research findings and community structures to harness positive outcomes. The aim of the ESMPIN demand creation activities were primarily to increase uptake of modern child spacing and child survival products. Examples of demand creation activities targeting providers are product detailing and provisions of IEC materials. Product detailing, which used provider behavior change communication (PBCC) techniques, helped to uncover and address provider concerns over child spacing and child survival products promoted by the ESMPIN project. After these “So many of our women die daily from poor reproductive and maternal and child health. I am grateful sessions, providers were motivated to offer services with these commodities. to USAID for their investment through the ESMPIN project that employs our people to educate For men and women of reproductive age, demand creation activities included community members. I implore all traditional and community leaders to join in mobilizing their people at community gatherings, religious gatherings and other channels to educate them on the routine house-to-house and marketplace IPC, special male involvement sessions, benefit of child spacing as well as the correct prevention and treatment of diarrhea and malaria.” special HF sessions at ANCs and CWCs, town hall meetings, bulk SMS, community

 ALHAJI SANI UMAR JABBI, The Sarkin Yakin-Gagi (leader in charge of health affairs under the Sultanate). drama shows, community gathering sessions, IEC materials and mass media.

→ SECTION 13 Brief Description of Demand Creation Activities Statistics A one-off analysis of the impact S/N ACTIVITY DESCRIPTION of demand creation on malaria  objectives was conducted 01 IPC Sessions Typical 1:1 or 1:G IPC sessions to MWRA across ESMPIN health themes. Contacts who change in Bauchi (IPT uptake trend) SUCCESS STORY Mr. Jimmy behavior are offered direct services or referred to appropriate health facilities or SDPs and Akwa Ibom (RDT use) Aninege, a states, respectively. The father of three and secretary 02 Male Involvement Sessions Special IPC sessions with organized groups of men within intervention communities engaged monthly comparison was for six months on various topics with the sole aim of gaining greater male participation in family health Using Radio to of Ogoja (before a select intervention LGA, Cross period) and six months into Prevent Diarrhea River State 03 ANCs and CWCs Special Sessions Group IPC sessions targeting expectant and nursing mothers at special clinics the intervention period. on adopting healthy behaviors around the ESMPIN health areas

04 Provider Town Hall Meetings A meeting of healthcare providers with key community stakeholders for the purpose of persuading providers to offer The HF IPT uptake results from quality cost effective care and encouraging stakeholders to become advocates for promoted ESMPIN behaviors Bauchi showed an average 34% INCREASE in IPT1 Mass media is one of the ways the ESMPIN which saved my son’s life; we also learned ways to uptake and 61% INCREASE for  05 Bulk SMS Framed messages sent out on a monthly basis designed to reinforce key messages projects disseminate health messages to prevent diarrhea. Now, my son and his siblings learned by IPC contacts and providers during the call or meeting sessions IPT2 uptake. RDT use in Akwa sensitize people on adopting healthy behaviors. live diarrhea-free because we tuned [into] to Ibom recorded an average The project used a 60-second adverts, 15-minute this SFH drama titled ‘One Thing at a Time’.” 06 Movercado Use of SMS services (free to community participants such as IPCAs, IPC contacts, increase of 391% within radio dramas and 15-minute radio magazine Jimmy Aninege, a father of three children healthcare providers and FP clients) employed in exit intervention communities to the intervention period. programs. These complementary forms of residing in Ogoja LGA of Cross River state, track outcomes of IPC contacts and health facility referral outcomes communication helped reinforce health recounted this story to SFH. As the secretary of The periodic impact survey messages and promote behavior change. Ogoja LGA, he shared this at the ESMPIN town 07 Community Drama Shows Drama shows that depict typical community experiences and how adopting (NIGERBUS, 2016) of the ESMPIN “I am a proud beneficiary of an SFH intervention hall meetings he attended as a policy maker. ESMPIN-promoted behaviors can improve situations radio mass media campaigns through a radio drama called ‘One Thing at a He explained that the program gave him a showed an average recall of Time.’ My wife and I had almost lost our son to comprehensive answer to diarrhea management. 08 Community Gathering Sessions Special IPC sessions on ESMPIN health themes targeting community gatherings diarrhea, despite several treatments from his He is now an advocate for correct diarrhea such as churches, mosques, community or family festivals FP MESSAGES 47% doctor including ORS. Unfortunately, these yielded treatment and uses his office to promote it. MALARIA MESSAGES 44% little result, and my son was gradually ‘drying ESMPIN radio dramas were designed to appeal 09 up’ day by day despite the medical attention. One to all men and women of reproductive age across IEC and Promotional Materials Posters (placed at HFs and SDPs), leaflets and fliers (shared to IPC contacts and handed to providers for EBF MESSAGES 39% their clients) and promotional materials supporting specific ESMPIN health behavior or products morning, I took a drive from home [and] tuned major Nigerian languages. They were also designed DIARRHEA MESSAGES 38% my radio. I heard the radio program sponsored across all ESMPIN health areas including child 10 Wall Murals Wall paintings at strategic locations of intervention communities serving as reminders to its by SFH and the discussion was on diarrhea spacing, malaria and exclusive breastfeeding. members to uphold the healthy behaviors promoted by the project during implementation A total of 15,123,844 IPC prevention and treatment. For the first time, contacts were recorded I heard of the complete treatment of diarrhea 11 Mass Media A 15-minute radio drama series aired twice weekly in four Nigerian languages that covered through the entire Cycle 1-10 with ORS and Zinc. I quickly spoke to my wife of the ESMPIN program (at all ESMPIN health areas across Nigeria; a 15-minute radio magazine program called “Ya ta and we purchased ORS and Zinc (co-packed) Now, my son and his siblings live 102% of planned target) along which worked like magic. Indeed, that experience kene Arewa” in the northern Hausa speaking part of the country; and a 60-minute radio spot diarrhea-free because we turned to aired in four Nigerian languages across all ESMPIN health areas across the country with 598,037 redeemed FP was a life-transforming moment, because we referrals (at 80% of target). learned how to handle diarrhea at our home the SFH drama ‘One Thing at a Time.” 14 ESMPIN  Integrated Health Implementation Report DEMAND CREATION ACTIVITIES SECTION Integrated Health Implementation Report  ESMPIN 15

LESSONS LEARNED To create demand efficiently among specific target groups, a good understanding of both the language and culture is critical for success, both in the design of materials as well as during message delivery. At each point, the project sought to recruit agents who  Sustainability were community locals, residing within and nominated by Element community stakeholders. In addition, PPMVs, which serve as a first The ESMPIN project leaves port of health call, are an effective means of changing behavior. behind a pool of trained agents who work with other local organizations to continue demand around its health objectives. Similarly, personnel for several radio stations build capacity to develop programs across these health objectives. In addition, community stakeholders (policy makers, community leaders and other local partners) were motivated to support demand creation activities at the project close out. Finally, IEC materials, like posters and leaflets for clients who visit health providers, would continue to be made widely available, particularly across SDPs. 16 ESMPIN  Integrated Health Implementation Report SECTION SECTION 3 Integrated Health Implementation Report  ESMPIN 17

SERVICE PROVISION ACTIVITIES

“The ESMPIN CHEW strategy ESMPIN Service provision refers to the direct offer of family planning has been a tremendous  (FP) as well as to health workers engaged in maternal and child health (MCH) success. The highlight for me is seeing the CHEWs services during the project’s implementation phase. Service provision under take FP services to the the project covered all health areas of FP, diarrhea, malaria and pneumonia. people, especially in very The ESMPIN service provision strategy addressed certain gaps identified rural communities and at discounted rates, without during project design and implementation. Some of these include: a dearth compromising quality. This of service delivery points (especially in northern Nigeria); an inadequate is why we are buying into number of trained FP service providers; frequent product stock-outs (due to the project’s strategy to make sure that the gains poor stock requisition systems, especially for the public sector, and inadequate [for] the people in the past cash base to ensure consistent shelf presence for the private sector); a high six months [do] not end. We number of IPC contacts not completing their referrals (largely due to perceived therefore plan to engage some of the same faces high service costs at health facilities, proximity to healthcare facilities (i.e. the CHEWs) whom the and the consequent high costs of transportation to these facilities). people have come to trust to Therefore, the direct service provision activities were designed and implemented continue offering services.”  to bridget the gap between inadequate staff strength, inconsistent product  MR. FRANCIS ILOK MODE Primary Health Coordinator, A door-to-door availability and the perceived high cost of services at the public and private sector. Ogoja, Cross River State field IPC session. The strategies employed herein include the CBD, iCCM and CHEWs approaches.

→ Statistics SERVICE PROVISION ACTIVITIES 19

The ESMPIN CBD Approach Unit Sales of Commodities under the CBD Approach

PRODUCT 2012 2013 2014 2015 2016 SUCCESS STORY Service provision under the community-based distribution Condoms 34,926 192,157 781,178 813,651 572,226 approach was implemented in Offering Improved four (4) northern states. It was Cycle Beads 23,494 59,563 203,170 190,794 103,046 Quality Child Health aimed at improving access to child spacing and child survival Services Through iCCM Cycle Beads 3,323 8,740 16,381 6,889 16,967 products by addressing issues The private sector-focused iCCM around insufficient public and  P&G Purifier of Water 746 178,856 450,124 320,004 137,177  pilot in Ebonyi State improved the private sector outlets. The practices of PPMVSs to implement this approach prioritized unethical FP A PPMV trained WaterGuard + WaterGuard Plus 17,269 6,257 10 1,286 1,138 objective. Select PPMVs were trained to on the EXMPIN commodities such as male and assess, classify and treat children who iCCM pilot. female condoms, CycleBeads and ORS and Zinc 0 1,795 44,940 119,106 98,711 have malaria, pneumonia, diarrhea or oral pills (Combination 3). The malnutrition and refer critical cases other MCH products promoted to public and private health facilities. by the approach included ORS Specifically, they learned to diagnosis and Zinc, P&G Purifier of Water THE ESMPIN CHEW APPROACH malaria fevers with RDTs, probe for (PUR) and WaterGuard Plus. This approach was implemented alongside the IPC program and leveraged the task-shifting policy diarrheal history and monitor respiratory to engage CHEWs as interpersonal communication agents (IPCAs). ESMPIN, with the support of rates for pneumonia diagnoses. They were THE ESMPIN ICCM PILOT policy makers and other stakeholders, carefully selected unengaged CHEWs, trained them on There was a significantly higher also taught to treat using ACTs for positive level of awareness of the ESMPIN The iCCM pilot (Integrated Community Case-Management of childhood killer diseases) in 2 Ebonyi state the ESMPIN health areas and built their capacity on quality FP services within their scope. The RDTs, ORS and Zinc for diarrhea and promoted health objectives within CBD LGAs focused on addressing malaria, diarrhea and pneumonia through the private sector (i.e. through products of focus included: Noristerat, Depo-Provera and Combination 3 while referring clients intervention communities compared to Amoxicillin for positive pneumonia cases. the non-intervention communities. PPMVs). These PPMVs were trained to identify and properly diagnose these ailments, treat them with with LARC needs to referral facilities. The CHEWs were trained to create demand on child spacing, Mr. Ogbonna Alex, a PPMV from correct medications and dosages, and identify severe cases that required referral. A total of 295 PPMVs malaria, diarrhea and exclusive breastfeeding but offeredFP services only to wiling contacts. Umudomi community of Onicha LGA Awareness CBD: 56% Non-CBD: 32% participated in the six-month pilot with constant supervision and product resupply. within the state expressed his excitement: Ever used an FP method CBD: 17% Non-CBD: 5% “Before now, we were seen as unable to Services Provided by CHEWs Through the Six-Month Cycle 10 Period (UNIT SALES) take care of children. We were called Currently use Cases Treated Under the 6 month iCCM Pilot for Ebonyi State METHOD JUL AU. SEP OCT NOV DEC TOTAL CYP an FP method CBD: 10% Non-CBD: 3% quacks. But now the community believes AREA JAN FEB MAR APR MAY JUN TOTAL in us. Before the training, all fever cases 2,367 7,589 10,291 9,202 8,617 6,758 44,824 11,206 The percentage of children were treated as malaria. But now, if a child Depo-Provera under five who had an episode Malaria 1,246 1,087 1,447 2,090 2,440 2,692 11,002 has [a] fever, I carry out an RDT. And if of diarrhea and were treated Noristerat 1,724 5,338 6,221 4,689 4,776 5,813 28,561 4,760 with ORS/Zinc combination was positive, I give the child an ACT according higher in the CBD communities Diarrhea 1,573 1,505 1,065 956 699 569 6,367 to the age of the child and advise the Combination 3 4,407 10,174 13,724 14,969 11,541 9,509 64,324 4,948 CBD COMMUNITIES 60% parent to bring the child back in three Pneumonia 277 266 319 308 304 382 1,856 days for [a] follow up. But if it is negative, NON-CBD COMMUNITIES 45% we refer for further tests and follow up.”  The project achieved a combined total of 20,914 CYPs with 349 CHEWs through the Cycle 10 six-month period.

20 ESMPIN  Integrated Health Implementation Report SERVICE PROVISION ACTIVITIES SECTION Integrated Health Implementation Report  ESMPIN 21

SUCCESS STORY Offering Quality FP Services through CHEWs  Sustainability Proximity to health facilities (and the and trained CHEWs who created demand Element  corresponding transport costs), inadequate for FP within intervention communities and staffing (with consequences such as long wait offered FP services as appropriate afterwards. The ESMPIN service times and unfavorable provider attitudes) and In this way, they offered subsidized FP services provision activities recorded the relatively high cost of FP services remain a to bridge the gap on proximity and cost. some sustainable outcomes. challenge to access of FP (and MCH) products Modupe Adejo is a beneficiary of such FP For instance, under the CBD and services. As a result, most community services. She lives in the Chokocho community implementation, agents members resort to services from unqualified of Rivers state with her three children. Before joined together to create sources such as PPMVs, who often offer services the ESMPIN intervention commenced in her registered CBD Networks beyond their scope. The ESMPIN project recruited community, she was receiving Depo-Provera to access and sell the (a family planning method) commodities they promoted from a PPMV. Nevertheless, during the implementation she reported wrong dosing: Modupe Adejo phase. Similarly, CHEWs the PPMV administered a LESSONS LEARNED  (seated in chair) who were engaged as IPCAs benefiting from double dose (i.e. 2 ampoules) A Health organized themselves across CHEW services to last for a six-month Although policies are in place encouraging task shifting, as well as Communicaitons various communities even period, instead of one every Coordinator after exiting, with the aim of three months, with no proper follow-up. engagement of other lower level healthcare providers such as PPMVs, providing guidance sustaining sales or service When she participated in an IPC session with there is still a need to gain the support and active participation of all to a CHEW-IPCA on provision. Furthermore, one of the ESMPIN trained CHEWs, she learned service provision. some states such as Cross the correct information. She then opted for relevant groups such as the government, regulatory authorities, health River and Edo are currently another method, which the CHEW provided. working to continue She says, “I thank you for correcting the mistake association groups and community leaders. Planning for interventions offering similar services from the Chemist (PPMV). I plan to have another must also include minor issues such as the provision of consumables using the CHEWs under baby three years after my last issue. I am now the payroll of the state. more confident that I will have one again.” required for offering services or waste disposal strategies for mobile agents. 22 ESMPIN  Integrated Health Implementation Report SECTION SECTION 4 Integrated Health Implementation Report  ESMPIN 23

ORS & ZINC A Winning Diarrhea Response

Diarrhea remains a major cause of illness 2. Training, detailing and supporting health  and death for children under the age of five in care providers including PPMVs to promote the Nigeria, although it is preventable and treatable use of ORS and Zinc. with low-osmolarity ORS and Zinc tablets. ORS/ 3. Engaging and supporting private sector Zinc is a combination therapy recommended manufacturers in the local production of ORS and by the World Health Organization (WHO) Zinc. In supporting local manufacturers of ORS and for management of diarrhea in children. At a Zinc, SFH commits to opening up the market and prevalence rate of 10.2%, only 33.7% of children providing these manufacturers with links to our receive any form of ORS and only 2.3% receive extensive wholesale and retail networks across the “ORS and Zinc Zinc during an episode of diarrhea (NDHS, 36 states of Nigeria (and the FCT). This potentially [are] the magical 2013) due to lack of access and availability. catalyzes and accelerates access to ORS and Zinc. SFH, through the Expanded Social Marketing With support from USAID, ESMPIN promoted medicine[s] that Project in Nigeria (ESMPIN), embarked on local production of ORS and Zinc through its stopped my child’s making the products readily available and partnership with CHI pharmaceuticals. CHI diarrhea within 12 accessible to save the lives of children in rural, Pharmaceuticals is a Nigerian company which hours of starting hard-to-reach areas and in urban Nigeria. launched the first co-packed low osmolarity ORS/ treatment.” ESMPIN was committed to increasing the use Zinc tablet within the country. This has meant that of ORS and Zinc to improve child survival and caregivers could receive a combination of ORS and  MRS. SUWAIBA SULAIMAN elminate childhood death from diarrhea in Nigeria. Zinc in one pack to treat diarrhea. Additionally, Caregiver of three children who The project used a three-pronged approach: a capacity assessment of several pharmaceutical had lost two to diarrhea. She is 1. Building demand for ORS and Zinc among companies in Nigeria revealed that there is good now an advocate for ORS and caregivers using generic mass media campaigns capacity in-country, and with adequate support, Zinc in her Tsakuwa community of Katagum LGA of Bauchi state. and strategic community mobilization. they are able to locally produce the commodities.

→ Statistics Some gaps that have ORS & ZINC Integrated Health Implementation Report  ESMPIN 25 been addressed through ESMPIN’s intervention in promoting ORS/Zinc:

MANUFACTURE SUCCESS STORY Facilitated engagement and support for local production of ORS and Zinc. Creating the Collaborative Partnership DISTRIBUTION ORS & Zinc Market SFH committed to providing Improving Local the manufacturers with links Production of to our extensive wholesale and Before the ESMPIN intervention, the agents worked in communities across 22 ORS/Zinc retail networks across the 36  combined use of ORS/Zinc in Nigeria was states in Nigeria conducting door-to-door and states of Nigeria (and the FCT), practically nonexistent, despite the WHO group sessions with caregivers to promote thereby creating the potential recommendation. ESMPIN intervention diarrhea treatment practices. In this way, Mr. Steve Onya is the managing director to catalyze and accelerate  with government, manufacturers, healthcare the ESMPIN project recorded 8,819,725 of CHI Pharmaceuticals Limited and says the access to ORS and Zinc. providers, other partners and local communities IPC contacts on diarrhea management. experience of pioneering the local manufacture sparked and created the now-increasing SFH worked with national committees such as of ORS/Zinc in Nigeria is one of mixed feeling. POLICY demand for the products used in the treatment the National Essential Medicines Coordinating “There is that feeling of joy and satisfaction in Strengthened national policy of diarrhea. This landmark initiative enabled Committee (NEMCM) and other partners being the pioneer of an important medicine implementation on the use of ORS/ the growth of the market for locally produced to expand demand generation and product intervention relevant to child healthcare. There Zinc combination in management ORS/Zinc and has since seen the inclusion redistribution. The collective effort of NEMCM is also the joy of meeting the desire of the world of childhood diarrhea. Through of four other local manufacturers. partners brought about both an increase in health community to see locally manufactured the NEMCM platform, facilitated The project’s interventions also strengthened awareness and product penetration to rural quality essential medicine in Nigeria which inclusion of ORS and Zinc in the implementation of the national policy on use of and hard-to-reach communities through the LESSONS LEARNED remains the most populous nation in Africa. national essential medicines list. co-packed ORS/Zinc for diarrhea management. government and private sector channels. The flip side of the feeling is in the business Collaboration with federal and state ministries Similarly, ESMPIN leveraged on the SFH’s part, reflected by the poor return on [a] huge DEMAND GENERATION A major lesson learned through the promotion of ORS/ of health achieved this goal. Similarly, through nationwide distribution networks to promote investment. We believe that better government Built demand for ORS and Zinc SFH’s vast distribution networks, the product now product distribution within the private Zinc use was that to further strengthen the local market and other relevant agencies’ support would among caregivers through generic enjoys nationwide demand and availability in the sector. SFH detailers and sales representatives make a big difference.” The CHI Pharma mass media campaigns and and improve local production, the Nigerian government private sector (pharmacies, hospitals and PPMVs). also conducted capacity building sessions brand of dispersible Zinc sulphate tablets and strategic community mobilization. with pharmacists, doctors and PPMVs to must actively participate along with development low-osmolarity ORS have always met quality improve knowledge and understanding of the specification in all tests carried out locally PROVIDER CAPACITY Demand Generation ESMPIN conducted nationwide demand product. The demand generation activities partners and providers. Together, they must prioritize and internationally. CHI Pharmaceuticals Trained, detailed and supported generation through mass media campaigns resulted in an increase in knowledge and is currently producing at 45% capacity and health care providers including the procurement of locally manufactured ORS/ to increase caregivers’ knowledge and utilization with about 50% (NIGERBUS, 2016) has an installed the capacity to produce 1.2 PPMVs to improve provider awareness on proper diarrhea treatment of caregivers who understand that the use billion tablets of Zinc and 925 million sachets knowledge and promote Zinc by federal and state governments to further using the ORS/Zinc tablet. In addition, IPC of combination of ORS/Zinc is appropriate of ORS per annum. They currently export the use of ORS and Zinc. treatment for diarrhea in children under 5. stimulate the market for local production. the products to other African countries. 26 ESMPIN  Integrated Health Implementation Report SECTION SECTION 5 Integrated Health Implementation Report  ESMPIN 27

ADVOCACY & COLLABORATION

Advocacy and collaboration was prioritized on the ESMPIN project with A  focus on the government, funders, peer organizations, private sector stakeholders and community stakeholders all with the aim of achieving its objectives. Advocacy was continuous under ESMPIN and events were held with all stakeholders to inform, build buy-in and support, gain active participation on activities, receive

“The ESMPIN project has done a lot for the state through demand generation. What is of their contribution in addressing challenges and share outcomes of project activities interest to me is seeing women in the communities walk into the health facility with a referral to stimulate ownership. ESMPIN engaged in numerous collaborations and form to demand FP service. The work of ESMPIN interpersonal communication agents in partnerships with government agencies at the state and local levels. Traditional/ mobilizing clients makes work easy for the provider. Your support with consumables to referral health facilities has been helpful in addressing some of the challenges of these facilities.” religious institutions and other implementing partners proved beneficial in leading family planning, malaria and diarrhea community-level interventions across  MRS. JOYCE AMAEWHWE Rivers State Family Planning coordinator. 22 intervention states. All project activities, including selection of intervention communities and field agents, were done in collaboration with local authorities.

→ Statistics28 ESMPIN  Integrated Health Implementation Report ADVOCACY & COLLABORATION Integrated Health Implementation Report  ESMPIN 29

Mass Media

The ESMPIN project used mass media to reach audiences 10: everywhere in Nigeria. ESMPIN New programs were aired media jingles and provided introduced in different equipment to select media partner stations on RMNCH. organizations to improve their  Policy Change Through iCCM ESMPIN’s intervention with government,  Special Events with States & Federal Government capacity to produce and air FP ESMPIN worked with MalariaCare in manufacturers, healthcare providers, other ESMPIN worked closely with state and federal and child survival programs 5: collaboration with the Federal Ministry of partners and local communities created a government ministries of health to host special events through a collaborative Existing MCH programs in Health (FMoH) and Ebonyi State Ministry of growing demand, building capacity for the that aimed at improving women’s and children’s health. arrangement. Producers and different partner stations Health (ESMoH) to implement the iCCM pilot local production of ORS/Zinc. At the end of the The 2015 child spacing day event in Zamfara State is presenters of health programmes improved their content in Ebonyi. ESMPIN trained 295 PPMVs on case ESMPIN project, four other local manufacturers an example of such special events. Prior to the event, and popular programmes and production and all management (diagnosis and treatment) of joined in. CHI Pharmaceuticals, the pioneer advocacy visits were held with religious and traditional participated in ESMPIN training partner stations now have uncomplicated malaria, pneumonia and diarrhea. local manufacturer, has an installed capacity leadership who helped with community mobilization and in-house mentoring health programmes that They were trained to identify malnutrition in to produce 1.2 bilion tablets of Zinc and and sensitization. On that single day 568 women conducted by BBC Media Action. address RMNCH issues. children and to refer all complicated cases to 925 million sachets of ORS per annum. willingly accepted different types of FP methods. a health facility. ESMPIN’s collaboration with Beneficiaries of the project are the FMoH and MalariaCare to implement the  Male Involvement Method Uptake at Zamfara Child Spacing Day Event 465: grateful for the opportunity. iCCM pilot will provide evidence required In most Nigerian communities, men hold S/N METHOD PROVIDED QUANTITY Media practitioners attended for wide scale training of a lower cadre decision-making power and their influence workshops on thematic health workers (such as PPMVs) on proper impacts the choice and use of maternal and child Customer buying 1 Implanon 301 and production issues. BLESSING LAWYER diagnoses and treatment of serious childhood child survival health commodities. However, these men are often RADIO RIVERS: illnesses such as pneumonia and malaria. products from excluded from FP programmes and interventions. 2 Jadelle 58 “I learned interview skills because I a PPMV Lack of spousal support is a barrier to acceptance 72: know that was my major problem.  Local Manufacture of ORS/Zinc and uptake of FP counselling and services. The 3 IUCD 15 I learned how to get to the heart Media practitioners ESMPIN facilitated engagement and support of ESMPIN project prioritized male involvement to of my listener and I learned how to 4 Depo-Provera 04 received specialized get to the heart of my interviewee.” local production of ORS/Zinc in Nigeria through increase support among men for family planning training on production for its partnership with CHI Pharmaceuticals. The and greater participation in women’s health. The 5 Oral Pills 120 improving reproductive, partnership led to the pioneer production of male involvement sessions were held in 22 priority maternal, neonatal and VIVIAN OSAGIE locally manufactured co-packed ORS/Zinc, states. The project conducted planned interactions 6 Condoms 70 CITY FM, LAGOS: child health (RMNCH). making it easy for caregivers to access the product with male groups designed to change social norms “I got one special tool, a zoom in one pack for the treatment of diarrheal and improve male participation in women’s health. recorder. I take it everywhere episodes. Prior to ESMPIN’s intervention, the Studies showed that the intervention strategy ESMPIN with me, it makes my job also collaborated with the SMoH across all 62: easier. Basically, this tool has use of ORS/Zinc in Nigeria was low, as 2.3% A male involvement contributed to higher spousal communication of its priority states to support and participate in Chief executive officers took helped me, this has helped of children who had diarrhea received Zinc session in Southern on family planning in the communities where organizing special health day celebrations amidst Nigeria part in master classes. me with my interviews.” and only 33.7% received any form of ORS. ESMPIN worked (IPC & CBD Evaluation, 2016). specific technical working groups. 30 ESMPIN  Integrated Health Implementation Report ADVOCACY & COLLABORATION SECTION Integrated Health Implementation Report A crossESMPI sectionN 31 of the ESMPIN team with the Kogi State Commissioner of Health and SMoH officials SUCCESS STORIES

FP Training Impact on Outcomes of Demand Creation Activities

ESMPIN collaborated with other  implementing partners to provide complete FP training for providers. This is because ESMPIN focused on demand  generation, its core strength. FH+, a The Onuh of Obocho project implemented by Marie Stopes Community in Kogi International Organisation Nigeria State and Celest Carr, (MSION), collaborated with the ESMPIN Senior Planning and project across various states where Program Advisor, ESMPIN implemented community-level USAID during a USAID/ ESMPIN field visit intervention, such as in Imo State. In Imo, uptake of modern FP methods, especially LARCs, was very low. During their collaboration, MSION conducted LESSONS LEARNED training of providers on LARCs while ESMPIN generated demand for services. Advocacy works. Through advocacy, doors of opportunity As a result, service uptake jumped from five in January 2016 to 834 by June 2016. opened for the project. We gained trust, acceptance and In addition, the method of acceptance active participation of stakeholders on project activities. changed to more LARCs from zero to 68. Collaboration brings leverage. Through collaboration, ESMPIN leveraged the strengths of other partners to achieve its mandate, while contributing its strength to these organizations, resulting in a win-win situation for all parties. 32 ESMPIN  Integrated Health Implementation Report

partnerships with several international donors, Media Action reaches some 200 million ESMPIN Ministries of Health and other organizations people through local broadcast partners, BBC to create health solutions that are built to last. channels (especially the BBC World Service), PARTNERS online, mobile and print platforms and through interpersonal communication. In Nigeria, we  The Association for Reproductive work in partnership with more than 300 radio and Family Health (ARFH) and TV broadcasters – more than any other ARFH, established in 1989, is a leading fully development organization in the country. Since  USAID indigenous non – profit and Non- Governmental 1999, we have delivered more than 16 health We partner to end extreme poverty and organization in Nigeria, committed to improving governance projects reaching and engaging promote resilient, democratic societies while the quality of life of individuals and families Nigerians across all 36 states and the Federal advancing our security and prosperity. by promoting and increasing access to quality Capita Territory. About 8.6million Nigerians health information and services. ARFH has a listen to Ya Take Ne Arewa in the north, a Hausa Go Deeper multi-skilled workforce of 170 staff with the radio programme produced under the Expanded  Society for Family Health (SFH) capacity to design, implement and evaluate Social Marketing Project in Nigeria (ESMPIN). For more ESPMIN project SFH is an indigenous, non profit, non-political, model initiatives, many of which have gained resources, please find the non governmental organization in Nigeria with national and international recognition and following online briefs: a mission to empower Nigerians, particularly are being replicated. Within the 28 years of  Population Services International (PSI) the poor and vulnerable, to lead healthier existence, the organization has successfully PSI makes it easier for people in the developing SUCCESS STORIES lives. Working with private and public sectors, managed and implemented over 150 innovative world to lead healthier lives and plan the families http://bit.ly/2mhWcgb SFH uses social marketing and evidence-based reproductive health and development projects they desire by marketing affordable products and behavior change communication to improve across the 36 states and the FCT and other services. A global health network of more than BOOK OF ABSTRACTS access to essential health information, services neighbouring countries, most of which have 50 local organizations, PSI focuses on serious http://bit.ly/2mlclSL and products to motivate the adoption of healthy gained national recognition, shaped national challenges like a lack of family planning, HIV behaviors. SFH implements and demonstrates responses to public health challenges and a and AIDS, barriers to maternal health, and the BOOK OF STANDARDS significant impact in various health fields number are presently replicated nationwide. greatest threats to children under five, including http://bit.ly/2mNtaD9 including maternal and child health, malaria malaria, diarrhea, pneumonia and malnutrition. prevention and treatment, HIV & AIDS A hallmark of PSI is a commitment to the TECHNICAL BRIEFS prevention, reproductive health, family planning  BBC Media Action principle that health services and products are http://bit.ly/2mldoSC and safe water systems. SFH also provides health Established in 1998, BBC Media Action is the most effective when they are accompanied by products and clinical services to Nigerians in international charity of the BBC. Working robust communication and distribution efforts GUARD BOOKS urban and rural areas, especially among the with media and communication to help that help ensure wide acceptance and proper use. http://bit.ly/2mSLIBb most vulnerable. SFH in collaboration with reduce poverty and support people in claiming PSI works in partnership with local governments, Population Services International (PSI) embraces their rights, our aim is to inform, connect ministries of health and local organizations to POLICY BRIEFS opportunities for furthering its mission through and empower people around the world. BBC create health solutions that are built to last. http://bit.ly/2m2FoHX ESMPIN Expanded Social Marketing Project in Nigeria

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