MATERNAL AND CHILD SURVIVAL PROGRAM – ROUTINE IMMUNIZATION Quarterly Report Program Year 4 Quarter 1 [October 1 to December 31, 2017]

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

Submitted by: Dr. Femi Oyewole, national immunization technical advisor John Snow, Inc. (JSI) Plot 448 Reuben Okoya Street Wuye, Abuja, Nigeria

PROGRAM SUMMARY Maternal and Child Survival Program Nigeria - Program Name Routine Immunization

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

Name of Prime Implementing Partner John Snow, Inc. (JSI) Agreement Number AID -OAA -A-14 -00028 National Primary Health Care Development Agency , Expanded Programme on Immunization, The Bill & Melinda Gates Foundation, Dangote Foundation, Solina Health, World Health Organization, United Nations Children’s Fund, US Centers for Disease Control and Prevention N- STOP Project, European Union-funded Support Major Partner Organizations Immunization Governance in Nigeria, Bauchi and Primary Health Care Development Agencies, ministries of local government, local government authorities, Northern Traditional and Religious Leaders’ Council, ward development committees, community-based health volun teers , Chigari Foundation Geographic Coverage (cities and or Abuja FCT, Bauchi and Sokoto States, Nigeria countries) Reporting Period Program Year 4 , October 1 to December 31 , 2017

ACRONYMS

AEFI adverse event following imm unization BGRISP Basic Guide for RI Service Providers BMGF Bill & Melinda Gates Foundation BSPHCDA Bauchi State Primary Health Care Development Agency CBHV community-based health volunteer CCE cold chain equipment CDC N-STOP U.S. Centers for Disease Contro l and Prevention N -STOP Project CRG community resource group DHIS2 District Health Information System version 2 DQS data quality assessment HF health facility IPD Immunization Plus Day LGA local government area LIO LGA immunization officer M&E monitoring and evaluation MCSP Maternal and Child Survival Program MOU memorandum of understanding NPHCDA National Primary Health Care Development Agency PHC primary health care PY program year REW Reaching Every Ward RI routine immunization SP serv ice provider SERICC State Emergency for Routine Immunization Coordination Center SPHCDA state primary health care development agency SSPHCDA Sokoto State Primary Health Care Development Agency TFI Task Force on Immunization UNICEF United Nations Children’s Fund USAID United States Agency for International Development VCM village community mobilizer VDC village development committee WHO World Health Organization

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TABLE OF CONTENTS

ACRONYMS ...... 1

1. PROGRAM OVERVIEW ...... 3 1.1 Quarterly Achievement Highlights ...... 4

2. ACTIVITY IMPLEMENTATION PROGRESS ...... 8 2.1 Progress Summary ...... 8 Improving coordination of RI management and data quality ...... 8 2.2 MOU Thematic Area 1: Governance and Accountability ...... 10 2.3 MOU Thematic Area 2: Improving Accessibility and Utilization ...... 13 2.4 MOU Thematic Area 3: Vaccine Security, Cold Chain, and Logistics ...... 15 Bauchi ...... 15 Sokoto ...... 16 2.5 MOU Thematic Area 4: Monitoring and Evaluation/Supportive Supervision...... 16 Bauchi ...... 16 Sokoto ...... 18 2.6 MOU Thematic Area 5: Community Partnership ...... 20 2.7 MOU Thematic Area 6: Capacity Building and Training ...... 23 Bauchi ...... 23 Sokoto ...... 24 2.8 National-Level Support ...... 25 2.9 Learning Activities ...... 25 2.10 Implementation Challenges ...... 27

3. Management and Administration ...... 27

4. Sub-Agreements ...... 28

5. Activities Planned Next Quarter ...... 29

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1. PROGRAM OVERVIEW

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

MCSP has launched multiple activities in Nigeria. These include a routine immunization (RI) technical assistance program in Bauchi and Sokoto States, a project aimed at reducing maternal, newborn, and child (MNCH) deaths in Kogi and Ebonyi States, and a public-private partnership through the Mobile Alliance for Maternal Action (MAMA). This quarterly report covers MCSP/Nigeria RI program assistance to Bauchi and Sokoto States. The program aims to strengthen systems to increase and sustain RI coverage and reduce childhood illness and death. USAID MCSP’s RI program is fully operational at the national level (in Abuja), and in Bauchi and Sokoto.

MCSP/Nigeria RI program objectives: • Objective 1: Support state-led and -owned efforts to achieve >80 percent RI coverage in every ward of Bauchi State by the end of December 2017, and in Sokoto State by the end of December 2018. • Objective 2: Support state-led and -owned efforts to expand the availability and quality of RI services by providing technical assistance in the areas of capacity building and training, supportive supervision, monitoring and use of data, supply/cold chain, and community engagement. • Objective 3: Promote the transition of all responsibility for sustaining and building on these gains to Bauchi State by January 2018, and to Sokoto State by January 2019, by improving capacity to promote, deliver, and monitor RI services at the state, local government area (LGA), health facility (HF), and community levels.

MCSP has been supporting implementation of the Bauchi State Primary Health Care Development Agency’s (BSPHCDA’s) quadripartite RI-strengthening memorandum of understanding (MOU) since January 2015,1 and the Sokoto SPHCDA’s quadripartite RI-strengthening MOU since October 2015. The program has been tasked by each state’s SPHCDA and the three remaining MOU signatories—USAID, the Bill & Melinda Gates Foundation (BMGF), and the Dangote Foundation—to focus on providing four areas of technical assistance: 1) monitoring and use of data; 2) supportive supervision; 3) community partnership; and 4) capacity building and training This report covers the period from October 1 to December 31 2017 of program year 4 (PY4 Q1). It should be noted, however, that MCSP/Nigeria RI PY follows a calendar-year cycle, in line with Nigerian state government annual planning cycles. Included in this report is a summary of program achievements for the quarter, planned activities for the second quarter, and challenges, opportunities, and recommendations.

1 Skeletal operations started in January 2015; full program implementation started in July 2015.

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1.1 Quarterly Achievement Highlights

BAUCHI MOU Thematic Area 1 – Governance and Accountability The harmonized MOU workplan for 2018 has been developed and approved by the state task force for immunization (TFI). MCSP contributed technical support to State Emergency for Routine Immunization Coordination Center (SERICC) to develop and finalize the plan. All 15 planned state -level SERI CC and sub -working group meetings were convened with MCSP’s technical and facilitation support and active membership. MCSP followed action points as requested by the BSPHCDA. MOU Thematic Area 2 – Access and Utilization 91% of a total 12,201 fixed RI sessions and 89% of a total 8,206 RI outreach sessions planned were conducted during the quarter. Also, 94% of Bauchi’s health facilities are now providing at least one RI session. Supported 1,029 of 1,090 health facilities across 20 LGAs to review and update their RI microplans for the period under review. There was a 6% increase in immunization sessions (fixed and outreach) conducted per month among all health facilities providing RI compared to the previous quarter. MOU Thematic Area 3 – Vaccine Security, Cold Chain , & Logistics All 323 (100%) ward -level satellite health facilities (HFs) in the state have ha d functional cold chain equipment since October 2017. MCSP continued to strengthen the processes for the LGAs to track and report faulty cold chain equipment, conduct basic preventive maintenance, and track bi-weekly vaccine stock availability at LGA and ward HF cold stores through mentoring of the LGA and ward cold chain officers. MOU Thematic Area 4 – Monitoring and Evaluation/Supportive Supervision 61% of the 3,087 planned RI visits to the 1,029 health facilities offering RI were conducted. MCSP facilitated SS from the LGA to the HF level in 578 of the 984 HFs supervised, as assigned by the LGA PHC teams. Supervisors conducted interviews, observed RI service delivery, provided on-the-job coaching, reviewed HF action plans, and planned support for subsequent visits. All monthly RI reports submitted by the HFs during LGA data working group meetings were validated and checked for completeness and accuracy. Any HF found to have discrepancy was supported to make corrections. At the end of the quarter, timeliness of submission was 95% and completeness was 97%. This is an improvement from last quarter, where timeliness was 91% and completeness was 93%. Data quality a ssessments (D QA ) spot checks were conducted to improv e RI quality at the HF level . Accordingly, 528 HFs were followed up on this activity during the quarter. Data are being analyzed by state M&E working groups. MOU Thematic Area 5 – Community Partnership Over 800 of 1,029 RI service providers received on -the -job training using immunization registers to identify children immunized by age and settlement, summarize, and present results to community resource persons during monthly meetings. This information was used to trace defaulters in low coverage settlements. 5,104 newborns were reported to have been referred to HFs for RI services by traditional barbers and other community resource groups such as village community mobilizers (VCMs) and traditional birth attendants (TBAs) volunteering in some HFs. 875 defaulters were also tracked by community resource groups (CRGs), making the total number of tracked and referred newborns 5,979 in PY4 Q1. The data show that about 90% (5,426) have been immunized with various antigens (BCG, HEP0

4 and OPV0 , while 9% ( 553 ) failed to go to HFs for immunization , an increase of 1% since the previous quarter. MOU Thematic Area 6 – Capacity Building and Training Ahead of the measles campaign exercise across the state, MCSP helpe d the state conduct a training of trainers for 20 LGAs primary health care (PHC) teams. MCSP facilitated the trainings on community linkage, adverse event following immunization (AEFI) causes and management, harmonization of RI data and measles data microplanning. 5 health personnel comprising local immunization officers (LIOs), environmental health officers, cold chain, M&E, and surveillance officers were drawn from each LGA for the training. A total of 877 men and 103 women, including RI providers and community leaders were trained. SOKOTO MOU Thematic Area 1 – Governance and Accountability 475 (91%) of 523 HFs currently providing RI services received and retired their RI funds during the reporting period. MCSP continues to support the state through the finance working group to monitor fund use and retirement. The consistently timely release of funds was evident in the quarter under review, which facilitates conduct of SS and outreach immunization activities. 97% of the 69 planned RI monthly review meet ings with service providers were conducted across 23 LGAs. LGA teams are now preparing meeting agendas and document action items with minimal support from partners. 512 HFs (98% of the targeted HF s) providing RI in Sokoto state updated their Reaching Ever y Ward (REW) microplans during the reporting quarter. MCSP supported the service providers to review their session plans, and doses of vaccine needed to cover their catchment area population. MOU Thematic Area 2 – Improving Accessibility and Utilization MCSP helped assess 79 HFs in Sokoto potential to initiate RI services . 41 of these have since initiated regular RI services. This brings the HFs providing RI services in the state to 523 (69% of the total HFs in the state). 6,226 fixed sessions were plann ed during the reporting period , of which 6,029 (97%) were conducted. Similarly, 5,893 (98%) outreach sessions were conducted of the 6,075 planned. MCSP and the LGA team and other partners provided supportive supervision in recording, vaccine management, and proper coordination with community structures during outreach services to 475 HFs. MOU Thematic Area 3 – Vaccine Security, Cold Chain, & Logistics 215 (91%) of 236 health facilities were co ached on vaccine management . Through the logistics working group, MCSP provided mentoring support to the states’ 23 LGA cold chain officers and 244 HF in-charges from satellite cold stores (HFs with CCE) to review vaccine stock levels, vaccine consumption, wastage rates, and cold chain performance; and to use data to inform decisions. Together with Solina, UNICEF, and SSPHCDA, MCSP trained 23 LGA cold chain officers on us e of the vaccine dashboard to review vaccine stock for all the antigens, diluents, and safety boxes. Only one LGA (Sokoto-North) reported 1–2 vaccines below minimum level. No LGA reported stock-out of diluents or safety boxes. MOU Thematic Area 4 – Monitoring and Evaluation/Supportive Supervision MCSP supported the development of joint supportive supervision plan in collaboration with the state and RI MOU partners. In the reporting quarter, 1,543 of the 1,626 (95%) planned RISS were conducted by the LGA team and partners. MCSP supported 337 HFSS sessions and follow-up visits to HFs during RI fixed and outreach sessions across the state. 327 RI servic e providers (SPs) (192 male and 135 female) were given on -the -job support on data management and vaccine administration/management to improve their skills for effective RI service delivery and to ensure that sessions (both fixed and outreach) are conducted as planned. Follow-up

5 visits indicated a considerable improvement in the areas of data entry, consistency and timely reporting on vaccine stock level performance, documentation and administration (right dosage of potent vaccine given at the right site and right route and in good condition). There were d ata quality spot check s in 92 HFs across 18 LGAs during the reporting period . 151 SPs (82 male and 69 female) were trained on proper recording and reporting using the RI tools. Findings and action points were documented in the supervisory log book for follow up. Data analysis and use is improving gradually, as seen in SP ability to interpret monitoring charts and conduct settlement analysis. Conduct ed DQA follow -up visits in four LGAs (, , S okoto North , and ). Eight HFs were selected for the follow-up activity to check implementation status of DQA recommendations. During follow-up visits, SPs were noted to comply with good recording practices. MOU Thematic Area 5 – Community Part nership MCSP supported the planning of and co -facilitated the state -led orientation of 86 district heads, 272 village heads, 3,480 settlement heads, 23 LGA community engagement focal persons and 244 ward community engagement focal persons on operationalization and implementation of community name-based registration of newborns and children under one-year. Orientation included learning and practicing the use of name-based registers for tracking immunization status of children. In an effort to improve track ing and referral of drop ped -out and left -out children into the RI system, MCSP provided on-the-job mentoring on interpersonal communication skills and appropriate documentation of newborn identification, defaulter tracing, and referral to 2,796 community resource groups (VCMs, community-based health volunteer [CBHVs], & TBAs). The state social mobilization working group has recorded 528 children who received vaccination through the referral system. The program team supported 512 SP s to conduct monthly feed back meetings with 221 village development committees (VDCs). The meetings included a session on conducting settlement analysis and providing lists of defaulters and unimmunized children to the community resource groups for follow up. MOU Thematic Area 6 – Capacity Building and Training 1,374 participants ( male 973, female 401) consisting of state and LGA staff were trained on basic guide for RI SPs. MCSP and partners (Solina, CDC, UNICEF, and BMGF) and SSPHCDA supported the state to conduct and cascade the training to the LGA level. The basic guide training is conducted to introduce SPs to the updated and reviewed guide on routine immunization for more effective RI services at the HFs. In collaboration with partners Solina, UNICEF, and BMGF , MCSP support ed the state to train 1,223 state and LGA staff (male 873, female 350) on developing microplans for measles supplemental immunization and implementation across the state. All 23 LGA team members, comprising LIOs, cold chain officers, M&E officers, RI focal person, health educators, and PHC coordinators were present. Through the training working group, MCSP provided technical support to SSPHCDA to train 512 SPs (male 323, female 189) on vaccine administration, waste management, data management, and AEFI management for the implementation of MNCH week across the state. MCSP’s support was in adaptation of the training tools from the national level and in facilitating the training. MCSP supp orted SSPHCDA to train 488 (356 male , 132 female ) as vaccinators and re corders per 244 wards across the state to conduct fixed-post activities during Immunization Plus Days (IPDs) in Sokoto State. National MCSP and other partners supported National Primary Health Care Development Agency (NPHCDA) to conduct a national TOT on the revised Basic Guide for RI Service Providers (BGRISP).

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MCSP and p artners (including CHAI, WHO, UNICEF, CDC STOP, and Save the Children) participated in the NPHCDA-chaired National Emergency for RI Coordinating Center (NERICC) meetings and sub-group meetings. MCSP contributed to the finalization of routine immunization supportive supervision standard operation procedures (RI-SS SOPs) and the updated RI flip chart job aid. Supported NPHCDA to develop the national training guidelines for BGRISP. Learni ng Agenda In Bauchi, global information systems ( GIS ) data collection has been completed and 199 HF catchment area maps have been produced. In Sokoto, the data collection process is still in progress but so far the following data has been collected: points of interest=99 (worship places, markets, schools, etc.); HFs=81; public buildings=9; and settlements=8,600. The table on page 26 shows differences between the hand-drawn and GIS maps. Key next steps include: training of RI providers to understand the maps and use them for microplanning, and reviewing and validating the maps with HFs and community leaders. An interview guide for the MOU workshop in Abuja has been developed and is undergoing refinement so that responses from the selected health workers will complement the development of the MOU documentation guide. In Sokoto, ahead of the newborn tracking activity commencement, baseline data was obtained after a community assessment. Data was collected among women with children 0–23 months across the 10 selected LGAs and are being analyzed. Preliminary findings will be shared with SERICC and the social mobilization working group in January 2018. Sub -Award Black Swan activities have been ongoing in and Sokoto South LGAs within 3 HFs/ward. During planned sessions, data and photographs of children whose caregivers bring them for RI services are being captured.

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2. ACTIVITY IMPLEMENTATION PROGRESS

2.1 Progress Summary

This report covers the MCSP/Nigeria RI program’s PY4 Q1 implementation progress and results. Results presented in this report primarily rely on service statistics from Bauchi and Sokoto States’ routine health management information systems, state RI working group and sub-working group reports, and program records. In both states, Ministries of Health (MOHs) and SPHCDAs continued to record important progress in strengthening the RI system to contribute to reductions in vaccine-preventable childhood morbidity and mortality.

Activities implemented in PY4 Q1 built on and strengthened the accomplishments of the previous quarter by scaling up interventions to increase RI coverage in both states. MCSP continues to support the state to improve capacity for developing, delivering, and promoting RI services at the state, LGA, and HF levels, significantly increasing access to and use of RI services. Specifically, the establishment of community engagement working groups and onboarding of community engagement focal persons in the quarter greatly contributed to strengthening technical demand-creation across all LGAs in both Bauchi and Sokoto.

During the quarter, MCSP joined other MOU partners to help Bauchi and Sokoto States finalize their harmonized RI MOU workplans for 2018, which will be used to guide RI activity implementation. The two state governments have released a total of 202.3 million naira (Bauchi=N114.9 million, Sokoto=N87.4 million) per their financial commitment to the RI MOU basket fund. PY4 Q1 initially marked the last quarter for the RI MOU in Bauchi but it has been extended to December 2018, and the quarter marked Sokoto’s second year since the signing of the RI MOU in December 2016. Timely disbursement of RI funds and retirement continues to improve in both states. Sokoto has updated and begun implementing a revised financial management (automated using software in December 2017) process to better track disbursement, use, and retirement of RI funds and reporting (quarterly, annual, and financial). In December 2017, HFs retired 100 percent of their funds on time across 23 LGAs.

Improving coordination of RI management and data quality MCSP continues to participate and provide technical assistance in routine planning coordination and review meetings of the emergency operations center, state and LGA TFIs, SERICC, and sub-working groups. Program staff continue to serve as active members of the SERICC and other RI coordinating bodies in Bauchi and Sokoto, building the capacity of state and LGA staff in coordination, leadership, management, and data analysis. MCSP consultants continued to participate in LGA monthly review meetings and TFI meetings, promoting proper planning and coordination of RI activities, data analysis, and use at both the LGA and health facility levels. The SOPs for LGA review meetings were revised through MCSP’s engagement in the state working groups to include a dedicated session on peer learning among the RI service providers and data quality checks. Furthermore, the review meetings continued to be platform for observing and coaching LGA M&E officers and service providers’ application of knowledge and skills to complete RI forms and make data quality spot checks and corrections. Three DQAs were conducted in 14 LGAs in Bauchi and preliminary findings show a 7 percent improvement in consistency between the tally sheet and the NHMIS summary and a 31 percent decrease in over- reporting. The community DQA also showed a 16 percent increase in fully immunized children and a 5 percent decrease in non-immunized children. MCSP is working closely with other MOU partners providing technical assistance to the state M&E sub-working group to analyze findings and develop plans for follow-up activities and on-the-job training for individuals involved in the RI data management system.

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Expanding access and use of RI services When compared with previous quarters, both states recorded an approximate 5 percentage-points decrease in the number of children who received Penta3 by 12 months of age. The slight decline in percentage coverage might be due partly to early improvement in data quality as observed during data spot-check activities. However, the sustained percentage coverage of over the targeted 80 percent in the two states could be connected to several factors, including corresponding increases in fixed and outreach immunization sessions as recorded in both states, and availability of vaccines at service delivery points. In Bauchi, 91 percent of a total 12,201 fixed RI sessions planned and 89 percent of a total 8,206 RI outreach sessions planned were conducted during the quarter. 94 percent of Bauchi’s health facilities are now providing at least one RI session per week. In Sokoto, 97 percent of a total 6,029 planned fixed RI sessions and 6,075 planned outreach RI sessions were held during the quarter. 69 percent of Sokoto’s 763 health facilities are now providing at least one RI session per month.

Improving vaccine supply chain and logistics Bauchi continued to record notable improvements in cold chain system and vaccine distribution. Since October 2017, all the 323 ward-level satellite HFs in the state have been equipped with functional cold chain equipment (CCE) to increase vaccine availability to all RI service delivery points. Similarly, in Sokoto, 86 percent (209) of ward-level HFs have been equipped with functional CCE for storing and distributing vaccines to non-equipped health facilities. MCSP continued to support the LGAs to strengthen their ability and processes to track and report faulty CCE, conduct basic preventive maintenance, and track bi-weekly vaccine stock availability at LGA and ward-level health facility cold stores. Furthermore, the program team continued to support the state logistics working group to use the vaccine dashboard and re-adjusted forecast figures by LGA to prevent gross over- and under- stocking of vaccines.

Sustaining community linkages with RI services The two states intensified their MOU-driven community engagement initiatives in October 2017 by rolling out the name-based registration and tracking immunization status of children under one-year by settlement heads. Under this new intervention, children identified by the settlement heads are referred to the HF for the services due. The strategy has been piloted in LGA of Sokoto State, and findings are being reviewed and will be used to scale up the intervention. MCSP’s LGA consultants continued to participate in HF review meetings with communities and provided technical assistance and mentorship to SPs to share RI performance with community structures. Eight-hundred-and-eleven RI SPs received on-the-job training for using immunization registers to identify numbers of children immunized by age and settlement and to summarize and present results to the community resource persons during monthly meetings. This process has improved SP skills in defaulter tracing, especially during outreach sessions.

Building capacity of RI service providers to deliver high-quality service MCSP continue to collaborate with MOU partners to support Bauchi and Sokoto to build the capacity of RI service providers to deliver high-quality RI services and strengthen the vaccine supply chain system. During the quarter, 1,374 LGA and HF staff in Sokoto received training on RI-related topics. Similarly 2,200 (Bauchi=977, Sokoto=1,223) LGA and HF staff were trained on developing microplans for measles supplemental immunization. MCSP helps to bring focus to immunization by supporting trained professionals at temporary fixed posts administering RI injections; assisting in accurate reporting of children immunized per post; encouraging town announcers to mobilize caregivers of eligible children to RI services at the fixed post; and during house visits, checking immunization cards for <1yr eligible children and referring eligible children who don’t have the cards.

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2.2 MOU Thematic Area 1: Governance and Accountability

Bauchi

LGAs conduct TFI and RI review meetings on RI activities During the reporting quarter, 85 percent of TFI meetings and 95 percent of RI review meetings were conducted across all 20 LGAs. The reduced number of the meetings conducted was as a result of too many activities during this last period of the year. The meetings are used to give feedback to service providers and are an opportunity to build SP capacity to improve RI service quality at LGAs. Topics discussed during these meetings include importance of documentation of community focal points/ward development committees (WDCs)/VDCs meeting minutes with SPs, the need for better documentation of action points from supportive supervision visits to health facilities, motivation of non-active barbers to begin documenting their activities, and the expected roles of TFI members to ensure a successful 2017 state-wide measles vaccination campaign. Other issues raised by the MCSP include concern over misconception on immunization in some LGAs and the steps to be taken by the district heads to dispel it. MCSP also stressed the need for a sustained community mobilization on RI by the HEOs.

Additionally, TFI members were asked to support LGA supervisors to track implementation of SS for timely REW microplan and monitoring chart updates. HFs with high dropout rates were identified and will be supported by LGA team and other partners during SS. MCSP collaborated with the LGA data working group to validate reports submitted by SPs during the meetings, which to some extent contributed to increase awareness of the TFI members on the importance of improving reporting timelines and completeness and other data quality issues.

MCSP supported TFI members by identifying pathways they can use to encourage support SPs in their respective catchment areas to conduct regular community meetings to resolve RI-related problems. The adoption of the newly-developed “accountability framework for all resource persons” led to agreement that adequate support needs to be given to newly inaugurated community engagement strategy focal persons. It was also agreed that service providers must conduct community mobilization through community town announcers a day before the immunization session. The SPs were also asked to keep their community heads informed ahead of time.

Other action points taken during these meetings were to supervise RI and SIA activities, and all non- compliant cases were followed up and resolved. SPs were also asked to ensure accountability framework for vaccine waste management and timely vaccine ledger update. It was also agreed that HFs with high dropout rates and negative dropout ensure good social mobilization before and during the measles vaccination campaign in their communities. SPs were urged to ensure all eligible children were fully immunized during the campaign.

Support finance WG to monitor disbursement of RI fund for supervision and outreach MCSP provides ways that financial disbursement can be strengthened, particularly at the service-delivery level. During the quarter, MCSP supported the systematic identification of improper filling of financial retirement forms by SPs in LGAs in which retirement forms were signed and countersigned by SPs without involving the community heads or WDCs chairs. Although occurrence of this issue is decreasing, LGAs were notified and asked to act if it was observed. MCSP also provided on-the-job training to the concerned service providers to fill financial retirement forms correctly. MCSP and the LGA team will follow up the HFs to monitor compliance and to ensure village heads and WDCs chairs are included in the process henceforth. Measures were also taken by LGAs to ensure that funds for any planned outreach session are returned if not sessions are not conducted. All these efforts have resulted in financial management tool use in 739 HFs. These efforts have improved documentation and timely

10 submission of retirements of used RI funds by all the HFs to the LGA accountant for submission to the state.

MCSP’s role in supporting state-level activities MCSP supported the quarterly meeting organized by the commissioner state Ministry of Health to obtain feedback from partners on the activities they implemented in the last quarter and those planned for the next. MCSP presented its progress and promised to widen collaborative RI efforts with other partners.

MCSP also supported the state to review its 2018 RI work plan and planned for the training of HF service providers on the National RI Basic Guide scheduled for January.

MCSP supported the state to advocate for support to the Ministry of Education and Local Government for support for the coming IPD campaigns.

MCSP participated and supported the plan for the USAID Health, Population and Nutrition (HPN) team visit to the state and LGAs/HFs for three days. The visit included visits to the state cold store, Bauchi LGA cold store, BACATMA, Urban Maternity Kofar Ran in Bauchi LGA, Dass LGA, and the chair of BASECOH who is also HR the Emir of Dass. The objective of the visit was to jointly review the RI progress, challenges, and way forward in Bauchi.

MCSP participated in a meeting with Solina and Chigari Foundation to strengthen collaboration and devise more means of strengthening community engagement, transparency, and accountability in the use of RI funds as partners with the state. The action point from the meeting was to meet with the executive chair and share their agreed plans with the BSSPHCDA staff.

Sokoto

Management and coordination of RI activities Under the new dispensation of SERICC, Sokoto continued to record remarkable improvement in RI service administration at both state and LGAs through increasing number of LGAs conducting RI task force meetings and inauguration of the task force committee. In line with an administrative directive to LGA chairs, the SPHCDA and leadership of 11 LGA committees (, Sokoto South, Bodinga, , Rabah, Kware, Illela, , Wammakko, Yabo, and ) were inaugurated and inaugural meeting conducted with agreed action points developed. Additional efforts to establish a SERICC-related management structure for RI at LGA level (LERICC) are being facilitated by SPHCDA to improve planning, coordination, and accountability for RI-related investments.

Disbursement and use of RI funds A critical area of RI operation is the need for funds to conduct supportive supervision, outreach sessions, and monthly review meetings at the LGA level. To this end, funds for the quarter under review were disbursed to 475 health facilities of the 523 providing RI across all 23 LGAs in the state. Through the finance working group, MCSP and Solina continue to collaborate to strengthen the financial system. MCSP provided information to the yet-unopened 86 HFs on how to open accounts and complete bank forms. In line with the accountability framework, MCSP state and LGA teams are working with SPHCDA to ensure effective session implementation and accountability through spot checking, supervision, and monitoring of RI. 123 outreach sessions were supervised. HFs were encouraged to retire the funds they received in preparation for subsequent disbursement. 475 HFs have submitted complete retirement of RI funds to their respective LGAs, compared to 512 HFs in the previous

11 quarter. MCSP will investigate why fewer HFs retired funds in PY4 Q1 and will continue to provide support to HFs to do so in future quarters.

MCSP conducted post-implementation verification and validation of the financial tools to ensure consistency and accuracy. Timely release of RI funds improved over those of the previous quarter, which had been delayed due to the revision of SOPs for the finance working group activities.

Reviewing and updating REW microplans Through its LGA immunization consultants, MCSP continued to provide capacity-building support to LGA and HF staff to review and update their microplans. As of December 2017, 98 percent of Sokoto’s HFs providing RI had an updated microplan, as observed at the HFs during RI SS, review meetings, and site visits for session planning. MCSP supported the SPs to use and adhere to REW provision in session planning, which supported vaccine availability, reduction of session cancelations, and plans to reach underserved and/or hard-to-reach communities on a more regular basis. MCSP supported LGA and HF staff to ensure adherence to planned activities (fixed and outreach) as contained in their respective REW plans. LGA monthly RI review meeting Monthly RI review meetings with SPs are a major institutional platform at which LGA and HF teams review and emphasize decisions related to community engagement, data management, and reporting. During the reporting period, 67 of 69 RI monthly review meetings with service providers were conducted in the 23 LGAs. The meetings were held at the LGA headquarters and chaired by LGA chairs, directorate of primary health care coordinators, or LIOs. MCSP supported the LGA teams to use their data meaningfully by reviewing RI indicators, analyzing performance as presented in the DHIS2 dashboard, and giving feedback to service providers.

The following are the major topics and discussion: 1. Performance feedback by HFs using monthly RI analysis table and DHIS2 feedback report. 2. Emphasis on establishment of LERICC at respective LGAs and sharing findings and issues emanating from RI supportive supervision at various facilities.

The following system challenges were discussed and immediate actions and solution were proposed: 1. Lack of adherence to planned sessions, especially outreach. 2. Data quality: discrepancies across management of data tools and procedures. 3. Inadequate community leader engagement and awareness creation, which contributes to dropout, low patronage of services, and missed opportunities.

Through various level of support to the system, MCSP will follow-up on implementation of the agreed action points by responsible persons at LGA level and during supportive supervision in health facilities.

LGA-level task force meeting State and LGA monthly task force meetings are MOU requirements. During the reporting period, 67 of 69 (97 percent) LGA task force meetings on RI were conducted across 23 LGAs. Two of the 23 LGAs did not conduct their task force meeting for the month of December due to competing priorities. MCSP is working with the LGAs to ensure the continual conduct of the task force meetings. SPHCDA, in accordance with the executive governor’s directives, inaugurated 23 LGA-level RI task forces. MCSP providing a detailed update on RI service performances.

In addition to the update, the following issues were presented and discussed:

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1. Quality affecting RI SS to HFs during sessions and follow up visits (e.g., poor SS from LGAs to HFs, poor attitudes of LGA team members, and gaps in knowledge of how to conduct effective SS). 2. Improving service providers’ communication skills and attitude. 3. Data quality efforts aimed at reducing under-reporting and discrepancies across all levels of data management. 4. Engaging the community and involvement of settlement heads in planning and monitoring of fixed and outreach sessions.

2.3 MOU Thematic Area 2: Improving Accessibility and Utilization

Bauchi

Improving the number and quality of RI sessions MCSP continued to support the review of HF RI fixed sessions to find out if there is potential to increase sessions based and therefore RI coverage based on the revised GIS target population estimates. MCSP helped the 20 LGAs expand availability of and access to RI services by building local capacity to plan and deliver high-quality RI services. In collaboration with other RI MOU partners, MCSP has supported the LGAs to assess HFs with potential to increase their number of fixed sessions to reduce the work load and reduce client wait-time. Of the 12,201 planned fixed sessions in the state 11,146 (91 percent) were conducted. Of the 8,206 outreach sessions planned, 7,296 (89 percent) were conducted. Since January 2017, the state has conducted over 85 percent of its planned RI sessions. This is a 10 percentage point increase compared to the MOU target set for the year, as shown in the figure below. These visits included on-the-job training and SP mentoring on RI-related topics, including the REW approach, the consistent monitoring and follow-up of RI session plans. The program also supported REW training sessions for LGA management and HF staff in all 20 LGAs. All these efforts improved the quality of RI services in HFs that were already providing RI.

Percentage of planned, fixed, and xutreach immunization sessions held Bauchi State, January to December 2017 (MOU Target = 65%)

100 90 80 70 60 50 40 30 20 10 0

Outreach Fixed MOU Target

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Sokoto

Improving the number and quality of RI sessions The strategy to assess efforts made to increase the number and quality of RI sessions is to compare planned RI sessions (fixed and outreach) against the number of immunized children from a given population. During the quarter under review, 97 percent of the fixed and 97 percent of the outreach sessions planned were conducted by HFs across the state. MCSP tracked the conduct of outreach sessions and supported review of RI fund retirement forms and other monitoring tools (immunization registers and tally sheets) during supportive supervision visits at the HFs.

RI sessions increased from 5,974 in Q4PY3 to 6,029 in the period under review, partly due to consistent supportive supervision and mentorship by MCSP, other partners (CDC, UNICEF, Solina), and review meetings with the SPs to identify and resolve challenges. To further make sure that high-quality RI services were rendered at health facilities per the accountability framework, SERICC developed disciplinary actions for SPs who defaulted in the course of duty. As in Bauchi, an encouraging trend was observed in Sokoto in the percentage of planned RI sessions held. More than 90 percent of planned RI sessions were conducted by the health facilities in the period since January 2017, as shown below.

Percentage of planned, fixed, and outreach immunization sessions held Sokoto State, January to December 2017 (MOU Target = 65%)

100 90 80 70 60 50 40 30 20 10 0

Outreach Fixed MOU Target

As part of the key strategies to increase access, MCSP collaborated with LGA teams to conduct a rapid assessment of child immunization status in 156 communities using the community survey tool. ) Of the 1565 children sampled, 606 (39%) children were fully immunized, 491 (31%) were partially immunized, and 468 (30%) never received any immunization. Additionally, 1,092 (70%) children had immunization cards.

MCSP participated in the planning and development of itinerary for IPD fixed post and provided technical support during the training that improved SP performance on proper vaccine handling and administration, including antigens that are supposed to be administered simultaneously. During the period under review there was gradual improvement on data (data collection processes and consistency of HF reporting timeliness and completeness) as well as use of waste management resources.

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The program helped assess 79 HFs for their potential to initiate RI services by reviewing the availability of qualified health workers, client flow, availability of CCE equipment and available space to provide RI. 41 of the 79 have since initiated regular RI services. As of December 2017, 523, (69 percent) of HFs are providing RI services across the 23 LGAs. However, 39identified HFs with potential to provide RI services are yet to start the services due to shortage of data tools, and the 41 that recently commenced RI services have yet to receive RI basket funds. MCSP is working with other partners through the M&E working group to provide data tools so these HFs can take up RI services. For those HFs that have yet to receive funds, MCSP and partners (Solina, UNICEF CDC) are urging the finance working group to initiate release of the funds.

2.4 MOU Thematic Area 3: Vaccine Security, Cold Chain, and Logistics

Bauchi

Monitoring vaccine availability in health facilities MCSP, in collaboration with UNICEF and Solina Health, continued to use SS to monitor the LGA cold store for the availability of buffer stock, which is always within maximum and minimum level. During the period under review, MCSP supported the SPHCDA in the monitoring of vaccine availability in 323 HFs with CCE to ensure stock adequacy of all RI antigens as well as CCE functionality. In addition, monitoring contributes in improving vaccine availability at service delivery points by mentoring RI providers on multi-dose vial policy to avoid vaccine wastage during sessions. MCSP also helped ward focal persons ensure that vaccines are collected from the equipped HFs to non-equipped HFs. MCSP helped some RI service providers in charge of the CCE improve their vaccine accountability framework by regular checking vaccine ledgers for stock count in the CCE compartment so that vendors know the accurate amount of vaccines for the next delivery cycle.

Problems discovered during MCSP vaccine monitoring visits included a lack of vaccine ledgers in some HFs, leading staff to use improvised notebooks for stock recording, sometimes on an irregular basis. There was observed LGA stock-out of BCG, yellow fever, measles, and inactivated polio vaccines due to high wastage rates in some cascade HFs. MCSP also discovered facilities with vaccine over-stock caused by failure to follow multi-dose vial policy. MCSP showed SPs at these facilities how to implement multi- dose open vial policy and trained them on vaccine requirement calculation.

MCSP helped the LGAs retrieve excess vaccines found in HFs. Also noted was failure to update temperature charts in some facilities, apparently because of there were none of the charts; poor maintenance of CCEs in some facilities, which resulted in increase in device temperature and to some extent contributed to changing the vaccine vial monitor status. MCSP informed SPs in such facilities of the implications, and replaced the ice packs. MCSP conducted on-the-job training on vaccine requirement calculation and ledger update for easy arrival at the correct number of the required vaccine to avoid over/under stocking.

The program team continued to work through the state supply and logistics sub-working groups to review vaccine stock performance data by monitoring the state vaccine dashboard, which indicates vaccine status by LGA. The program then provided technical assistance to the LGAs and cold chain officers at ward level to use this data to trigger coordinated adjustments to vaccine stock levels at CCE health facilities. At the end of the quarter, wastage rate stood at 4 percent, a 9 percent decrease from the previous quarter.

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Sokoto

Improving the functionality of cold chain facilities In the quarter under review, MCSP intensified support to the state in the area of vaccine security and cold chain. Along with other RI partners (Solina, UNICEF, CDC), cold chain officers, in-charges, and service providers were monitored in all 23 LGAs. 215 HFs (91 percent) of the 236 satellite cold stores in the state were monitored to ensure proper functioning of the CCEs to improve vaccine delivery. The monitoring focused on assessing CCE availability and functionality, assessing LGA and HF use of facilities including temperature monitoring devices, provision of weekly stock performance updates, and making sure all planned sessions obtain the required antigens according to microplan. An improvement was noticed, as vaccine supplies stood at 89 percent at RI service delivery points and 86 percent at cold chain facilities. Further, of the 244 HFs visited, 211 were functional. MCSP provided technical assistance in monitoring cold chain equipment functionality in 215 satellite stores at HFs across the state. All HFs and satellite stores visited were found to have functional CCEs through use and implementation of plan preventive maintenance using the log book, proper reading of temperature on the solar direct drive fridges and proper arrangement of different vaccines in the refrigerator compartment. There is a marked improvement as the cold chain officers have shown improvement in this area compared to their performance during the inception of the program. Improving vaccine management at LGA and HF level MCSP supported SSPHCDA to conduct data spot check on supplies, use, and availability of vaccines at 23 LGAs and 512 HFs. A random sampling method was used to assess and ascertain the quality of vaccine use at service delivery points, with the aim of reducing wastage of vaccine. The following findings were observed at a subset of the 512 HFs: 1. Multi-dose open vial policy not considered in vaccine use and handling. 2. No proper documentation of vaccine using KPI tools. 3. Temperature charting looked suspicious (same range for over 10 days). 4. Responsibility not shared among the staff at some HFs.

Based on these findings, MCSP supported 116 SPs and HF in-charges (49 male and 67 female) on the process of reducing and prevention of vaccine wastage. This activity was meant to improve the use of multi-dose vaccine vial policy and to prevent missed vaccination opportunities at HFs. Tracking and improving vaccine stock availability MCSP worked with the LGA teams and other RI partners (Solina, CDC, WHO, UNICEF) through SS to monitor vaccine delivery to 215 (91 percent) of the 236 ward satellite cold store health facilities. The purpose of this activity was to improve vaccine security, and cold chain and logistics management. Another reason for this activity was to ensure that all non-equipped health facilities are supplied with relevant RI vaccines, thereby avoiding stock-outs. There was no stock-out recorded in the state; in the last quarter there were stock-out of measles, PENTA, and BCG vaccines in about five LGAs.

2.5 MOU Thematic Area 4: Monitoring and Evaluation/Supportive Supervision

Bauchi Improving supportive supervision at LGAs and HFs Of the 1,883 planned (61 percent) RI SS visits conducted, MCSP conducted 578 (31%) from LGA to health facilities. In collaboration with state and LGA PHC team members, MCSP provided on-the-job training and mentoring to service providers on how to prepare and conduct session plans and how to

16 update vaccine ledgers. Service providers were also guided to develop agendas for VDC meetings, extract meeting minutes, and revitalize dormant VDCs. MCSP emphasized the importance of card retention at VDC meetings by advising SPs to advise families to keep the card with the mai’ unguwas; laminate the card after their last visit; and protect the card by placing it in a plastic bag. MCSP will follow up during community survey to determine which method works best to retain the cards.

MCSP sensitized SPs at all HFs on importance of building data quality culture and requested that the standard procedure for updating data tools during the sessions be inculcated. Mentoring on how to make entries into the RI register and tally book was given. Service providers were sensitized on the need to bring relevant data tools to outreach sessions for proper record keeping and data entry. All MCSP efforts have contributed to improving knowledge of the service providers on proper data entry and generation of high-quality data. The major issues identified during supervision included:

1. No demarcation line between sessions in tally sheets at some HFs, making summation difficult. At some HFs, there was no summation on the tally sheets. 2. Children were not registered by birth month in some HFs. 3. Some children sampled during community survey were not immunized. 4. Data inconsistency between register and tally sheets in most HFs. 5. SPs at some HFs failed to convey the six key messages on immunization to their clients. 6. Filled safety boxes above the required ¾ level in some facilities. Non-availability of minutes from meetings with communities. 7. Knowledge gap in plotting and charting of Penta and TT monitoring charts in some HFs. 8. High numbers of defaulters in RI registers at some HFs due to lack of implementation of defaulter tracing mechanism. 9. Sensitizing of CRG to sustainability of using of child tracking card tools. Improving data quality through spot checks DQA spot checks were adopted to ensure generation of high-quality RI data at the health facilities across the states. During the quarter, 528 HFs were followed on this activity during SS. On-the-job training in areas of weaknesses was given to service providers to improve the quality of data produced at the facility level.

All monthly RI reports submitted by the HF were validated and checked by the LGA data working group for completeness and accuracy. Any health facility with data discrepancy was mentored to make corrections. This process has helped ensure that RI reports were of better quality. At the end of the quarter, timeliness of submission was 95 percent and completeness was 97 percent. MCSP performing data quality spot check at General Hospital BOI, Bogoro. LGA. Photo: MCSP/JSI MCSP during the period under review has supported all seven LGAs to ensure that all the HFs submitted their reports on time. MCSP followed with defaulters to ensure they submitted their reports. Also, MCSP supported the data by ensuring all entries are shown after downloading the data on the pivot table to avoid missing some health facilities data. MCSP advised the data clerks to ensure they have good network coverage before entering data into DHIS2 to ensure uninterrupted uploads. These efforts have contributed to the improvement in timeliness and completeness of RI reports on the DHIS2 platform.

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Sokoto Improving supportive supervision at LGAs and HFs In the reporting quarter, 1,543 (95 percent) of 1,626 RI SS were conducted by the LGA team and partners. MCSP supported 337 supportive supervision and mentoring visits to HFs during RI fixed and outreach sessions across the state. On-the-job training was conducted on gaps identified and action points documented. It was noticed that updated REW microplans were available and in use in all HFs providing RI, and service providers have improved vaccine administration since previous quarters. MCSP also made sure that the antigens (oral polio vaccine, inactivated polio vaccine, TD, and hepatitis b vaccine) found in vaccine vial monitor stages 3 & 4 were taken to the LGA cold store by the service providers in Badau and Zangalawa PHCs.

Other findings included: 1. Data inconsistency 2. Registration not done by settlement. 3. Poor community linkage and engagement in RI service in HFs. 4. Most HFs have no defaulter tracking mechanism in place. 5. No evidence of HFs meeting with communities (VDCs).

DQA dissemination and follow-up visits to health facilities In PY4 Q1, MCSP through the M&E working group supported the state to disseminate DQA findings during the LIOs and M&E officer monthly review meeting with all the 23 LGA RI focal persons in attendance. During the meeting, participants shared their views on the findings and held an extensive discussion on the way forward. Copies of the DQA recommendations were provided to participants, as was a follow-up action plan. Each participant was assigned a role to fast-track the action points. The M&E working group is expected to follow up with the LIOs, M&E officers, SP, and RI focal persons to ensure implementation of the DQA action plan.

During the reporting period, as an on-going activity, MCSP and other partners (Solina, UNICEF, and CDC) supported the SSPHCDA to conduct DQA follow-up visits to Sabon Birni, Rabah, Sokoto North and Sokoto South with two HFs from each LGA to certify LGA compliance with DQA recommendations. The visits were also an avenue for capacity building as MCSP along with other partners provided on-the-job mentoring and coaching in data management, use of tally sheets, registering and reporting based on established standard and use of settlement-based registration to facilitate identification of underserved communities in their respective catchment areas. The visit revealed that service providers complied with the recommendations of the DQA. However, the follow up visits have not commenced in the remaining 19 LGAs due to competing priorities in the state. The activity will be conducted and finalized before the commencement of the next DQA, which is expected in January 2018.

HFs using data to make decisions 475 HFs in the 23 LGAs used data (immunization registers, monitoring charts, and HF RI performance feedback) to make decisions to improve RI coverage, including conducting community sensitization and mobilization and providing lists of defaulters to the VCMs for tracking and referral to the HFs for RI services.

Improving card distribution and retention through supportive supervision MCSP supported the state to conduct supportive supervision at Bodinga LGA, which was chosen by random selection. The survey revealed 80 percent card retention and of 10 children sampled randomly,

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7 (70 percent) were fully immunized; 1 (10 percent) was partially immunized; and 2 (20 percent) were not immunized. Other findings included: 1. The community is aware of RI (number of visit, vaccine received, and number of doses). 2. Irregular monthly community feedback meetings. 3. Session plan not updated. 4. 4th quarter REW microplan not updated. 5. Poor turn out during sessions. Across the 23 LGAs in the state, 1,565 children were sampled in 156 communities, of which 606 children were fully immunized, 491 partially immunized, and 1,092 (70 percent) had RI cards. This represents 70% of children with cards in the communities sampled.

Improving quality of RI data management and data spot checks MCSP mentored and provided on the job training to 327 RI service providers (192 male and 135 female) to improve their skills on data management, and vaccine administration and management to ensure that high-quality service is conducted as planned for both fixed and outreach.

151 service providers (82 male and 69 female) were trained on the job on data during the spot checks. MCSP supported the LGA to conduct data spot checks using a checklist at 92 HFs in18 LGAs during the reporting period. Findings and action points were documented in the supervisory log book and training provided on gaps.

Findings included: 1. Discrepancy between data recorded in the RI data tools in some HFs across the state (RI register, tally sheet, and HF summary) and total column summation not filled). 2. Data discrepancy between monthly RI summary report and NHIMS reporting form. 3. Vaccine Management Form 1A & B not in use for vaccine accountability. 4. Tally sheet not used during sessions. 5. All RI data tools were available in the HFs visited. 6. Monitoring chart updated but some service providers still have problem in interpretation MCSP orienting service providers on child tracking activities. and use for decision making. Photo: MCSP/JSI 7. Settlement analysis problems were settled with onsite coaching. There was considerable improvement in data entry and accuracy as a result of regular data spot checks during supportive supervision visits. In addition, some previous agreed action points have been implemented by the service providers. MCSP will follow up to ensure implementations of action points and will continue to monitor SP performance for smooth RI service delivery at the HFs. MCSP continues to work with LGA health educators and service providers to create community awareness and mobilize caregivers to HF for immunization.

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2.6 MOU Thematic Area 5: Community Partnership

Bauchi

Monitoring the distribution of child tracking tools to traditional barbers at ward level In an effort to improve quality in the coverage of RI data across the state, MCSP continued supporting the engagement of traditional barbers and other community resource groups in referring newborn and defaulter tracing through the use of tracking cards. During the reporting period, MCSP visited 306 wards across the 20 LGAs and no HF was found to be stocked-out of color coded cards. This development is due to the mentorship from MCSP and other RI partners to the service providers and CRGs on the need to continue recycling the referral cards. It has also shown improvement over the 293 wards visited in the previous quarter.

Tracking use and reporting of referral and feedback by traditional barbers and RI in-charges MCSP supported the state in monitoring the effectiveness of traditional barbers and other community resource groups in newborn referral and defaulter tracking across the 987 HFs providing RI in the state. During the quarter, 5,104 newborns were reported to have been referred to HFs for RI services by traditional barbers and other community resource groups such as VCMs and TBAs. Similarly, 875 defaulters were tracked by the CRGs, totaling 4,214 tracked and referred newborns, 91 percent of whom were immunized and 438 (9 percent) had no record of going to the hospital for vaccination. A follow-up mechanism has been put in place during the monthly HFs feedback and TFI meetings to trace and refer unimmunized children for immunization. MCSP newborn tracking activities were monitored using a template at the HFs and LGA dashboards. Capacity building to improve tracking and referral for vaccination was provided to traditional barbers and other resource groups.

MCSP supports community feedback meetings During the reporting quarter, the 287 HFs feedback meetings attended and supported by MCSP increased awareness of how to access RI services and integration, sustainability, and ownership of RI and other PHC services. MCSP supported VDCs and HFs to conduct feedback meetings on agenda development, involvement of stakeholders in RI and other health- related activities, provision of updates on the status of HFs by SPs, implementation of the agreed action points, including waste disposal and improved documentation on newborn tracking and defaulter tracing activities.

MCSP helped LGAs identify inactive traditional barbers, and sensitized and reoriented them to their activities, MCSP and LGA attending WDC/VDC meeting at Kashuri , Itas which greatly improved newborn referral and defaulter Gadau LGA tracing.

Strengthening community activities through social mobilization working group (SMWG) MCSP has been a major player in the planning and implementation of community engagement activities at the state and LGA levels. Through the SMWG, MCSP supported the state by participating in meetings and engaging in discussions on how to re-strategize the implementation of community engagement at all levels. This informed the establishment of community engagement working group at the state and LGA levels to meet on a bi-weekly basis.

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MCSP supported the state in identification and inauguration of 343 community engagement focal persons from each of the 20 LGAs (18 men and 2 women) and 323 wards (323 men). They were oriented along with the 255 village heads on the use of community-based immunization tracking register and distribution of the registers to the LGAs. 2,305 of the 6,500 targeted settlement heads (Mai` uguwas) were also supported by MCSP on distribution of registers to commence line list of all under one children as well as updating the names of all new born in the register within their domain through social mobilization working group. The remaining Mai` uguwas were supported by other RI partners, including WHO, CDC, UNICEF and the state.

MCSP supports state in RI advocacy visits to ministries During the reporting quarter, MCSP has supported the state primary health care development agency (SPHCDA) in conducting RI advocacy visits to non-heath stakeholders and ministries for Education and Local Government affairs. The objective of the advocacy led by the executive chairman of the SPHCDA was to educate authorities on the commitment of the agency in the ongoing RI strengthening efforts and the need for every eligible child to be immunized. Part of the issues discussed during the advocacy visit was soliciting the support of the two ministries in promoting RI by directing both public and private schools to allow vaccination team into their schools in other to access every eligible child. The permanent secretaries of the two ministries graciously granted approval for the request tendered by the RI advocacy team. Following the visit, the ministry of health issued a circular directing all schools to allow vaccination teams conduct vaccination exercise during IPDs and MNCH week activities within the school premises during school sessions. Consequently, MCSP will support the tracking of children immunized in the schools.

During the last USAID HPN visit to Bauchi in October 2017, to the team visited some HFs in the state and also paid an advocacy visit to the palace of the Emir of Dass (BASECOH chairman) with the objective of seeking feedback from the traditional leaders on the impact of MCSP’s intervention in the state and also to know what else can be done differently to the system to increase more access and use for the RI services.

Sokoto

In PY4 Q1, MCSP and the Sultanate Council Committee on Health (SCCOH) supported SPHCDA to orient 86 district heads, 272 village heads, 3,480 settlement heads, 23 local government community engagement focal persons, and 244 ward community engagement focal persons on the operationalization and implementation of community name- based registers for newborns and children under one-year to improve the uptake of RI services and tracking defaulters. In addition, MCSP is supervising enumeration exercises while providing support and mentoring during the exercise. All children identified are being linked to health facilities. MCSP continued to support SSPHCDA in collaboration with UNICEF, WHO, and CDC-NSTOP through HF monthly HF in -charge facilitating community feedback meeting in Rimawa community of meetings with community structures for .

21 feedback on RI activities. This quarter, 1,120 meetings were supported through co-facilitation, taking of minutes, and development of action points with clear roles for all stakeholders. The meetings were aimed at strengthening community linkages and participation in RI activities. Follow-up visits indicated that community leaders increased their commitments and participation in the supervision of fixed and outreach sessions.

To increase demand for routine immunization and improve caregiver knowledge about the benefits of RI, MCSP in collaboration with UNICEF, WHO, and CDC NSTOP supported SPHCDA in the planning and the co-facilitation of 1,120 community sensitization and awareness-creation sessions on the importance of RI, schedule, session days, card retention, side effects, and how to handle them, and the roles of community and religious leaders in improving demand for RI services in their communities. The awareness creation sessions were conducted in six LGAs (Kware, Dange-Shuni, Gada, Gwadabawa, Illela, and ) reaching about 457 caregivers (157 female and 300 male). In an effort to ensure the application of knowledge acquired from the sessions, subsequent follow up visits conducted sighted the increase in number of clients (children under-one referred) for RI services in those communities.

In the reporting quarter, efforts were made to improve tracking and referral of newborn in the state. MCSP in collaboration with UNICEF through SPHCDA continued to provide on-the-job training and mentoring to 2,796 community resource groups (VCMs, CBHVs, and TBAs) on the appropriate documentation of newborns tracked and defaulters traced in their catchment communities. Additionally, orientation on interpersonal communication skills was provided to the volunteers to help them communicate effectively during counseling sessions with caregivers before and after referral.

MCSP worked with the SCCOH and Chigari Foundation to support community-based enumeration of under-one children to aid defaulter and newborn tracking and identification of unimmunized children in Bodinga. MCSP facilitated the orientation of 70 village heads, 70 village scribes, and 27 RI services providers on how to conduct enumeration exercises in their communities. In addition, MCSP supervised the enumeration exercises and provided support and clarification. The data collected indicated a high number of unimmunized children beyond the current facilities’ target populations in most of the communities.

Following the data analysis and tabulation workshop of the Community Partnership Assessment, dissemination meetings were conducted with representatives from SSPHCDA, SMOH, and MOU partners (Chigari Foundation, Solina, BMGF & Dangote Foundation, UNICEF, and CDC N-STOP). The next level of dissemination will be at the RI technical working group before the MCSP LGA RI consultant facilitating a session on community line -list engagement of a consultant to develop a registration with ward community engagement focal person s. Photo: community engagement strategy for RI. MCSP/JSI

MCSP provided on-the-job orientation to 489 all-female community resource group (VCMs, CBHVs, and TBAs) members on best practices in newborn tracking and defaulters tracing in their communities.

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MCSP and SSPHCDA, SCCOH, and Chigari Foundation co-facilitated a training of 496 village heads, settlement heads, and CRGs (TBAs, TA, and TBs) on RI demand-creation and community engagement in nine LGAs (, , Tangaza, Rabah, Isa, , Yabo, Kebbe, and Bodinga).

MCSP continued to help SSPHCDA conduct 401 HF monthly review meetings with community structures for feedback on RI activities. MCSP develop agendas, co-facilitated the proceedings, took minutes, and developed action points with clear roles for all stakeholders. This is aimed at strengthening the community linkages and participation in RI activities. Defaulter tracking and tracing of newborns for referrals to facilities for RI was emphasized.

MCSP helped the SSPHCDA plan meetings with 1,536 communities for the implementation of fixed post sessions during IPDs in April. MCSP will be responsible for ensuring proper documentation during IPDs to improve service quality at the fixed post. MCSP supported the activity by building the capacity of 512 SPs to plan outreach for hard-to-reach and underserved communities in the 23 LGAs and ensure documentation of RI activities during IPDs.

MCSP helped the LGA health team create community awareness on the importance of RI, age of eligible children, number of visit required to be fully immunized, importance of antigens, possible side effects and treatment, and the importance of card retention. These awareness-creation activities took place at Gujiya settlement in Katami South ward, Gunki in Marafa ward of LGA, Gandaba, PHC G/Madi, and Tangaza in Tangaza LGA. Improvement in the total number of immunized children was recorded in all the communities covered; this improvement will be quantified going forward.

2.7 MOU Thematic Area 6: Capacity Building and Training

Bauchi

Training service providers for measles vaccination and basic guide for RI In line with its policies of providing technical assistance to health personnel to strengthen RI and other vaccine-preventable diseases system, MCSP supported the state to facilitate training ahead of the measles campaign for 100 people (97 men, 3 women) comprising 5 officials from each of the 20 LGAs PHC teams (LIOs, HEOs, M&E officers, cold chain officers, and surveillance officer) The one-week training was used adult learning techniques, interactive exercises, and demonstration.

Training on demand creation During the reporting quarter, MCSP and other partners supported training on demand creation for RI providers in all 20 LGAs. The training covered primary roles and responsibilities of different community structures such as WDCs and VDCs, and participants learned how to support referral systems and improve regular ANC attendance, labor, and deliveries. A total of 877 male and 103 female trainees were trained. MCSP will in collaboration with other partners will follow-up with mentoring and on-site support to ascertain the level of improvement in conducting their duties.

Training participants for IPDs MCSP was also involved in the training of IPDs participants in all the 20 LGAs of the state. A total of 10,500 persons (male 7,275, female 3,225) attended the training, which included presentations on topics like cold chain management, data tools, and other IPC skills. MCSP also supported pre-and post-tests, including grading and selecting teams, participated in pre-implementation meetings, and supported team

23 distribution. MCSP worked with other RI partners in the LGAs to ensure that eligible children receive not only oral polio but also and other RI vaccines.

Measles vaccine campaign 2017 training In preparation for the 2017 measles campaign, an LGA-level training was organized to give participants knowledge and skills to conduct the campaign and provide high-quality regular routine services thereafter. A total of 7,472 people (4,783 men and 2,689 women) were trained. This training included:

1. Roles and responsibilities of keys players. 2. Logistics planning/wastage avoidance. 3. Role play for MVC demand creation. 4. Micro planning, supervision, and validation. 5. Accountability framework for state, LGA, and WFPs/action points. 6. Practical demonstration of a measles vaccination campaign.

Inauguration/orientation of ward community engagement focal persons MCSP held an oriented for the focal persons, who include traditional and religious leaders and other CRG, responsible for implementing the community engagement strategy in the LGAs. The engagement strategy includes: 1. Community mobilization. 2. Immunization session planning. 3. Immunization session monitoring. 4. Data collection and reporting. 5. Newborn tracking, defaulter tracing, and referrals.

MCSP helped prepare the orientation venue and printed the agenda. During orientation, MCSP discussed the process of community registration by settlement, and the roles and responsibilities of district and village heads. After they were inaugurated, the ward community engagement focal persons promised to work hard to ensure the successful implementation of all immunization activities at their various wards. They also promised to support the Mai’unguwas register at the community level.

Sokoto

During the quarter under review, MCSP and RI partners (WHO, UNICEF, Solina, Chigari, BMGF) in the state supported SSPHCDA to train the 23 LGAs M&E officers, LIOs, CCOs, health educators, 2 LGA RI focal persons per LGA, PHC coordinators, SPs, state representatives and partners on the revised Basic guide for RI service providers. 1,374 participants (973 male and 401 female) were trained at the state and LGA levels. The training is a follow up of the national training on RI basic guide which aims at updating the knowledge of the participants on the current methods of conducting routine immunization in the country.

MCSP in collaboration with the RI partners supported the SSPHCDA to train a total number 1,223 state and LGA staff (873 male and 350 female) on development of measles microplans and on measles implementation. Measles is one of the EPI targeted diseases, and MCSP used this opportunity leverage support for catching up <1 year old children and defaulters.

In the reporting quarter, MCSP through the training working group and in collaboration with SSPHCDA and RI partners supported the state to train 1,000 vaccinators and recorders (679 male and 321 female) in 244 wards across the state for the conduct of fixed post activities during IPDs and MNCH week in the state. MCSP leveraged this platform to provide refresher training to SPs and update their knowledge and skills on RI service delivery, cold chain, and vaccine, data, and was management.

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2.8 National-Level Support

Government-led coordinating mechanisms MCSP/Nigeria RI has provided technical support to NERICC since its inception in PY3 Q3. A key contribution during this quarter was MCSP’s support in the finalization of the RI-SS SOPs, which now incorporate mentoring based on MCSP’s contributions and are used at the national level and being adopted by the states. MCSP also updated the RI flip chart job aide, and prepared a pool of mentors who can assist the state with the rollout.

MCSP/Nigeria RI helped NPHCDA develop the national training guidelines, which will be used to standardize training modules, coordinate training activities, and provide guidelines for state training working groups.

MCSP and other RI stakeholders participated in the recently concluded 2017 annual national expanded program on immunization (EPI) review workshop. The main activities during the workshop included looking the RI system performance of the states, conveying the strategic direction for RI from the national level, supporting the states to start developing plans for improving RI in 2018 and beyond, and defining the roles and responsibilities for the state immunization officers and the program managers of the newly created SERICCs.

Partner coordination efforts MCSP provided technical support to NPHCDA during the national TOT on the revised BGRISP. MCSP will also support the state TOT in Bauchi and Sokoto States. The revised BGRISP is a national guide to support RI service providers to provide basic training to health staff.

Top officers of the various state PHCDAs and national and state RI partners held a brainstorming session to improve RI coverage in the six MOU states. Resolutions made included expanding RI services in secondary facilities, conducting DQS at least semi-annually, strengthening LGA RI review meetings, deeper community engagement in lot-quality assessment surveys.

MCSP meetings held separate coordination meetings with UNICEF and CHAI to clarify partner roles and MCSP value-add, especially in Bauchi and Sokoto. MCSP also met with Solina on Bauchi and Sokoto RI MOU documentation and it ways that MCSP will support to Solina in MOU documentation in Borno, Kaduna, Kano, and Yobe States. These meetings have improved coordination and collaboration.

2.9 Learning Activities

Activity MMEL 4 (Learning Activity): Support states to test the use of spatial tools (GIS data and global positioning system technology) to improve PHC HF catchment area maps for better targeting of RI services. MCSP continued to make notable progress in its effort to support the two states in using GIS tools to improve catchment area mapping and planning. During the reporting period under review, the program team held a two-day review meeting with e-Health and the newly appointed SERICC program managers and other key staff of Bauchi and Sokoto PHCDAs to review the learning activity through comparative study of hand-drawn and equivalent GIS maps and their common elements (key features, legend signs, etc.). The table below shows the differences between the two maps. During the meeting, participants agreed that microplanning using electronic maps can only be effective if SPs are familiar with them. They identified a number of health personnel who need training on GIS at LGA and state levels, including SIOs/LIOs, cold chain officers, M&E officers, and RI service providers. GIS trainings for both states have

25 been scheduled for February 2018. In Bauchi, data collection was completed and199 HFs catchment area maps have been produced. In Sokoto, data collection continues but the data for the following has been collected; point of interest= 99 (worship places, markets, schools, etc.); HFs=81; public buildings=9; and village heads=5. Key next step include: 1) validation meeting for the two states scheduled for February 2018, and; 2) training of LGA and HF staff on use and application of GIS catchment area maps for microplanning, scheduled for March 2018.

Table: Comparison of HF catchment area maps (Hand drawn versus GIS) Hand drawn maps Electronic maps Number of settlements (28) Number of settlements (36) based on map including those outside the catchment area Key for point s of interest (POIs) (e.g., school, POI s not on map mosque, etc) but not found on the map Number of settlements for each fixed, outreach Service types not identified and mobile session were identified but it was difficult to count because map was not clear Population was represented on map next to each Population in table settlement Roads show n on legend and map Roads shown on map but not in legend Rivers shown on map and legend Rivers shown on map and legend Railroad shown Does not shown extent (size) of settlement Shows feature extraction but no name s Catchment area definition was not a straight line Captured all settlements in catchment but catchment polygon (the line) cut across. Need criteria for assigning settlements to one catchment. Poor feature location accuracy More accurate location Settleme nt names should be located on the map

Activity MMEL 3 (Learning Activity): Lessons from implementing a quadripartite MOU to strengthen RI systems in Bauchi and Sokoto States The MOU brief that summarizes the experience of implementing an RI MOU from Bauchi and Sokoto perspectives developed last quarter has been finalized. In preparation for the MOU workshop in Abuja, an interview guide has been developed and is undergoing refinement so that responses from the health workers selected for the interview will complement the development of the MOU documentation guide. MCSP and Solina will be working collaboratively to develop the guide, with MCSP focusing on the experience in Bauchi and Sokoto, and Solina incorporating experiences from the other four MOU states of Borno, Kaduna, Kano, and Yobe.

Activity MMEL 5 (Learning Activity): Support the state to test whether traditional barbers and other community resources persons can be engaged to improve demand for RI services in Sokoto State and document the processes, opportunities, and challenges associated with community-based newborn tracking A sub-agreement was signed on November 17 th 2017 with Data Research and Mapping Consult Ltd (DRMC) to conduct the base- and end-line survey for the newborn tracking activity. Following the signing, DRMC mobilized in Sokoto and held several consultative meetings with SERICC and established a steering committee led by the SERICC project manager to oversee the study. Ten LGAs (intervention=5; control =5) were selected using defined criteria (i.e., security risks and potential for minimal contamination). Survey tools were developed and tested and 54 survey personnel (female interviewers=48, supervisors=6) recruited and trained. Data was collected among women with children

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0–23 months across the10 selected LGAs. Data is being analyzed and preliminary findings will be shared with SERICC and the social mobilization working group in January 2018. Key activities planned for next quarter include dissemination of baseline data to Sokoto SERICC, rolling out the newborn tracking intervention in the10 selected LGAs of Sokoto, and conducting in-depth interviews and focus group discussions in Bauchi.

2.10 Implementation Challenges

Challenges with MOU implementation over the past three months are summarized below. MCSP is working closely with the SPHCDA and other RI MOU partners to resolve these issue.

1. Data inflation to match vaccine doses opened remains a major challenge in some health facilities in the states. 2. Inadequate conduct of monthly review meeting at the facility. 3. Competing priorities of activities in the state led to a failure to train some traditional barbers in the 10 remaining LGAs. 4. Shortage of data tools and inadequate documentation at HF and LGA levels. 5. Data quality issues and challenges (DHIS2, DVD vs national surveys). 6. State and LGA staff expect more from MCSP than from other partners. 7. Withholding of meeting and training transport reimbursement for some state and LGA staff. 8. Inadequate retention of immunization cards at community level. 9. Security challenges in some locations hindering access to some HFs. 10. Difficult to reach some communities due to terrain problems involving roads, riverine, and flooding. 11. Other health system demands distracting state and LGA attention to RI services. 12. Duplication and inadequate coordination of community engagement activities.

3. MANAGEMENT AND ADMINISTRATION

The finance and administration team continues to oversee and support the implementation of program activities to ensure efficiency, accountability, and effective delivery of program objectives. In addition to ensuring that financial deadlines and donor requirements are met, MCSP ensures that all JSI procedures and policies are followed, implemented, and applied correctly to all levels of the program.

Staffing At the close of Q1 PY4, the MCSP/Nigeria RI program had 44 staff members: 4 in Abuja, 16 in Sokoto, and 24 in Bauchi. The program’s technical support team includes 49 long-term LGA immunization officer consultants; 26 in Bauchi and 23 in Sokoto. The addition of staff and consultants was based on approval from USAID to ensure that all the implemetation locations have enough staff to manage the program. During the review period, one staff member departed and was replaced. MCSP introduced the idea of having program and finance interns in all program locations to build capacity of young aspiring graduates. During the year that just ended, four interns were enaged in the Bauchi office and one in Sokoto. Plans for interns in Abuja are in progress. Each internship lasts 90 days.

Security Security in the northeast is still a challenge, but there have been recent advances and progress in the fight against the insurgency. Bauchi, Abuja, and especially Sokoto have remained relatively calm, with minimal pockets of reported incidences in Bauchi ranging from cattle rustling, kidnapping, and robbery

27 on local market days in some parts of Ganjuwa, Toro, and Nigi LGAs. Despite the security challenges in some locations, the program never suspended. The program’s security officer provides staff and consultants with daily security tips and shares weekly intelligence reports, which have helped program staff avoid areas considered security risks. The MCSP team has a security and safety manual to help ensure the safety of staff lives and program property. Trackers have been installed in all project vehicles and security strenghtened in all offices to enhance security.

Inventory MCSP has been managing the transferred vehicles and generators from closed-out USAID projects (TSHIP, AIDSFree, and FHI 360/MAPS). During the quarter in review, Bauchi had five vehicles, Sokoto four, and Abuja one. Three generators were transferred to MCSP and two more procured to replace inactive generators in Abuja and Sokoto. All vehicles and generators are currently in working condition. Considering the number of years these vehicles and generators have been used by previous projects and now by MCSP, the intermittent power supply in Nigeria that requires generators to run for long hours each day, and the fact that MCSP is expanding in scope, MCSP is counting on USAID to approve transfer of additional vehicles from any closed project.

4. SUB-AGREEMENTS

Black Swan Black Swan activities have been ongoing in Kware and Sokoto South LGAs within three HFs/wards. During planned sessions, data and photographs of children who caregivers bring for RI services are being captured. To date, Black Swan has enrolled over 1,400 children in the program and is testing voice and text messaging with three groups of 50 caregivers. Black Swan is also working to ensure compliance with program and financial procedures, and is still following the issue of branding with the state. As recommended, the state needs stakeholders to finalize the idea that the community partnership officer and director community of mobilization are expected to facilitate with respect to branding. A major challenge is the unavailability of data to analyze and use to guide further action.

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5. ACTIVITIES PLANNED NEXT QUARTER

Bauchi Train SPs on the revised b asic guide. Continue roll out of community -based register in all the settlements across the 20 LGAs and health facility - community meetings. Continue to support the state and LGAs to conduct high -quality SS across RI HFs and LGAs using the revised national guideline and by strengthening mentoring. Continue to support the state wide system to track and report newborn defaulter tracing and referrals by the traditional barbers and other CRGs. Support the state to conduct step -down training on demand creatio n to community stakeholders. Support the state conduct quarterly review meetings with LGA HEOs, district heads , and community engagement focal persons. Pilot the use of My Village My Home (MVMH) approach with community registers in 52 settlements. Suppo rt ward -level validation meetings for GIS RI catchment area maps in LGAs of Bauchi, Darazo , and Itas Gadau. Support the state to orient LGAs on revised monthly review meeting guidelines. Sokoto Support finalization of Q1 M OU wo rk plan, development of MO U end -of -year presentation , and review activities. Support SPHCDA to increase number of HFs providing RI and additional sessions across the state . Support CCE assessment and vaccines accountability . Support adoption and implementation of newly revised R I-SS and mentoring SOP s at state and LGA level s. Support data quality improvement activities and capacity building at state and LGA level s. Support community engagement activities (rolling out community engagement strategy, MVMH/name -base d registration, mHealth, and HFs meeting with community structures). Review post -basic guide training action points and monitor implementation. Support implementation of the three MCSP learning activities at state and LGA level s. National Support printing of seed cop ies of the revised National Immunization Policy (NIP) . Support dissemination of revised NIP . Participate and support the mid -level manager modules revision, adoption, and TOT . Collaborate with partners to support documentation of the RI MOU . Attend an d strengthen various national and state government -led RI coordinating groups (training, logistics, M&E, and SS groups) to which MCSP belongs. Learning Activities Hold validation meeting for the 2 stat es in February 2018 . T rain LGA and HF staff on use an d application of GIS catchment area maps for microplanning (scheduled for March 2018). Conduct in -depth interviews with key stakeholders to complement information obtained from the collaborative workshop. Disseminate baseline findings to Sokoto SERICC an d roll out the newborn tracking intervention in the 10 selected LGAs. Conduct in-depth interviews and focus group discussion in Bauchi.

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SUCCESS STORY NIGERIA Cleric and Former Critic of Routine Immunization Turns Advocate in Bauchi State, Northern Nigeria Mallam Mutari, chief Imam of the community central Mosque in Giade Ward, Bauchi State, is a highly influential cleric. As sociocultural and religious leader, he plays a key role in shaping the direction of his congregation and uses his Friday congregation to convey important messages to members of the community. His community admires him and considers him a role model, in part because of his uncompromising and dogged pursuit of issues he believes in.

One of the issues Mallam Muntari has strong opinions about is routine immunization. The cleric used to express great animosity towards efforts to prevent polio and other vaccine-preventable diseases. In his boundless enthusiasm, he would warn families not to bring their children to health facilities for immunization. The local government facilitator, state training Mallam Muntari educates Imams of various mosques and members facilitator, and sectional head of the LGA team all tried to change his mind of his community, preaching the importance of routine immunization during the congregational prayer. August 2017. during Immunization Plus Days but nothing worked. This cleric was a firm Photo: MCSP/Amina Bulama critic of routine immunization.

In July 2017, the United States Agency for International Development- funded Maternal and Child Survival Program (MCSP) organized an orientation for religious leaders from all LGAs in Bauchi on the importance NAME of routine immunization and the negative effects of non-immunization. Mallam Muntari Mallam Muntari attended the training on behalf of his LGA. During the orientation, he asked pertinent questions which were answered by the ROLE facilitators in very simple terms. The facilitators gave him an audience and a Islamic Cleric chance to change his mind about routine immunization.

After the training, Mallam Muntari surprised everyone when he said, “Tun LOCATION farko akayi kuskure saboda rashin samu Malamai cikin masu wayar da kan al umma Giade, Bauchi State, Nigeria akan alluran rigakafi, amma yanzu da aka fahimtar da mu muhimmancin sa zamu yi iya kokarin mu.” This means, “Excluding [the clerics] in the beginning of community routine immunization sensitization was responsible for the non-compliance ,but now that SUMMARY you carried us along we will put in our best to ensure absolute compliance.” Citizens of Giade Ward A in Giade LGA, Bauchi State, had been receiving negative Immediately following the orientation, Mallam Muntari started gathering messages about routine immunization from community members in front of his house and educating them on the the Chief Imam of their central mosque. importance of routine immunization. He told members of his community After several efforts to convince him why children should not be deprived of basic health care services. otherwise, Cleric Mallam Muntari was Furthermore, to strengthen his points, he recited qur’anic verses that support routine immunization. adamant in opposing routine immunization. After attending an orientation for religious During a follow-up visit to Giade in August 2017, MCSP found Mallam leaders on community engagement, the Muntari advocating for families to take their children for routine Chief Imam finally changed his mind. immunization. This former critic is now an advocate, and as a result, rejection of routine immunization is no longer an issue in Giade LGA. by: Amina Bulama, Suleiman Musa, and Boyo Egure