Worried by the poor delivery of Primary Healthcare governance and services in Kaduna State, the State Government (KDSG), entered into a strategic partnership with the United Kingdom’s Department for International Development (DFID) and the Bill and Melinda Gates Foundation (BMGF) to strengthen primary healthcare delivery in rural communities. In September 2016, a Memorandum of Understanding (MoU) was signed between the three parties to address the root causes of poor performance in primary healthcare, through the Primary Healthcare Under One Roof Policy (PHCUOR). Read remarks by the Executive Governor of Kaduna State, Malam Nasir El-Rufai
After a one-year of implementing the PHCUOR, the Executive Governor of Kaduna State, Malam Nasir El-Rufai, at the Chatham House in London, while giving a background on the health situation in Kaduna State before his administration, attributed the poor health indices in Kaduna State to a weak national health care system at the primary level. According to him, multiple institutional structures managing health at various levels, the challenges associated with leadership and coordination of health care at the national level, inadequate number and skills mix of human resources, lack of a clear approach, and stock-out of commodities in many health facilities, were factors that plagued the health system in Kaduna State before his administration.
The Primary Health Care Under One Roof (PHCUOR) is a policy that seeks to reduce fragmentation in the delivery of Primary Health Care (PHC) services. It involves the integration of all PHC services under one authority. Fragmentation has been identified as a major problem facing PHC services. It significantly affects utilization rates and health indices such as governance, accountability, the distribution of health care workers, financing and management processes, data systems, accessibility to essential medicines, as well as primary health care delivery.
The key elements of the Primary Health Care Under One Roof policy include:
- Integration of all PHC services delivered under one authority;
- A single management body with adequate capacity to control services and resources, especially human and financial resources;
- Decentralized authority, responsibility, and accountability;
- The 3-ones principle: one management, one plan, and one monitoring and evaluation system;
- An integrated and supportive supervisory system;
- An effective referral system between and across the different levels of care;
- Enabling legislation and regulations.
In June 2017, the DFID’s Partnership to Engage, Reform and Learn (PERL) set out to improve the organisational/institutional and human resources capability and capacities of the State Primary Healthcare Development Agency (SPHCDA) to ensure effective service delivery at the primary health care level. PERL facilitated the Corporate Planning (CP) Technical Working Group in developing the organization’s CP to ensure ownership. The CP process includes the establishment of governance structures (Steering Committee and CP Working Group), a review of documents earlier identified by consultants, the development of and agreement on a work plan, sensitization of state and non-state actors, and the introduction of the Corporate Planning framework and process.
To improve primary health care service delivery, PERL also supported the Establishment and Workforce Planning of Kaduna State SPHCDA. PERL collaborated with Health Strategy and Delivery Foundation, MNCH2, and corresponding partners in contributing to both financing and technical facilitation.
Taking Action
Working in close partnership with PERL, Bill and Melinda Gates Foundation, Health Strategy and Delivery Foundation (HSDF), and the Maternal and Newborn Child Health2 (MNCH2) program, the state government increased the health budget allocation from 7.5% to 11.57%. There was a dramatic reduction in average turnaround time for processing and delivering an order for drugs; the time was reduced from 13 days to 72 hours through supply chain transformation. In addition, there was 39% increase in outreach in 2017, compared to 2016 and 20% increase in uptake of services at night in solar supported facilities. The Executive Governor of Kaduna State, Malam Nasir Ahmad El-Rufai, revealed full details on results while making a keynote address on “Primary Healthcare Policy, Universal Health Coverage and Health Security in Nigeria: Optimizing Global Opportunities and Partnerships for Success” at Chatham House in London, on 22nd September 2017. During his address he stated that, “the MoU, which focuses on the overall strengthening of the PHC system, has affected significant number of achievements in the past 12 months of implementation.
According to him, a Minimum Service Package (MSP) for Primary Health Care has been developed. The MSP defines standards required for Infrastructure, Human Resources, Equipment, Drugs & Supplies across PHC facilities in Kaduna State in-line with National guidelines. The content of the MSP, which was defined in accordance with service delivery packages, affects Maternal, Neo-natal and Child Health services, as well as Nutrition, Health Education, Communicable Diseases and Non-Communicable diseases.
The Governor said “key deliverable of the MoU on PHC strengthening was the development of a costed Primary Health Care Service Delivery Plan (SDP) that is effective, affordable and sustainable for Kaduna State’s fiscal space, and other contextual realities. This has been achieved as well and the SDP, costed at N25.7bn (US $70 million), has been approved by the State Executive Council and a 4-year Implementation Plan has also been activated.”
“The SDP clearly spells out the number of PHC Centres and Clinics required for meeting the needs of the population, the human resources required to staff these facilities with the aim of providing 24/7 services as well as the cost of essential medicines, commodities, supply chain management and other necessary support systems,” said the Governor.
“The third key achievement within the MoU includes the organisational Capacity Assessments and Organisational Strengthening Programmes which helped to highlight the strengths and weaknesses of the SPHCDA, the Local Government health teams and the PHC facilities with structured interventions put in place to address the identified gaps. In addition, implementing the MoU has also provided huge support in Maternal, New-born and Child Health Programming, with service delivery and demand creation being key target areas. The partners in the MoU are also playing key supporting roles in the training of Primary Health Care workers, development of Human Resources for Health Information System for the PHC workforce and the strengthening of data and performance management across the PHC spectrum. The partnership has also supported the institutionalisation of financial management structures and practices at all levels of the PHC spectrum to better manage and account for funds meant for programming and operations,” he added house in London when he said, “Our vision as a government is to ensure that every resident has access to a package of health care, at an affordable cost and within reasonable and non-prohibitive distances from their dwelling place.”
Kaduna State has continued to improve its human resources capacity and capabilities in accordance with the PHC Under One Roof policy. The state has successfully pooled over 5,000 staff working in Primary Health Care from the State Ministry of Health and Human Services, the 23 Local Governments and the Local Government Service Commission into the SPHCDA. This has gone a long way in addressing the unequal distribution of health workers, and non-uniformity of program implementation across the state. Similarly, the State Executive Council has recently given approval for the recruitment of 100 Medical Officers of Health, to enable the deployment of at least one for each of the 23 Local Government Areas of the State.
Kaduna State Government is also working with health education institutions in the state to ensure effective training of all cadres of PHC workers and the appropriate accreditation of academic and professional programs with the aim of meeting the need for skilled workers in the PHC system. The training institutions are also being expanded to introduce and accommodate a multi-campus arrangement with the aim of giving more young people the opportunity to be trained as health caregivers.
Another pointer to the commitment of the state government to health is the improvement in total health spending of the state between 2014 and 2017. Malam El Rufai, while at Chatham, London said that total health spending of the state in 2014 was N6.11 billion. This increased to N8.65 billion in 2016, and to N24.87 billion in 2017.
Besides, the increase in health expenditure, the 255 Primary Care Centres (1 PHC Centre per ward) are undergoing revamping, according to the Governor, who said “Kaduna State is also refitting referral centres, one located in each of the 23 local government headquarters. We are in the concluding stages of the civil work upgrades, expansions and building renovations to ensure that every single one of these centres meets nationally defined standards.”
Lessons
Receptive to Change: There is little doubt that the management of the Agency is intent on reforming the way things are done at the agency in a ‘holistic’ manner to improve service delivery. This is evident by the functional changes, including the enforcement of reward and sanctions, were introduced. The energy, focus, interest and enthusiasm in the CP process demonstrated by the management and TWG were commendable.
Local Ownership: There was complete ownership of the CP process as PERL was considered and acknowledged only as a facilitator. The Chairman of the TWG drives the process while members look up to him for clarification on administrative and technical implications of the issues being discussed.
Responsiveness: The Agency was clearly prepared and ready for the exercise. Every information and document requested were either made available immediately or within a couple of hours in soft and hard copies. Participants made themselves available for two consecutive weeks plus two days in spite of their normal schedules.
Management Support: Management support was essential for the delivery of the assignment. The assignment required members of the TWG to ‘set aside’ their demanding schedule to create time and make themselves available for all the sessions.
Urgency of Assignment: The Chairman of the TWG created a sense of urgency for the CP process. This helped to create a sense and feeling that the group was ‘on a mission from above’ to solve a problem. This kept the interest and enthusiasm of participants.
Adoption of Interactive Approach: Participants’ empowerment was essential for the progress and success of the process. An engaging, hands-on and interactive approach, that taught participants ‘what to do’ and ‘how to do it,’ was beneficial. This puts responsibility for the success of the process on the participants and also supported them to deliver the required output. This approach engendered a sense of freedom amongst the participants to openly contribute ideas and information, and ownership of the process and outputs.
Selection of TWG Members: Careful selection of members of the TWG contributed to the success of the process. The group included people that hold key positions, are informed, knowledgeable, experienced and somewhat extrovert. Selection was not based on hierarchy, which normally makes participants afraid to contribute or debate issues openly.