PATHS Final programme report: "Togetherness in Health" the Enugu ...

"Togetherness in Health"the Enugu Experience inHealth Sector Reform2002-2008FINAL PROGRAMME REPORT

“PATHS is a name everybody is grateful for as theirpresence in this facility and community broughta turn around in health care delivery. Since theycame, new things started happening to the peopleof this area. They brought changes, equipment,drugs. Everything that we needed to work, theyassisted us with and we’ve been doing the workand everyone is happy”.Mrs Stella Ani, Officer In-charge,Ozalla Primary Health Care centre2 PATHS Final Programme Report

FORWARDI am very pleased on behalf of the Ministry of Health, Enugu State government tocommend the Partnership for Transforming Health Systems (PATHS) final report2002-2008 to you.PATHS has been working in the state now for six years and during that period hasbecome a household name and trusted friend for many of us involved in the delivery ofhealth care and even beyond the boundaries of health.PATHS has worked with a number of Health Commissioners and Permanent Secretariesduring its lifetime, all of whom have held the programme in high regard and recognisethat the programme has had a significant impact in changing the face of health care inthe state.It has supported the implementation of the District Health System which has doneso much towards integrating our previously fragmented services and revitalising ourprimary care services. It has supported the development and implementation of theunderpinning systems necessary to make the District Health System work and, workingin partnership with the Health Commodities Procurement project, has brought muchneeded drugs and equipment to our facilities. It has trained well over two thousandhealth care workers, both clinical and non clinical, in an effort to help improve thequality of care provided; all of which has moved the state closer towards achieving theMillennium Development Goals. It has supported the pioneering of ground breakingpractices in Public Private Partnerships by enabling the Government to work hand inhand with communities and the private and faith based sectors.PATHS has done so much that it is difficult to list it all, but the state is extremely gratefuland will long remember PATHS for its unfailing support and efforts.Our sincere thanks go to the Department for International Development (DFID) whofunded the programme; and the staff of the PATHS office who helped make it possible.You will be missed, but we hope that PATHS 2 will continue to support the stategovernment in its efforts towards improving health care for the people of Enugu state.Dr Martin ChukwunweikeCommissioner for HealthState Ministry of Health“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 3

This report is dedicated to the memory of Dr.H.U. Enih,who sadly died on February 10th 2008. He was the ChiefExecutive of Agbani District Health Board from its inceptionin September 2004 and his enthusiasm and drive for theDistrict Health System did so much to put Agbani DistrictHealth Board on the map as a model District Health Board.He will be sorely missed by the PATHS staff and itsmany consultants who came into contact with him.May his soul rest in peace.4 PATHS Final Programme Report

6 PATHS Final Programme Report

SUMMARYThe PATHS programme was operational in Enugu State from 2002 to 2008 and duringthat period worked with four Health Commissioners and six Permanent Secretaries. It washoused within the State Health Board premises which did much to promote a harmoniousand cohesive working relationship with government structures. Whilst PATHS workedpredominantly with the State Ministry of Health, it also worked in partnership with anumber of other government ministries; including Local Government, Economic Planningand Finance and the Local Government Services Commission. In addition, the programmeworked with a number of faith-based hospitals; a large selection of NGOs and CBOs; and itspartner DFID programmes, particularly the State and Local Government Programme andthe Health Commodities Procurement project.The introduction of a District Health System (DHS) was at the heart of Enugu State’s health reformagenda. The vision was that a DHS would allow primary and secondary health services to beintegrated, marking an end to fragmented and inefficient service delivery. The devolution ofmanagement under the DHS was also expected to create new opportunities to revitalise poorlyfunctioning primary health care facilities.PATHS support to the State Ministry of Health (SMOH) in Enugu focused on the development andstrengthening of the underpinning systems that would allow the DHS to function. Once the basicsystems were in place, efforts turned to improving service delivery. With the support of the DFIDHealth Commodities Project, much-needed drugs and equipment were supplied to the health facilitiesthat were supported by PATHS (approximately 100 at the conclusion of the programme). A MinimumService Package, standards of care, and a Drug Revolving Fund were introduced, all of which helpedto improve service delivery and increase access. Extensive staff training, both clinical and non-clinical,was provided in 28 key areas. Approximately 2,500 staff benefited from training in Life Saving Skills(LSS), financial management systems (FMS), business planning, health management informationsystems (HMIS), and inter-personnel communication skills (IPCC), among others.Given that in 2002 the majority of patients in Enugu used private or faith-based facilities, PATHSsupported the SMOH to develop public, private partnerships in health. The provision of EmergencyObstetric Care (EOC) services by three faith-based hospitals, with funding provided by the EnuguDistrict Health Board, was pioneered under the Enugu EOC+ Pilot Scheme. Early results suggested thatthe scheme had resulted in a number of mothers’ lives being saved, and was a promising example of apublic-private partnership.PATHS also supported the SMOH and the constituent bodies of the DHS to develop partnerships withNGOs and community-based organisations, with the aim of utilising their skills, competencies andlinks with communities to create demand for services. Efforts were also made to increase communityparticipation and engagement in local service delivery. To this end, community representation on“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 7

Section 1:Setting the Enugu ContextEnugu, one of the 36 constitutionally recognized states in Nigeria, has a population of approximately3.2 million inhabitants based on the 1991 census. The preliminary findings of the 2006 census indicatethat the population has increased to 3.9 million. The people primarily belong to the Igbo ethnic group,which is one of the three largest ethnic groups in Nigeria.The state capital is Enugu (derived from enu ugwu meaning “hill top”). The state was created on 27 thAugust 1991 from the old Anambra State. Enugu town was previously the capital of the then EasternRegion and also East Central State.hthEnugu is an inland state and one of the five states in the South East geo-political zone of Nigeriaoccupying a surface area of 8,000 sq. km. It shares its boundaries in the east with Ebonyi State, in thewest with Anambra State, in the north with Kogi and Benue States and in the south with Abia State.The two major towns are Enugu and Nsukka.Political StructureAninriAwguEnugu EastEnugu NorthThe state comprises of three geo-political zones made up of 17 legally constituted Local GovernmentAuthorities (LGAs), although a further 39 Local Government Development Centres (LGDCs) Enugu were Southcreated in 2004 by the then Governor. The latter are not recognised by the Federal government. EzeaguThelatest administration has redesignated the LGDCs as Local Government Development Areas. TheseIgbo EtitiIgbo-Eze NorthLocal Government Areas in EnuguIgbo-Eze SouthAninriIsi-UzoAwguNkanu EastEnugu EastNkanu WestEnugu NorthNsukkaEnugu SouthOji RiverEzeaguUdenuIgbo EtitiUdiIgbo-Eze NorthUzo-UwaniIgbo-Eze SouthIsi-UzoNkanu EastNkanu WestNsukkaOji RiverUdenu“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 9Udi

are managed by an Administrator rather than an appointed Chairman and have reverted to beingaccountable to their parent LGA.At the time of the introduction of the PATHS programme the state was under the Governorship ofPeople’s Democratic Party (PDP) Governor, Dr. Chimaroke Nnamani. In April 2003 he was re-electedfor a further term of office completing in March 2007. Sullivan Chime, the previous Enugu StateGovernment Attorney General, was elected as Governor in April 2007 also under the banner of PDP.EmploymentThe state is predominantly agrarian but is regarded as an “educational state” since it has apreponderance of primary, secondary and tertiary educational institutions.The major mineral for which Enugu is known worldwide is coal and this gives the state the sobriquet“Coal City State”. The major employer of labour in the state is government (local and state), althoughthere is a vibrant private sector made up of mainly small and medium scale enterprises. In health,some 1,330 staff are employed by the Ministry of Health with a further estimated 3,000 employed bylocal government .Health StatusEnugu State has a disease burden similar to other parts of tropical Africa. The most prevalent diseasesin the state are malaria and typhoid fever. However, pregnant women and children are vulnerable to amultitude of health problems, including in the case of women, to high levels of maternal mortality andmorbidity. Except for HIV/AIDS, the health indices in Enugu are better than the national indices.Whilst the uptake of routine immunisation in Enugu is better than many states in the north of Nigeriait remains below an acceptable level. By 1990, Nigeria had attained globally acceptable immunizationcoverage standards, but these standards were seriously undermined throughout the 1990s by politicaland administrative problems and vaccine shortages. In 1999 the national coverage for key antigensfor under one year old children were as low as 43% (BCG), 23.4% (DPT3), 18.3% (Polio3) and 35%(measles). However, the trend is currently being reversed. In 2005, the following coverage estimateswere obtained for the same key antigens in Enugu – 68.6% (BCG), 53.5% (DPT3), 60.7% (polio3) and62.4% (measles) for under 1 year olds (NICS 2006).10 PATHS Final Programme Report

KEY FACTSHealth Indices: Comparison of Enugu with National FiguresHealth IndicatorNational(NDHS* 2003)South-east Zone(NDHS 2003)Enugu(SEEDS** report)Infant mortality rate(per 1,000 live births)109 66 74.3Under 5 mortality rate (per 1,000) 217 103 74.3Maternal mortality rate800 (per 100,000live births)Not available286 (per 100,000live births)Child malnutritionStunting38.3%19.7%19%Wasting9.2%4.9%7%Under weight28.7%8.5%10%Prevalence of HIV among adults 3.9% Not available 4.9%Teenage pregnancies (mothersbelow 20 years)Contraceptive use by marriedwomen25.2% 6.2% Not available12.6% 22.5% Not availableFertility rate 5.7 4.1 Not available*NDHS – National Demographic and Health Survey** SEEDS – State Economic Empowerment Development Strategy“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 11

Improving Maternal Health Services in EnuguA recent piece of research (Onah et al 2005) indicated that only about 40% of deliveries in EnuguState are attended to by skilled personnel in either public or private facilities. About 60% ofwomen depend on Traditional Birth Attendants (TBAs), religious homes, and other places thatlack skilled attendants for deliveries.Places of last delivery (from Onah et al 2005)Place where last delivery took place No SBA SBAs*At home 203 (18.5%)Church/prayer house/healing home 185 (16.9%)Traditional birth attendant 191 (17.4%)Maternity home/government health center** 96 (8.8%)General/mission/private hospital 54 (4.9%)Tertiary care (UNTH2/Parklane Specialist Hospital) 172 (15.7%)Private obstetrician 194 (17.7%)Total 675 (61.6%0 420 (38.4%)* SBA – Skilled Birth Attendant** Most of these births are not with SBAsIn 2006 it was estimated that out of a projected population of 654,917 women of reproductiveage, 163,729 (25%) would become pregnant. However, records show that only 11,414 (7%)women actually attended public health facilities that year for antenatal care (ANC). Also strikingis that of the estimated 130,983 deliveries in 2006, only 4,927 (4%) reportedly delivered in nontertiarylevel public health facilities in Enugu (HMIS, 2006 report). HMIS data also indicates thatvery few facilities have significant numbers of deliveries.All this information is critical in designing safe motherhood programmes.Health System - Institutional ArrangementsWhen PATHS began in 2002, the make up of public sector health facilities was the same as in otherstates. However, with the advent of the District Health System the public health service became aunitary system with single lines of accountability (for details see later). Five types of facilities wererecognised - health posts, health clinics, health centres, cottage hospitals, and district hospitals. Healthposts, health clinics and health centres deliver primary health care services. Cottage hospitals providelimited secondary care services and each District has a district hospital which is the locus of secondarycare. The exception to this is Enugu Municipality which lacks a district hospital.The minimum standard is that each district hospital will contain six units: Medicine, Surgery, Obstetricsand Gynaecology, Paediatrics, Diagnostic laboratory and Pharmacy. The district hospital is linked to all12 PATHS Final Programme Report

PHC centres and cottage hospitals in the district to ensure that each facility provides health servicesappropriate to their resources, capacity and role, and to facilitate effective patient referral.Despite the fact that the public sector had 436 facilities at the start of the PATHS programme, due tothe very poor state of these facilities, much of the health care delivery was provided by the private andfaith-based sectors.Maternity Ward, EnuguEzike HospitalMaternity Ward,Agbani Hospital“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 13

KEY FACTSPublic sector health facilities (436)2 Tertiary hospitals, UNTH (Federal) and ESUTSpecialist Teaching hospital, Park Lane (State)6 District hospitals2 Sub district hospitals8 Specialist clinics3 Dental clinics56 Cottage hospitals189 Health centres39 Health clinics131 Health postsPrivate/faith based facilities (488)84 Clinics28 Clinics and maternity homes10 Dental centres/clinics20 Eye clinics5 Health centres2 Homeopathic hospitals119 Hospitals with maternity services69 Maternity homes128 Hospitals23 Medical centresFor a variety of reasons including irregularpayment of salaries, non payment of allowances,poor working conditions and lack of staffaccommodation, many individuals employedin the public sector ran their own private clinicsand some were known to actively divert patientsaway from the public sector to their own facilities.The level of commitment to the delivery ofgood public sector services by those employedwithin the sector was low, resulting in frequentabsenteeism. Since absenteeism was also an issuewithin the management cadres, this reduced theincentives to use sanctions to deal with this andthe other human resource related problems thatbeset the sector.Substantial state Government health funds wereprovided for the upgrading of the State’s mainsecondary hospital to a tertiary teaching facility.This left the remaining facilities short of funds.ChallengesThe under-utilization of public healthfacilities in Enugu State is frequentlyattributed to:••••••••high informal chargespoor staff attitude to work and patientsdeplorable state of infrastructureinadequate drug supplypoor work environmentinadequate incentivesinaccessibility of facilitiespoor quality of care• inadequate staffing, particularly medicalstaffing and pharmacists14 PATHS Final Programme Report

Section 2:Overview of the PATHSProgrammeThe PATHS programme commenced nationally in June 2002 and was introduced into Enugu state inJuly 2002 with the recruitment of the State Team Leader. The programme started with a core staff ofseven people; a State Team Leader, a State Programme Officer, an Administrator, an Accountant, anOffice Assistant and two drivers. In 2005 the establishment was expanded to include a Logistician, anAccounts Supervisor and a further driver.Inevitably over the six year timeframe of the programme there were a number of staff changesincluding the State Team Leader in 2004, State Programme Officer in 2005, three changes ofAdministrator in 2006 and five drivers. The longest serving member of staff was Ugochi Egbujor, theAccountant, who was with the programme from inception onwards.PATHS Enugu StaffDr Andrew McKenzie State Team Leader July 02 - February 04Angie Roques State Team leader July 04 - June 08Gloria Onyeabo State Programme Officer October 02 - September 04Dr Chibuzo Oguoma State Programme Officer January 05 - June 08Klara Aqua Administrator September 02 - December 05Ifeanyi Echefu Administrator March 06 - September 06Amaka Umeigbo Administrator October 06 - June 08Ugochi Egbujor Accountant October 02 - June 08Mohammed Salihu Accountants Supervisor September 05 - June 08Amaka Umeigbo Logistician April 05 - September 06Rita Nkwam Office Assistant May 03 - July 07Ikechukwu Alioke Office Assistant November 06 - June 08Mba Kalu Driver July 02 - March 05Eze Livinus Driver May 03 - April 05Uchenna Ezeala Driver April 05 - June 08Gabriel Ogbu Driver April 05 - November 05Hyginus Chinze Driver April 05 - November 05Vincent Uzochukwu Driver December 05 - June 08Raymond Browne Driver January 06 - June 07Ignatius Ndubuisi Driver July 06 - June 07“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 15

Combined Entrance to the PATHS Office and the State Health BoardThe programme was initially located in the same building as the DFID Enugu office but it was feltto be too distant from its stakeholders. Therefore in 2003 an agreement was reached with the thenState Hospital Management Board to relocate to their site. This was situated very near to the mainMinistry of Health buildings. Four rooms were released and renovated by PATHS and the office wasofficially inaugurated by the Health Commissioner, Dr. Simon Idike in September 2003. As its workloadincreased PATHS sought additional space and again the State Board came to the rescue by offeringtwo further rooms which were integrated into the main office in 2006. A further small three roomedbuilding was also loaned to the programme and used initially by the production team of the Changeand Smile programme and then subsequently by the Health Commodities Procurement Project (HCP) .This location proved enormously beneficial and did much to promote collaborative working sincethe office was viewed as an integral part of the State Hospital Management Board (now State HealthBoard).Key Stakeholders and InitiativesPATHS worked with a number of Health Commissioners during its lifetime, namely Dr. P.O. Asadu(2002), Dr Simon Idike, (2003-2004 & 2007), Dr Festus Uzor (2004-2007) and Dr. Martin Chukwunweike(2004 & 2007). There were six Permanent Secretaries during the lifetime of the programme: Mr. Okoro(2002-2003), Mr.G.C. Asuke (2003-2004), Dr Mrs B. Orji Chukwu (2004-2006), Sir Sam Umesie (2006), MrC.J.Nnamani (2006-2007) and Mrs C.E.Okenwa (2007).The programme supported 31 different initiatives, which were mainly focused on the public sector.However, the period 2006-2008 saw an increasing emphasis on the development of partnerships withthe faith based sector and with NGOs and CBOs. At its height of busyness (January to June 06 businessplanning period) it was managing 25 different initiatives at the same time, shared across the fourPATHS themes.16 PATHS Final Programme Report

Stakeholder initiatives supported by PATHS were grouped into four key theme areas as follows:Theme 1Improved quality and sustainability of basic services relating to MDGsImprovements to Emergency Obstetric Care (2003-2008)Increasing Routine Immunisation (RI) (2005-2006)Raising awareness of HIV/AIDS & TB/DOTS (2003-2004)Improving Laboratory services - Community Diagnostic Programme (CDP) (2003-2008)Developing and implementing Public Private Partnerships (PPP) (2005-2008)Strengthening local management through PPRHAA/IMPACT (2003-2008)Strengthening Human Resource Management & Development (HRM/HRD) (2004-2006)Development of a Planned Preventive Maintenance (PPM) system (2006-2008)Developing and implementing Packages of Care (PoC) (2004-2008)Establishment of Continuing Professional Development (CPD) Centres (2006)Improvements to hospital infrastructure (2004-2006)Supporting the provision of Health Commodities (2004-2007)Theme 2Sustainable access to quality essential drugsDevelopment of a Drug Directory (2003-2005)Implementation of a Drug Revolving Fund (DRF) (2003-2008)Strengthening Central Medical Stores (CMS) (2003-2007)Theme 3Prioritised, costed, operationalised, government health policies adequatelyreflected in National Economic Empowerment and Development Strategy (NEEDS)and State Economic Empowerment and Development Strategy (SEEDS)Development and implementation of a District Health System (DHS) (2003-2008)Strengthening Financial Management Systems (FMS) (2004-2006)Re-establishing Health Management Information System (HMIS) (2003-2008)Introducing Business Planning (2004-2008)Supporting Public Expenditure Management (PEM) (2004-2008)Development of a Health Strategy (2003-2008)Development of District Health System Legislation (2003-2005)Supporting integrated supportive supervision (ISS) (2006-2008)“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 17

ExpenditureThe following charts provide an overview of the PATHS’s expenditure levels in Enugu. At completion inJune 2008 the programme will have spent in the region of £4 million (1 billion naira) in Enugu.Expenditure by Business Plan, 2004 - 2008Cost in GBP£1,400,000£1,200,000£1,000,000£800,000£600,000£400,000Cost% of Total40%35%30%25%20%15%10%Cost in Percent of TotalCost in % of Total£200,0005%£0Jan-Jun04Jul-Dec04Jan-Jun05Jul-Dec05Jan-Jun06Jul-Dec06Jan-Feb07Mar 07-Jun 080%Workplan periodExpenditure by Theme, 2004 - 2008Cost by Theme£1,800,000£1,683,621% of Total50%£1,600,00045%45%Cost in GBP£1,400,000£1,200,000£1,000,000£800,000£600,000£400,000£200,000£354,7589%£1,216,13032%£541,95714%40%35%30%25%20%15%10%5%% of Total£0Theme 1 Theme 2 Theme 3 Theme 40%“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 19

PATHS ApproachEngagement Process with State GovernmentGiven the poor state of the public sector, the programme’s initial focus was to work actively with theState Government, particularly the Ministry of Health, although other Ministries such as Finance,Women’s Affairs and Social Development and Ministry of Economic Planning andFinance were also actively involved in key initiatives at various points.In an effort to ensure that the engagement process was supportive and collaborative, in 2002 PATHSrequested that the Health Commissioner establish an inception phase Committee with representationfrom across the SMoH. The purpose of the Committee was to lead and guide the direction of thePATHS interventions. Following an inception phase review of PATHS in late 2003, the inception phaseCommittee was dissolved and a PATHS Steering Committee was established with an expandedmembership to include NGO and private sector representation.Despite the best of intentions, the committee was slow to demonstrate leadership of the varioushealth reform initiatives underway within the state. In an effort to resolve this, four sub committees,linked to the PATHS themes, were introduced in 2005 enabling broader engagement of stakeholderswith specific expertise. Each sub committee was chaired by a member of the Steering Committee.Despite concerted efforts by PATHS, these committees met infrequently, and when they did,attendance was poor. Following discussion with the Health Commissioner a decision was made toreconstitute the Steering Committee as a State Planning and Co-ordinating Committee. The idea wasthat the Committee would play a proactive role in managing not only the PATHS supported initiatives,but also play a leadership role on behalf of the SMoH in relation to other donor health programmes,thereby ensuring greater co-ordination and integration. Ensuring that this important Committeecontinues to operate effectively is a key challenge for the future.Increasing Stakeholder OwnershipThe state-wide focus of the District Health System meant that PATHS provided support across all 17Local Government Authorities (LGAs), the seven constituted District Health Boards (DHBs) and, from2005 onwards, 56 Local Health Authorities (LHAs). As the District Health System became increasinglymore established the emphasis shifted to direct management of the different reform initiatives bythe seven Districts. This included initiatives such as Peer and Participatory Rapid Health Appraisalfor Action (PPRHAA), integrated supportive supervision (ISS), business planning and interpersonalcommunications skills training for health providers (IPCC). The DHS provided the flexibility for differentdistricts to undertake different activities in line with their respective business plans, which, in turn,reflected locally identified health needs.Over the period 2006-2008, individual stakeholders took increasing ownership of many of the PATHSsupported initiatives which they led and managed.20 PATHS Final Programme Report

Engagement with Other Development Partnersand the Private SectorAlongside the support for public sector reform initiatives, PATHS worked increasingly (from 2005onwards) with six faith-based hospitals and a selection of their primary care facilities, as well as sevenNGOs (one per district) and a number of CBOs.Early linkages with German Leprosy Relief Agency (GLRA) were established to support thestrengthening of TB services, in particular by the provision of motorbikes for 17 Tuberculosis andLeprosy (TBL) supervisors; improved signage for facilities providing TB/DOTS services; and capacitybuilding of laboratory staff in a number of laboratories providing TB services.Links with UNICEF were established aroundthe provision of immunisation servicesand by providing support for a limitednumber of LGAs to strengthen their focuson key household practices for IntegratedManagement of Childhood Illnesses (IMCI).PATHS also worked closely with three of theother DFID funded programmes in the State:the State and Local Government Programme(SLGP) on the development of Ministry ofHealth budget and plans; StrengtheningNigeria’s Response to HIV/AIDS (SNR) incommunity mobilisation; and the HealthCommodities Procurement (HCP) projectwhich provided drugs and equipment forhealth facilities across the state.Development Partners operating inhealth in Enugu :World Bank (HSDPII), German Leprosy ReliefAgency (GLRA), WHO, UNICEF, Action Aid.DFID programmesState and Local Government Programme (SLGP)Strengthening Nigeria’s Response to HIV/AIDS(SNR)Health Commodities Procurement Project (HCP)As the World Bank funded Health Systems Development Programme (HSDPII) was also providing anumber of facilities with drugs and equipment it was essential to link with the programme in order toprevent duplication. This proved challenging for a number of reasons.PATHS was also a member of the Contact Officers Group (COG) which brought together theCommissioners of key line Ministries with representatives of the DFID programmes. The aim of theforum was to ensure collaboration and co-ordination of effort across the State. The chair was sharedbetween the Secretary to the State Government and the DFID Regional Co-ordinator. In early 2008 aset of key performance indicators for the COG were agreed, with members expected to monitor theirperformance against the indicators on a regular basis.Systems StrengtheningA key focus of the PATHS programme in Enugu was to strengthen the underpinning systems foreffective implementation of the District Health System management structure and to produce aframework to enable effective engagement and joined up thinking amongst a wide range of healthstakeholders (see Section 3 for more detail).“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 21

Pro-poor FocusPATHS pro-poor focus was operationalised in Enugu in the following ways:••••Increasing access to servicesReducing the cost of services to clientsImproving the skills of staff in their handling of all clients, including the very poorMobilisation of communities in order to increase demand.Some of the pro-poor initiatives supported by the programme included:••••••Development of the Emergency Obstetric Care Plus (EOC+) scheme managed by EnuguMetropolitan Health Board. This provided subsidised access to EOC services for poor womenState-wide introduction of low cost, quality drugs through introduction of a Drug Revolving Fund(DRF). Although deferral and exemptions (D&E) are an integral part of this, their introduction wasdelayed as it was felt necessary to get the DRF established firstSupport for the development of a free Maternal and Child Health (MCH) policyPromoting safer practice amongst TBAs by orientation and provision of free gloves and soapBuilding capacity among Community Based organisations (CBOs) to undertake communitymobilisation, including in hard to reach areasMonitoring of service charges through LHA reviews• Development of a pro-poor SMoH Health Strategy22 PATHS Final Programme Report

Section 3:ImplementationTheme 1Improved quality and sustainability ofbasic services relating to MDGsTheme 2Sustainable access to quality essentialdrugsTheme 3Prioritised, costed, operationalised,government health policies adequatelyreflected in NEEDS and SEEDSTheme 4Stimulated demand side andaccountability in relation to MDGsAs with all PATHS-supported states, the activitiesundertaken in Enugu were divided into four themes.However, unlike the other PATHS supported states,the request by the State government early in theprogramme to support the implementation of aDistrict Health System across the whole state created aframework within which the different initiatives couldbe situated. This is illustrated in the diagram below.In practice, many of the initiatives were implementedsimultaneously.Examples of initiatives undertakenDeveloping the District Health SystemStrengthening underpinning systemsEnabling service deliveryPromoting improved service deliveryin the facilitiesReorganisation of existing institutionalarrangements &Capacity building of constituent bodiesDevelopment of systems(e.g. HMIS, FMS) &Capacity building of health staffSupplying of drugs and equipment &Rehabilitation of infrastructureDevelopment of facility staff to deliver MinimumService Package &Promoting public private partnerships &Introduction of Integrated Supportive SupervisionIncreasing demand from communitiesCommunity mobilisation and CBO trainingIncreased patient patronageReduced maternal and infant mortalityand increased consumer demand inboth public and private managedprimary and secondary care facilities“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 23

“PATHS has indeed impacted very positivelyon the health care delivery system inEnugu State. She has in a very short timemade 56 primary health care facilities andthree District hospitals very functional.The capacity of the health workers andadministrators has also been improvedtremendously”Edmund Ndibuagu,Director of Medical ServicesState Health BoardWhen asked if she knew of the PATHSprogramme Onovo Gloria, a Community HealthExtension Worker commented:“Yes. PATHS programme has taught us a lotof things. They’ve taught us things we didn’tknow. Drugs are now available and not asexpensive as those sold outside, equipmenthas been supplied, the health centre hasbeen renovated. As a result of these changes,we have had an increase in patient turnout.”In this section five key areas (developing the District Health System; strengthening underpinningsystems; enabling service delivery; promoting improved service delivery in the facilities; andincreasing demand for services from communities) will be discussed. This will be followed by Section 4where evidence of programme outcomes will be presented.24 PATHS Final Programme Report

Developing the District Health SystemWith the political commitment and active support of theState Governor, in October 2003 the State Council on Healthrecommended that the state introduce a District Health Systemas its framework for health care delivery. In order to achieve thisvision there was a need to move away from a centrally managedand fragmented model of health service delivery to one ofintegration at all levels of service delivery with a special emphasison management at the district level.The introduction of the District Health System requiredrestructuring of the Ministry of Health:• A new Policy Development and Planning Directorate (PDPD)was created, which was responsible for strategic planning andpolicy development;• The State Hospital Management Board evolved into the StateHealth Board (SHB); and• Seven newly created District Health Boards (DHBs) and 56Local Health Authorities (LHAs) were established. The Boardsand Authorities were responsible for all aspects of servicedelivery.The DHS promoted:•••Decentralisation of servicesIntegration of primary and secondary servicesDelegated decision making as close to the patient as possible• Increased accountability for service delivery among providersand their managers• Greater opportunities for public private partnerships• More effective referral systemsDeveloping theDistrict HealthSystemStrengtheningunderpinningsystemsEnablingservice deliveryPromoting improvedservice delivery inthe facilitiesIncreasing demandfrom communitiesIncreased patientpatronageReduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedprimary and secondarycare facilitiesThe DHS approach was formally adopted by the State Government in January 2004, Developing and the resulting Districtlegislation introducing the District Health System was passed by the House of Assembly Health in System August2005. While the legislation was pending, the planned constituent bodies of the DHS were establishedin shadow form.StrengtheningunderpinningOnce the State Executive Council had approved the introduction of the system in 2003 systems it becameincreasingly apparent that the DHS framework needed to be sufficiently in place before efforts weremade to develop either the underpinning systems or to improve service delivery. A considerableamount of effort was thus invested in supporting the realisation of the State vision of Enabling a District HealthSystem.service deliveryIn the early days of DHS implementation, the commitment and drive of some key individuals helped toPromoting improvedensure positive progress. This included the then Health Commissioner, Dr FestusserviceUzor, thedeliverytwo HealthinAdministrators of the State Health Board, the seven Chief Executives of the District the Health facilities Boards and“Togetherness in Health” the Enugu Experience in Health Sector Reform, Increasing 2002-2008 demand 25from communities

the 56 Executive Secretaries of Local Health Authorities. The Boards and Authorities created their ownsupport networks in order to learn from what worked or did not work well in each district or healthDHS StructureCommissioner for HealthState HealthBoard (SHB)Policy Development andPlanning DirectorateDistrict HealthBoards (7 DHBs)Local HealthAuthorities (56 LHAs)Map Showing Enugu State District Health Boardwith Health Facilities as at February, 2006 Igb o -Eze-N orthIgb o-Eze-So uth U den u Nsu kkaIsi-UzoU zo -Uwan i Ig bo -Etiti En ug u EastU di Ezeag u Enu gu N orth En u gu So uth N kanu W est N kanu East Oji-River Aw gu An in ri LGA boundariesPublic Health FacilitiesPrivate Health FacilitiesDistrict Health BoardEnugu MetroUdiAwguNsukkaIsi-UzoEnugu EzikeAgbani26 PATHS Final Programme Report

authority catchment area. This helped ensure that the Boards and Authorities had a united voice whenadvocating for changes within the DHS.The implementation of the DHS required a fundamental shift in the roles, responsibilities, andapproaches of all the constituent bodies. To facilitate these changes PATHS provided support in thefollowing areas:•The framing of the required legislation to introduce the District Health System;• The establishment of the constituent bodies i.e. the Policy Development and Planning Directorate(PDPD), the State Health Board (SHB), the seven District Health Boards (DHB) and 56 Local HealthAuthorities (LHA);• The establishment of District Headquarters;• Extensive capacity building for 776 members of the constituent bodies to orientate them to theirrevised roles and responsibilities;• Design, development and implementation of the underpinning systems for financialmanagement, human resource management, health management information and drug revolvingfunds, all adapted to reflect the new structure;• Development of business plans and budgets for each of the constituent bodies and the workinginterfaces between them;• Engagement and advocacy aimed at Local Government to improve their knowledge andunderstanding of the new system;• Strengthening the new management lines of accountability to support the shift away from LocalGovernment control of primary care;• Encouragement of reporting channels within and between the constituent bodies;• A study tour to learn from the Ghana District Health System.A newly constructed DHB Headquarters for Enugu Metropolitan District Health BoardConsiderable technical assistance was provided from 2003 onwards in all the above areas. Overtime, increasing responsibility for implementation of the various reform initiatives shifted to the State“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 27

Health Board and the Districts. The LHAs’ knowledge and understanding of their “patch” was greatlystrengthened by the introduction of a quarterly review process. This commenced in 2006, and theprocess was chaired by the Permanent Secretary of the SMOH with support from the Ministry of LocalGovernment and the Local Government Service Commission.Despite the positive developments, by early 2008 there is still a considerable way to go before it couldbe said that the District Health System was functioning in its entirety. Such wide-ranging fundamentalchange takes time to take root.The LHAs quarterly review process brings together the Permanent Secretary (PS) SMoH asChair; PS, Ministry of Local Government; PS, Local Government Services Commission andrepresentatives of the State Health Board as the review panel. The LHAs report against an agreedreport format on all the happenings in their respective LHAs for the three month review period.A set of indicators has been developed and each LHA is scored against the indicators. If an LHAremains at the lowest score possible on more than three occasions then the LHA ExecutiveSecretary is removed. The respective DHB members are expected to be in attendance and canbe held acountable for the poor performance of their LHAs.Agbani District HealthBoard Members“How effectively can you implement adecision that you were not part of? That wasour fate before the DHS. Today you met usin a meeting of the Agbani District HealthBoard. We review issues and exchange ideaswith our bosses for the betterment of thewhole system. This communication systemhas improved so many things that have ledto better service delivery and also improvedthe quality of care.”Mrs Nnaji, LHA Executive Secretary“But when PATHS came, the numerouscapacity building trainings they gave usopened a new page in our approach tohospital management; in terms of personnel,management of drugs, equipment andfinances, client/staff relationships, generalplanning and resource management. Infact, DHS has given me a broader view andinsight on how to manage both human andmaterial resources.”Dr Enih, CEO Agbani DHB28 PATHS Final Programme Report

Development of anSMoH Health StrategyAll activities undertaken by theMinistry of Health should beunderpinned by a State HealthStrategy. Enugu had a state healthplan which was due to end in2006. Thus it seemed appropriate,particularly with the advent of theDistrict Health System, to developa State Strategy for Health. Theidea was that this would form thelink between the Federal and Statepoverty reduction strategies (NEEDSand SEEDS respectively) and theSMoH business plan.The purposes of the strategy were:International Health policy(Millennium Development Goals)Federal Government NEEDS(Reflecting international requirements e.g. MDGs)Enugu State SEEDS(Reflecting DHS & NEEDS requirements + MDGs)Health Strategy - MoH(Reflecting DHS & SEEDS requirements + MDGs)••to support and provide aframework for the current andBusiness Plan - MoHfuture health systems reform(Including SHB/LHA business plans)processes as enunciated in theEnugu State Health Law 2005 andthe SEEDS documentFacility Business Plansto drive health delivery atDistrict, Local Government andcommunity levels within the context of social development issues prioritized in the State’s PovertyReduction Strategy document.The strategic health planning initiative began in 2005. The intention was that this process wouldprovide an ideal opportunity for PDPD, within their revised remit under the DHS, to demonstrateleadership of the policy development process. However, despite the provision of considerableinternational and regional consultancy support, progress was not as rapid as had been hoped, partlydue to poor capacity within PDPD. In late 2005 a concept note was produced as a way of deepeningstakeholders’ understanding of the strategic development process. The concept note proposed thatthe health strategy should cover the period 2006 to 2010 and that the development process beparticipatory and driven by PDPD.The following steps were recommended••••Undertaking a Situational AnalysisDissemination of study findings and widespread discussion, and consensus building amongstakeholdersDrafting the Health Strategy and submission for state approvalDissemination of the content of the strategy and preparing for its launchFurther work in early 2006 produced a very early draft outline. However, a change in circumstanceswithin the PATHS programme left further development on the back burner until mid-2007. In 2007“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 29

it was agreed that the original idea of producing a detailed and costed strategy should be modifiedin favour of a framework strategy. A series of workshops across a range of stakeholders produced anoutline strategy.The Enugu Health Strategy focuses on four strategic themes:• Service delivery• Underpinning systems• Working in partnership• Research and developmentand is predicated on a number of principles:• Targeting the poor• Provision of a minimum service package to be delivered by every public health facility• Achieving affordable and accessible services• Increased community engagement• Promoting public /private partnershipWide consultation followed, involving government, non government and donor stakeholders. TheEnugu SMoH Health Strategy 2008-2013 was published and will be launched at the State Council forHealth meeting scheduled for May 2008.Public Private Partnership Engagement (PPP)Following the development of the national PPP policy and given the number of private and faithbasedproviders in Enugu, it was felt important to engage pro-actively with this sector. To identifypotential areas for engagement, an extensive round of discussions was undertaken with PDPD, theState Health Board, the District Health Boards and private sector providers. These discussions aimed toraise awareness of the potential benefits of PPP working, and to develop ‘road maps’ for progressingPPP initiatives.The following areas of work were agreed:•••••Mapping of all health facilities across the State using Global Positioning System technology(undertaken in 2005)Strengthening the registration and licensing of private sector health facilities (undertaken over2005-2006)Developing a PPP policy for Enugu State (completed in 2006)Setting up district based PPP networks (started in 2006)Design and implementation of a PPP to deliver Emergency Obstetric Care within Enugu District(started in 2005 and handed over to the SMoH in 2008).By engaging and working closely with the private sector, it was anticipated that benefits would spillover into the public sector and also improve health care delivery to communities in Enugu. One suchactivity (the EOC+ scheme) is described later.30 PATHS Final Programme Report

Strengthening Underpinning SystemsDeveloping theOnce the basic structure of the District Health District System Health was in placeand the constituent bodies were starting to function, System the stateturned its attention to putting in place the necessary underpinningsystems that would allow the DHS to function.A number of systems were considered of high Strengthening priority and thusunderpinningwere developed concurrently:systems• Business planningEnabling• Health Management Information (HMIS) service delivery• Public Expenditure Management (PEM) Promoting including improved FinancialManagement Systems (FMS) service delivery inthe facilities• Human Resource Management & Development (HRM&D)Increasing demand• Improving Management through Participatory from communities Appraisal andContinuous Transformation/Peer and Participatory RapidHealth Appraisal for Action (IMPACT/PPRHAAIncreased patientpatronage• Implementation of a Drug Revolving Fund (DRF)Reduced maternal andinfant mortality and“It is worthy of note that DHS management, increased like consumer that ofmany organizations, rests on a tripod: demand finance, both logistics publicand private managedand personnel.”primary and secondarycare facilitiesHealth Administrator, SHBDeveloping the DistrictHealth SystemStrengtheningunderpinningsystemsEnablingservice deliveryPromoting improvedservice delivery inthe facilitiesIncreasing demandfrom communitiesIncreased patientpatronageReduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedprimary and secondarycare facilitiesBusiness PlanningDeveloping the DistrictHealth SystemDeveloping the DistrictHealth System“The culture of business planning has resulted in more focused health care delivery StrengtheningandStrengtheningmonitoring of services, particularly by the underpinningunderpinning State Health Board and the District staff.”systemssystemsChief Executive Officer, DHBEnablingIt was anticipated that the introduction of a culture Enabling of business planning would achieve service the delivery following:service delivery• Bring together the members of the various constituent bodies (i.e. PDPD, SHB, DHBs) and providea concrete activity on which they could work together as a teamPromoting improvedPromoting improvedservice delivery in• Enable agreement on the relevant service priorities delivery of each in of the constituent bodiesthe facilitiesthe facilities• Allow realistic objectives to be setIncreasing demand• Define activities for the objectives, and Increasing build demand on them on a six-monthly basis from communitiesfrom communities“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 31Increased patientIncreased patientpatronagepatronage

•••Working to an agreed timeframeWorking to an agreed set of performance indicators and targetsProvide a monitoring tool to review the performance of each of the constituent bodies.The form and scope that the six-month DHA and SHB business plans took were agreed and developedon the basis of common objectives for all the DHBs.The plans included the actions necessary toestablish the DHS and were informed by asituational analysis. Six-monthly plans wereproduced in line with the PATHS planning cyclestarting formally with the January - June 2005business plan. This was continued throughout2006; annual plans were then produced for 2007and 2008 and costings were added.A significant weakness of the first six month plan,was the lack of a performance managementmechanism. Therefore, an implementationplanning template was created utilising amonthly activity form. This resulted in sufficientlycomprehensive plans that served as the basis ofthe business plan review process and facilitatedfuture co-ordination among health donors.With the inauguration of the Local HealthAuthorities in September 2005, the LHAs wereincluded in the business plans for 2006. Initiallyplanning was undertaken by the LHAs’ respectiveDistrict, but over time the LHAs became moreactively engaged in the planning process. Byearly 2008 plans were being produced at facilitylevel and costings had been added. At the timeof writing, the 2009 costed business plans werenearing completion.A donor forum provided an opportunity for donoragencies to input into the respective businessplans. However, by early 2008 harmonisation ofdonor activities with state health plans remainedweak, with donors continuing implementation ofparallel health programmes.“Before we can have successful delivery ofhealth services, we must plan well. This isnot like before. We must get informationfrom the areas we serve in order to knowwhat is needed.”Content of Business Plans• service delivery (with a focus onachieving MDGs)SHB member• systems development (focusing on DHSimplementation)••human resourcesinfrastructureDHS Constituent BodiesReview ProcessesPDPD, SHB and DHBs are subject to amedium and end of term (i.e. quarterly)business planning review which is chairedby the Commissioner for Health. Eachorganisation presents a progress reporton the implementation of their respectivebusiness plans. Following this, eachorganisation faces questioning by theCommissioner and other Districts regardingissues that require clarification or defending.By early 2008 business planning was sufficiently institutionalised for it to have become a year on yearactivity. The Planning, Research and Statistics Directorate located within PDPD played a vital role inleading the planning process.32 PATHS Final Programme Report

Health Management Information System (HMIS)When PATHS commenced there was a near absence of proper record keeping at any level of the healthsystem. Both the quantity and quality of data were extremely poor and no management decisionswere informed by an analysis of health data. In response, an HMIS pilot scheme (utilising the DistrictHealth Information System - DHIS) was introduced in five of the 17 Local Government Areas in early2003 with the aim of improving the quantity andquality of data. The scheme went state-wide in2004; all 17 M&E officers across the states wereinvolved in capacity building initiatives. Withthe introduction of the DHS the HMIS formatwas adapted to reflect the new institutionalarrangements.“I now have an information system that canshow performance changes from 2005 to2008.”DHB CEOThe HMIS process is managed by a core HMIS management team of five officers at state level; sevenDistrict Information Teams; and 17 technical M&E LGA officers who collect and collate the data.A data set of 122 data elements derivedfrom 42 basic state indicators was selectedfrom the myriad of report forms and sundryparallel health programmes.Extensive training was conducted for morethan 1,000 staff from PDPD level right down tofacility level. Appropriate feedback mechanismswere introduced, both on the quality of the data(completeness, correctness and consistency) andthe interpretation of the analysed data.By early 2008 more than 98% of facilities were returning data on a regular basis. In addition, efforts toimprove the quality of HMIS data were being made through the double-blind checking of 42 sentinelsites.Core Enugu HMIS team and the 17 LGA M&E officers“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 33

PATHS provided much of the infrastructurerequired to support the establishment of theHMIS. This included: setting up and equippingthe PDPD and SHB computer rooms; provisionof computers and software at District level;maintenance of the machines/software; andsending key HMIS personnel on both nationaland international training in order to enhancetheir skills. In early 2008, PATHS provided supportHMIS TrainingThis focused on computer use, datacollection, data collation, data querying,quality assurance, software use and handling,data generation and data analysisso that the state could migrate to the National Health Management Information System (NHMIS) 1 . Thiseffort focused initially on the training of community volunteers, TBAs and facility staff, some 1200 intotal to date.By early 2008 health data was increasingly being used to inform management decision-making,budgeting and policy and strategy development processes. However, whilst the quantity of datacollected had improved considerably, quality remained an issue. Further support will be needed inthis area. In particular, this will need to focus on the private sector where data collection remains veryweak.Publc Expenditure ManagementAs the business planning process was refined, so were the financial management system and publicexpenditure management processes. PATHS invested very heavily in supporting the improvementof both these systems within the Ministry of Health. The process started in February 2004 with aninitial review of the feasibility of implementing a financial management system within the StateHospital Management Board and six district hospitals. However, with the advent of the DHS the focusshifted to the financing of, and the financial systems associated with, the DHS. It also considered theestablishment of the proposed State Health Fund and the need for adequate systems of accountability.Extensive TA was provided by PATHS to support the process of strengthening public expendituremanagement throughout the programme lifetime, and some very substantial progress had beenmade by early 2008:•••••••Design and implementation of a financial management system throughout the DHSProvision of FMS training for Finance Officers and facility staffRevision of the Chart of Accounts to reflect the District Health SystemProduction of a more refined MoH 2007 budget informed by District calculations of their overheadrequirementsDevelopment of an Excel spreadsheet activity-based budget templateRefinement of the budget for 2008 down to facility level using the budget template linked to theChart of Accounts, enabling for the first time realistic activity-based budgeting. 2Use of HMIS data to inform the budget1 For more detail see PATHS Technical Brief on HMIS.2 This was based on core functions and core activities in order to achieve a minimum baseline service package in allfacilities.34 PATHS Final Programme Report

PATHS budget team Enugu••••Establishment of a SMoH budget group which was able to progress the work without externalassistanceTraining the budget group in use of the activity-based budget templateAchieving a release of funds for the constituent bodies (albeit only for a limited period)Establishment of regular FMS monitoring to encourage transparency in financial accountingAll the above resulted in the production of computerised activity-based and costed budgetarysubmissions which were considerably more advanced that those produced by any other ministry inEnugu. This provided a model for other ministries – and indeed other states – to follow.Despite these very positive advances, an on-going and very significant challenge was the decisionto channel substantial funds into the upgrading of the Park Lane Hospital so that it could become atertiary facility. This severely reduced the operational funding available to the rest of the health sector.It also meant that progress with setting up the much needed State Health Fund was curtailed.Human Resource Management and DevelopmentHuman resource management aims to achieve: the right people, in the right place, at the right time,with the right skills.The SMOH recognised that a considerable amount of work needed to be undertaken in an effortto improve human resource management and development. Nevertheless, this area proved verychallenging and early work stalled due to the paucity of data on staff numbers and their actualplace of employment. Local Government data, in particular, proved virtually impossible to access.This was compounded by the high level of staff absenteeism. However, the period 2006-2008 sawa considerable improvement in staffing data with the Local Health Authorities in particular havingbetter access to data that would enable them to determine their staffing base. Data was much easier“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 35

to access for the Ministry of Health staff due to the computerisation of the payroll. By early 2008, threeLGAs were in the process of piloting a computerised payroll.Training was undertaken for seven district Human Resource Managers, who were later joined bya small number of people from the private sector. Efforts were made to develop potential staffingestablishments for each of the facilities, and proposals for the redeployment of staff, but work did notprogress very far until more accurate data could be accessed. This is an area that needs considerablefurther work to ensure that best use is made of staff through redeployment. Only then will it beclear whether or not additional staff need to be recruited. A further step will be the introduction ofperformance management, which will introduce the incentives and sanctions that will help increaseaccountability within the system.IMPACT/PPRHAAEarly in the PATHS programme the Peer and Participatory Rapid Health Appraisal for Action (PPRHAA)initiative was introduced as a mechanism for local change. This process provided a mechanismthrough which health providers, clients and members of the wider community could be involved in aprocess of facility or local government performance assessment.Standard assessment tools were developed for both primary and secondary care and an initialappraisal of six hospitals, two LGAs and two primary care facilities was undertaken in 2003. Theprocess identified the main areas that needed to be strengthened as well as the strategies for doingso. The process proved an effective means of involving providers and their managers in a detailed butrapid assessment of the institution, and of building local ownership of the subsequent change process.The appraisal component of PPRHAA was supported by a process of bringing together all participantsat an annual summit, which provided a learning opportunity for peers within the health sector.In September 2004 all the PATHS supported states came together to review progress withimplementing PPRHAA and discussed how the process itself could be further refined. As a result of thismeeting, PPRHAA evolved into IMPACT (Improving Management Through Participatory Appraisal andContinuous Transformation), a four-stage change management process. It will take some time beforethe four elements of IMPACT are fully implemented in the state.The IMPACT InitiativeCOMPONENT 1:Appraisal and Planning (PPRHAA)COMPONENT 4:Quality Assessment andRecognitionBETTER HEALTHSERVICES FORCOMMUNITIESCOMPONENT 2:Building Systems andCapacity (HMIS, IMCI, SMI,Financial Management,DRFs, etc.)COMPONENT 3:Integrated SupportiveSupervision (ISS)36 PATHS Final Programme Report

Over time, implementation of PPRHAA evolved. With theadvent of the DHS responsibility for PPRHAA was devolvedfrom a state PPRHAA team to seven district teams,although a small central core PPRHAA team continued toprovide support.In 2006 the Catholic Society for Nigeria rolled out PPRHAAacross all 18 of their facilities in Enugu.Participants trained in PPRHAA:2004: 1472005: 1512006: 432007: 46The spider diagram shows the scores achieved (out of 20 possible points) on completion of aPPRHAA exercise. The method provides a means of visually assessing functioning at the time ofthe appraisal and over time (as the PPRHAA is an annual event, comparisons can be made withprevious spider diagrams).A PPRHAA spidergram from Bishop Shanahan Hospital, EnuguPatient CareManagementServiceOutputInternalManagementClient andCommunity Views5101520Finance,Equipment andInfrastructureImplementation of a Drug Revolving Fund (DRF)The SMOH introduced a Drug Revolving Fund in an effort to prevent the frequent occurrence of “out ofstock syndrome”, a common feature of most public health facilities.Initial preparatory work prior to the establishment of a DRF included a scoping mission, followed by areview of the Enugu Central Medical Stores. In February 2004 consideration was given to the possibledecentralisation of the DRF to six District hospitals. Throughout 2004 and 2005 the wider PATHSprogramme supported the development of a DRF model for both primary and secondary care. Thisculminated in a roundtable event in February 2006 where the models were finalised. In Enugu thespecific issues relating to implementation of a DRF model within the context of a DHS were reviewed“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 37

and the core DRF models used in other PATHSstates were adapted to fit the Enugu context.Prior to the introduction of the DRF considerablepreparatory work was undertaken including:“There was always out of stock syndromeand laxity on the part of staff, or you comeand you don’t see patients and you have nodrugs to give them”.• Determining an essential drug listThe Officer-in-Charge at Ozalla PHC facility,• Selection of participating facilitiesAni Stella, describes the situation before the• Ensuring facility preparedness for a DRF (e.g.initiation of the DRF programme•safe and secure drug storage areas)Removal of all expired drugs from the•facilities and their destructionRemoval of all “private” stocks of drugs• Up-to-date stocktake of the remaining drugs• Quantification exercise to determine the volume of drugs required by each facility• Submission to the Health Commodities Programme of information on drug requirements• Design and implementation of the financial management system to underpin the DRF to ensurethat decapitalisation did not occur• Training of four DRF teams responsible for the implementation of the scheme (these comprisedeight accountants and eight pharmacists, four from each of the private and public sectors)• Preparation of CMS, including provision of additional finance staffAt the end of the first quarter of 2006 DRF implementation began using a two-phased approach:• Capacity building of facility staff on DRF procedures• Mobilisation of facility catchment communitiesInitial difficulties encountered included:• Capacity of staff to manage the DRF and associated FMS• Provision of off-site rather than on-site training, which reduced the impact• Poor quantification resulting in an over-supply of drugs• Large volume of paperwork• Challenging replenishment logistics• Slow lodgement of DRF funds• Outmoded CMS systemsOver time and with ongoing supportive supervision most of these challenges dissipated and facilitiesbegan to implement the scheme effectively. Replenishments were frequent and no stock-outs ordecapitalisation had been recorded by early 2008.As of early 2008 the DRF was managed entirely by SMoH staff and had been introduced into 100facilities - both public and private, primary and secondary care. Other positive developments includethe fact that several private sector facilities were starting to replenish their stocks at the CentralMedical Stores rather than use private suppliers. Nevertheless, frequent and robust monitoringwill be essential if the scheme is to continue to succeed, but given the logistics and expense, thiswill be challenging to achieve. Ensuring that adequate funds are included in the health budget formonitoring activities will be essential. A further challenge is that with the implementation of a free38 PATHS Final Programme Report

MCH programme (the policy was developed in late 2007) appropriate funding must be set aside toensure that the DRF does not decapitalise.Local communities attenda drugs and equipmentdelivery at the healthfacility“Immediately after the roll out, patientsstarted coming to see if it was true. …They now have confidence that the place haschanged for good, and they can find drugsfor affordable prices. Our relationships withpatients have also changed for good as weare happy to be working with them’.The Officer-in-Charge at Ozalla PHC facility,Ani Stella“My people travelled long distances tosource drugs and medication. The services ofPATHS are a significant milestone and franklyspeaking we have never had it so good andthis kind of partnership with governmentshould be sustained.”Chief Lawrence Ozochukwu, Chairman of theHealth Committee, Oyofo Oghe CommunityLocal Chiefs at a health facility with facility staff and the Project Manager of theHealth Commodities Procurement Project“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 39

Enabling Service DeliveryDeveloping theDistrict HealthDeveloping the DistrictThe following key issues were tackled so as to enable serviceSystemHealth Systemdelivery across the DHS to progress smoothly:•Infrastructure development• Planned preventive maintenanceStrengtheningStrengthening• underpinning Procurement of drugs and equipment underpinningsystemssystems• Production of a drug directory• Enabling Development of laboratory servicesservice deliveryEnablingservice deliveryDeveloping the DistrictHealth SystemStrengtheningunderpinningsystemsEnablingservice deliveryPromoting improvedservice Infrastructure delivery in Development Promoting improvedthe facilitiesPromoting improvedservice delivery inservice delivery inFollowing many years of neglect and the absence the facilities of anythe facilitiesmaintenance plan, all aspects of health facility infrastructure inIncreasing demandfrom Enugu communities required attention. An initial report commissioned byIncreasing demandPATHS in 2003/2004 focused on the need to tackle the neglectedIncreasing demandfrom communitiesfrom communitiesinfrastructure and proposed that the six District Hospitals (Agbani,Increased patientNsukka, Ikem, Awgu, Enugu Ezike, Udi) should be prioritised forpatronageIncreased patientrehabilitation. Enugu Metropolitan District’s hospital was initiallyIncreased patientpatronagepatronagePark Lane Hospital, but during the period of the programme thisReduced maternal andfacility was undergoing renovation and refurbishment so that itinfant mortality andReduced maternal andincreased could operate consumer as a tertiary facility thus leaving the District without aReduced maternal andinfant mortality anddemand District in both hospital. publicinfant mortality andincreased consumerand private managedincreased consumerdemand in both publicprimary and secondarydemand in both publicA detailed needs assessment of the hospitals and private was managed carried outcare facilitiesand private managedprimary and secondaryin mid-2004 by a small team from the SMOH and the Ministryprimary and secondarycare facilitiesof Works (MOW). However, this resulted in the production ofcare facilitiesoverly ambitious and poorly costed plans. External support wasprovided by PATHS to support the process of designing a workableinfrastructure programme.Developing the DistrictDeveloping the DistrictHealth SystemDeveloping the DistrictHealth SystemHealth SystemIn most locations there was no need to expand the number of health facilities. Instead a rationalisationprogramme was required which focused onStrengtheninga comprehensive overhaul of key buildings.StrengtheningStrengtheningunderpinningTwenty-six underpinningunderpinningbuilding companies pre-qualified and systems contracts were awarded to four contractors.systemssystemsHowever, the quality of their work was extremely variable; only one contractor met the requiredstandards and deadlines without very considerable supervision. This put a heavy burden on all thoseEnablinginvolved in the management of the initiative and Enabling resulted in considerably more international inputEnablingservice deliverythan was originally anticipated.service deliveryservice deliveryA limited budget and the problems with supervision meant that the programme of work Promoting at each improvedPromoting improvedsiteservice delivery inPromoting was restricted improved to essential remodelling of the service main delivery buildings. in Wherever possible, water supplies werethe facilitiesservice improved delivery and electrical in connections reinstated the to facilities the national grid. The work was kept as simple aspossible the facilities to reduce the burden of future repairs and maintenance.Increasing demandEach hospital required a different approach,Increasingand everydemandfrom communitieseffort was made to ensure that the ideas andIncreasing demandfrom communitiesrequests of the State Health Board, which was responsible for the hospitals, were taken on board.from communities40 Increased PATHS patient Final Programme ReportpatronageIncreased patientpatronageIncreased patientpatronage

In order to carry out the necessary buildingworks a clear strategy was preparedincluding:••••••Contracting a local architectProduction of architectural drawingsPre-qualifying contractorsEstablishing a tender procedureOpening of bids by a tender committeeAwarding of contracts• Final agreement on the contract priceand documentation• Monitoring of the building work• Signing off on the completed building• Payment of contractors• Final checks• Completion of payment• Documentation of the whole processRenovated corridor with patients at AgbanihospitalThe final decision about how the work was to beprioritised was made by the Commissioner forHealth.Because of a change in priorities, only four outof the six district hospitals initially earmarked forrehabilitation benefited from the infrastructureprogramme. However, the programme alsosupported the rehabilitation of the Awgu Schoolof Midwifery.“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 41

Procurement of Drugs and EquipmentThe poor provision of drugs and equipment within public health facilities had a negative impact onpatient attendance, with patients seeing little point in visiting facilities that were not able to providethem with what they viewed as the key essential for treatment, drugs.In Igbo speaking states, hospitals areknown as “Ulo Ogwu- House of drugs”In an effort to reverse this situation, PATHSworked in close collaboration with the HealthCommodities Procurement Project, another DFIDfundedprogramme, whose remit was to providedrugs and equipment. In September 2004 Enuguundertook an initial scoping exercise to determine the state of readiness of the facilities to receivedrugs and equipment. They were found woefully lacking. In 2005 an initial 21 facilities were selected tobe the first recipients of drugs and equipment. These facilities became known as the ‘Early Bird Clinics’.Local Government support was provided to get the facilities in a state of readiness to receive the drugsand equipment.The amount and type of equipment required was determined, along with the quantity and rangeof drugs. Orders were then placed with HCP. A first tranche of drugs and equipment was received inMarch 2006. A further two tranches of primary facilities were then selected along with the six districtand six faith-based hospitals, and further orders were placed. As of the middle of 2008, 100 facilitieswere due to receive drugs and equipment from HCP.Planned Preventive MaintenanceThe provision of planned preventive maintenance isessential if facilities are to be properly equipped andmaintained to the point where they can offer a reasonablelevel of care.“ An ounce of prevention is worth apound of cure”Benjamin FranklinTo ensure that the substantial amount of equipment that was in the process of being provided byboth the Health Commodities Procurement Project and the Health Systems Development Programme,had as long a life as possible, the Ministry of Health recognised that it needed a system of PlannedPreventive Maintenance. The infrastructure that had been rehabilitated also needed ongoingmaintenance.Planned Preventive Maintenance is anestablished system by which infrastructure,equipment and vehicles are kept in as healthy astate of repair as possible through:••••Instruction regarding best practice of useRegular and planned monitoringActive maintenance to prevent breakdownSpeedy repair to prevent unnecessarydeterioration and decay42 PATHS Final Programme Report

Participants of the first PPM course run by Annunciation HospitalIn order to develop the PPM system the following activities were implemented:•••••••Training of selected staff so that they could take on the role of PPM OfficersRe-categorising the trained staff for their new role as PPM officersDeployment of PPM Officers to the DistrictsProvision of necessary toolsTraining other facility staff in use of equipment and equipment maintenance requirementsProvision of integrated supportive supervisionProvision of funding for the PPM serviceAnnunciation Specialist Hospital already ran aplanned preventive maintenance course and wascontracted to deliver the training. The existingcurriculum was adapted to meet the needs ofthe two groups of students. The first was a groupof 13 who had some technical background inmaintenance: the second group of 16 had norelevant technical expertise.Objective of the trainingprogrammeTo ensure the appropriate operation,functioning, service repair and maintenanceof all hospital equipment and infrastructureBoth courses proved challenging for many of the students. The first group commenced training inFebruary 2006 and completed in May 2006 - 11 out of 13 participants successfully completed thecourse. The second group commenced in June 2006 and completed in December 2006 - 15 out of 16participants were successful. Their success related not only to their passing the course, but also to theirown personal development and increase in self-confidence.All 26 successful officers were equipped with a set of tools sufficient to be able to provide a basic levelof service. As of early 2008 further tools and the creation of district maintenance workshops were“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 43

equired in order to ensure that more extensiverepairs could be carried out and a full servicedelivered. An allocation for both was included inthe 2008 SMoH budget.Monitoring of the PPM Officers progresssuggested that all new equipment was in useand some previously broken equipment hadbeen repaired and was back in use.“Professionally the course was an eye opener.I learnt more on plumbing job, how to handleplans and services, how to handle hospitalequipment and more about management.Personally it made me proud of myself, andproud of my job. When we went to UwaniClinic there were two baby weighing scaleswhich were dumped but I picked them up andrepaired them. They are using them now. AtAkpuoga Nike Clinic there were new tablesscattered, even drawers, which we picked upand repaired and they are making use of themnow.”Iziga Edwino, previously a carpenter who is nowPPM team leader for Enugu Metropolitan District44 PATHS Final Programme Report

Production of a Drug DirectoryNigeria is renowned for its preponderance of fake drugs, which are freely available across the country.PATHS supported the development of a Drug Directory of information on genuine medicines andconsumables. This involved identifying available generic and brand dosage forms, their compositionsand strengths, NAFDAC numbers, manufacturers, Nigerian representatives, agents, importers and theirdistributors and contact addresses.It was hoped that the Directory would help to:• Improve the quality of care provided by private or public medical practitioners, pharmacists etc;• Alert all stakeholders in health to their duties in checking fake, counterfeit, substandard orunwholesome drugs;• Improve the co-operation of pharmaceutical companies in making available all addresses of theircompanies, agents and distributors so that public sector drugs procurement could avoid the opendrug market;• Remove the doubt of some pharmaceutical manufacturers that the initiative intended to provethat they dumped their products in open markets and lacked distributors.Copies of the Drug Directory were widely circulated to pharmacists across the public and privatesectors, pharmacy outlets, and the National Council for Pharmacists for Nigeria. The Directory was wellreceived.Development of Laboratory ServicesThe laboratory strengthening initiative commenced early in the programme. The idea was to developlaboratory services linked to the private sector in Nsukka. For a number of reasons, however, theinitiative was not taken forward and the direction changed in 2006 when all the PATHS states cametogether to agree a way forward. The outcome of the discussions was implementation of a communitydiagnostic programme (CDP) to improve the testing of malaria, TB and Hb estimation. Much of thein-state TB work was managed in conjunction with German Leprosy Relief Association (GLRA) and theSMoH TB Supervisor, who provided the data and microscopes.A programme of work was agreed including:• Provision of equipment, reagents and Malaria Rapid Diagnostic Tests (RDTs)• Training of laboratory scientists/technicians/assistants from the public and private sectors• Community mobilisation to encourage utilisation of laboratory services• Provision of TB/DOTS (Directly Observed Treatment Shortcourse) signage and InformationEducation and Communication materials• Provision of motorcycles for TB & Leprosy supervisors• Development of standard operating procedures• Establishment of a quality assurance scheme• An independent review of all the SMOH-listed TB laboratories.A survey of TB/DOTS clinics/laboratories across the state found that of the 112 facilities that weresupposed to be providing these services, in practice only 25% were offering a genuine service. As aresult, a decision was made to focus the laboratory strengthening work on 20 laboratories (eight PHCand 12 SHC facilities: of which six were in the faith-based sector).“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 45

Training in the laboratory of Annunciation HospitalA core team of nine staff from Enugu was trained as master trainers, from which four were selected tobe state representatives. These and staff from other states were trained with international support.The master trainers trained 43 laboratory staff and 71 facility staff (the latter only in the use of RapidDiagnostic Tests for malaria). A set of standard operating procedures were developed and a rangeof equipment and reagents were procured, centred on improving TB, malaria and Hb estimationdiagnosis.To test the effectiveness of the training, but more importantly to determine the quality of the slideresults, a Quality Assurance Scheme was developed using Annunciation Specialist Hospital’s laboratoryas the reference laboratory.46 PATHS Final Programme Report

Reduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedPromoting Improved Service Delivery incare facilitiesthe Facilitiesprimary and secondaryIn order to improve the quality of health services, systemsstrengthening initiatives need to go hand in hand with initiativesthat aim, directly, to improve services. This section describes anumber of initiatives that focused on working directly with serviceproviders at facility level. These included:•Introduction of a Minimum Service packageDeveloping the DistrictHealth SystemStrengtheningunderpinningsystems••••Development of Packages of CareImproved management of Emergency Obstetric CareImmunisationIntegrated Supportive SupervisionEnablingservice deliveryPromoting improvedservice delivery inthe facilitiesIntroduction of a Minimum ServicePackage (MSP)Given the paucity of service provision in the public sector, theDistrict Chief Executive Officers agreed in late 2004 that everyfacility should be in a position to offer a minimum level of service toits clients.A Minimum Service Package was developed. This was based on fourelements:• A reasonable state of infrastructure, including provision ofelectricity and water• Specific services that should be offered by the facility• Specific drugs and equipment that should be available in the facility• Packages of care that would guide health staff in their delivery of services.Increasing demandfrom communitiesIncreased patientpatronageReduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedprimary and secondarycare facilities“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 47

The services to be delivered were agreed as:MSP in Primary Health CareMSP in Secondary Health CareMaternal Health•Ante-Natal Care (from 12 to 40 weeks)•Ante-Natal Care (from 12 to 40 weeks)•Safe Delivery•Safe Delivery•Post Natal Care (for up to 6 weeks)•Post Natal Care (for up to 6 weeks)••Basic Emergency Obstetric Care (BEOC)Routine Immunization (including TetanusToxoid)••Comprehensive Emergency Obstetric Care(CEOC)Routine Immunization (including TT)•Family Planning•Family PlanningChild Health•Growth monitoring•Growth monitoring•Nutritional supplements•Nutritional supplements•Routine Immunization•Routine Immunization•Health Education•Health Education••••Treatment and management of minorailments including malaria, diarrhoea,acute respiratory infectionFebrile convulsionsDewormingMale circumcision••••Treatment and management of minorailments including malaria, diarrhoea,acute respiratory infection, febrileconvulsionsDewormingIntermediate SurgeryManagement of Emergency Tracheotomy•Male circumcisionAdult Health•Minor surgery for incision and drainage ofabscesses, abrasions and cuts•Intermediate Surgery – incision anddrainage of abscesses, abrasions and cuts•Treatment and management of variousailments e.g. diabetes screening,hypertension, malaria, arthritis,gastroenteritis and TB.•Treatment and management of variousailments e.g. diabetes screening,hypertension, malaria, arthritis,gastroenteritis and TB, HIV/AIDS•Acute respiratory infections, cardiacfailure, peptic ulcers, sexually transmittedinfections and pelvic inflammatorydiseases48 PATHS Final Programme Report

In order to ensure that the MSP could beprovided effectively, extensive training wasprovided in a number of key clinical areas in aneffort to improve the services on offer within thefacilities.The work to introduce the MSP took place overthe period 2005-2008. The expectation is that bymid 2008 35% of the health facilities in Enuguwill be in a position to deliver the MSP.“Before PATHS, the maximum patient turnoutper day was never more than 12. At times,by the end of the month we may score up to150 patients. But now with the training andorganisation, coupled with the communitymobilization, we record up 30-40 patients aday.”Dr Enih DHB CEODevelopment of Packages of CareIn order to support improved service delivery,and informed by the agreed Minimum ServicePackage, a decision was made to develop anumber of Packages of Care (POC). The ideawas that these would provide a guide to bestpractice.Work commenced in April 2004. The decisionabout what packages of care should bedeveloped emerged through consultation.Between April 2004 and July 2005 twelvemedical and four surgical packages of care weredeveloped.The purpose of the packages of care was tohelp all staff provide safe and relevant care forany patient. They identified where care shouldbe given, and who the care provider shouldbe. Each POC was based on a holistic model ofcare, detailing preventive, promotive, curativeand rehabilitative care activities at each level.The skills and capacity available at each level ofcare were recognised in the development of thepackages.A package of care wasdefined as:“a protocol to be observed by ALL healthcare providers, which includes wherehealth care will be provided, by whom, andto what basic and specific standards.”* * *Enugu Packages of CareMedical: acute respiratory tract infection,common worm infestation, gastro-enteritis,HIV/AIDS, hypertension, malaria, maternalhealth, measles, osteoarthritis, diabetes,IMCI, TBSurgical: Basic surgery, Gynaecology,Obstetrics, Trauma/OrthopaedicsEach package contained a limited number of standards of care including:• Every patient is treated with dignity, respect and confidentiality• Every patient will have prompt access to appropriately trained health care providers in anemergency, or within an hour of arrival at the facility• Every patient is given enough information to make an informed choice• Every patient will have a clear and comprehensive medical record• Every patient will have easy and quick access to affordable drugs• Every patient will be cared for by staff using good infection control practices• The health facility is kept clean, safe and user-friendly.“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 49

Where care is givenEnugu’s health system has five different levels of public health facilities, namely: health post,health clinic, health centre, cottage hospital and district hospital. In addition there are a largenumber of varying sized private and faith-based facilities. The packages of care distinguishbetween primary facilities, covering the health post, health clinic, health centre and secondaryfacilities, covering cottage hospital and district hospital.Care providers* * *A number of professional and non-professional staff were assigned roles in the packages,including:DoctorsNursesMidwivesPublic Health NursesPharmacists and Pharmacy TechniciansRadiographers and Radiography TechniciansLaboratory Scientists and Laboratory Technicians Community Health OfficersCommunity Health Extension WorkersEnvironmental Health OfficersRecords OfficersIn September 2005, 36 master trainers were trained, of whom 18 were given responsibility foroverseeing the roll-out to facilities. The medical packages of care were introduced in 2005 and thesurgical packages in 2006. By early 2008, 1,040 people had been trained in their use. It is anticipatedthat additional staff will be trained prior to completion of the programme.Improved Management of Emergency Obstetric CareActivity in this area focused on:••Training of doctors, nurses and CHEWs in life-saving skillsOrientation of TBAs to danger signs and the need for prompt referral• Development of a contracting mechanism through faith-based hospitals for provision ofEmergency Obstetric Care for the public sector• Provision of equipment to both public and faith-based facilitiesTraining in Life Saving Skills (LSS)Given the need to work towards reducing maternal mortality, a reproductive health scoping missionwas undertaken in late 2003 to determine the target issues for the state. In April 2005 a furtherneeds assessment confirmed that one focus should be the provision of life saving skills for doctors,nurses and CHEWS. As a result, 12 doctors and 16 nurses were trained as master trainers in December2005 and February 2006 respectively. The facilities to be used for training purposes were agreedbased on their number of deliveries. This helped to ensure that the participants would benefit fromcompetency-based training. Both public and faith-based facilities were involved in the training.50 PATHS Final Programme Report

Training of facility staff began in February 2006 with expanded life saving skills (ELSS) for medical staff,life saving skills (LSS) for nurses and midwives and modified life saving skills (MLSS) for CHEWS. Byearly 2008, 32 doctors, 178 nurses and 171 CHEWS had been trained.Initially, training participants were drawn from the six district hospitals and 56 Early Bird Clinics, allof which had by then been provided with both drugs and basic equipment. However, given that thebulk of deliveries in Enugu took place in the private/faith-based sector, staff from these facilities wereincluded in the training from 2007 onwards.“The knowledge I gained from thisprogramme is enormous. I can’t finish talkingabout it now. It has improved my skillsand knowledge, and it’s going to help meimprove the quality of health services andthe care I offer my patients”.Dr. Christian Ogbodo, Resident Doctor,Obstertics and Gyneacology Department,Parklane Specialist Hospital Enugu‘Attendance as at 2005 was like one patientin a week and in a month no delivery wasrecorded; even when recorded, it used to beone in months and no drugs to administer topatients. But now in a month we record upto six or more deliveries and more patientsnow visit the health center’Mary Egbo, health worker, Mburumbu PrimaryHealth CentreTraining TBAsGiven that TBAs are important providers of delivery care for many women in Enugu, the SMoH decidedto orient TBAs on the maternal danger signs. The idea was that this would result in earlier referral ofwomen in danger to a Comprehensive Emergency Obstetric Care (CEOC) centre.A short programme was developed to meet these needs and the orientation of TBAs commencedin September 2007. As of early 2008, approximately 165 TBAs had been oriented. One district, Udi,established a TBA network in an effort to encourage and improve dialogue with this influential groupof health providers. Over 300 TBAs had joined the network by early 2008.Provision of EquipmentIn an effort to rapidly improve EOC management, each of the State’s six district hospitals was providedwith an EOC kit in 2005. These kits were initially not used to the extent expected, but this changedsomewhat when LSS was provided. PHC facilities supported by PATHS were provided with sufficientequipment to provide basic emergency obstetric care. HMIS data indicated that there had been asubstantial increase in the number of public facility deliveries over the period 2003-2007, although thefigures need to be viewed with caution given the gross under-reporting of deliveries.“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 51

Enugu State Total Deliveries in Public Facilities, 2003 - 2007No. Live Births5,0004,5004,0003,5003,0002,5002,0001,5001,00050002003 2004 2005 2006 2007YEARS“I am recommending to friends to come herenow. Last year, I would not say the same. Butnow the conditions are not the same.”A patient awaiting care at Ozalla PHC facility2007 Data provisional (Oct - Dec being collated)Staff using the new EOC equipment52 PATHS Final Programme Report

“Before now I had nightmares as thedelivery period approached. For me it alwayshappened in the quiet hours of the night.Nurses were rarely at the centre and werenever there during those late nights. OnlyGod, grandmother, and mother came tomy rescue. We looked like an abandonedgeneration. Now that PATHS has trained ournurses and re-equipped our health centrewe come here daily for care. At the worstwe receive an initial attention before beingreferred to the big hospital.”Enugu now has six functioning CEOC centresand 56 functioning BEOC centres in the publicsector, while enhanced care is being provided ina number of faith-based hospitals.Mary Ani, a patient at a primaryhealth care facilityPublic Private Partnership -Contracting Emergency Obstetric Care ServicesPerhaps the most innovative of all the EOC work was the provison of public emergency obstetric careservices through three faith-based hospitals at public sector prices. This public-private partnershipaimed to make EOC services more accessible to those who would otherwise be forced to incur verysubstantial costs in the private sector. The rationale for the pilot scheme was the absence of a DistrictHospital in Enugu Metropolitan District. This led to an exploration of ways to use private sectorfacilities to provide the equivalent secondary care services. The Enugu Metropolitan DHB decided toconcentrate on the provision of emergency obstetric care for poorer women living in the rural partsof the metropolitan district. PATHS agreed to support the pilot by providing technical assistance andfunding the provision of services during the life of the pilot.The initial concept was that woman using the scheme would be charged the same official user feeas those attending district hospitals in other parts of the State. If, however, the cost was greater, thedifference would be made up by the DHB.The key steps for developing and managing the pilot were:• Securing the support and political backing of the Hon. Commissioner of Health;• Information gathering by the DHB through visits and meetings with key opinion formers in bothpublic and private facilities and with key SMOH and State Health Board officials;• Selection of providers for the pilot scheme following an open, transparent and objective processthat assessed potential providers against an agreed set of criteria;• Selection of referring clinics;• Setting up the mechanisms to deliver the service;• Training staff of the primary care referring centres;• Mobilising communities in order to promote the scheme;• Tracking utilisation of the scheme.“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 53

The selection process resulted in three faith-based hospitals providing care under the scheme; oneeach for the north, central and south sections of the district. Contract details were agreed and amemorandum of understanding to inform the day-to-day operation of the scheme was signed bythe respective partners. The scope of the scheme was restricted to those requiring inpatient care upto and including a 14 day period beyond delivery. Given the limited budget available for what wasthought would be a high demand scheme, robust monitoring and control mechanisms were builtinto the pilot. The referrals were initially restricted to the PATHS supported clinics located in the ruralparts of the district, which were zoned with one of the faith-based providers. The clinics were asked toexercise discretion so that women who would not normally use private or faith-based hospitals, due tocost, were given priority for referral. However, the referring clinics were later expanded given the lownumber of referrals initially.The women referred were charged a maximum of N 10,000 (approx £40) for services, regardless of theactual cost. This constituted on average about 25% of the cost. A joint committee representing theDHB, providers and PATHS was established to monitor implementation of the pilot.The pilot started in November 2006. It ceased asa pilot in December 2007 when the governmenttook over the funding of the scheme. Whilst theuptake of the scheme was initially very muchslower than anticipated, the number of womenusing the scheme increased in 2007, and by early2008 80 women had benefited.“Mother of Christ has cared for 29 womenthrough the scheme. After 12 months Iwould suggest that 50% of the women caredfor would have died had the scheme notexisted.”Consultant Obstetrician,Mother of Christ HospitalImmunisationConsiderable thought was given to what action could be undertaken by the state in order to promotean increase in the uptake of routine immunisation (the idea was that this should complement theFMOH’s supplemental immunisation campaigns).A decision was made to commission an NGO,CREASUP, to use their highly successful peerto-peerchild support approach to encourageschool children to educate their peers, parentsand communities of the need for all childrento be routinely immunised. The campaign wascentred on schools, both primary and secondary,and in the communities surrounding theEarly Bird Clinics. These were the first PATHSsupportedclinics and were selected to maximiseimpact, given the training of the EBC staff. Overthe period October 2005 to September 2006,the NGO trained 1,350 peer educators andschool facilitators who reached some 40,000secondary school children, 43,000 primaryschool children and 50,000 people across thelinked communities.CREASUP is an NGO that works withchildren to effect behaviour change. Asmall core of children who are linkedto the NGO learn about the particularrequirements of the work from seniorCREASUP staff. They become the trainersand, using drama as a learning medium,they teach other children and adults inschools or at community level about issuesaround which changes in behaviourwill help save lives (or bring about otherpositive changes at individual, householdand community level). The children arenot only highly effective, but also in highdemand.54 PATHS Final Programme Report

“The introduction of routine immunisationhas gradually reduced the belief in “Ogbanje”which was the traditional reason given forthe high infant mortality rate amongst ourpeople for many years.”Mothers waiting to have their babiesimmunised at Bishop Shanahan HospitalIgwe Kingsley ChimeIntegrated Supportive SupervisionTo ensure that positive changes among providers and at facility level could be sustained, on-goingsupervisory support was essential. Supervision needs to be supportive rather than punitive if thegreatest change is to be effected. Recognising this, PATHS worked with the various state teams todevelop and implement separate monitoring and evaluation mechanisms for many of the individualsystems strengthening and service delivery improvement activities. However, this approach provedvery costly and time-consuming on the part of the monitoring teams, and demanding on facilitystaff. In line with the other PATHS states, Enugu moved towards an Integrated Supportive Supervisionapproach.An ISS approach and tools (covering all the constituent bodies of the DHS, including facilities) wasdeveloped on a consultative basis. This was piloted in three districts in late 2007 and later rolledout to the SHB, DHBs, LHAs and all facilities. Early results from the ISS teams indicated that 50%of the facilities were moving in the right direction. Most of the facilities that scored well had beeninvolved in the systems strengthening or service delivery improvement activities. This suggests thatfacilities require some element of support from either Government or donors if they are to improve,consolidate and sustain their services.“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 55

Reduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedprimary and secondaryReduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedprimary and secondaryIncreasing Demand care facilities from Communitiescare facilitiesReduinfaincdemandprimThe early work undertaken on demand creation centred onlimited community mobilisation campaigns Developing which the District were mainlymanaged by the Districts. In addition, PATHS Health supported System theuse of the media as a means of promoting wider health-relatedbehavioural change.StrengtheningunderpinningDemand creation efforts were stepped up in systems 2006 and focusedon the Early Bird Clinics where services were reasonably wellestablished. These activities included working with:• Community Development Councils Enablingservice delivery• Communities• NGOs and CBOsPromoting improved• Staff across the SMoH, particularly service the Community delivery inMobilisation Managersthe facilities• A range of mediaIncreasing demandThe focus of the work was on Behaviour from Change communities Communication(BCC) activities and Interpersonal Communication and CounsellingSkills (IPCC).Increased patientpatronageTo maximise the impact of the activities a communicationframework was developed. This helped to ensure that demandcreation activities were designed, developed Reduced maternal and implemented and ininfant mortality andan integrated and comprehensive manner.increased consumerdemand in both publicThe following initiatives are described and in private more detail managed below:primary and secondary• Communicating through the media care facilities• Support to Community Development and Co-ordinatingCouncil (CDCC) and Community Development Committees(CDCs)• NGO and CBO mobilisation• Mass mobilisation in the Nsukka DHB• Inter-personal Communication and Counselling• Radio Distance Learning ProgrammeDeveloping the DistrictHealth SystemStrengtheningunderpinningsystemsEnablingservice deliveryPromoting improvedservice delivery inthe facilitiesIncreasing demandfrom communitiesIncreased patientpatronageReduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedprimary and secondarycare facilitiesRaapr56 PATHS Final Programme Report

Communicating Through the MediaIn 2002 the airing of two radio programmes was supported by PATHS, one relating to general healtheducation and the other a radio diary of people living with HIV/AIDS. The latter in particular provedincreasingly popular and had enabled the diarists to go public by the time it ended in 2004.It was agreed that PATHS would focus its investment on a TV series and thus “Change and Smile” wasborn. A proposal was submitted by an NGO, the Ama Dialog Foundation, in collaboration with EnuguNational Television Authority. It had an additional benefit of training local unemployed youths in TVproduction and script writing. The idea was to develop a TV series that provided a two-way channel ofcommunication between the people and the government. Initially, the programme was developed inconjunction with the other DFID-funded programmes in the state and had a multi-sectrol focus. Later,however, the programme focused entirely on health-related issues.In 2003 over 50 stakeholders, including representatives from the State ministries, NGOs, Churches,faith-based organisations and community members met to develop the content for the TV series.Fifty topics were initially proposed, out of which 26 topics were selected and their content developed.The format was based on a short play, followed by a commentary from a relevant technical expert,leading to a series of vox pops from community members. A theme tune was developed and everyprogramme concluded with the phase “keep changing, keep smiling”. The pilot programme was fieldtestedand some adjustments made, especially in the use of language. The series commenced in July2004. The feedback received from the audience through emails and text messages was very positiveand suggested that the programme was very popular. Given its apparent success a further series wascommissioned. This was supported by a radio phone-in programme.“I know that tomorrow’s topic is goingto be wonderful. I have only missed theprogramme once since I came to Enugu.God bless you people real good for yourinformation, good night.”Text message received by theproducer of Change and SmileA Local Hero Award was introduced in 2004 toencourage community participation and selfhelpcommunity improvements. The focus of theaward was ordinary men and women or groupsin society who had gone out of their way tomake a difference to their community. This awardprovided the content of two of the episodes. Itwas intended that the award money would bere-invested to benefit the community further.A first prize of N100,000 (£400) was awarded, a second of N50,000 and a third of N25,000 for therespective winning communities, and a plaque was presented to all winners. The awards werepresented at a formal ceremony and the winning communities invited. Three rounds of awards werepresented in total.Local Hero Award Selection PanelThe Ministry of HealthThe Governor’s OfficeThe Change & Smile programmeThe Anglican ChurchThe Ministry of JusticeThe CDCCThe Catholic ChurchThe Ministry of Chieftaincy Affairs“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 57

By the conclusion of the second series, it was felt that a review should be undertaken of theprogramme’s effectiveness in changing health seeking behaviour and also whether it made sense toconvert to the medium of radio. However, a prolonged delay in starting the review process resulted inthe re-airing of the second series between July and December 2007. The review took place in February2008 and at the time of writing this report the outcome was not yet known.First local hero award winner fromEtiti Obeleagu community whobuilt a Community Health Centrefor their communitySecond local heroaward winners fromUgwuoba communitywho embarked on ruralelectrification and thebuilding of a link bridgefor their communityThird local heroaward winners fromAmangwu Obuofiacommunity whobuilt a multi purposecivic centre58 PATHS Final Programme Report

Support to Community Development and Co-ordinatingCouncil (CDCC) and Community Development Committees(CDCs)The Enugu Community Development and CoordinatingCouncil (CDCC), established by theGovernor to promote development activitiesat community level, established a number ofCommunity Development Committees in 2005and 2006. PATHS capitalised on this opportunityand used the CDCs to raise awareness atcommunity level of the DHS, and to encouragecommunity members to use public facilities. Atotal of 340 autonomous communities (out of630) across the length and breadth of EnuguState participated in these awareness raisingactivities.When asked if the community hadsupported the health centre in anyway, Chief George.N. Oko replied: “Yes.The community assist by keeping thesurroundings clean and also some youthsin the community volunteer to secureequipment and drugs supplied by PATHS.They have been doing this for about twoyears now.”Chief George N. Oko, Community Leader,Emana, Amafor UgbawkaNGO and CBO MobilisationThe important role to be played by NGOs and CBOs in engaging with communities on health-relatedissues was recognised early on in the programme. Significant capacity building support was providedto NGOs and CBOs over the lifetime of the programme.NGO WARO undertaking community mobilisation training“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 59

With the advent of the DHS it was agreed that one NGO would be attached to each District andwould work consistently with that District. On the whole, this arrangement worked well and a strongrelationship was established between the NGOs and the DHAs, and between the NGOs and the CBOsthey supported.The most extensive training provided to NGOs and CBOs focused on the Better Health Kit and CBOmanual. The Better Health Kit dealt with specific common conditions, offering information and simpleremedies that facility staff could use, all targeted at contributing to the achievement of the MillenniumDevelopment Goals 4 and 5. The CBO manual outlined effective community mobilization strategies,skills and techniques.In preparation for the roll-out of these trainings, six representatives from six NGOs were selectedand trained as master trainers in Abuja. The NGO trainers came back to Enugu and trained 21 NGOrepresentatives from seven Enugu-based NGOs. These individuals became master trainers who wereresponsible for cascading the training down to CBOs and facility staff. More than 600 CBOs weretrained in the use of the CBO manual, while 372 CBOs and 124 facility staff were trained in the use ofboth the CBO manual and the Better Health Kit.Even though PATHS Enugu worked primarily with seven NGOs, another five NGOs benefited fromextensive capacity building support in the following areas: communication skills, mobilization andengagement strategies, report writing, TB/DOTS campaign strategies and IPCC. One of the maindifficulties, however, was the rapid turnover of NGO staff.Q. Have you ever heard of communitymobilizers who talk on health issues?How did you know about them?A. Yes. I got to know about them whenthey demonstrated how to preparesalt sugar solution to the villagers. Itried using it and it worked.Q. Did they teach you about Malaria?A. They did. They taught us to clear thebushes around us and to throw awayempty cans that can trap water.Igweze Ikoma Umuueze, Okoma communityEunice Ani, Umoalor communityCommunity Mobilisationefforts60 PATHS Final Programme Report

Mass Mobilization in Nsukka District Health Board (DHB)Due to the very low client turnout at Nsukka District Hospital, a major stakeholder mobilizationexercise was undertaken in August 2007. The purpose of the exercise was to pilot in Nsukka DHB thepromotion of greater cohesion in the working relationship between trained CBOs and communitieswithin the Local Health Authority. The ultimate aim was to increase patronage of the hospital. Twoworkshops were held, focused on Nsukka District Hospital. Traditional rulers, NGOs, CBOs, Officers inCharge of health facilities, DHB and LHA officials and other community representatives were invited toattend.At the end of the training, the following key decisions were made:• To uplift the status of the Nsukka District Hospital;• To increase linkages between the communities and the hospital;• To form Facility Health Committees;• To reconstitute the drug revolving fund committee; and• To renew commitment by both health workers and community members to improve the quality ofservices and patronage of the hospital.Nsukka District Hospital experienced an increase in clients from 2,065 in 2006 to 4,886 in 2007. Morethan 80% of the 2007 increase occurred after the August exercise. The challenge, however, will be tofind ways to sustain the improved relationship between communities and providers.Nsukka District Hospital Utilization,3 Months Pre & 3 Months Post Community Mobilization600No. Clients/Patients5004003002001000Apr 07 May 07 Jun 07 Sep 07 Oct 07 Nov 07MonthsAug07 was month of mobilization and therefore, not reflected“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 61

Inter-Personal Communication and Counselling (IPCC)IPCC was introduced in the state in 2005 asa tool to equip health workers with relevantskills and techniques to relate better to theirclients. Initially IPCC training was delivered bynational consultants but, in 2006, eight SMOHstaff trained as master trainers and assumedresponsibility for the training, which was coordinatedthrough a state focal person. 554providers were trained on IPCC across both thepublic and private sectors .The IPCC training curriculum includes:i) Client centred approach and customerserviceii)iii)Values clarificationInterpersonal communication and stepsin behaviour change;iv)Counselling using the “GATHER” process“Before, the people who were here were notattending to people nicely. They were nottaking good care of me. You would comeand they would not meet you or they wouldtell you that they are not on duty. Now youcan come anytime and get good care.”Patient attending Ozalla Health Clinicv) Use of role-play to demonstrate somechallenging moments in counsellingvi)Role-play using the information andactivities in the Better Health Kit onhealth issues such as Safe Motherhood,DRF, Diarrhoea, TB, and Immunizationvii) Reaching out to the community (apractical guide on community outreach)“Whenever I came here for delivery, the nurseswere always harsh and not friendly, but nowthey are more friendly and humane.”Health providers at IPCC TrainingA patient62 PATHS Final Programme Report

Radio Distant Learning Programme (DLP)The Radio Distance Learning Programme aimed to share common health knowledge withcommunities and health providers. Twenty-six episodes were prepared by PATHS Abuja and thentranslated into Igbo language locally and field-tested. Radio Nigeria FM station Enugu was contractedto air the episodes. Listening groups were established and CBOs/NGOs followed up after the episodes.A total of 62 listening groups were formed, centred on the 56 Early Bird Clinics and six DistrictHospitals. Six CBOs were selected from the local catchment communities and one member fromeach CBO would join the listening group. Two facility staff also participated, bringing the RadioDistance Learning Group membership to eight. In total, 496 individuals were involved. Prior to thecommencement of the DLP programme in Enugu, preparation was undertaken of both the contractedNGOs and a number of CBOs which were to be members of the listening groups. This includedorientation on the use of the Health Kits previously prepared for use by the Community HealthExtension Workers (CHEWs) and other PHC workers in the State.The initiative was managed and monitored by NGOs whose role was to ensure full understanding ofthe content of the programmes.The first series of the DLP began in June 2007 and 13 episodes ran until early August 2007. At the endof the first series, all 62 listening groups were assessed based on:••••attendanceknowledge acquiredcommunity mobilization activities carried outevidence of community engagementA score was allocated and those not achieving 60% were disbanded. This resulted in a reduction from62 groups to 52 for the second series. The latter started in September and ended in December 2007,after which another assessment was carried out. Of the 52 listening groups, four (8%) scored less than60% on average. The overall score for the second series was 97% compared to 90% for the first series.Facility distancelearning group“Yes, our group is very efficient. The Chairman ofour town union is one of us so he makes sure thateverybody attends every class and carries out allwe have agreed to carry out. Before we leave heretoday we will agree on what to do and we will makesure that each representative does it in four of ourcommunities.”Officer In-charge Umuabi PHC“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 63

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StrengtheningunderpinningsystemsStrengtheningunderpinningsystemsEnablingservice deliveryromoting improvedservice delivery inthe facilitiesIncreasing demandfrom communitiesEnablingservice deliveryPromoting improvedservice delivery inthe facilitiesIncreasing demandfrom communitiesSection 4:Results andImpactIncreased patientpatronageduced maternal andnfant mortality andncreased consumermand in both publicnd private managedimary and secondarycare facilitiesIncreased patientpatronageReduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedprimary and secondarycare facilities“The PATHS programme has taught usa lot of things. It taught us things wedidn’t know. Drugs are now available andnot as expensive as those sold outside,equipment has been supplied, the healthcentre has been renovated. As a result ofthese changes, we have had an increasein patient turnout.”Onovo Gloria, CHEW, Agbani Health CentreDeveloping the DistrictHealth SystemStrengtheningunderpinningsystemsEnablingservice deliveryPromoting improvedservice delivery inthe facilitiesncreasing demandfrom communitiesDeveloping the DistrictHealth SystemStrengtheningunderpinningsystemsEnablingservice deliveryPromoting improvedservice delivery inthe facilitiesIncreasing demandfrom communitiesA very great deal has been achieved over thesix-year life span of the programme, with anumber of tangible benefits already evident.The first section describes some intermediateoutputs, while the second section describesincreases in utilisation and coverage. At thisstage there is limited data on outcomes (e.g.reduced maternal and infant mortality).Increased patientpatronageIncreased patientpatronageReduced maternal andinfant mortality andincreased consumerdemand in both publicand private managedprimary and secondarycare facilitiesReduced maternaland infant mortalityand increasedconsumer demandin both publicand private managedprimary and secondarycare facilities“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 65

Intermediate Outputs1) The DHS structure has:••delegated decision making down to the level of LHAsstrengthened accountability between the LHAs and their DHBs• reduced duplication through the merging of up to eight primary care centres and cottagehospitals, where these were located on the same site• increased access to medical care, particularly primary care, through the rotation of medicalstaff across the districts• enhanced management skills of the members of the SHB, DHB and LHAs• created effective entry points for targeted action• built effective collaborative working relationships between public and private sectors• provided in-depth knowledge of service provision across the state• developed an accurate database of public and private health facilities.From an LHA quarterly review report relating to strengthened accountability:“meetings held with DHB - 3numbers of reports submitted to the DHB - 4”“ I returned to Enugu after two years to findthe District Health System idea had takenroot in the minds, language and actions ofhealth managers at State, district and locallevel to the extent that terms like ‘DistrictHealth System, objectives, goals, outputsand community participation’ had become apart of everyday language.”Nana Enyimayew,PATHS consultant from Ghana“The success story of this integration is thatwhen you want to embark on immunizationthese days, we normally reach out to theseprivate facilities, their staff will come and betrained and they partake in immunization.That makes sure that immunization coverseverywhere, including in their own facilities.”Dr. Eze, CEO, Enugu Ezike DHB66 PATHS Final Programme Report

2) 100 facilities across the public and faith-based sectors had received drugs, resulting in a numberof tangible benefits:•••••••••A significant increase in the number of patients attending the facilitiesSubstantially increased Internally Generated Revenue (IGR)Improved drug managementRe-engaged and motivated staffImproved infrastructure and more secure facilitiesImproved storage areasIncreased community engagementEstablished Facility Health/DRF CommitteesImplemented DRF/Sustainable Drug Supply Systems (SDSS)• Improved underpinning systems inboth the facilities and CMS• Improved procurement processes• Increased transparency at facility level• Reduced facility staff absenteeism• Improved inventory control• Reduced quantity of expiredmedicines“Before they used to say drugs were notavailable but now drugs are available. I’vewitnessed it. Before, only prescriptions weregiven to us to purchase drugs outside, butnow we are given the drugs here.”Patient attending a health centre3) The same 100 facilities were supplied with equipment and by early 2008 were providing access toan increased number of services including:••••••DeliveriesAntenatal careInpatient careSurgeryHIV/AIDS voluntary counselling and testingLaboratory tests4) Over 2,500 staff have undergone capacity building across an array of skills including:LSSELSSHMISISSMLSSIPCCPPRHAADRF“Trainings like Life Saving Skills, EOC,POC, IPCC have been organized for us, thehealth workers. Since then, the traininghas been helping us to achieve our aimand work together.”FMSPOCHRMPPMMrs Ann Uzoamaka Mgbo, OIC, Agbani PHCLaboratory testingEquipment usage“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 67

5) A culture of business planning and planned preventive maintenance now exists across all thedistricts.6) A series of district-based networks and teams were established for:•••••PPPTBAsPPRHAAISSPPM“We have an offshoot of the District HealthSystem which we call PPP, that is PublicPrivate Partnership and it runs across all theareas of interest in the healthcare delivery,from laboratory test to X-Ray and the rest ofthem.”“PATHS trained a group of men who wereintroduced to us and asked that wheneveranything goes wrong with the equipment,we should report to them.”CEO, DHBHealth provider talking about thenewly instigated PPM service7) Seven NGOs and approximately 600 CBOs underwent extensive training in communitymobilisation and creating demand for health services.“The make up of the [CBOs] are membersof the community. They go back, sensitizethe people, tell them about the changesand encourage them to start attending theHealth Centre….. when [the health facility]has a problem that could be solved by thecommunity, they go back and tell themwhat the problem of the health centre is.”Officer In-charge, PHC Facility“There is abundant improvement in theservices provided here. Before when youcame here, there were no drugs and nolaboratory for testing. But from a few yearsago, they said some people make drugsavailable here and now you can obtainprescribed drugs and at cheap rates and thenurses sent here are OK for their profession.Also, attendance here has improved….because of their services. There is no delayand the midwives are doing fine.”A patient attending a clinic8) By early 2008 there were many stakeholders, especially at mid-management level, who coulddrive the health needs of the state.“Having been trained by PATHS in the Drug Revolving Fund, financial management systems,budgeting processes and PPRHAA I am now very thrilled that I have lead responsibility on behalfof the State Health Board for the training of other staff across the State in all areas of financialmanagement. I would very much like to see myself continuing in this role after PATHS completes.”Mrs Amoge Ani, Principal Accountant to the Enugu State Health Board68 PATHS Final Programme Report

Trends in Utilisation and CoverageThere was a steady increase in routine immunisation rates (apart from BCG, due to supply deficits inboth 2006 and 2007 3 ).Enugu State Sentinel Sites Utilization, 2003 - 2007Enugu State Sentinel Sites Utilization, 2003 - 200760,000PHCs SHCs60,000PHCs SHCs50,00050,00040,00040,00030,00030,00020,00020,00010,00010,00002003 2004 2005 2006 200702003 2004 Years2005 2006 2007YearsAll of the above resulted in a dramatic increase in patient attendance.Enugu State District Hospitals Utilization, 2003 - 2007Enugu State District Hospitals Utilization, 2003 - 2007No. Clients/PatientsNo. Clients / Patients12,00012,00010,00010,0008,0008,0006,0006,0004,0004,000No. Clients/PatientsNo. Clients / Patients2,0002,0000Agbani DH Awgu DH Enugu Ezike DH Nsukka DH Isi Uzo DH Udi DH0Agbani DH Awgu DH Enugu District Ezike DH Hospitals Nsukka DH Isi Uzo DH Udi DHDistrict HospitalsThe graph above shows that all four hospitalsfully supported by PATHS (Agbani, Enugu Ezike,Nsukka, Udi) showed an increase in attendance.Awgu Hospital showed a decline in patientattendance between 2005-2007. Althoughthis facility was originally among those to besupported by PATHS, for various reasons thisdid not happen. PATHS did not support Isi UzoDistrict Hospital. The rise in patient attendanceat this facility was due to the fact that a youthcorper doctor was posted to this facility, thusattracting patients.2003200420032005200420062005200720062007“Before they started, patient attendance ina month was about 30 persons, but we didour roll-out last year in April and since thenwe’ve been having about 200-300 patientsin a month. Presently, we have about 380patients in attendance every month.”Facility Officer In-charge3 This was a nationwide problem“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 69

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Section 5:ChallengesWhilst there were some very positivechanges in the functioning of the healthsystem and in the delivery of services,many challenges remain.1) By early 2008 the State Government was not yet supporting regular monthly releases so that theconstituent bodies of the District Health System could run their respective services. Apart froma six month period between September 2006 and March 2007, a very significant funding gapremained an issue. This had four main effects:••Constrained the process of bringing health services up to a basic level of provisionHampered the efforts of the Boards and Authorities in implementing the DHS• Negatively affected the enthusiasm and drive of those individuals who were committed tochange• Provide an excuse for individuals who were resistant to the health reform efforts to not doanything.2) Building the capacity of many staff to absorb and respond to the change brought about by farreachinghealth reform can be problematic. This was particularly the case for those individualswho had been appointed to posts through patronage rather than ability.3) Resistance to the reform process by those who saw themselves as the “losers” in terms of theirprevious responsibilities and their revised roles, particularly those in the most senior positions,was a reality.“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 71

4) The tendency for politicians to divert efforts away from identified needs in order to achievepolitical imperatives consistently deprived patients and communities of their right to accessible,affordability and acceptable health services.5) The timeframe of the programme did not allow sufficient time for the radical changes that weresupported to become sufficiently embedded.6) By early 2008 the leadership skills and political will to sustain the ongoing health reformsremained fragile.72 PATHS Final Programme Report

Lessons LearntMany lessons have been learnt from all the initiatives. The points below highlight some of the keyprinciples that need to be considered for effective implementation and outcomes.•••••••Before engagement in major health reform initiatives, overt state government commitmentshould be demonstrated and evident (e.g. through MOUs).The building of capacity often starts from a low base, thus is a lengthy and sustained process.Ongoing monitoring, supervision and support are essential if quality standards are to be achievedand sustained in resource poor environments.It is important to acknowledge all the challenges (technical, institutional, political) to effectiveservice delivery, and analyse which of these can be won, and which cannot. In the latter case, itmay still be possible to adopt a management strategy that allows for some gains.Political interests are enormously influential and need to be taken into account when planningprogrammes of work.Bringing donors together in a cohesive and collaborative forum can be highly beneficial and costeffective.The interest of, and engagement from, most stakeholders has a strong pecuniary influence.Concluding CommentsDespite the many challenges faced by the PATHS programme there is little doubt by those whohave come into contact with it, both clients and stakeholders, that it is held in high regard and has areputation for achievement.However none of this could have happened without the very considerable commitment and inputfrom an enormous number of people including government employees, private sectors employees,NGOs, CBOs and communities.Eternal thanks go to them all for making the programme in Enugu what it is today, a well known,popular and highly respected programme.“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 73

Abbreviations and AcronymsANCBCCBEOCCBOCDCCDCCCDPCEOCEOCCHEWCMSCSNDFIDDHBDHSDRFELSSEOCFMSGLRAHCPHMBHMISHRMAnte Natal CareBehavioural Change CommunicationBasic Emergency Obstetric CareCommunity Based OrganisationCommunity Development CouncilCommunity Development Co-ordinating CommitteeCommunity Diagnostic ProgrammeChief Executive OfficerComprehensive Emergency Obstetric CareCommunity Health Extension WorkerCentral Medical StoresCatholic Secretariat of NigeriaDepartment for International DevelopmentDistrict Health BoardDistrict Health SystemDrug Revolving FundExpanded Life Saving SkillsEmergency Obstetric CareFinancial Management SystemGerman Leprosy Relief AssociationHealth Commodities Procurement ProjectHospital Management BoardHealth Management Information SystemHuman Resource Management74 PATHS Final Programme Report

IGRIMPACTIPCCISSLHALSSMLSSMSPNGOOICPDPDPHCPOCPPMPPPPPRHAARDTsSDSSSHBSHCSMoHSNRSOPsTBATBLInternally Generated RevenueImproving Management through Participatory Appraisal and Continuous TransformationInterpersonal Communication and CounsellingIntegrated Supportive SupervisionLocal Health AuthorityLife Saving SkillsModified Life Saving SkillsMinimum Service PackageNon Government OrganisationOfficer In-chargePolicy Development and Planning DirectoratePrimary Health CarePackages of CarePlanned Preventive MaintenancePublic Private PartnershipPeer and Participatory Rapid Health Appraisal for ActionRapid Diagnostic TestsSustainable Drug Supply SystemState Health BoardSecondary Health CareState Ministry of HealthStrengthening Nigeria’s Response to HIV/AIDSStandard Operating ProceduresTraditional Birth AttendantTuberculosis and Leprosy“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 75

AcknowledgementsThe PATHS programme is grateful to the following for their assistance during the lifetime of theprogramme:Name Designation OrganisationDr. Simon Idike Commissioner for Health SMoHDr. F.S.A Uzor Commissioner for Health SMoHDr. Martin. Chukwunweike Commissioner for Health SMoHMr. J. Okoro Permanent Secretary SMoHMr. G.C. Asuke Permanent Secretary SMoHSir Sam Umesie Permanent Secretary SMoHDr, Mrs B. Orji- Chukwu Permanent Secretary SMoHMr. C.J.Nnamani Permanent Secretary SMoHMrs. C.E Okenwa Permanent Secretary SMoHStaff of the PolicyDevelopment and PlanningDirectorateMembers and staff of theState Health BoardMembers of the 7 DistrictHealth BoardsMembers of the 56 LocalHealth AuthoritiesStaff of the participatingPrimary and Secondary carefacilitiesSister Jane Francis and herstaffAdministratorSMoHSMoHSMoHLGAsSMoHAnnunciation SpecialistHospitalSr Mary Francis Anaduaka Administrator Mother of Christ SpecialistHospital76 PATHS Final Programme Report

Mr Akujeze Administrator Good Shepherd SpecialistHospitalAll other participating faithbased hospitalsWACOLWAROCREASUPGHARFA-CODECIRDDOCYOUTHYORDEL AfricaVOICDEFNAWOJWINETCBOsCatholic Dioceses of EnuguNsukka and AwguNGONGONGONGONGONGONGONGONGONGONGOAcross Enugu stateDr Edwin Nwobodo Lead national consultant PATHSMartins OnyiaLead officer for PPRHAA andDRFPDPDDorothy Aguosuo Lead officer for HMIS PDPDChrisitian Eze HMIS team member PDPDWinnie Onodu Leader officer for MCH PDPDWinnie Mgbodile Leader officer for IPCC PDPDMembers of the DRF teamsMembers of the PPRHAAteamsMembers of the ISS teamsMembers of the budgetgroupMembers of the FMS teamsSMoHSMoHSMoHSMoHSMoH and private sector“Togetherness in Health” the Enugu Experience in Health Sector Reform, 2002-2008 77

Master trainersSMoH/faith based sector17 LGA M&E officers LGAsMrs. M. Lan Administrator Catholic Secretariat of NigeriaInternational, regional andnational consultantsUK, Ghana, South Africa,Mozambique, USA, NigeriaPATHS78 PATHS Final Programme Report

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