Rational

Primary Health Care delivery is a core contribution to NSHDP implementation.

Over 90% of inputs in the Health services delivery and Human resources for health SDAs of NHSDP(Leadership & Governance, Health financing, NHIS, Community participation & Ownership, Partnership for health, Research for health).

In order to improve participation and ownership by the service delivery points , the PHC reviews should focus on the operational unit which is the LGAs.
NHSDP Costing Analysis, 2010

Challenges of NHSDP operational planning

The 2011 State Operational Plans were not consistent with the level of ambition of the SSHDPs, costed activities were mainly based on lower level inputs and that budgets are not consistent with the NHSDP allocation criteria. More funding still allocated for clinical services and capital costs. The 2011 Operational Plans showed no prioritization to focus on Primary Health Care as the anchor of Service Delivery and Human Resources for health and there was no link of the planning process and actual budget allocation. There was no logical framework for reviewing the data inputs and linkages with the on-going work on developing the M&E Framework for results-based monitoring. There are multiple systems for data collection and reporting that are unrelated leading to duplication with no feedback to the Service Delivery Points (States and LGAs). Despite several processes that have been put in place including 1) incorporating the ATM indicators into HMIS and the 2) development of the Integration and Decentralisation Guidelines; Programs and Partners still collect and manage their own M&E systems. There is no current system to develop capacity for the LGAs to fully own and implement PHC programs. There was no systematic process for quantifying the bottlenecks and no outline for assigning roles and responsibilities in managing the identified corrective actions.

Process of PHC Review

Harmonize indicators, collect and validate existing data from different sources (Progs + NHMIS) in order to inform PHC reviews. Use PHCs reviews to identify, remove & follow up bottlenecks to improve service delivery. Develop LGA PHC action plans to address bottlenecks through coordinated actions of all stakeholders. Support development of LGA annual Operational plans that derives from and contributes to the SSHDPs. Provide feedback to inform State and Federal planning and review.
D.I.V.A methodology for PHCUOR

Framework

Improved Health Plan Results

Conduct PHC Reviews

Using DIVA methodology

Implement PHCUOR and Minimum Standards

The 4 steps of DIVA

Identify disparities and analyze barriers to access of services (Diagnose) Prioritize and implement solutions to overcome identified barriers (Intervene) In real-time, monitor progress in reducing barriers (Verify) Adjust solutions and strategies during implementation as needed (Adjust)

What is D-I-V-A?
A systematic, flexible, outcome-based approach to equitable programming and realtime monitoring that strengthens the ward health system, complementing and building on what exists.

Prioritization of interventions
Main causes of morbidity and mortality identified and linked to poverty. Core package of intervention determined by service delivery point.
Clinical , Population based and Community/Households.

Coverage of interventions varies by state and LGAs. Need for context specificity in planning.

Increasing No. of Interventions and Skilled Staff

Malaria VPD Diarrhea etc Maternal Newborn Child Health etc

Burden of Disease

Hypertension Cancer etc Cancer etc

Increasing Resources Required

Major Causes of U-5 Deaths in Nigeria

Other, 10% Injuries, 3% HIV/AIDs, 3% Measles, 4% Neonatal, 37%

Up to 1 million children die before the age of five.

Malaria, 8%
Under-nutrition (underlying cause)

Diarrhea, 17% Pneumonia, 19%

50% underlying cause is under nutrition.

36% are neonatal deaths (284,000).

Examples of using a Bottleneck Analysis

Equity & Impact : High Burden diseases in Q1 have known, very effective, low cost interventions
(Under Five Mortality Rate per 1000 Live Births)
Others
21.6 4.9 36.7

250

Injuries AIDS
Pneumonia

200

150

6.6

Measles
56.3

100
50 8.8 1.6 13.9 1.6 22.1 11 40.7 26.9

Malaria

Diarrhea
Neonatal

50

0 Nigeria: Nigeria Q1 Nigeria: Nigeria Q5 (richest)

8 Tracer Interventions for PHC Reviews

Defined National priority Tracer interventions 1. PMTCT and ARV prophylaxis 2. Immunization 3. Childhood Illnesses Malaria 4. Ante Natal Care 5. Skilled Birth Attendance & Community based New Born Care 6. Infant and Young Child Feeding 7. Vitamin A Supplementation 8. Community Management of Acute malnutrition Identify the most deprived LGAs Adapt to the existing health system and ongoing processes

D-I-V-A approach: scope and applicability

Health

Health System
WASH

HIV/ AIDS

Nutrition

BOTTLENECK ANALYSIS CONCEPT

 A health system bottleneck can be defined as a constraint, problem, barrier that hinders the health performance A bottleneck is a loss of system efficiency

Using a bottleneck analysis to investigate low coverage

There are many interventions that are known to be effective at reducing maternal and child mortality Most of these interventions are already included in Nigeria National HSDP These interventions do not always reach the people that need them most, due to bottlenecks within the health system Resolving problems causing bottlenecks requires both evidence-based interventions AND evidencebased strategies at federal, State and LGA levels
16

Introduction to Bottleneck Analysis

Tanahashi: a bottleneck constrains the flow of resources through a health system, limiting the output; i.e. coverage of an intervention

Multiple interventions

Introduction to Bottleneck Analysis

Bottleneck analysis is a horizontal approach

Nutrition HIV EPI Family WASH Planning TB Social services

Community based services (Family oriented )

Population oriented outreach services

Facility-Based services

Effective Quality coverage for specific target populations

18

Introduction to Bottleneck Analysis

Six coverage determinants, from supply to demand side, analyze where health system bottlenecks exist. A bottleneck is a loss of system efficiency
Effective coverage quality/impact Adequate coverage continuity/completion Initial utilization first contact of multi-contact services Accessibility physical access of services Availability human resources Availability essential health commodities
Target Population
Adapted from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2) http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf
19

Introduction to Bottleneck Analysis

We look for bottlenecks between the determinants of coverage

Determinants are major health system functions that DETERMINE the level of coverage possible for an intervention. Supply-side determinants:
1. Availability of essential commodities. 2. Availability of human resources. 3. Geographical accessibility.

Demand-side determinants:
4. Initial use: the first contact 5. Adequate and complete use 6. Effective, or Quality, Coverage that gets IMPACT
20

Introduction to Bottleneck Analysis

The Tanahashi Model to assess system bottlenecks

Nigeria application 2006

100%
90% 80% 70%

GAP

Target Population

60% 50% 40% 30%

20% 10% 0%
% District with LLITN's or nets + insecticide in stock % villages with HR providing LLITNs % villages selling or distribution LLITN or nets + insecticide % households having at least one bed net % pregnant women using MN last night % pregnant women using ITMN

Adapted by T. OConnell from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2) http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf

21

Introduction to Bottleneck Analysis

Coverage Determinants and Bottlenecks: improving coverage of Quality treatment of ARI

Clinical management of U5 pneumonia
100% 75% 50% 25% 0%
COMMODITIES: % HUMAN RES: % health facilities PHC facilities with with no Essential sufficient Meds stock-out professionals ACCESS: % UTILISATION: % 0- CONTINUITY: % 0- EFFECTIVE COV: % families living 59 mos 59 mos ARI/fever 0-59 mos. ARI and near health w/pneumonia cases Tx fever cases facility with taken to trained w/antibiotics by treated by IMCIsufficient staff provider trained worker trained worker
22

Introduction to Bottleneck Analysis

70%

60%

50%

40%

Availability of the correct human resources

1 Bottleneck is too few access points for CHWs w/antibiotics

Too much $$ (so Moms save antibiotics for next time); thus quality is low

Points of access/distribution

Commodities

30%

Initial use of product or service

20%

Continuous use of product or service

10%

A 2nd major bottleneck is QUALITY: few children finish antibiotic course

0%

QUALITY Child given antibiotics Child completes full antibiotic treatment < 24 23 hrs

Stock of antibiotics in district

# of fully trained VHTs vs. national target

% villages with complete VHT

Child with ARI seen by VHT

Introduction to Bottleneck Analysis

Identify bottlenecks in the Tracer Interventions

Identify the main supply, demand, and quality bottlenecks
And we do not have enough people to give them out!

We do not have enough bednets!

100%
Example: Removing coverage bottlenecks to scale up ITNs

And few people are sleeping under them!

And they are not treated: we are not getting IMPACT!!!

75%
50% 25% 0% ITN in district HEWs Families Using net with Net Using treated net

36% 20% 16% 4% 1%

Introduction to Bottleneck Analysis

Corrective measures identified

Procured >200,000 ITN 100% Trained and deployed HEWs in the LGAs 80% 75%
Example: Removing 50% coverage bottlenecks to scale up ITNs 25%

Behavioral change communication campaign 75% 72%

Policy decision: long lasting ITN

80%

65%

36% 20% 16% 4% 1%

Using treated net

2007 2005

0%
ITN in district HEWs Families with Net Using net

Introduction to Bottleneck Analysis

Example: PMTCT Bottleneck Analysis Nigeria

GAP
100 % 90 % 80 %

83 %

Target Population

70 % 60 % 50 % 40 % 30 %

33 %

33 % 25 %

20 %
10 % 0% Commodity Human Resources Geographical Access Utilization Continuity Quality

6%

26

PMTCT (Ikeja, Lagos)

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Corrective Action: Train staff from other facilities Plausible Cause: Trained staff concentrated in model facilities Bottleneck 1: Only 4 out of 10 facilities provide CT

Corrective Action: Increase social mobilization/ social marketing

Plausible Cause: Lack of awareness of available services and benefits of ANC

Bottleneck 2: Pregnant W. not attending ANC

Proportion of ANC Number of HF staff centers without trained for PMTCT stock out of HIV test kits over the last 3 months

% of HFs that provide ANC services with HIV counselling and testing in PMTCT

% of pregnant women who know their HIV status

% of pregnant women who received ARVs to reduce MTCT

% of infants born to HIV+ women receiving ARV prophylaxy to reduce MTCT

IPTp in Makurdi PHC, Benue State

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Corrective Action: Advocacy with State and partners to release funds for training Plausible Cause: No recent training in 2011. Small # trained due to $. Corrective Action: Provision of transportation OR stipend for transportation Plausible Cause: Distance/financial barrier. (+ Underreporting). Bottleneck 2: Apparent dropout

Bottleneck 2: Insufficient trained staff

% of HFs without % of ANC % of HFs stock out of SP in providers trained providing ANC the last 3 months on prevention of Malaria in Pregnancy

% of pregnant women who received IPT1

% of pregnant % of pregnant women who women who received IPT2 received IPT2 in during the last 3rd trimester birth

Analyze the bottlenecks and their possible causes

Carried out by the existing Committees State /LGAs with key stakeholders (including private sector, civil society and community representatives) in collaboration with regional/provincial health officers/supervisors
Includes these steps: 1. Analyze the root causes of identified bottlenecks (Causality Analysis) 2. Identify and prioritize context-specific and equity focused solutions 3. Validate findings and recommended solutions through a stakeholder consultation

Analyze root causes

a. Supply side causality analysis
Type of bottleneck Common bottlenecks Lack of OR insufficient availability Causes of common bottlenecks Lack of established positions Ineffective recruitment Ineffective deployment High vacancy rates and turn over High absenteeism Lack of staff training opportunities Lack of mentoring and supervision Insufficient, inequitable, untimely salaries Lack of performance-based incentives Disruptive working environment Lack of physical facilities and/or equipment Facilities are not functional Ineffective planning Infective implementation Community health workers are not carrying out designated activities Financial barriers (direct costs, indirect costs and insufficient social protection mechanisms)

Availability of human resources

Lack of OR Insufficient skills Lack of OR Insufficient motivation

Geographic accessibility

Lack of OR Insufficient health facilities Lack of OR Insufficient outreach sessions (not done, not of sufficient scope and/or quality) Lack of OR Insufficient community coverage (CHWs)

Analyze root causes:

b. Demand side causality analysis
Type of bottleneck Common bottlenecks Financial barriers Causes of common bottlenecks Family cannot afford to pay user fees or to travel long distances to facilities

Socio-cultural barriers and gender dynamics Initial utilization Belief that illness is caused by factors that cannot be addressed at health facility (e.g witchcraft)

Mothers must obtain permission from others in household prior to seeking care Social norms are not supportive to specific interventions Limited information (for example on childhood illness danger signs) available to families in deprived settings

Loss to follow-up/drop-outs Timely, continued utilisation

Lack of active follow up systems Negative experience with provider/facility

Analyze root causes:

b. Quality causality analysis
Type of Common bottleneck bottlenecks Low quality Timeliness Completeness Appropriateness Causes of common bottlenecks Regular standards: not developed, not approved, and not used Inadequate staffing and skills in quality of care Service organization: overload, inadequate equipment and supply

Initial utilization

Identification of corrective measures

Carried out by existing Committees State /LGAs with key stakeholders (including private sector, civil society and community representatives) in collaboration with regional/provincial health officers/supervisors
Includes these steps: 1. Identify and prioritize context-specific and equity focused solutions 2. Validate findings and recommended solutions through a stakeholder consultation

Summarize bottlenecks, solutions and strategies

INTERVENTION:.
Quarter/Year: Determinant Baseline Main Plausible Causes Proposed Solutions / Indicator? as of: Bneck? (indicate if further _______ (mark investigation required) X) Responsible person & partners involved Timeframe Target as of: _________

Conclusion
The PHC Reviews will contribute to the successful implementation of the National Health Plan and the achievement of results in line with health-related MDGs. Collective action and responsibilities are required from the Federal, State and LGAs levels for improving the delivery of services for children, women and other vulnerable populations. Partners and Donors will require to fully buy-in and contribute to the PHC Reviews. Government leadership and ownership is cardinal.