Primary Health Care

One of the key principles guiding the PRRINN-MNCH programme is collaboration. It is important to collaborate and align activities with states and local governments. To this end, PRRINN-MNCH has supported states and Local Government Areas (LGAs) to carry out strategic and operational planning. We then align these plans with programme plans to harmonise activities and to promote efficiency. In the states and at national level, PRRINN-MNCH promotes donor harmonisation. We have established state level committees to speed this up. However, collaboration goes beyond development partners and government bodies. The PRRINN-MNCH programme engages regularly with traditional and religious leaders to ensure that their voices are heard and taken into account in developing and implementing plans. Similarly, we involve community structures in a wide variety of programme activities so that issues regarding barriers to accessing services are understood and addressed. Other programmes

• PATHS 2 (Partnership for Transforming Health Systems Phase II)
• SuNMaP (Support to Nigeria Malaria Program)
• SAVI (State Accountability and Voice Initiative)
• ESSPIN (Education Sector Support Programme in Nigeria)
• SPARC (State Partnership for Accountability Responsiveness and Capability)
• SRIK (Support to Routine Immunization in Kano)
• MAPS (Malaria Action Program for States)

Governments, ministries and parastatals

• Jigawa State
• Katsina State
• Yobe State
• Zamfara State
• Federal Ministry of Health (FMOH)
• Federal Ministry of National Planning
• National Primary Health Care Development Agency of Nigeria (NPHCDA)
• National Health Insurance Scheme (NHIS)

Research and academic institutions

• Indepth Network, Ghana
• Navrongo Health Research Center, Ghana
• Mailman School of Public Health (MSPH), Columbia University, USA
• Ahmadu Bello University (ABU) Zaria, Nigeria
• University of Maiduguri, Borno, Nigeria
• Department of Community Medicine, Bayero University, Kano, Nigeria

We are tracking seven key areas or outputs in 2012 -2013. Each of these is highlighted below: Output 1 – Governance Output 2 – Human Resources (HR) Output 3 – Systems and services Output 4 – Operations Research (OR) Output 5 – Information management Output 6 – Communication and demand Output 7 – Federal level Output 1 - Governance: Government commitment and resources are essential for sustainable delivery of maternal, newborn and child health (MNCH) services at all levels of government. “Bringing PHC under one roof”: At state level, particularly in Zamfara and Yobe, the programme will support four areas – strengthening the capacity of the new Boards; restructuring systems, especially finance and human resources; placing services and systems under the new structures; and repositioning of all bodies to their new roles and responsibilities. At federal level, following the acceptance of “Bringing PHC under one roof” as policy, we will work with other stakeholders to ensure rollout. Minimum service package MSP (MSP) / free Maternal, Newborn and Child Health (MNCH) care: The model for costing MSP and free MNCH services, developed in 2011, will be packaged for use at state and federal levels. High level meetings will be held to showcase the tool. It is hoped that this will lead to wider acceptance and use as a tool to develop a service delivery or investment plan. In addition, we will continue to track progress with the free NHIS schemes. Advocacy:  The revised approach will see greater emphasis resting at state level and with the state teams. Progress in key advocacy areas will be monitored. Pooled funds: Experience with the Gunduma pool fund in Jigawa and the PHC fund in Zamfara will be documented and shared as models that can be used elsewhere in Nigeria. Planning, budgeting and performance reviews: a major focus will be on linking these three activities and ensuring that state Ministries regularly review progress against agreed plans. Collaborating with SPARC and SAVI: Two of the DFID lead programmes (State Partnership for Accountability, Responsiveness and Capability and the State Accountability and Voice Initiative) have arrived to strengthen governance related activities in Katsina, Yobe and Zamfara.   Output 2 – Human Resources (HR) Human resources for health (HRH) are at the core of successful PHC services and in the states the mix and distribution is affected by politics. It is hoped that the arrival of SAVI and SPARC will strengthen activities in this output. Continue to strengthen HRH committees: This is a key activity to ensure that these committees function optimally . Health Resource Information System (HRIS):  The target is to ensure reliable and up to date HRH information available on staff distribution and skill mix in target facilities in Clusters 1, 2 and 3 so as to allow HR managers and committees information for advocacy and management purposes. Support to new SPHCDA Boards: The purpose will be to strengthen the HR components within these new structures for optimal and efficient management of HR resources. Training school accreditation: we will advocate for and assist the training schools to get accreditation.   Output 3 – Systems and services High quality MNCH services need a strong underlying system that provides the necessary drugs, transportation, equipment and supervision. The cluster approach is firmly entrenched and 2012 will see rollout into clusters 3,4 and 5. Maternal, newborn and child health care Midwives service scheme (MSS): support for this in 2012 will include developing and implementing a retention strategy, induction in clusters 4&5, training and supportive supervision and documentation of lessons learnt. Emergency obstetric care (EOC): ongoing LSS training in old and new clusters, evaluation of impact and strengthening the referral system. Quality improvement (QI): building QI teams at state and facility levels, supporting maternal and perinatal death reviews, exploring QI initiatives through performance based financing (PBF). Maternal: ongoing support for training and commodity supply for focused antenatal care (FANC), postnatal care (PNC) and family planning (FP). Newborn and child: supporting the community based service delivery (CBSD) initiative, kangaroo mother care, integrated management of childhood illnesses (IMCI) training and general child health services. Immunisation: supporting the new vaccine initiative (Penta and MenAfric), seizing all opportunities to strengthen routine immunisation (RI) services including integrating RI with MNCH services and the polio eradication initiative (PEI), and minimising missed opportunities for RI. Systems Sustainable Drug Supply Systems: rolling out to clusters 2,3&4, strengthening the central medical store (CMS) and the facility health committees (FHCs) to play an oversight role, support CBSD schemes and integrate free health care and SDSS. Rehabilitation, equipment and transport: continue to support roll out all the way to cluster 6. Integrated supportive supervision (ISS): key focus is to institutionalise the ISS system and link this to the performance review system.   Output 4 – Operations Research (OR) Through operational research, PRRINN-MNCH aims to transform maternal, newborn and child health in Northern Nigeria by establishing an organisational home and institutionalising evidence-based approaches to improving health policy, decision-making and programming. Dissemination of findings: advocacy to translate research findings into policy, plans and practice. Expand pilots: cross output collaboration to expand and rollout pilots – namely PBF, CBSD and the emergency transport scheme (ETS). Institutional strengthening: training of OR governance institutions and preparing the Health Demographic  Surveillance System (HDSS) site for registration with the InDepth Network and state Ministry of Health management.   Output 5 – Information Management Knowledge management is high on PRRINN-MNCH’s agenda: improved data collection systems, innovative information technological methods, and improved data quality can strengthen the management of a health care system and can be used to document and disseminate learning and successes. Routine Health Management Information System (HMIS): continue to strengthen the routine system with an increasing emphasis on data quality and use of data. Knowledge management: this is the year for the programme to capture and record all the important initiatives and innovations across the seven outputs. Monitoring and evaluation (M&E): continue to strengthen the system and document the impact on programme functioning.   Output 6 – Communication and Demand PRRINN-MNCH’s community engagement strategy is built on a thorough understanding of the barriers of awareness, access, acceptability and affordability that prevent people from using MNCH and RI services. By working with communities, the programme can build demand and use of services and improve health outcomes. Community engagement (CE): roll out model to clusters 4,5&6; institutionalise the model through engagement with SPHCDA Boards, Islamiyya schools, the national union of road transport workers (NURTW) and through developing guidelines and strengthening LGA demand creation teams. Community based service delivery (CBSD): rollout the model, train the community health extension workers (CHEWs), strengthen the safe spaces (SS) programme and revise manuals and tools. Communication: review health promotion policies and provide training; produce and disseminate various communication materials; work closely with religious leaders.   Output 7 – Federal Level Ongoing efforts at federal level will strengthen the links between what is happening at state level and the need to get this information into federal level discussions and policy. “Bringing PHC under one roof”: collaborate with other partners to ensure effective rollout of the policy and the implementation guidelines. Peer and Participatory Rapid Health Appraisal for Action (PPRHAA): package and share this approach at federal level to ensure wider adoption. Advocacy: strengthen Health Reform Foundation of Nigeria (HERFON’s) advocacy capacity and assist in the development of regulations for the health bill. Immunisation: use all opportunities to strengthen RI; strengthen the cold chain; follow up on recommendations from the PEI study and the effective vaccine management (EVM) assessment. Midwives service scheme (MSS): continue with support for training and reviews; introduce the maternal death review approach piloted by our programme. Leveraging extra resources: continue with support for the Global Alliance for Vaccines Initiative (GAVI) fund, support the Millennium Development Goal (MDG) fund review process and continue tracking the National Health Insurance Scheme (NHIS).

The key principles adopted by our PRRINN-MNCH team in strengthening both the demand and supply side of maternal, newborn and child health services include:

• Collaboration with all stakeholders; from political leaders through to key government managers and service providers at all levels (federal, state and local government) and inclusive of communities and community leaders (religious and traditional)
• Sharing our expertise and experience developed in Nigeria, in Africa and in the broader world - so as to expose all stakeholders to current issues and challenges applicable to the Northern Nigerian situation
• Evidence-based decision making through rigorously testing new ideas in the Learning Local Government Areas (LLGAs), and exposing leaders, health workers and communities to these outcomes
• Challenging and provoking stakeholders to think differently and to adopt new ways of addressing old problems
• Aligning our resources (financial and technical) with those of our stakeholders to ensure synergy, efficiency and effectiveness
• Empowering team members and stakeholders to ensure sustainability during and after the programme.

The aims of the programme are to help each state achieve the following:

• Good care for maternity emergencies and fewer maternal deaths
• 50% more women receiving antenatal care, with many more deliveries by skilled birth attendants
• 60% of infants under 1 year fully immunized, so there is 80% less measles
• Numerous health centres rehabilitated and working well, serving 50% more women and children
• More trained health staff at health centres and hospitals
• Greatly increased Nigerian and outside funding for primary health care - effectively used and controlled
• Strong, integrated management of primary health care services – from state level down to grass-roots
• Greater accountability and responsiveness to patients and communities
• Effective collaboration between key state ministries, agencies and donors in health sector reforms
• Practical and concrete federal support for primary health care
• World-class operational research by Northern Nigerians, finding solutions for prioritised local problems.

PRRINN-MNCH is a Maternal, Newborn and Child Health (MNCH) and routine immunization programme as well as a Primary Health Care (PHC) programme. MNCH: Our programme’s focus is on MNCH services through developing Comprehensive Emergency Obstetric Care (CEOC) clusters serving around 500,000 people. However, this entails much more than immediate service needs. Systems that directly impact on these MNCH services - such as drug supply, transport management and infrastructure maintenance systems – need reinforcing. Routine immunization: Routine immunization is often an entry point into primary health care. However, in the PRRINN-MNCH states, routine immunization coverage is low, indicating a lack of access to PHC services. The programme is working with all stakeholders at all levels to ensure that routine immunization services are available and that vaccines arrive safely, on time, to the people that need them. PHC: Stakeholders, development partners and the programme team all realise that to strengthen MNCH services it is necessary to address PHC services as a whole. Many Nigerians acknowledge that PHC services (largely run by local government) are the weak link in the health chain. Thus, for sustainable outcomes, it is important to strengthen supply-side services within the broader context and not in isolation. Therefore, the remit of the programme is also:

• to engage with the governance aspects that affect how the MNCH services are organised and resourced
• to understand and influence how human resources are managed
• to work on demand side aspects to ensure that services become more accessible and of a higher quality
• to strengthen the information services so that plans and decisions can be evidence-based.

(See the case studies page for explanation of above terms.) Underpinning this is an operational research agenda that will pilot appropriate approaches in Learning Local Government Areas (LLGAs) and roll out success across the states. The brief of the in-country team and the consortium partners is to work closely with all stakeholders to ensure that the work of the PRRINN-MNCH programme is closely aligned and supports stakeholder plans and activities.

PRRINN-MNCH is managed by a national management team based in Kano, along with the four State Team Managers. The national team is best placed to listen to the needs of national level stakeholders and to develop with them approaches to programme challenges that are culturally sensitive and context specific. Our United Kingdom programme office provides contractual support. The Programme Management Board offers internal governance and oversight. Senior Technical Advisers provide extra technical support.

Programme Management Board (PMB)

The Programme Management Board provides support to the in-country management team and oversees internal governance of the programme. Bryan Haddon is a health systems management analyst who specialises in the management, planning, appraisal and reform of the health sector. He has over 30 years experience in the sector and in the past decade has worked in Ghana, Malawi, Nigeria, South Africa and Tanzania. He is Executive Chairman of Health Partners International and was part of the Management Board and a Senior Technical Adviser for the Partnership for Transforming Health Systems (PATHS), Nigeria (2002-2008). Susan Grant is a specialist in humanitarian best practice interventions in the context of relief and development. Over the past two decades she has overseen change management processes, supervised multi-donor programmes and led processes of change management in different countries, in situations of emergency, transition and development. She has worked as Country Director for Save the Children in Liberia, and currently works in this role in Nigeria. Ike Osakwe is a chartered accountant with over 25 years experience in financial management, organisational systems reviews, strategic and corporate planning, and accounting systems development. He is Managing Director of GRID Consulting, Nigeria. His experience includes providing financial management services for the Benue Health Fund Project in Nigeria (1999-2001), and being on the Management Board for the Partnership for Transforming Health Systems (PATHS), Nigeria (2002-2008).

National

The in-country team is led by the National Programme Manager, Dr Ahmad Abdulwahab, and the Deputy National Programme Manager, Dr Solomon Mengiste. Dr Ahmad Abdulwahab, specialises in public health, programme management and monitoring and evaluation. He has worked in the health sector for 14 years. Prior to becoming State Team Manager for Zamfara he was Director of Primary Health Care and Disease Control at the Yobe Ministry of Health (2005-2007). Dr Solomon Mengiste, National technical advisers

Amina Auta	Midwifery Adviser
Anthony Aboda	MNCH Adviser
Ben Anyene	National Immunization Policy Adviser
Yusuf Yusufari	Health Systems Management Adviser
Miniratu Soyoola	Social Development and Community Engagement Adviser
Godwin Afenyadu	Health Systems Research Manager
	Operations Research Adviser
Dije Gimba	Communications Adviser
	Health Information Management Adviser

States

Each state has its own staff team which is led by a State Team Manager (STM) and includes State Programme Officers and LGA (Local Government Area) Engagement Officers as well as finance, logistics and support personnel. Jigawa State Team Manager Dr Ahmad Said Katsina State Team Manager Dr Musa Usman Matazu played a leading role in the development of the integrated supportive supervision checklist (ISS), supported the establishment of the Eminent Persons Group and multiple training workshops in DHIS software in his capacity as PRRINN-MNCH Senior State Programme Officer. He was a Board Member (2004-2006) of the Federal Medical Centre in Katsina and has been involved in advocacy with the State Government. Yobe State (Acting) Team Manager Abdulaziz Mohammed specializes in Development, Health Information Management and M&E. He has worked in the health sector in different capacities for over 23 years and has a wealth of experience working for many projects funded by the World Bank, UN organizations and USAID. Zamfara State (Acting) Team Manager Dr Sani Dahiru Abubakar

Senior Technical Advisers (STAs)

Our Senior Technical Advisers provide expert support and guidance in their respective fields throughout the life of the programme.

Dr Ahmed Gana (HERFON)	Advocacy and change agents
Dr Andrew McKenzie (HPI)	Health management systems
Anne McArthur (HPI)	Vaccine management
Dr Anthony Klouda (SC UK)	Demand creation and equity
Bryan Haddon (HPI)	Governance
Cathy Green (HPI)	Demand creation and equity
David Melody (SC UK)	Public finance management
Ebenezer Ajimokunola (GRID)	Financial management
Eric Swedburg (SC UK)	Maternal, neonatal and child health
Prof Sally Findley (Columbia University)	Operational research
Amrita Gill-Bailey (JHU-CCP)	Behaviour change communications
Margaret Caffrey (LATH)	Human resources
Michael Siebert (HPI)	Human resources; health management systems
Nynke van den Broek (LATH)	Maternal, neonatal and child health
Patrick Okonji (GRID)	Public financial management
Dr Shehu Sule	Governance
Simon Foot (HPI)	Governance
Vincent Shaw (University of Oslo)	Health Management Information Systems (HMIS); knowledge management

Implementing partners

PRRINN-MNCH is managed by a consortium led by Health Partners International, who run the programme's UK office, and also comprising GRID Consulting and Save the Children, International. The programme also has several associate and network partners: Mailman School of Public Health, Columbia University (MSPH) Health Reform Foundation of Nigeria (HERFON) John Hopkins University-Centre for Communications (JHU-CCP) Program for Appropriate Technology in Health (PATH) University of Oslo Transaid Ahmadu Bello University

The PRRINN-MNCH programme operates in four northern Nigerian states: Jigawa, Katsina and Zamfara in the north-west zone and Yobe in the north-east zone. The estimated population served in 2009 is just over 17 million (Katsina 6.4 million, Jigawa 4.7 million, Zamfara 3.6 million and Yobe 2.6 million). Each state has its own programme office with a staff team who work closely with local policy makers and communities to realise the programme’s goals. Activities in each state are implemented by State Teams with the support of the national office staff, based in Kano, and Senior Technical Advisers.

We started the Programme for Reviving Routine Immunization in Northern Nigeria (PRRINN) in late 2006 with support from UKaid from DFID (Department for International Development, United Kingdom) to help address the ongoing challenge of eradicating polio and improving coverage of other vaccines in Northern Nigeria. Realising the importance of an improved immunization system within a strengthened primary health care (PHC) system and maternal, newborn and child health (MNCH) system, the State Department of the Norwegian Government added significant resources in 2008 to create the PRRINN-MNCH programme. Where we work: The PRRINN-MNCH programme is operational in four northern Nigerian states (Jigawa, Katsina, Yobe and Zamfara) and has a national office in Kano with a presence in the federal capital, Abuja. Our team: The in-country team is led by Nigerian nationals, with additional team members from other countries - including Ghana, Ethiopia, South Africa and Uganda. This roots the programme in the northern Nigerian context but allows experience and expertise, largely from other African countries, to contribute to addressing the challenges the programme faces. The programme is managed by a consortium led by Health Partners International, with GRID Consulting, Nigeria and Save the Children, UK.