Federal Republic of Nigeria. Saving One Million Lives

Transcription

1 Federal Republic of Nigeria Saving One Million Lives Accelerating improvements in Nigeria s Health Outcomes through a new approach to basic services delivery Program Document August 13, 2012 Office of the Honorable Minister of State for Health Federal Ministry of Health

2 TABLE OF CONTENTS Table of Contents EXECUTIVE SUMMARY 7 PROGRAM CONTEXT 8 RATIONALE FOR CHANGE 9 PROGRAM OBJECTIVES 10 PROGRAM COMPONENTS 11 Program Component 1: Improving Maternal, Newborn and Child Health (MNCH) 12 Program Component 2: Improving routine immunization coverage and achieving polio eradication 15 Program Component 3: Elimination of Mother to Child Transmission of HIV (emtct) 18 Program Component 4: Scale up of childhood essential medicines and commodities 23 Program Component 5: Improve Malaria Control 27 Program Component 6: Improving childhood nutrition 30 ENABLING Component: Logistics and Supply Chain Management 33 ENABLING Component: Increase innovation and use of technology to improve health services 36 IMPLEMENTATION AND PARTNERSHIP ARRANGEMENTS 37 A. Governance and Coordination 38 B. DATA TRANSPARENCY AND PERFORMANCE MANAGEMENT 41 C. PROGRAM DELIVERY UNIT 44

3 FINANCIAL MANAGEMENT, DISBURSEMENTS AND PROCUREMENT 47 APPENDIX: Programmatic targets and costs 54 GLOSSARY AA Artesunate Amodiaquine ACT Artemisinin-based Combination Therapy AIDS Acquired Immune Deficiency Syndrome ALGON Association of Local Governments of Nigeria ANC Antenatal Care ARI Acute Respiratory Infection ARV Antiretrovirals BCG Bacillus Calmette-Guerin BMGF Bill and Melinda Gates Foundation CBOs Community Based Organizations CCT Conditional Cash Transfer CDC Center for Disease and Control CHAI Clinton Health Access Initiative CHEW Community Health Extension Worker CHWs Community Health Workers CIDA Canadian International Development Agency CIFF Children Investment Fund Foundation CMAM Community-based management of severe acute malnutrition DALY Disability-adjusted life year DFDS Department of Food and Drug Services DFID UK Department for International Development DOTS Directly observed therapy, short course (for tuberculosis) DP Development Partners DPT Diphtheria, Pertusis and Tetanus DQS Data Quality Self-Assessment EID Early Infant Detection EMP Environment Management Plan emtct Elimination of Mother-to-Child-Transmission of HIV EPI Expanded Programme on Immunization FCT Federal Capital Territory FM Financial Management FMoH Federal Ministry of Health FMS Federal Medical Stores FOREX Foreign Exchange GAVI Global Alliance for Vaccines and Immunization

4 GDP GFATM GH GON HBB HCT HCW HERFON HiB HIV IDA IMNCH IPT ITN IUFR IYCF JFA JSI KPI LGA LiST LLINs M & E MDG MDG-DRG MDTF MICS MIS MMR MNCH MSS NACA NAFDAC NARHS NASCP NDHS NDP NGO NHIS NNR NPC Gross Domestic Product Global Fund for AIDS, Tuberculosis, and Malaria General Hospital Government of Nigeria Helping Babies Breathe HIV Counseling and Testing Healthcare Workers Health Reform Foundation of Nigeria Haemophilus Influenza B Human Immunodeficiency Virus International Development Association Integrated Maternal, Neonatal and Child Health Strategy Intermittent Preventive Treatment Insecticide Treated Nets Interim Unaudited Financial Report Infant and Young Child Feeding Joint Financing Agreement John Snow International Key Performance Indicators Local Government Area Lives Saved Tool Long Lasting Insecticide-treated Nets Monitoring and Evaluation Millennium Development Goals MDG- Debt Relief Grant Multi-Donor Trust Fund Multiple Indicator Cluster Survey Malaria Indicator Survey Maternal Mortality Ratio Maternal, Neonatal and Child Health Midwives Service Scheme National Agency for the Control of AIDS National Food and Drugs Administration and Control National AIDS and Reproductive Health Survey National AIDS and STDs Control Programme Nigeria Demographic Health Survey National Drug Policy Non-governmental organization National Health Insurance Scheme Neonatal Mortality Rate National Planning Commission

5 NPHCDA National Primary Health Care Development Agency NSHDP National Strategic Health Development Plan OPV Oral Polio Vaccine ORS Oral rehydration solution OSSAP-MDGs Office of the Senior Special Assistant to the President on MDGs OTP Outpatient Therapeutic Programme PCV Pneumococcal Vaccine PDU Program Delivery Unit PEPFAR The President s Emergency Plan for AIDS Relief PHC Primary Health Care PIU Project Implementation Unit PLHIV People living with HIV PMTCT Prevention of Mother to Child Transmission of HIV/AIDS PNC Postnatal Care PPMV Proprietary Patent Medicine Vendors PPP Public Private Partnership PSC Program Steering Committee RBM Roll Back Malaria RDTs Rapid Diagnostic Tests RF Result Framework RI Routine Immunization RUTF Ready-to-Use Therapeutic Foods SAM Severe Acute Malnutrition SC Stabilization Center SCMS Supply Chain Management System SDPs Service Delivery Points SFH Society for Family Health SIAS Supplementary Immunization Activities SMART Standardized Monitoring and Assessment of Relief and Transition SMF Social Management Framework SMOH State Ministry of Health SOML Saving One Million Lives SP Sulphadoxine Pyrimethamine SQEAC Semi Quantitative Evaluation of Access and Coverage SURE P Subsidy Re-investment and Empowerment Programme TA Technical Assistance TB Tuberculosis

6 TH Tertiary Hospitals TOR Terms of Reference TT Tetanus Toxoid U5 Under 5 UNDP United Nations Development Program UNICEF United Nations Children s Fund USAID United States Agency for International Development VHW Village Health Worker WB World Bank WHO World Health Organization YF Yellow Fever

7 EXECUTIVE SUMMARY Nigeria s population health outcomes are relatively low compared to other countries with similar levels of resources and endowments. The country is constrained by inequitable distribution of resources, inadequate quality of health services, and a complex federalized structure. Despite best efforts to address these challenges, Nigeria still comprises a large share of the world s burden of child and maternal morbidity and mortality. It is estimated that approximately one million women and children die every year in Nigeria from largely preventable causes. The status quo is an obstacle to success, and obstacle to making Nigeria s people healthier and saving lives. Excellent policies and programs designed will not lead to an improvement in outcomes without strong execution and dramatic innovation in the way health programs are delivered. Saving One Million Lives is not a new health program. It builds on existing policies, strategic documents and frameworks as outlined by the National Strategic Health Development Plan and Mr. President s Transformation Agenda. Rather, it is a drive to focus on outcomes, through strengthening execution and delivery of Nigeria s existing basic health services by setting clear, ambitious targets for real impact and a simple, yet laser-focused system of performance management to achieve them. It is a new delivery mechanism, working towards real change on the ground. With this approach, Nigeria will save one million lives (predominantly women and children) by Three factors underpin this new approach: (i) A robust data management system to support performance management; (ii) A steering committee comprising public, private sector and development partners to enhance coordination, transparency and mutual accountability for results and outcomes; and (iii) A Program delivery unit to drive execution and routines necessary for effective delivery.

8 PROGRAM CONTEXT 1. Nigeria underperforms other countries with similar levels of resources and endowments in its average population health outcomes. With an estimated 545 maternal deaths for every 100,000 live births in 2008, Nigeria contributes about 10% of global burden of maternal deaths. The under-five mortality rate, at 157 per 1,000 live births (2008), is also declining too slowly to achieve the MDG4 target of less than 67 per 1,000 live births by The infant mortality rate of 75 per 1,000 live births, as at 2008 is on a steady decline, but still higher than that of other countries in Sub Saharan Africa. 2. In addition to the poor outcomes, the distribution of the health outcomes and utilization of health services is highly inequitable. For example, the difference between the wealthiest quintile and poorest quintile in access to skilled birth attendance at delivery is almost eight fold. Similarly, the difference in full immunization coverage between the wealthiest and poorest quintiles is almost 10 fold. Inter-regional and inter-state disparities in health outcomes are also stark. Coverage of key interventions is low, and the most basic services do not reach the poorest segments. 3. Consequently, it is estimated that approximately one million women and children die every year in Nigeria from largely preventable causes; 33,000 women are estimated to die from pregnancy-related causes, and about 946,000 children under- 5 die of which 241,000 are newborns. The preventable causes of morbidity and mortality among women include pregnancy, anemia due to malaria, intra-partum and post-partum hemorrhage, post-partum sepsis, eclampsia, and complications from obstructed labor. Among children, these include malaria, vaccine preventable communicable diseases (tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, measles, bacterial pneumonias), diarrheal diseases, pediatric HIV, and the underlying problem of malnutrition. 4. The quality of health services provided in most facilities remains inadequate. Most of the 23,000 frontline Primary Health Care (PHC) facilities often lack skilled practitioners, and a large percentage of the facilities do not have basic pharmaceuticals and commodities consistently in-stock. Not surprisingly, more than 50% of the households are dissatisfied with the services in public facilities and use them infrequently.

9 The private sector, which provides at least half of the health services is fragmented, poorly regulated, poorly understood and practically unengaged by the public health sector, especially at the primary care level. 5. This is despite relatively modest levels of health spending, compared to other parts of Africa, both in absolute terms and as a proportion of gross domestic product (GDP): total health expenditure per capita, PPP (constant 2005 international dollar) was $121 as at 2010; total health expenditure per capita (current US dollar) was $63 as at 2010, amounting to about 5.1% of GDP 1. Comparing the data from 2003 and 2008 Demographic and Health Surveys (DHSs) it is evident that Nigeria has made limited progress in delivering critical health services. 6. Nigeria s health system also faces a structural constraint with the fiscally decentralized system of government whereby Federal, States and Local Governments all have concurrent constitutional responsibilities regarding health, yet there are no intergovernmental accountability mechanisms. Whilst the national health policy of 2004 places responsibility for the implementation of primary health care in the Local governments, Federal and State governments are not absolved of the responsibility to improve the health of Nigerians. RATIONALE FOR CHANGE 7. In spite of best efforts by the government and its partners to address the health issues in Nigeria, outcomes have remained sub-optimal. A review of programs shows that while there are good policies and strategies in place, there are clear challenges in their delivery and execution. There is often significant fragmentation of efforts, suboptimal coordination, and focus on inputs and processes, rather than the outcomes and results. 8. Saving One Million Lives (SOML) is an approach to delivery that reflects lessons learned from previously implemented programs and analyses of the health sector in the country. It includes: (1) A shift in focus from inputs to focusing on results 1. 1 World Bank, World Development Indicators 2012.

10 and outcomes; (2) Strengthened local ownership and accountability mechanisms, especially at the ward levels; (3) Better coordination and engagement across agencies, between different tiers of government and amongst development partners; (4) Testing of innovative approaches that fit the Nigerian context; (5) Strong capability and skill building and technical assistance to address constraints within the system. (6) Stringent monitoring and evaluation /performance management framework. Overall SOML will focus significantly on execution and program delivery. It will set clear, ambitious targets for real impact and a simple, yet laserfocused system of performance management to achieve them. 9. Continuing business as usual is not a viable option. As Nigeria marches towards attaining Universal Health Coverage, no time should be wasted in improving the health status of people through delivery of known, effective health interventions. 10. Bold innovations and changes in the approach to delivery in the sector are necessary to shift the focus from inputs and processes to strengthening direct service delivery and improve health outcomes. This inevitably requires a paradigm shift in approach to basic health services in the sector. This approach remains entirely consistent with the Transformation Agenda of Mr. President and with the NSHDP. PROGRAM OBJECTIVES 11. The objective of the program initiative is to save one million lives in Nigeria by 2015, through integration of essential priority interventions into primary health care, equitably increasing access to, and utilization of quality cost-effective basic health interventions. A breakdown of the lives saved by program component and disease area is specified in Annex The program comprises 8 components, which will contribute to the above stated objective to save one million lives. Within each program, ambitious goals have been set, namely: a. Improving Maternal, Newborn and Child Health: delivering an integrated package of MNCH interventions at 5,000 primary health care clinics to increase the rate of skilled attendants at birth and the coverage of 4 ANC visits to 80%;

11 b. (ii) Improving routine immunization coverage: eradicating polio and achieve DTP 3/pentavalent, OPV3 coverage of 87% and to introduce new Hib and pneumonia vaccines; c. (iii) Elimination of Mother to Child Transmission of HIV; d. (iv) Scaling up access to essential medicines and commodities: treating 80% of children with diarrhea, pneumonia or malaria with the recommended treatment ; e. (v) Malaria control; f. (vi)improving child nutrition; treating 90% of children with severe malnutrition with CMAM services. 13. In addition, two enablers have been included, namely: (vii) Strengthening logistics and supply chain management and (viii) Promoting innovation and use of technology to improve health services. 14. This will be achieved with a new, strong performance management vehicle a delivery unit - that will closely track, troubleshoot, and hold accountable Nigeria s health programs. The program will be government owned and led, and implemented in close coordination and cooperation with the development partners (DP). A joint financing arrangement (JFA) for this partnership is planned to guide investments, and a steering committee will oversee progress. The program components and its goals, and the accompanying delivery unit are described in detail herein. 15. Overall program costs stand at $ 5.8 billion with existing donor and government commitment of an estimated $ 2.2 billion by 2015 (See Annex 3). While the current costing exercise has incorporated key on-going programmatic and funding interventions and commitments, a bottom-up refinement of individual cost elements is on-going. PROGRAM COMPONENTS 16. As outlined above, this program comprises eight (8) components, which will contribute to the above stated objective. The components are: (1) Improving Maternal, Newborn and Child Health; (2) Improving routine immunization coverage and achieving polio eradication; (3) Elimination of Mother to Child Transmission of HIV; (4) Scaling up access to essential medicines and commodities; (5) Malaria control; (6) Improving child nutrition; (7) Strengthening logistics and supply

12 chain management; and (8) Promoting Innovation and use of technology to improve health services. Program Component 1: Improving Maternal, Newborn and Child Health (MNCH) 17. Current statistics for maternal mortality indicate that 33,000 women die every year in Nigeria due to complications from pregnancy and delivery 2. The under-five mortality numbers show that approximately 1 million children do not live to see their fifth birthday each year. 70% of these deaths are due to preventable and treatable causes such as malaria, pneumonia, diarrhea, measles and HIV/AIDS There have been efforts to scale up maternal and child health care in Nigeria with measurable success. Maternal mortality rate fell by 32% from 800/ 100,000 live births in 2003 to 545/ 100,000 live births in However in order to meet the target for MDG 4 and 5 by 2015, the current MCH services need to be improved. 19. The National Council on Health approved the Integrated Maternal, Newborn and Child Health Strategy (IMNCH) in 2007 as part of efforts to scale up maternal and child health in Nigeria. The strategy aims to address the causes of 90% of deaths of women and children under the age of 5 years, through: i) focused ANC, (ii) Intrapartum care (III) Emergency Obstetrics and Newborn (iv) Newborn Care. (v) Routine Postnatal Care (Vi) Infant and Young Child Feeding. If implemented, it would have saved up to 6 million children and more than 200,000 women by However implementation thus far is not on track to achieving such outcomes. 20. Recently, a revised approach has been developed to include supply and demand side interventions. On the supply side, each PHC will receive a full complement of skilled health workers, basic commodities, equipment and refurbishment of infrastructure. On the demand side, health promotion and education will be intensified through campaigns at the national, state and local government levels. The Ward 1. 2 Nigeria.unfpa.org World Development Indicators

13 Development Committees (WDCs) will be activated to boost community engagement in decision-making. Conditional Cash Transfers (CCT) have been introduced through the SURE P MCH program to address the indirect costs of care seeking that may partially contribute to the low demand for ANC and delivery services at the PHC facilities. 21. Several programs that work towards these objectives are already underway; they include the Midwives Service Scheme and more recently, the SURE-P MCH program and the Helping Babies Breath initiative. A total of up to 4300 facilities (2,000 PHCs to be covered under the ongoing MSS and SURE P MCH projects and 2,300 PHCs through the National Health Insurance Scheme MCH, project funded by MDG-DRG) will be reached in this program. 22. At the facilities, Frontline Health workers will be trained on the Helping Babies Breathe (HBB) initiative, to increase their skills in neonatal resuscitation in a bid to reduce the incidence of birth asphyxia and neonatal deaths. The HBB interventions will focus on training provision of equipment for resuscitation. The HBB interventions include immediate thermal care, initiation of exclusive breastfeeding within the first hour, hygienic cord and skin care, neonatal resuscitation with bag and mask, case management of neonatal sepsis, meningitis and pneumonia, kangaroo mother care for preterm and low birth weight babies, management of newborn jaundice and extra support for feeding small and preterm babies. 23. Birth attendants at the primary health care facility level will be primarily targeted, but the interventions will also be adapted to care within the community and at the secondary level of referral care. 24. The MSS program under NPHCDA is responsible for the upgrade of PHCs and human resources. The SURE-P and MSS facilities will serve as points of integration for all healthcare services provided by the 8 components under the SOML Program. 25. IThis component aims to ensure the availability of essential livesaving maternal and neonatal health commodities in the PHCs, as outlined in the table below: Continuum of Care Commodity Usage

14 Reproductive health Maternal Health Newborn Health Female Condoms Implants Emergency Contraception Oxytocin Misoprostol Magnesium sulphate Injectable Antibiotics Antenatal Corticosteroids Chlorhexidine Resuscitation equipment Family planning/contraception Family planning/contraception Family planning/contraception Post- Partum Hemorrhage Post- Partum Hemorrhage Eclampsia, severe Preeclampsia/Toxaemia Newborn sepsis Respiratory distress syndrome for preterm babies Newborn Cord care Newborn asphyxia Impact: The above outlined interventions have the potential to save up to 662,900 lives, of which there are 16,800 maternal lives, 180,800 neonatal lives, 465,300 post neonatal and child lives by The program aims to achieve the following a. Reduce maternal mortality ratio from 545/100,0005 live births to 250/100,000 live births by 2015 b. Reduce the neonatal mortality rate from 40/1,000 5 live births to 14/1,000 live births c. Increase the proportion of births attended by a skilled birth attendant from 38.9% in to 85% in d. Increase the proportion of pregnant women attending 4 or more ANC visits from 45% 5 in 2008 to 80% in Nigeria Demographic Health Survey Nigeria Strategic Health Development Plan

15 e. Increase the number of upgraded primary healthcare facilities from 1,000 MSS sites in 2012 to 5,000 sites in Data tracking and monitoring: At each level of government, there is a MCH liaison officer responsible for the collection of data. Monitoring and evaluation officers visit MSS facilities monthly to collect data at the LGA level and report to the State liaison, who then reports to the Federal level. Under the MCH Program, data is collected at the facility level as well, to mitigate the delays in data flow across different levels of government. Monitoring and evaluation officers from the national level visit MSS facilities monthly to collect data at the LGA level and report directly to NPHCDA. 29. Resources required to achieving targets: Current plans to scale-up the MSS model of maternal and neonatal health services delivery at the PHC-level target an additional 5,000 facilities by This scale-up, combined with demand generation activities including conditional cash transfers is estimated to cost $ 783 million from 2012 to 2015 (See Annex 3). Federal Government of Nigeria committed funding stands at $ 581 million, hence a funding gap of $ 202 million. Program Component 2: Improving routine immunization coverage and achieving polio eradication 30. In the past, coverage levels for immunization under the Expanded Program on Immunization (EPI) have fluctuated due to inadequate funding, weak cold chain and logistics management, weak service delivery capacity at the frontlines, lack of community involvement, poor outreach services, and inadequate awareness of the immunization schedule and social support In recent years, the routine immunization program has improved as demonstrated by rising coverage rates. Full immunization coverage increased from 23 percent in 2008 to more than 50 percent according to the National Immunization Coverage Survey The DPT3 coverage increased from 42 percent in 2008 to 67 percent in Polio incidence has declined dramatically in recent years compared to the past when thousands of Nigerian children were paralyzed by the 1. 7 Comprehensive EPI Multi-year Plan

16 virus annually. However, the programs have struggled to sustain this rate of progress. 32. Recognizing the need to sustain recent gains, the Federal Government has increased its own financing for the immunization program. In 2012, the Government allocated USD 30 million to the polio eradication effort and appointed a Presidential Task Force on Polio Eradation. The Government also allocated USD 38 million to the routine immunization program. With support from the Global Alliance for Vaccines and Immunization (GAVI), the Federal Government began the phased introduction of pentavalent vaccine (DPT+HepB+Hib) in collaboration with 12 States. The remaining States and FCT will be covered in The pneumococcal vaccine is planned to be introduced to the country in 2013 with the support of GAVI. 33. This component of the program will focus on saving lives of children through further strengthening of the immunization program to deliver the following key interventions: a. Working with State governments to strengthen Routine Immunisation, improve Immunization plus Days and Reach Every Ward, b. Ensuring continued operational finances and procurement of components of bundled vaccines, c. Extending cold chain and logistics networks to rural wards, developing a comprehensive, timely and complete reporting system with necessary feedback mechanisms, thereby further strengthening the supply chain for vaccines in Nigeria, d. Stepping up social mobilisation and advocacy to stimulate the uptake of Yellow Fever and Hepatitis B vaccines, the new pentavalent vaccine, e. Stepping up Polio Supplementary Immunization Activities (SIAs) with OPV mass campaigns targeting 0-59 months. f. Social mobilization and community awareness activities (media campaigns, engaging Ward Development Committees, traditional leaders, CCTs, vouchers) g. Using facility-level consumption data to inform forecasting, stock management processes and other logistics

17 h. Conducting monthly supportive supervision at national, state, LGA and facility levels to train each level of the immunization system on the following tasks: Immunization session planning Conducting monthly vaccine quantifications Disease tracking Outreach planning and execution 34. Impact: The Country Multi Year Plan of the EPI targets a coverage rate of 87% of vaccine-preventable diseases in infants (under-12 months of age) by 2015 and ensures the introduction of new vaccines and technologies. It is estimated that the introduction of the new Hib vaccine to the immunization schedule will result in 29,514 deaths averted by 2015 while pneumonia vaccine is estimated to add 40,495 lives saved Under the Saving One Million Lives Program, the key target indicators that will be monitored to track success include a. The proportion of infants receiving DPT 3/Pentavalent vaccine in target PHC facilities and communities. The target is to increase this from 47% in 2011 to 87% in 2015; b. The percentage coverage of OPV3. The target is to increase this from 73% in 2011 to 87% by end of 2015 c. Facility-level consumption data used to inform forecasting and procurement processes d. Proportion of facilities conducting planned monthly immunization fixed and outreach sessions 36. Data tracking and monitoring: The NPHCDA receives Routine Immunization and Logistics reports on a monthly basis from the facilities. These reports are broken-down by the coverage of antigens based on fixed RI sessions at the health facility and coverage during outreach activities carried out. The reports are compiled and reported quarterly by the NPHCDA. To assess the quality of the monthly data collected, the government and partners conduct a Data Quality Self- Assessment (DQS) quarterly An Introduction plan for Pneumococcal Conjugate Vaccines in Nigeria s EPI Programme (2011) 9 Report of Data Quality Self-Assessment on Routine Immunization in Nigeria

18 37. The cost of conducting the DQS is covered by the Federal Government budget for NPHCDA while the costs associated with carrying out the monthly data collection is embedded in the Monitoring and Evaluation budget line. 38. Resources required to achieving targets: The total costs for immunization activities are drawn from the Final Immunization Mid-Year Plan, , and include both routine and supplemental activities necessary to reach target coverage levels of 87% by Total immunization costs from 2012 to 2015 are estimated at $ 1.5 billion (See Annex 3). Committed funding stands at $ 842 million, hence a funding gap of $ 611 million. Program Component 3: Elimination of Mother to Child Transmission of HIV (emtct) 39. Nigeria reported its first case of HIV/AIDS in 1986, and by 2011, there were 3.1 million people living with HIV/AIDS (PLHIV) in the country with 281,180 new infections of HIV each year 10. The statistics are sobering: 40. An estimated 360,000 children currently live with HIV and AIDS in Nigeria. Nearly 230,000 pregnant women are living with the disease each year. 41. The rate of transmission from these HIV positive pregnant mothers to their infants is 30%, resulting in approximately 69,300 new HIV infections in children each year (whereas in the developed world and in other Sub-Saharan countries, the rate of transmission is less than 2%). This accounts for almost 30% of the world s new HIV infections in children annually The rate of mother to child transmission and resulting number of new infections in children has barely improved over the past years, with only a 2% decline in number of new infections in children since 2009 (70,900 in 2009, 69,300 in 2011). 43. This picture means that, at the current rate, Nigeria will not come close to virtual elimination of mother to child transmission of HIV by 2015, the target, set as per the Global Plan Towards the Elimination of New HIV Infections Among Children by 2015 and Keeping Their Mothers Alive, launched in Fact Sheet 2011: Brief on HIV Response in Nigeria 11 Together We Will End AIDS, UNAIDS (2012)

19 2011 in Abuja by Her Excellency, the First Lady, Dame Patience Jonathan. 44. Despite these dire statistics and a tremendous amount of external resources directed toward PMTCT, Nigeria s emtct program is not operating at scale. Coverage of essential PMTCT services in Nigeria is still very low with only 13% of pregnant women being tested for HIV in 2009, with 27% of those tested positive receiving ARVs. These coverage rates are unacceptable. 45. Slow progress is being made to address this gap in coverage of interventions; for example, the coverage of pregnant women living with HIV and AIDS who have received antiretroviral drugs (ARVs) to prevent MTCT increased from 7% in 2007 to 22% in The majority of these services in Nigeria are supported by The United States President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund for AIDS, Tuberculosis, and Malaria (GFATM). The National AIDS and STIs Control Program at the Federal Ministry of Health plays a leading role in policy, with the National Agency for the Control of AIDS (NACA) acting as a coordinating agency for all HIV/AIDS programs in the Nation. 46. Nonetheless, the program remains sub-scale, with only 1040 clinics providing PMTCT services in March of Nearly all of these facilities are within the public sector, notwithstanding the fact that, in many parts of the country, more than half of all pregnant women seek care for maternity services from private providers. 47. As with many programs, there exists a strong national policy that faces challenges in being translated into execution and delivery. The current set of PMTCT guidelines, which were revised in 2010, provide the recommended standard of care for the administration of antiretroviral drugs for treating HIV positive pregnant women and preventing HIV infections in infants. 48. The National PMTCT scale up plan in Nigeria has set specific targets for 2015 under Prong 3 13 : 1. a. At least 90% of all pregnant women have access to quality HIV testing and counseling by 2015 from 13% in Exact number of facilities offering PMTCT sites fluctuates by source 13 National Guidelines for Prevention of Mother to Child Transmission of HIV (PMTCT) 2010

20 b. At least 90% of all HIV positive pregnant women and HIV exposed infants access more efficacious ARV prophylaxis by 2015 from 22% and 8% 15 for positive pregnant women and exposed infant respectively in 2009 c. At least 90% of HIV positive pregnant women have access to quality infant feeding counseling by d. At least 90% of all HIV exposed infants have access to early infant diagnosis service by These targets are highly ambitious and, since 2010, Nigeria s progress toward them has not been steady; however, renewed energy among FMoH and NACA leadership, increased focus from international partners and donors, hard work of implementing partners in-country, and an urgent deadline are contributing to a turning of the tide on PMTCT in Nigeria. 50. At the federal level, the National PMTCT Scale-Up Technical Working Group is helping 12 states plus the FCT form concrete, achievable actions plans for scale-up. State-level Ministries of Health and State AIDS Control Agencies are beginning to take the reins on these plans. 51. Development partners, such as PEPFAR, the Global Fund, the World Bank; corporate partners, such as Chevron; and normative partners such as UNICEF and WHO are increasing their focus and attention on PMTCT in Nigeria to support the country in identifying innovative ways to scale the program. Under this program, the approach to scaling up includes, but is not limited to the following: 2. a. Scale-up of PMTCT services where women need them most, at the primary care level: The focus should be on scaling up services within primary care facilities, where they will be most accessible to women and families. Currently, the vertical approach to PMTCT programming is being revised in favor of an integration of PMTCT interventions into existing MNCH services offering a continuum of care package including focused antenatal care (ANC), skilled birth attendance at 14 Towards Universal Access: Scaling up Priority HIV/AIDS interventions in the Health Sector 15 The 8% is assumed to be due to home deliveries 16 This indicator is currently not tracked by the NDHS but contains the underlying assumption that every mother who has access to ANC services should have access to infant feeding and counselling 17 Clinton Health Access Initiative

21 delivery, immediate postnatal care (PNC), and family planning. The primary health care centers, have the network with the largest reach. The implementation will follow the existing hub and spoke model within these programmes, with linkages to secondary referral facilities. b. Know your status: rapid scale-up of HIV counselling and testing, into public and private facilities not currently being supported for HIV services c. Introducing PMTCT services into quality private provider settings: currently, there is no organized mechanism at scale for private providers to offer their patients HCT or ARVs, despite the fact that, in many parts of Nigeria, over half of maternity care is sought in the private sector. Efforts are underway to understand and pilot a mechanism to harness this potential. d. Task-shifting the initiation of ARVs for PMTCT: enabling a larger cadre of health workers to initiate ARVs for pregnant women living with HIV e. Implementation of Option B (or B+): where appropriate, Nigeria and its partners are implementing Option B (and, in some cases, B+) for PMTCT, which operationally simplifies the steps required to prevent new infections in children in many Nigerian contexts. The scale up will prioritize 12 States and the FCT initially, and then expand to the other states as already prioritized by the National PMTCT Scale-Up Technical Committee. 52. An assessment and revamping of the Logistics Management of PMTCT supplies is essential to drive anticipated results. Procurement and distribution of HIV test kits and ARVs are currently managed in large part by PEPFAR. Within the FMoH, distribution is out-sourced to Dalex 18. Due to the short half-life of PMTCT drugs, the current distribution method is carried out in a 2 tier system. The Federal Medical Store (FMS) packages their commodities based on the bi-monthly reports/requisition submitted by healthcare facilities A Push system has only been used for the distribution of drugs for opportunistic infections when the drugs were nearing expiration. It is discouraged to minimize wastage due to the lack of storage at the healthcare facilities. This can be avoided HIV/AIDS Division Response to 2 nd quarter meeting (unpublished)

22 through the prompt distribution of drugs. On the other hand, the Pull system is used for ARVs based on facility report/requisition. 54. A central National Logistics System is important to improve logistic system for Nigeria and is currently being developed with DFDS leading the process Data tracking and monitoring: Monitoring and evaluation within the PMTCT program is coordinated by NACA. The Save One Million Lives program will track the progress of the key HIV indicators by collecting data from the PMTCT sites on a monthly basis, to constantly monitor the progress of PMTCT at the facility level, and use the ANC HIV Sentinel, and NDHS for verification. Performance management conversations will be had on a monthly basis to troubleshoot areas that are facing challenges and implement fast-acting solutions. 56. Key Implementing organizations like PEPFAR already collect monthly data from their respective PMTCT sites, and compile and report to NACA. NASCP carries out the major nationwide monitoring and evaluation exercise on the status of HIV/AIDS in the country by conducting the National AIDS and Reproductive Health Survey- NARHS (biennially) and the ANC HIV Sentinel Survey reports at the facility level, which includes information on PMTCT. A new ANC HIV Sentinel survey is currently being conducted. 57. Impact: The program targets that by 2015, 90% of women attending ANC and delivering in intervention PHCs will have access to PMTCT, with a resulting 80% reduction in new paediatric infections. In addition to contributing to the projected lives saved, the additional adoption of this integrated approach is expected reduce new HIV infections in line with the Global Plan for Elimination of Mother-to-Child Transmission (emtct). 58. Resources required to achieve impact: The cost of scaling up PMTCT services through decentralization to the PHC level is about $665 million using the National PMTCT scale-up plan as a basis for calculation. (See Annex 3) The plan targets 90% coverage by Most investments have been frontloaded in 2012 and 2013, due to planned infrastructure improvements. The cost model is also based on the implementation of the Option B ARV initiation plan. Donor

23 committed funding stands at $ 180 million, hence a funding gap of $ 485 million. Program Component 4: Scale up of childhood essential medicines and commodities 59. Nearly 600,000 children under the age of five die annually in Nigeria due to pneumonia, diarrhea, and malaria, which together represent 55% of Nigeria s under-five mortality. 60. In spite of promising reductions in child mortality in the past decade, Nigeria needs to accelerate progress in reducing under-five-mortality rate including NNR by 13% per year to reach MDG 4 of cutting child mortality by two-thirds between 1990 and To achieve parity with developed countries by 2035, Nigeria will need to sustain mortality reduction by at least 7.5% per year. 61. The Childhood Essential Medicines Scale-Up Plan has been developed as an evidence-based response to Nigeria s high under-5 mortality rate. This plan aims to reach 80% coverage of recommended treatments for childhood diarrhea, pneumonia, and malaria by Indeed, achieving 80% treatment coverage for all children with these effective treatments has the potential to save over 458,000 lives by This rapid progress will only be possible through ambitious, concerted actions that address the greatest drivers of child mortality diarrhoea, malaria, and pneumonia. 62. In order to ensure such rapid progress, the National Essential Medicines Scale-Up Plan identifies and addresses the following three barriers to scale-up of effective treatment: (i) Low careseeking behavior for childhood illnesses. While care-seeking varies depending on the child s symptoms, on average, 30% of children with fever are treated at home (USAID, 2011). Moreover, for children with symptoms of diarrhea, pneumonia, or malaria, at least 29% receive no treatment at all (USAID, 2011); 63. (ii) Primary health providers in the public sector are often illequipped and ill-stocked to confront the most common childhood illnesses effectively. Community Health Extension Lives Saved by intervention (ORS, 112,667; zinc, 30,511; cotrim/amox, 125,331; ACTs, 190,434) were calculated using the Lives Saved Tool, developed by Johns Hopkins. Projections used baseline coverage data from national surveys and programmatic data and assume linear scale-up of interventions.

24 Workers (CHEWs) lack appropriate job aides and commodities for the diagnosis and treatment of these diseases with over 75% of Primary Health Centers (PHCs) reporting regular stock outs of essential medicines; 64. (iii) Primary health providers in the private sector often fail to treat the most common childhood illnesses effectively. No formal requirements or structures for the training and ongoing education of Proprietary Patent Medicine Vendors (PPMVs) exist, despite these retailers accounting for the majority of private-sector health provision for common childhood illnesses. As a result, caregivers often determine the treatment received from these providers, but poor awareness among caregivers of zinc and ORS means that few request these treatments for their children s diarrhea. 65. The package of interventions described in this section aims to rapidly transform the treatment landscape for diarrhea, pneumonia, and malaria in Nigeria by addressing the primary precipitants of poor care-seeking and the low use of appropriate treatments. 66. Four areas for action have been identified with key interventions under each: (i) Generate Demand and Promote Care seeking through conducting national action campaigns for child health leveraging mass media, key opinion leaders and free ample distribution; (ii) Improve availability and use in the public sector through leveraging existing central supply chains to increase public sector availability; improving knowledge and skill of PHC staff to increase appropriate treatments; and support increased procurement of essential medicines at state and local levels; (iii) Improve affordability through encouraging production of affordable high quality ORS and zinc; identifying and supporting actions to reduce cost and price of zinc and ORS; (iv)transform the private sector retail landscape through continuous education of private retailers, facilitation of supplier marketing to boost retail sales 67. Many of these interventions will build off and accelerate the progress of existing essential initiatives. For example, the recommended actions in the National Scale-Up Plan aim to strengthen the impact of the Integrated Management of Childhood Illness (IMCI) approach, which has been a cornerstone of Nigeria s child health strategy but has faced challenges in reaching its targeted scale. Additionally, the National Scale-Up Plan identifies new opportunities to

25 dramatically accelerate progress, including expanding access to high-quality, appropriate, and affordable treatment through the private sector, which is the source of treatment for more than half of children (USAID, 2011). 68. In general, the interventions recommended in the National Scale-Up Plan aim to overcome barriers to child health services overall as well barriers specific to the three target diseases: 69. For diarrhea, the aim of the strategy is to break the market trap that currently inhibits improved treatment coverage for zinc and ORS whereby low demand leads to and reinforces limited supply. To break this cycle, strategic interventions will simultaneously increase demand for zinc and ORS (e.g. through a large-scale creative marketing campaign to reshape caregivers perceptions of effective diarrhea treatment, engagement of key opinion leaders) while ensuring widespread availability of high-quality products at an affordable price. 70. For pneumonia and malaria, significant emphasis will be placed on improved care-seeking, especially around the recognition of fast breathing as a warning sign for pneumonia. As with diarrhea, the greatest focus will be placed on raising awareness of and demand for the recommended treatment among caregivers, health providers, and retailers. Another core component of the malaria and pneumonia scale-up efforts will be improving effective diagnosis through increasing the availability and appropriate usage of diagnostic tools and ensuring the appropriate treatment or care is provided. 71. Job aids, guidelines, and key messages on diarrhea, malaria, and pneumonia treatment will be incorporated into federal government led service delivery platforms such as MNCH Weeks, and the MSS and SURE Programme. Training modules incorporating the job aids and guidelines will be used in the training of primary health care workers who are part of these programmes. 72. Pharmaceutical retailers will be engaged with information, training, and behaviour change techniques on child illness management and product recommendations to ensure access to appropriate treatments. The project will tackle inadequate retailer knowledge for diarrhoea, malaria, and pneumonia treatment by cultivating and training networks of PPMVs to distribute appropriate treatments. The training will

26 provide pharmaceutical detailing and skills improvement for PPMVs on the management of childhood illnesses. 73. Targeted technical support will be provided, focused on improving supply chain management to ensure availability of essential medicines at the PHC facilities. Initiatives will be pursued to identify and expand commodity distribution initiatives to include essential medicines. Please see section on Supply Chain for details. 74. The program will aim to shift consumer preferences toward appropriate treatment by working closely with key manufacturers to develop co-packaged Zn/ORS products that are no more expensive than the combined individual products. This will enhance the use of both products and uptake of zinc could be increased by leveraging the existing high awareness and comparatively high usage of ORS. ORS would also benefit from rebranding within a co-pack to drive excitement around a new, more effective diarrhea treatment. 75. Providers and where legally permitted, community health workers (CHWs) will be trained to use improved diagnostic tools. The improved diagnostic skills and tools such as job aides and rapid breathing counters made available to CHWs will be leveraged to ensure the appropriate use of pneumonia treatments. Moreover, antibiotic packs for pneumonia treatment will be given special labeling to clearly indicate the appropriate indication and usage for each pack. 76. This plan includes the availability of live saving commodities identified by the UN Commission of live saving commodities, currently co-chaired by His Excellency, Mr. President. These include: Care Continuum Commodity Usage Child health Amoxicillin Pneumonia Oral rehydration salts Zinc Diarrhea Diarrhea In order to track the impact on treatment coverage attained through public PHCs, monitoring systems will be established in targeted PHCs that allow for near-real-time tracking of service provision, providing regular reports on children under-five

27 receiving appropriate treatment. This data will be regularly cross checked against estimates of diarrhea, malaria, and pneumonia incidence in covered localities (prepared by the monitoring and evaluation arm of the PDU) to track the key performance indicators. 79. Table 1: Key performance indicators, current status, and National Scale-Up Targets for Essential Medicines Scale-UP KPIs Current Status Scale-Up Target (2015) % of under-five diarrhea episodes treated with ORS and zinc 1% combination; ORS alone, 25.5%; zinc alone, <1% (NPC, 2008) 80% % of under-five malaria episodes treated with ACTs within the 24 hours % of under-five pneumonia episodes treated with cotrimoxazole or amoxicillin 5.9% (NMCP, 2010) 80% 22.5% (NPC, 2008) 80% Resources required achieving the targets: To achieve the national targets for Essential Medicines Scale-Up an investment of $ 147 million is required until 2015 (See Annex 3) Program Component 5: Improve Malaria Control 82. Malaria, a preventable and curable disease, remains a key public health problem in Nigeria, contributing 30% of childhood mortality and 11% of maternal mortality. It costs the nation at least $1bn every year 20. Nearly 110 million clinical cases of malaria are diagnosed each year 21. It exerts a significant social and economic burden on families causing the nation an annual loss of over N1billion (Jimoh et al., 2007) SunMap: Support to National Malaria Programme 21 Malaria Indicator Survey (MIS) 2010

28 Nigeria is responsible for a quarter of the deaths and suffering from Malaria in Africa. 83. The treatment of malaria currently covers about 49.1% 22 of Nigeria s population; with 13% and 87% of this population receiving services from the public and private sector respectively. All Nigerian states have adopted Artemisininbased Combination Therapy (ACT) i.e. Artemether Lumefantrine (AL), Artesunate Amodiaquine (AA) and Sulphadoxine Pyrimethamine (SP) as appropriate treatments of malaria. These medicines are accessible over the counter and administered at primary health facilities across Nigeria. 84. Some progress has been made in Malaria control, for instance, according to the LiST model, an estimated 57, 216 deaths were prevented between 2001 and 2010 in Nigeria. 1,314 of those lives saved were in children under Counting the Lives - Since 2001, an estimated 166,000 children under five have been saved by malaria control interventions and approximately 136,000 (or 82%) of the lives saved occurred in 2009 and 2010 alone. 85. Despite these efforts, Nigeria s progress towards achieving the Millennium Development Goals (MDGs) on Malaria struggles to remain on target. Key barriers towards this effort include poor awareness of ACTs as the most effective treatment for malaria and lack of access to and appropriate training on diagnostic tools. On the supply side, barriers such as poor availability of ACTs due to lack of appropriate forecasting and quantification of malaria medicines in the public sector as well as the high cost of ACTs in the private sector also contribute to Nigeria s current status on Malaria. 86. Ensuring the availability of and training on Rapid Diagnostic Tests (RDTs) in private pharmacies and Private Patent Medical Vendors (PPMVs) is critical to ensure access to acute malaria diagnosis and appropriate treatment and reduce the burden of Malaria. RDTs are currently being introduced to 6 states in the north by NMCP, and 6 states in the south by SFH 24. The availability of any diagnostic test for malaria in facilities is currently 3%. In addition, improving the management of severe UNICEF (2010). Nigeria Multiple Indicator Cluster Survey (MICS) Preliminary Report. Abuja: Nigeria. Accessed online at: 23 Progress and Impact Series: Saving Lives with Malaria Control (2010) 24 Independent Evaluations of the Affordable Medicines Facility Malaria (AMFm) Phase I

29 malaria (e.g. rectal Artesunate) through the introduction of suitable and easily applicable pre-referral treatment at peripheral health facilities is needed to reduce malaria case fatality in Nigeria The Nigeria Malaria Control Programme aims to reduce malaria-related morbidity and mortality by 50% by 2013 and to minimize the socio-economic impact of the disease using the following approaches: a. Increase in the percentage of children under-5 sleeping under ITN in the previous night from 29% in to 80% in b. Increase in the percentage of pregnant women sleeping under ITN in the previous night from 65% 27 in 2010 to 80% by c. Increase in the number of all eligible pregnant women receiving Intermittent Preventive Treatment (IPT): The 2008 NDHS reports that when IPT uptake was assessed using ANC facilities as the delivery point, 8% of women reported receiving at least one dose of SP for malaria prevention during an ANC visit and 5% received the recommended two doses of SP during ANC. d. Prompt diagnosis and treatment with effective medicines. From 200 NDHS, only 33% of children with fever (suspected malaria) receive anti-malarial medicines. 88. Key enablers. Given the lessons from the past and the current status of the Malaria program in Nigeria, reaching the set targets will depend on several key activities. These include: 1. a. Co-ordination: Create effective central project management for Malaria programme nationwide to ensure tracking and b. PHC/PPMV Training: Appropriate staffing and training at PHCs and PPMVs to ensure complete Malaria Case Management (Administering of Appropriate Treatment, Severe malaria intervention, RDT, IPTp) 25 CHAI-Essential Medicines. Nigeria Strategy draft, 2011.

30 c. Data tracking: Design appropriate methods to track KPIs (or proxies) on a monthly basis leveraging existing monthly facility level data capturing mechanism; Ensure creating of escalation mechanisms on intervene on underperforming facilities / areas. d. Supply Chain: Use facility-level consumption data to inform forecasting, stock management processes and other logistics to ensure consistent availability of ACT, RDTs, IPTs and other interventions. Build mechanisms to ensure appropriate feedback / incentives to the local facilities to ensure results e. Education/awareness campaign: Build grass-root level campaigns to build awareness in end-users on appropriate malaria prevention and treatment methods 89. Resources required achieving the targets: The total cost for the malaria program component is estimated at $ 2.2 billion until 2015 (See Annex 3). This estimate is based on the commodities and distribution costs for LLINs, ACTs, and RDTs, M&E using quantifications drawn from the national gap analysis which uses the global RBM methodology. Committed funding stands at $ 380 million, hence a funding gap of $ 1.8 billion. Program Component 6: Improving childhood nutrition 90. Malnutrition is the underlying cause of about half the number of deaths recorded in children under the age of 5 years in Nigeria. There has been no significant improvement recorded in Nigeria s efforts at addressing malnutrition with 41% of children under the age of 5 years stunted, 14% wasted and 23% underweight (NDHS 2008). 91. According to the 2008 NDHS, about 23.1% of children under 5 are considered underweight. Today, Nigeria is ranked high amongst the countries with the highest underweight in the world with over 6 million children underweight. It is being estimated that Nigeria will have an additional 1.6 million stunted children by , and in 13.4 million due to malnutrition in the country if no drastic interventions are done to improve the interventions in the country Life Free from hunger

31 92. In response to this current state of nutrition, Nigeria launched its National Policy on Food and Nutrition in 2002 with the overall goal of improving the nutritional status of all Nigerians. This policy sets specific targets, which include reduction of severe and moderate malnutrition among children under five by 30% by 2010, and reduction of micronutrient deficiencies (principally of vitamin A, iodine and iron) by 50% by This effort included the fortification of staple foods with Vitamin A, so that children will naturally consume Vitamin A in their food. This effort resulted in Vitamin A fortification of 70% sugar, 100% wheat flour and 55% vegetable oil sold on the market. Nigeria is also fortifying wheat flour with iron, thereby helping to protect children and mother s physical and mental health. 94. The Federal Government also launched the Home-Grown School Feeding and Health program in September 2005 under the coordination of the Federal Ministry of Education. The program aimed to provide a nutritionally-adequate meal during the school day. In addition, Nigeria currently has over 350 Community Management of Acute Malnutrition (CMAM) sites across Northern Nigeria serving approximately 140,000 lives. 95. Nigeria recently held its first Nutrition Summit to create a Roadmap to Scaling up Nutrition in Nigeria. Recommended interventions include, promoting optimal infant feeding practices, controlling micronutrient deficiency and anemia through vitamin and mineral supplementation, food fortification and dietary diversification and eliminating Iodine Deficiency Disorder through a salt iodization programme in Nigeria29. Recognition was also given to the role that other sectors e.g. agriculture play in improving food security. 96. The program is complimentary to other ongoing activities aimed at combating malnutrition and improving food security in the country, such as fortification programs, breast feeding promotion, health and nutrition education received by mothers from the community health workers. The specific program aims to ensure that every child suffering from severe acute malnutrition (SAM) be able to access an effective CMAM intervention, provided free of charge by a public UNICEF - Nigeria. June 2006

32 health facility. The nutrition program will be integrated with other existing primary health care intervention services. 97. Community mobilization: CMAM and IYCF are communitybased programs that require and encourage community participation in the early detection of severely acutely malnourished children. Traditional and religious leaders and leaders of core peer groups will be sensitized for optimal support in accessing CMAM services available within their localities. 98. Human resources capability will be strengthened. Each health facility providing CMAM services as well as Stabilization Care (SC) for referral of complicated SAM would need at least five health workers and 25 community volunteers attached to CMAM site for optimal service delivery. Additionally, Community Support groups that are members of Ward/Village Development Committees will be trained for the scale-up program. 99. The health workers will provide screening, admission, and the management of non-complications by feeding with RUTF for 8 weeks or more. Referrals to a stabilization centre will be made by the health worker for cases with medical complications. Community volunteers are responsible for the detection of acute malnutrition within the communities and referral to the Primary Healthcare Centers CMAM sites (OTP & SC) will be established within MSS and SURE Programme cluster facilities. Each facility will have C-IYCF activities integrated in order to scale up IYCF/CMAM interventions in MSS communities and, by extension, in Nigeria. Linkages with community support groups within catchment areas are part of the structures for service delivery 101. The program aims to save up to 100, ,000 child deaths being averted (lives saved) based on scale up of IYCF and CMAM. Indicators that will be tracked and targets that must be met include the following: a. Cure rates: Consistently achieve a cure rate of 75% of children admitted with for acute malnutrition from 71.4% 24 b. Number of CMAM sites: Increase the number of primary healthcare facilities offering CMAM services from 378 sites in the Northeast and Northwest only, to cover all 1,000 MSS sites nationwide

33 c. Case fatality rates: Consistently achieve a death rate of less than 10% of children admitted from 1.2% d. Default rates: Consistently achieve a default rate less than 15% from 25% of June A national data tracking mechanism needs to be instituted by the Federal government from the facility level to the national level to effectively track data flow from the CMAM sites. The Standardized Monitoring and Assessment of Relief and Transition (Smart Survey) is currently used to monitor CMAM data flow in 8 northern states, two times a year. This survey is used for rapid assessment of acute emergencies and based on the Nutritional Status of children under 5 and the mortality rate of the population. Expansion of this data tracking system to attain national coverage will enable the effective monitoring of the indicators needed to reach CMAM targets The SMART survey is a monthly report that will be verified biannually using a Semi Quantitative Evaluation of Access and Coverage (SQEAC) method. The cost of conducting the monitoring and evaluation exercise is factored into the Monitoring and Evaluation section of Annex Resources required achieving targets: Nutrition interventions covering CMAM are based on information provided by UNICEF s nutrition department. The total cost needed to provide 90% coverage of CMAM services in primary healthcare facilities by 2015 is estimated at $ 515 million. Committed funding stands at $ 69 million, hence a funding gap of $ 446 million. The yearly cost to scale up CMAM services was calculated by multiplying the unit cost per facility to the anticipated target coverage for the year. ENABLING Component: Logistics and Supply Chain Management 105. The availability of good quality, safe, efficacious and affordable health commodities in a timely manner to beneficiaries is a key enabler to meeting the objectives of the saving a million lives program and attaining the health related MDGs State CMAM report June 2012

34 106. The National Drug Policy, NDP (reviewed in 2005) provides the broad policy framework for the financing, selection, quantification, procurement, storage, distribution, sale and use of medicines and health commodities in both public and private facilities Despite several efforts by various actors including the department of food and drugs (FMOH), federal medical store, States, partners (USAID, DFID), implementing contractors (JSI, SCMS), NAFDAC, and local private sector partners to reach the NDP's goal of ensuring uninterrupted supply of essential medicines, there continues to be a fragmented, uncoordinated and sub-optimal supply chain and distribution system between Federal programs, States and facilities for the procurement, storage and distribution of medicines and medical supplies As a result, frequent stock outs, procurements of medicines with less than 80% shelf life, expiration of products and counterfeit penetration in service delivery points (SDPs) continue to be key challenges. The main causes of stock outs include error in quantification and forecasts of medicines and supplies, delay in delivery and insufficient transport facilities According to indicative facility based baseline data from John Snow International, as of 2011, the national average stock out rates for reproductive health commodities, ARVs and ACTs were; 30 40%, 15% and 90-95% respectively. In addition, the FMOH in collaboration with WHO, DFID and the European Union undertook an in-depth baseline assessment of the procurement and supply management systems in Nigeria in 2010 / Key findings include: a. Quantification: Only 44% of partners worked with the FMOH in the quantification process of their own programs. b. Expiry: 30% percent of procurements had remaining shelf life at delivery below the 80% requirement for rational procurement. Some medicines were procured with as low as 20% of remaining shelf life with the full price paid for them. c. Coordination: Only 38% of partners belonged to a working group in which procurement activities were coordinated; and of these, only 33% were under the leadership of the FMOH. d. Stock out: On average 54% of essential medicines were not available at public health facilities

35 110. As a result of the above constraints, the program will set up a system that will complement existing supply chain sytems within the country, with the support of a central logistics unit within the saving one million lives program delivery team. This unit will engage with relevant public and private sector stakeholders / partners leveraging on Steering Committee members to coordinate, align and problem solve any bottlenecks. This central logistics unit will be data driven and manage a logistics management information system (and online dashboard) to inform planning and decision making that is tied to services in a real and practical way Pilot two tiered system: This system will be run as a pilot in the first instance for a defined list of essential commodities in two tiers, consisting of the central level and the SDPs level with the FMS and warehouses (public or private) strategically selected in States to support delivery Up to 5,000 retail outlet will serve as service delivery points that will be covered as part of the program. In the initial phase of this program, these retail outlets will include the 1,250 MSS PHCs and general hospitals in the country. In the mid term include up to 5,000 primary healthcare centres and genaral hospitals, run under the MSS, SURE-P MCH and NHIS MDG programs will be included While the states play an important role in the provision of commodities in SDPs, an informed push system using an appropriate data collection mechanism, managed by the central logistics unit will reduce the burden on States (and SDPs) and ensure constant tracking and reporting of logistics performance metrics such as consumption and stock on hand information. These will form the basis of service level agreements with the private sector and donor partners who will support various components of the supply chain and ensure the availability of essential commodities at SDPs Service Level Agreements will be signed with private sector and partners to allow the distribution of health commodities through private sector partners at agreed intervals, performance standards and maximum / minimum stock threshhold levels. Reconciling total stock on hand (physical count), residual stock balance, adjustments (plus/minus); adjustment type; calendar days since last delivery; and days stocked out will be done by delivery partners at the SDP level and managed by the central logistics unit using developed

36 tools and logistics management information system to inform delivery A Financing and procurement framework which stipulates funding types and arrangement (parralel and pooled) will be mapped and streamlined taking into consideration the financing and procurement arrangement of existing programs and funding / commodity gaps which will be supported by independent procurement agents. The procurement schedule will be coordinated and aligned with the funding cycle and bridge financing mechanisms explored to mitigate against delays, interruptions in commodity flows and other risks In the mid to long term, there will also be a strategy and implementation roadmap with a focus on strengthening the existing government supply chain system The central logistics unit will routinely track a number of performance indicators. These indicators include the following (i) Stockout rates of a defined list of essential commodities; (ii) average months of stock on hand; (iii) coverage rates with respect to targeted facilities; (iv) rate of expired stock and losses / wastage; (v) shelf life of commodities on delivery and (vi) timeliness of deliveries Resources Required: Based on distribution and storage cost estimates of the six key interventions, supply chain resources required will total $418 million. This was estimated from distribution and supply chain budgets for essential medicines, nutrition, routine immunization, and MNH as well as 10% of commodity cost for malaria and e MTCT. ENABLING Component: Increase innovation and use of technology to improve health services 119. This component of the program will strive to promote innovations in approach to delivery of basic health services to the last mile This will entail development of creative approaches to problem solving, from resource mobilization, accountability and governance, human resources and task shifting, regulation, service delivery arrangements, public-private interface, supply chain and logistics management and demand creation.

37 121. The component will also promote the use mobile phone technology as a means of leap-frogging in the areas of health information, point of service support, financing, client engagement, quality assurance and logistics management. Further research on the use of mobile and other technologies for health will be commissioned as part of the program In addition, innovative financing mechanisms and other demand side innovations will be explored, such as the expansion of the conditional cash transfer program, resultsbased financing and other schemes and incentives As part of this program, the Federal Ministry of Health in Collaboration with the Federal Ministry of Communication Technology, will partner with organisations such as GSM Alliance, MHealth Alliance and other private sector partners in (i) Developing an mhealth strategy for the country; (ii) Piloting the use of mobile applications to improve access to services in hard to reach areas, train frontline staff and educate/remind patients on basic services and interventions Another key innovation is the explicit engagement of the Private Sector and the harnessing of its potential Engagement with the private sector is being carried out in two principal ways. The first is through unlocking the market potential of the private sector, in several aspects of the healthcare value chain, such as (i) health service provision especially of basic services; (ii) Payer and health insurance; (ii) pharmaceuticals and medical products, including essential medicines and live saving commodities; (iv) Access to finance and (v) support services such as supply chain and logistics The second approach is through engaging the business leaders in the broader private sector through the Nigeria Private Sector health Alliance. This Alliance would assist with advocacy, provide technical assistance, impact investing, for example, through the local manufacturing of essential commodities in Nigeria, and investing in local manufacture of bed nets. IMPLEMENTATION AND PARTNERSHIP ARRANGEMENTS 127. Saving One Million Lives is not a new government policy. It is rather a fundamental difference in approach to delivery and accountability. It draws from existing government policies such

38 as Mr. President s transformation agenda and the National Strategic Health Development Plan (NSHDP ), and is consistent with the aspirations of the Federal Government and most development partners. This is a sub-sector-wide program built around health outcomes in a federal system of governance The Program will support the existing government structure. It will not substitute this, but rather, it will strengthen the system through focused technical support to the Federal Ministry of Health and its Parastatals and improvement of accountability for results A review of existing programs in Nigeria reveals a pattern of poor execution, despite strong political support and good policies. Programs tend to suffer from the following: a. Disproportionate focus on measurement of inputs, rather than outcomes (e.g., number of workers trained vs. number of deaths averted from malaria); b. Fragmented implementation of programs with unclear mechanisms for accountability and coordination (e.g., no government single point accountability for any one program or set of programs); and c. Significant capacity and capability constraints (e.g., programs not staffed with sufficient number of people nor those with the appropriate skill sets) 130. Saving One Million Lives therefore presents a new approach that promotes a focus on outcomes, better coordination around results and effective program delivery. As a result, its implementation rests on three key factors: a. Governance and coordination among the public and private sector coalition partners supporting the initiative; b. Performance management and data tracking; c. Delivery mechanism to support Program implementation Actual implementation of the program will largely occur through existing mandated institutions, Federal level MDAs such as FMOH, OSSAP-MDGs, NPHCDA, NHIS, NACA; State Government Primary Health Care agencies and parastatals; and contracted non-governmental entities. A. Governance and Coordination

39 132. The program will be government-owned and led. The Honorable Minister, whose key responsibility is coordination of implementation of primary health care, will lead the program in a multi-stakeholder collaborative manner together with relevant Federal MDAs and the State Governments. National and International development partners (multilateral, bilateral, non-government agencies and private sector) will also play a very important role The overall Governance and Coordination will be driven by a Program Steering Committee (PSC) at the Federal Level. This PSC will build on the existing steering committee for the Results Based Financing Project supported by the World Bank Group. It s expanded membership will include: Key national public health sector leaders: Minister (of State) for Health, Permanent Secretary of Health, SSAP-MDGs, Director-General of NACA, Executive Director of NPHCDA, Executive Secretary of NHIS, National Coordinator of the Malaria Program, Director-General of the Nigeria Governor s Forum, 6 Representative State Commissioners of Health (3 in addition to the 3 in the RBF PSC), Representatives from ALGON, World Bank, WHO, UNICEF, UNFPA, USAID, CDC, CIDA, DFID, HERFON, CIFF, CHAI, BMGF, and 2 representatives from the Nigerian Private Sector Health Alliance The PSC will provide leadership to the program by(i) Aligning priorities, (ii) setting and agreeing on performance expectations with implementers; (iii) reviewing progress of implementation by focusing on results (program/state based scorecards) rather than processes; and (iv) assist to address any high level bottlenecks to attain the desired outcomes The PSC and the PDU will work with the various implementing partners to align approach to achieveing outcomes, and foster better coordination across implementing agencies and partners. It will also be a forum for increased transparency of different programs. In addition, the PSC will agree the performance expectations based on the respective program objectives and indicators as well as the potential number of lives to be saved by the interventions. This will form the basis for the review of implementation progress on a quarterly basis. Specific technical units within the PDU will meet with the implementing agencies at more frequent intervals and then update the members of the PDU monthly. If there is a major performance issue, this will be flagged and the PSC

40 convened, if required. The PSC will also problem-solve and address critical bottlenecks to implementation As part of its oversight functions, the PSC members may conduct supervisory missions with the PDU at the state of local government levels In some programs, such as the maternal and child health programs, oversight will be provided by the communities through the ward development committees, which are being activated in the wards where the programs are in place. Coordination with the State Governments 138. Nigeria operates a federal system of government, with fiscal devolution. Accordingly, states and local governments enjoy significant fiscal autonomy. Health provision is on the concurrent list, therefore primary and secondary care, are responsibilities of the local and state governments respectively. Therefore, given the central role of the primary health care system in the frontline service provision, engagement with the states is a critical element for the practical implementation of programs The PSC at the federal level will therefore actively engage with the states, through soft power. This will be carried out building on existing memoranda of understanding or other coordinating mechanisms present in the respective programs. The role of the governor s forum is also important and the close collaboration that has already commenced in the planning stages of this program will be sustained throughout implementation. In addition, performance information disaggregated at state level through state score cards will be used to measure state level performance and serve as a tool for dialogue and advocacy with the state governments There are four main areas of engagement with the states. These include: a. Program design: The Saving One Million Lives Program was developed in consultation with the state governments. The governor s forum, represented through the director-general and the health adviser, has been involved in review meetings during the preparatory phase of the project. In addition, a consultation was held with the commissioners of health and other representatives of the State governments in Abuja, where unanimous support was given to the program.

41 b. Governance and Coordination: We will work with the states to provide oversight on the programs that currently exist. Secondly, the PSC will comprise the Director General of the Governors Forum as well as six State Commissioners of Health (one from each geopolitical zone, representing the three from the RBF PSC plus three others). c. Data collection: States will be required to facilitate the sense-checking of the data being collected at PHC level, using the State M&E officers as focal persons. Data will also be sent directly to the central PDU. d. Implementation support: The program will build on existing agreements such as the MOUs that MSS currently has with state governments. Efforts to modify the PDU will also be undertaken B. DATA TRANSPARENCY AND PERFORMANCE MANAGEMENT 141. Results Monitoring and Evaluation: The Project will ensure a robust Results Framework and M&E system that will enable the effective tracking of results and implementation progress. The progress of the Project will be monitored against the results described in the Result Framework (RF) which will also feed into the Annual Review Performance management will involve five steps: (i) Developing results targets (ii) Designing data tools and templates, (iii) Creating data collection and collation routines and (iv) Analyzing and synthesizing data and (v) Establishing feedback loops with the respective implementing agency, stakeholders and the public First the program will select the appropriate indicators and expected trajectory towards achieving the set outcomes. Indicators will comprise a mix of outcome and output indicators. The program will minimize the use of inputs indicators to monitor progress. Examples in other systems show that this is best practice to select a limited number of KPIs that provide critical information on the progress of implementation Not all possible indicators will be tracked. Every program area already has indicators that are being measured. A subset of these indicators that are outcome focused and critical towards determining success of the program and lives saved,

42 will be selected. These are the indicators that will be tracked by the Program Delivery Unit Secondly, tools, templates and an integrated MIS system for collection will be developed. This will allow for effective monitoring across project areas. A combination of existing data reports and new databases for handling large amounts of data will be developed. This data collection tools and templates build on the existing HMIS templates and are currently being piloted in the MCH program. Different programs already have data collection templates and tools that will be built on Most of the data templates are paper-based. In the medium term we aspire to build a mobile data collection platform to create a more robust, reliable and faster system for managing data. This approach will be tested under the enabling component on innovation. In addition, surveys will be conducted periodically to monitor outcomes. The program will also leverage existing surveys where appropriate, such as health facility surveys and the resource tracking surveys The third step in the process will involve the data collection and reporting routines. For facility based data, they will be reported monthly and simultaneously to the state and Federal levels.this allows the PDU to analyse data faster, while allowing for the state to carry out verification of the information. Where needed, specific, focused surveys will be conducted. At the PHC levels, data officers collaborating with the Local Government M&E offices will have the responsibility for collecting data from the facility. This activity will be monitored by the State M&E officer and the state level PDU officer, who is a federal PDU employee, resident in the state. This person is responsible for assuring the quality of data being presented. Data collection will also be carried out by the agencies implementing the respective programs At the facility level, data will be compiled and recorded by a dedicated facility data collector that already exists within the State and LGA Primary Healthcare Development agencies. The information will be submitted to the State Liaison Agents from the facility using the standardized templates at the end of every week. Transportation allowances will be provided to the facility collectors pending the installation of a technological and more efficient method of collecting the information remotely.

43 149. The State Data agent collects and compiles all facility reports and submits to the Regional Coordinators on the first Wednesday of the subsequent month. This allows the State Agent a lag in time to compile a full month s data from the facility Creating accountability in the system will be critical to making this program more than just a promise. The national and state level targets and progress against them will be made fully public, which will enhance accountability and create competition amongst states and implementers Fourthly, the collated data will be analysed and synthesized centrally by the data analysts within the PDU. The key insights will be synthesized and detailed in meaningful ways for the PSC and other audience such as the state government. Quarterly Scorecards for the states will also be developed based on the analysed data The Regional coordinators work with Data Analysts and the Technical Assistants within each programmatic area of intervention to collate, review, and analyze the reports. There will be a maximum of one month s lag time between data submission by the facilities to the analyzed and reviewed monthly report at the Federal Level A program review is carried out every quarter by the Steering Committee to determine progress made, bottlenecks, constraints, propose corrective plans of action. Plans of action are made at the end of the review and implemented at the start of the next cycle. Please see (Annex 10) for a diagram illustrating this process) The PDU will and PSC will then use this information for feedback conversations and discussions with the implementing agencies and the state governments on the progress towards achieving the agreed health targets. It will also provide the basis for problem solving and addressing critical bottlenecks.

44 FIGURE C. PROGRAM DELIVERY UNIT 156. Effective delivery and implementation requires human resources with the right skills and execution mindset as well as the necessary routines for a robust performance management system. The Program Delivery Unit (PDU) will be constituted to provide this support to the PSC and to the implementing agencies. This PDU will have highly skilled resources that the states can draw on as well as the capacity needed to plan and manage the program. The PDU will also provide coaching and capability building to the Government staff that will be working alongside The PDU is the nerve centre of the whole reform. It will need a mix of public and private sector as well as local and international skill sets The PDU will monitor progress toward the program objectives, component by component. It will collect and analyze relevant data, coordinate with implementers to ensure that results are on track, solve problems early and rigorously, and when necessary, escalate issues to the PSC for corrective action to achieve aspirations.

45 159. The PDU will provide on demand technical assistance to the states in specific areas by troubleshooting delivery challenges and through capability building. The PDU will also support the Steering Committee in driving the Initiative and report regularly to the Chair of the PSC The PDU will also have functional expertise that states can draw on to drive execution. This functional expertise will include problem solving and analytical skills, strategy, demand generation, procurement, supply chain management, training, communication and data management and analysis The PDU will incorporate a team of data analysts. This team will define a list of KPIs to be collected on weekly and monthly bases and getting the system into the habit of collecting them. As data becomes available, it will be analyzed to create managerial reports that can be used to prioritize interventions and resolve performance issues A key element of the PDU is to coordinate the building of capabilities to drive and manage delivery at the State and Local Government levels and in the Primary Health facilities. The capability being build will cover both technical and managerial elements. On the technical side, the PDU will support scaling up of existing training and capability enhancing initiatives. It will focus enhancing competencies as will be monitored through improvement in performance On the managerial or systemic side the PDU will tailor training and capability building at multiple levels in the system on topics relevant to day to day management of health service delivery. Building on the success of the Middle-level management training organized by the NPHCDA, but with an expanded scope and range of participants, this will include; formal executive and leadership training for key leaders at the State level The PDU functions are in two major categories: the Administrative/Strategic staff and the Implementation Units. The Secretariat would be based in the Federal Capital Territory (FCT) and managed by the Project Coordinator/Adviser and Deputy Coordinator/Adviser The Strategy and Operations unit which consists of core staff like: a. Project Coordinator/Adviser: to drive the planning, implementation and eventual success of the Saving One

46 Million Lives Program. He/She will also serve as the secretariat to the PSC b. Deputy Coordinator/ Adviser: provides support to and deputizes for the Project Coordinator. c. Performance Management Adviser: responsible for monitoring and evaluation of the Programme. He will report directly to the Program Director and Deputy Director and will be based at the PDU Secretariat. d. Procurement Advisor: This person will report directly to the PDU secretariat. e. Financial Management Adviser: will ensure compliance with standard internal (e.g., audit) and external (e.g., disbursement) processes. He/She will also maintain adequate financial M&E and prepare quarterly reports for delivery unit and work with the Local Funding Agents and Project accountants for the relevant programs. f. Supply Chain Advisor: an expert in the supply chain management procurement, storage and distribution. He will report directly to the PDU Secretariat. He will coordinate a complementary supply chain system all implementation activities and managing SLA s with private sector and other partners The implementation unit is responsible for the core activities of the program components, monitoring and evaluation exercises. This unit will consist of: a. Six Regional Coordinators (RC): the RCs will report directly to the PDU Secretariat and will be responsible for liasing with state data agents to pursue, collect and review weekly data. In addition, they will conduct training exercises for State Agents in proper data collection and management b. Data analysts: works with the Regional Coordinator at the Federal level to review, analyze reports in preparation for presentations to the Steering Committee. They will be located within the PDU Secretariat in the FCT. c. State Liaison Agents: Two State liaison persons/agents present in 36 states and the FCT. The State Agents will report to the Regional Coordinators and will be responsible for pursuing facility data and providing monthly data reports to their respective Regional Coordinators. These agents will also maintain a comprehensive database of facilities, which will

47 include location, mobile number of key contacts, HR staffing and other relevant information. d. Technical Advisers: within each intervention area, a technical adviser will provide on-demand problem-solving expertise to regional data coordinators /state liaison officers and engage with relevant focus-area partners and implementing partners to ensure alignment with targets. e. Administrative staff: responsible for the day to day administrative activities of the secretariat This multiphase program over 1-2 years will reach the 37 Permanent Secretaries and other key positions at the state and local government levels It is anticipated that some DPs will support the GON s Saving One Million Lives initiative Program through a Sub -Sector Wide Program Approach. Some of this support would be financial. There will be a Joint Financing Arrangement (JFA) between the GON and these DPs. The JFA will guide both the pooled and non-pooled fund contributions of the DPs as well as provide detailed arrangements for disbursing, managing and reporting on the use of funds In addition, there will be a coherent multi-year integrated and consolidated TA plan of the Program, to support the Program implementation, strengthen institutional capacity at different levels, increase focus on achieving results as well as carrying out the agreed upon reforms. The GON will carry out the Project in accordance with the Environment Management Plan (EMP) and the Social Management Framework (SMF). FINANCIAL MANAGEMENT, DISBURSEMENTS AND PROCUREMENT 170. Given the SOML program is not designing new policies or new programs per se, but rather, a new approach to delivery, a lot of the outcomes can be achieved using existing resources more effectively. Therefore, the financing approach for the program will be one whereby available resources will be used to purchase specific results. The combination of existing and ongoing federal government budgetary provisions (MDG-DRG funded MSS, Polio, Routine Immunization, SURE-P MCH), existing and ongoing development partner funds (World Bank PBF, Malaria Booster, Polio Program Buy Down, US PEPFAR,

48 USAID, US CDC, DFID and CIDA) will be used to start the program However, additional resources to be mobilized (through World Bank, Global Fund, USAID, DFID and others will be required to fill any financing gaps as outlined in the program budgets and gap analysis. This section outlines the financial management architecture for the additional resources required to achieve the outcome targets Pooled funding approaches will be explored with willing partners, including Multi-Donor Trust Fund or Basket Fund. As implementation progress is made, additional resources will be mobilized to close any remaining funding gaps The funding sources will come from the government (existing and new commitments) as well as from development partners (DPs). It is anticipated that there will be three possible pools for financing the SOML program. These include (i) Parallel financing of specific projects currently under implementation by development partners for whom pooling is not an option. However, the expectation is that there will be significant alignment in approach and strategy and link to results. (ii) Pooling of funds by DPs through a Multi-Donor Trust Fund (MDTF). These funds could be managed by a third party such as the World Bank or through a reputable local fund agent. The pooled funding arrangement will be developed with assistance with the World Bank to ensure highest fiduciary standards are applied. An external, competitively recruited private sector fund manager will administer the pooled fund for attainment of the program objectives. (iii) Resources channeled through the GON Treasury system. DISBURSEMENT 174. Disbursement of funds will be based on quarterly Interim Unaudited Financial Management Reports (IUFRs), which include quarterly expenditures, and these are compared to the annual budgets. The IUFRs will include revenue expenditure, parallel/direct expenditure financed by non-pooling DPs thereby ensuring a comprehensive picture covering all expenditures of the health sector. Based on the project features the following arrangements can be agreed upon for financial management and disbursements under the Project:

49 175. Planning and Budgeting: Linkages will be maintained between project budget and the annual resource envelope for the program, which is a sub-sector program. As part of the implementation support, the PDU will share the annual program budget with the PSC. The DPs who are part of the MDTF will input into the annual budget. Others will share their annual contributions to their respective projects accordingly. This will give a more robust picture of the funding available for the program for the year Accounting and Reporting: For GON funds, and IDA and pooled funds channelled through the government Treasury System, accounting will follow the existing government system. Under this system, a central Financial Management unit will continue receiving and recording financial information for GON, IDA Credit and pooled funds and will be responsible for maintaining the sector accounts. For the MDTF, the local fund agent will be responsible for this, whereas with DPs using parallel financing mechanisms, this will follow their own reporting mechanisms 177. Internal Control: Government s General Financial Rules will be followed. There are clear guidelines for authorization and approval of financial transactions at various level/tiers of government Internal Audit: An outsourced private firm will carry out internal audits of the Project under an agreed TOR. The Internal Audit report, together with the management response and follow up action will be shared with the PSC within 15 days from date of the receipt of the report Fund Flow, Disbursement and Release procedures: An acceptable institute/donor will administer the funds channelled through the Multi Donor Trust Fund (MDTF). The MDTF resources will flow to a pooled FOREX Account maintained as a sub account of the GON treasury account. Figure 1 below depicts the arrangement of the flow of funds for the Program The first advance by DPs to the pooled Designated Account will be in an amount equivalent to its share of six months estimated eligible expenditures of the Project. Consolidated Financial Statements will be generated including a statement on funds required for the next six months so as to facilitate replenishment of DA (Treasury Account).

50 181. Project Reporting: Appropriate formats of the periodic financial reports (IUFRs) shall be agreed. A dedicated FM Unit (for government and IDA funds) or the LFA (For the MDTF) will support consolidation of financial data from the treasury system and direct payments through special commitment etc. Records evidencing eligible expenditures (e.g., contracts) will support the requests for direct payments. The Central FM Unit where the Withdrawal Application will be prepared and sent for reimbursement will consolidate these requests and documentation External Audit: The annual financial statement under the Project will be prepared by the GON and will be audited by CAG who is considered as an independent auditor to carry out annual audits. The audits will be conducted following country procedures and in accordance with an agreed TOR/Statement of Audit Needs which will specify essential elements of audit coverage under the Project. Throughout Project implementation, audit coverage, focus and steps for effective and timely follow up of audit observations will be driven by the Audit Strategy The figure below outlines possible financing options EXHIBIT 1 Possible flow of funds for the Program Parallel financing Multi Donor Trust Fund Public Sector Funding Source of revenue Development partners Development partners IDA Credit GoN Resource allocation Parallel financing Pooling of funds Separate funding pool Financial mgt Mechanism DP designated account Local Fund manager Designated account in CBN Projects Projects Projects Projects Projects Projects

51 PROCUREMENT 184. For the pooled funding (MTDF or basket fund), a detailed procurement plan for the first two years of the program will be developed for the program. A reputable procurement firm/agent may be engaged to handle procurement for the respective projects in compliance with standards of public procurement. To avoid undue interference in the procurement process, the general procurement manual, developed for IDAfinanced projects in Nigeria and the World Bank s standard bidding documents will be adapted for use by this program Inputs required to achieve the results will be procured using national procedures consistent with World Bank guidelines. Consultancy, goods and minor works, will be procured in accordance with the World Bank s Guidelines. Particular Methods of Procurement of Goods, Works, consultancy and Non-consultancy services will be determined during project preparation The operating costs include staff, travel expenditures and other travel-related allowances; vehicles rental; vehicle fuelling; utilities and communication expenses; and bank charges. Operating costs will be managed using the implementing agency s administrative procedures and for the PDU, using procedures consistent with Government of Nigeria Financial Regulations and applicable partner guidelines In addition, the following steps will be followed as part of procurement and implementation arrangements: (a) raise awareness among entities officials/staff about fraud & corruption issues; (b) make bidders generally aware about fraud & corruption issues; (c) the multiple dropping of bids will not be permissible for all procurement under the donor financed Project; (d) award of contracts within the initial bid validity period, and closely monitor the timing; (e) take action against corrupt bidders in accordance with Section I of the World Bank s Procurement/Consultant Guidelines; (f) preserve records and all documents regarding public procurement, in accordance with World Bank Guidelines; (g) publish contract award information in dgmarket/undb online and entities website within two weeks of contract award; and (h) ensure timely payments to the suppliers/ contractors/consultants and impose liquidated damages for delayed completion.

52 SUSTAINABILITY PLAN 188. This program is a Federal intervention program aimed at accelerating Nigeria s progress towards achieving MDG goals by Upon completion of the program, it is expected that the focus on improving access to basic services and life-saving interventions will continue In the National Health Bill under development, a primary healthcare fund will be established. It is expected that this program, with the focus on results, better coordination among development partners and government, and with an effective performance management, and with transparent fiduciary systems in place will serve as a platform for effectively channelling the resources from government (through the Primary Health care fund) and from development partners. ECONOMIC ANALYSIS 190. The program supports evidence-based cost-effective interventions: By supporting the delivery of FMOH s Minimum Package of primary and first-referral services, the program is supporting a highly cost-effective measure with a well documented impact on averting maternal and neo-natal deaths. In addition, the bulk of the services are to be provided at the primary and outreach levels. PHC services have the advantage over hospital care in that they are more accessible to the community. Because of their staffing and organization, they are less costly, and more easily able to provide comprehensive and integrated care A review of service delivery in Nigeria shows significant inequities in access to basic services with the poorest population quintiles and the rural dwellers significantly disadvantaged. This program, by targeting poor rural and urban communities, with a large concentration of the poor, this program addresses inequities in access to services in the country In addition, given the strong in-built monitoring and evaluation tools and systems, the program could also help establish a culture of systematic data collection, analysis and use in decision making, as well as accountability for expected results of spending decisions, all areas that currently are extremely weak.

53 193. The cost effectiveness of the specific interventions have been outlined in the program documents that have been developed for the respective programs For example, Malaria is responsible for an estimated 300,000 child deaths each year. The economic and social burden is substantial. At the macroeconomic level, the economic growth penalty of malaria endemicity over the 15 year period was estimated at US$17 billion, representing a per capita loss of US$156, or 18 percent of actual 1995 income. Market failures and the poverty dimensions of malaria control are a strong justification for public sector involvement Malaria control interventions have proven to be highly costeffective in many settings and studies, exhibiting costeffectiveness ratios lower than US$ 100 per Disability Adjusted Life Year (DALY) saved. Estimation of the Project potential impact, using the Marginal Budgeting for Bottleneck tool, showed that we can expect substantial reduction in child and maternal mortality at impressive cost-effectiveness ratios if the project reaches its coverage targets. Delivering malariaspecific interventions, along with other effective health interventions that can be delivered through the same mode, and are already present in the country, will have a higher impact but at a negligible increase in cost, when compared to combinations of pure malaria-specific interventions HIV/AIDS affects an economy through (a) reducing productivity, domestic savings and economic growth, and (b) increasing costs of treatment and care for both affected households and the society as a whole. AIDS strikes people in their most productive age, reducing both the size and growth of the nation's labor force. Care and treatment for AIDS impose enormous costs on households and the society at large. Households with AIDS patients are likely to lose the income of PLWHAs (often the main breadwinner) in addition to facing an increase in medical expenses. Some households are forced to withdraw their children from school in order to save money The economic benefits of the interventions are multifold. First, since this project aims to assist with scaling up interventions in HIV/AIDS control and mitigation, the majority of Nigerians will directly and indirectly benefit from increased access to HIV/AIDS prevention, treatment, care and mitigation activities. Secondly, new HIV infections in children will be reduced, due

54 to an expansion in coverage of the package of HIV/AIDS prevention activities supported by the project Pneumonia and Diarrhoea contribute to the cycle of poverty. It poses a significant economic burden for families and communities. The financial costs of pneumonia include hospital stays and medications, transportation to health centers, and the caretakers inability to work or take care of other family members while they are caring for a sick child In India an increase in coverage of diarrhoa interventions to 60% was associated with an 11% mortality reduction as well as significant improvements in health outcomes. The cost per DALY averted was US$0.24 ($0.21-$0.34) per DALY averted and US$6.68 ($5. 58-$9.19) per death averted relative to the control arm per 10,000 children 1-59 months. (LeFevre, 2011) Malnutrition remains a significant problem in Nigeria. The contribution of CMAM to child mortality and loss of healthy life years is now well quantified (Collins 2006a; Bhutta et al.2008a), and the urgent need to scale up effective interventions to both prevent and treat undernutrition can no longer be ignored (Bhutta et al. 2008b). While CMAM s effectiveness has been recognized globally for some time (Collins et al. 2006a; WHO et al. 2007), its cost-effectiveness was evaluated recently in a study by Bachmann in Lusaka (Bachmann 2009). The results clearly indicate that CMAM was cost-effective within the studies respective rural and urban contexts in southern Africa APPENDIX: Programmatic targets and costs

55 ANNEX 1: ESTIMATED BREAKDOWN OF NUMBER OF LIVES SAVED BY PROGRAM COMPONENT

56 ANNEX 2: LIST OF PERSONS CONSULTED OR INTERVIEWED Program area Organisation Contact person Routine NPHCDA Dr. Joseph Oteri Immunization NPHCDA Mrs Hassan MCH NPHCDA - MSS Dr Abdullahi NPHCDA - MSS Dr. Urua SURE-P Dr. Ugo Okoli SURE-P Dr. Tokunbo Oshin Nutrition FMOH Mrs. Roselyn Gabriel NPHCDA Dr. Nnenna Ihebuzor UNICEF Mr. Stanley Chitekwe UNICEF Mr Omotola UNICEF Ms. Angela Kangori Malaria Program NMCP Dr. Timothy Obot NMCP Dr. Femi Ajumobi NMCP Dr. Omede NMCP Dr. Sola Oresanya PMTCT NASCP Dr. Azeez Aderemi NACA Dr. Akudo Ikpeazu NACA Dr Uzoma Ene NASCP Dr. Anyaike NASCP Mrs. Jolaoso NASCP Dr Debbie Odoh NPHCDA Mr. Seye Abimbola PEPFAR MDG Health Alliance Anna Levine Essential Medicines CHAI NPHCDA Mr. Jason Houdek Dr. Nnenna Ihebuzor Implementation and Finance arrangement World Bank Mr Dinesh Nair

57 Supply chain and logistics USAID JSI JSI JSI JSI SCMS Department of Food and Drugs (FMOH) Ms Kelly Badiane Mr. Peter Hauslohner Ms. Elizabeth Obaje Mr Chuks Okoh Mr Emmanuel Sokpo Mr Bernard Fabre Pharm. Joy Ugwu State Designation Name Kogi State Permanent Secretary Adamu Ahmed Kogi State DPHC Dr. J.F. Olorunfemi Taraba DDPHC John D. Mboli Enugu State Hon. Commissioner Dr. Fidelia N. Akpa Yobe DPHC Dr. Hauwa L. Goni Anambra State DPHC Dr. C.J. Okoye Kaduna State DPHC Dr. Ado Zakari Benue Permanent Secretary Dr. J. Kwaghtsule Niger State Hon. Commissioner Dr. Ibrahim B. Sulemni Niger DPH Dr. M.B. Usman Ekiti State Hon. Commissioner Prof. O.B. Fasubaa Ekiti State DPHC Dr. Ayodele Seluba Kwara State Hon. Commissioner Alhaji Kayode Issa Kwara State DPHC Dr. A.P. Folorunso Ebonyi State Hon. Commissioner Dr. Sunday Nwangele Ebonyi State DPHC/DC Dr. Achi E.C. Ondo State Permanent Secretary Dr. E.T. Oni Ondo State DDPHC Dr. Adelusi Gombe State Hon. Commissioner Dr. Kennedy Ishaya Abia State DPHC Dr. Oluoha C.N. Abia State Hon. Commissioner Dr. O.S. Ogah

58 Delta State Senior Medical Officer Dr. Anibor Nasarawa State Hon. Commissioner Dr. E. Akabe Nasarawa State DPHC Dr. Z.T. Umar Ogun State Hon. Commissioner Dr. Olaokun Soyinka Borno State Hon. Commissioner Sr. S.A. Kolo Borno State DPHC Baba Gana Abiso Cross River State HOD for the Comm. Ekanlu Comfort Adamawa State DDC/ DPHC Dr. L.C. Bakar Organization Position Name NACA Director General Prof. John Idoko NPHCDA Executive Director Dr. Ado Muhammed NHIS DG Ab Okauru Governors Forum Health Policy Consultant Dr. Dale Ogunbayo NHIS GM Uweja Hope NHIS Ag. ES Dr. Abdulrahman Sambo PM Ajuoli N. N. Organization Position Name USAID MCH Manager Folake Olayinka UNICEF Consultant Dr. Anante USAID/DELIVER Snr Logistics Advisor Elizabeth Obaje USAID/DELIVER Assoc. Dir. Pub. Health Elizabeth Ighano CIDA Second Secretary Development Lisa Demoor UNICEF Chief of Health Naawa Sipliyambe DFID Health Advisor Susan Elden USAID-TSHIP MCHS Dr. Sadahi Ringim

59 UNFPA World Bank Senior Health Specialist Dinesh Nair ANNEX 3: OVERVIEW OF COSTING AND FUNDING GAP Programme Total Cost Probable Funding Funding Gap Malaria $ 2,198,787,844 $ 380,270,790 $ 1,818,517,055 MNCH $ 783,201,759 $ 581,006,986 $ 202,194,773 PMTCT $ 665,719,546 $ 373,600,000 $ 292,119,546 Essential Meds $ 146,851,698 $ - $ 146,851,698 Immunization $ 1,452,880,483 $ 841,807,612 $ 611,072,871 Nutrition $ 515,458,030 $ 69,252,228 $ 446,205,802 Delivery Unit $ 24,289,819 $ - $ 24,289,819 Infrastructure Improvement $ 212,370,782 $ - $ 212,370,782 Total ($) 5,787,189,179 2,245,937,616 3,541,251,563