WEST AFRICA INSTITUTE OF PUBLIC HEALTH (WAIPH)

Most of Nigeria’s Maternal and Child mortality and morbidity indices are among the worst globally. The Primary Health Care (PHC) system in Nigeria has failed to provide the expected care to at least 70% of the population.  The PHC service delivery has been estimated to reaching just 20% of the target population. The routine service delivery data that are used to track the targets and key performance indicators have not provided the true picture of the PHC service delivery in Nigeria. The marked and wide difference between the values of the administrative values of the performance indicators and the survey values for the performance indicators are suggestive of manipulation. The survey figures are much worse than the administrative values that are usually calculated from the routine primary data that are largely collected manually at the health facilities. 

Also, the current key PHC performance indicators  are all output centred, as such not robust and easy to manipulate or subject to clerical errors during entry into the primary data collection register and collation in the monthly summary forms prior to transmission to the next level of the data management hierarchy.   

In addition, there has been no structured feedback system from the communities, whose participation is the Key pillar of the PHC system as stated in the 1978 Alma Ata declaration.  Currently, the communities lack access to their catchment PHC facility data or analysed data for their information, planning , assessment or any other action that will improve PHC service delivery.

Despite the geometric increase in morbidity and mortality due to non -communicable diseases, there are no routine performance indicators at the PHC facility level for their monitoring.

The WAIPH PROXY PHC PERFORMANCE MEASUREMENT goes beyond being a performance tool, as it screens directly for obesity and indirectly for non-communicable diseases such as Diabetes and Hypertension. This solution is a better and people centred measurement of their health compared to the current number centred performance indicators. Also, it strengthens the community participation pillar of the PHC system 

The WAIPH Proxy indicators are indirect assessment of the PHC performance. They are more of output/outcome human centred indicators. The data are part of the current routinely collected in Nigeria but not analysed. These data are weight and height measurements of patients and clients, which are analysed to measure key child (stunting and wasting) and adult (undernutrition and overnutrition) prevalence rates in the Communities, thus a better measurement of the health of the Community.

Currently, our organisation is implementing this measurement in two PHC facilities in the Federal Capital Territory of Nigeria. A manual excel spreadsheet tool has been developed for the health facility designated staff in charge of monitoring and evaluation to use for the analysis. Also, the profile of the community such as number of deaths per month, births per month, number of houses and estimated population, and health performance indicators like DPT3 coverage, ANC attendance, child stunting and adult obesity rates as captured by the PHC facility staff are displayed on a notice board (Community Information Board) located in the Community leaders compound. This board has a suggestion box attached. During the 2 months implementation of our project, 58 suggestions have been received from the two sites. The next phase has plans for an electronic version, WAIPH PHC app that will include the Excel analysis tool, Community Information Board and suggestion box. This tool will also have provisions for individuals to calculate their BMIs, child stunting and wasting values and vaccination rates, and compare to the community averages. Thus, transforming the Primary Health Care into Primary care by getting individuals, family and Communities involved in their well being, as avenues are now available for them to know their nutritional state as compared to the optimum and community average, understand the implications for their nutritional status and that of the community and participate in the improving of the PHC facility service delivery and the community’s health.   The WAIPH Proxy PHC performance project will improve PHC services across Nigeria and benefit the 70% of the population targeted by the PHC level of Health care. It complements and improves upon the current measurements, which can seamlessly be incorporated.

Our solution will serve the 70% of the Nigerian population that are to be served by the PHC system. These population are majorly the vulnerable, deprived and underserved, living in urban slums and rural areas.

In addition to the current burden of infectious diseases, which this population bears an inequitable burden compared to those that reside in the urban formal areas, non-communicable diseases are fast becoming an equal burden. Currently in Nigeria’s Health Management Information System, there is no routine PHC performance indicator that measures malnutrition. And malnutrition has been implicated as an underlying cause in at least 50% of child deaths due to infections, and overnutrition being a risk factor in several metabolic and cardiovascular diseases that cost money, reduce quality of life and lead to mortalities. 

The two communities where the solution has been deployed are very rural and hard to reach villages in the Federal capital Territory of Nigeria. The communities are underserved as the PHC facility serving the communities is run down, understaffed and lower cadre of health workers. The community members are mainly farmers.

The West African Institute of Public Health has paid very special attention to PHC over the years. The WAIPH’s take on improving the PHC system in Nigeria is not about throwing money at it, but reforming the system for better outcomes using contextual evidence.  This position was based on findings from human centred PHC studies conducted in communities and learning experience of our participants. Participants in our annual Young Professionals in Public Health intakes (Virtual Internship Programme-VIP, Design Equity, Action Leadership-DEAL Fellows and Health Literacy and Leadership Programme-HLLP)) are schooled on PHC and have to write issues briefs on the challenges of the PHC system.

This solution was borne out of the communities’ belief that they do not know how their contributions are affecting the PHC system, are not aware of how the PHC facilities are performing and lack an effective feedback system that is responsive and accountable, and combined with the study findings of large proportion of stunted children, adult malnutrition especially among the teenage mothers and high prevalence of Hypertension. 

Based on the relationship built with the communities during a research activity in the area, the WAIPH felt compelled to improve their PHC services. The only intervention apart from deploying the solution has been improving the skills of their PHC facility’s only Health worker in nutrition education and counselling. In just two months, there has been a 20% drop in stunting among the Under 5 Children. The feedbacks from the two communities that are served by the PHC facility has helped to improve services. An example is the decision to shift the antenatal care session from the morning hours to evening, so that the pregnant farmers can attend after the day’s farm work.

Despite the security challenge that has made it suicidal to embark on a trip to the communities, the solution is running and meeting its objectives 

WAIPH is seeking technical and financial support to scale up the solution and deploy the appropriate technology.

The solution needs to be deployed across all the 30, 000 plus PHC facilities in Nigeria. The Health workers, community members and other PHC stakeholders need to be made aware of the solution. Also, we hope to pitch country localised / contextualised versions of the successful application to the other 14 countries of the Economic Community of West African States.

The solutions Android and IOS applications has to be developed. These applications will have broader solutions such as analysis of the routine Health facility performance indicators such as vaccination coverage rate, contraceptive use and ANC attendance. In addition, a USSD platform will be made available for those without Smart phones or access to internet.

   Based on the solutions short term results, the WAIPH will make a case for these proxy indicators to be captured in the National Health Management Information system as part of the routine data collection requirement.

This solution was developed with inputs from the community has been designed and deployed to address the PHC community participation fears and performance monitoring. The key innovation is that the solution serves as a proxy PHC measurement tool and directly and indirectly screens for non-communicable diseases. It measures both output and outcome health indices using routinely collected PHC data that are not prone to falsification.

For the first time, the community members will have access to their catchment PHC performance and vital health indices, know the community health status, can compare their individual and family wellbeing status to the community average and track the results of their feedbacks.

As another first, this solution provides information of the burden of malnutrition for all ages and thus an indirect predictor of the risk of the common prevalent non communicable diseases such as cardiovascular and metabolic diseases.

At the community level, evidence on the link between malnutrition on susceptibility to and severity of infectious diseases and several non-communicable diseases, are other deliverables of the solution

Within the first year, there will be improved PHC performance due to the increased participation of the communities in the monitoring of service, access to service delivery and feedback communication. The health workers increased capacity to use service delivery data for planning will also improve service delivery. In numeric terms, not less than 10% improvement over the baseline indices should be achieved at the end of the first year and annually henceforth.

Research findings have shown a significant cause of undernutrition in rural areas in Nigeria is knowledge lack and not food lack. Therefore, with the malnutrition indices measurement, context appropriate messages will be developed and delivered to the communities. A minimum of an annual 10% point reduction in prevalence of malnutrition (over and undernutrition) in the underserved and rural communities in Nigeria over the next 5 years.

The impact will be improved health and well-being of rural dwellers and urban underserved populations through much lower incidence of non-communicable diseases and understanding of nutrition.

Effectiveness and implementation researches are planned from the sixth month till the project end at month 60. Dissemination and knowledge translation of the research findings will be conducted very efficiently and making use of the most effective tools and means.

The project implementation will be driven by an evaluation framework.

The target is to get at least 30, 000 Health facility workers and 120, 000 community members to use the solutions app or ussd by the end of the 5 year period. The assumption is that over 48 months these targets will be met, with a 12 monthly target of 7,500 Health facility workers and 30, 000 community members.

The key indicators are the prevalence of undernutrition (stunting and wasting) and overnutrition (obesity) in children, Adult malnutrition prevalence rates, Diabetes prevalence rate, Hypertension prevalence rate and annual crude mortality rates due to Hypertension and Diabetes.

A monthly electronic report of the project progress will be published by the WAIPH team. The report will contain total number of downloads, active users and new users, and infographs on the status across these communities and their trends. 

The theory of change is evaluation centred. The goal is to measure the solution's effectiveness as it measures the PHC performance across Nigeria.

The assumptions made are based on the reviewed literature and success of the limited deployment of the manual version of the WAIPH solution. These evidence based assumptions will be made at each stage of the causal pathway from present to future (impact), as described in the solution’s theory of change. The theory of change concept has 6 stages and starts with the planning and situation analysis, next are the Input, process, output, outcome and impact stages. As described by UNICEF,  our theory of change explains how activities are understood to contribute to a series of results that produce the final intended impacts.

Planning and situation analysis - The aim of the solution is to achieve improved state of health and wellbeing of those who are served by the PHC system, which are made up of those in the rural areas and underserved communities in the urban areas. This will be achieved by improving the PHC performance through proxy assessment of output and outcome indicators based on analysis of routinely collected PHC service delivery data by the health workers and communities. The baseline for the malnutrition will be determined before scale up to a particular community. The 60 month implementation plan will be finalised and the WAIPH solution application and USSD tool will be fully developed at this stage. Also, the strategies(sensitisation and advocacy) to achieve buy in by relevant stakeholders are deliverables during this stage.

Input stage – The identified strategies will be used during the deployment of the WAIPH solution. The indicators include number of target sensitised and availability of solution tools, number of app downloads

Process – This captures the scope of deployment of the WAIPH solution in terms of health workers and community members. The proportion of solution apps that are active and USSDs, and geographical distribution of the active Apps and USSD

Output- Indicators such as Under 5 Child stunting prevalence, Under 5 Child prevalence, Pregnancy Obesity rates and obesity prevalence rates are key performance measurements that will be tracked in the output stage.

Outcome – In the first year of the project, we assume that the number of obese, hypertensives and diabetics will rise as the screening aspect of the solution will pick up more cases. But by the middle of the 5 year project, there should significant reduction number of obese, hypertensives and diabetics.

Impact – The expectation is to achieve improved well being of the target population as validated by the significant reduction in the crude mortality rates attributed to Hypertension and Diabetes.

The current solution in used is an hybrid version that uses a manual excel sheet (software) for data analysis and the mobile phone for transmission of the primary data and the results. The plan is to improve to another hybrid version, mobile application and software.

The PHC facilities health workers collect the needed data using the current national health management information management tools and the patients case notes. The payment of monthly token to these health workers to transfer the needed data to the solution's app or USSD platform to cover their incurred internet data cost will be a good incentive.

The WAIPH's drive for diversity, equity, and inclusivity into your work is mainstreamed at all levels. Without disregarding merit, appointments and selections are socio-demographically balanced. The WAIPH's ethical policy that includes our diversity, equity, and inclusivity statement that reinforces equity opportunities for and services to all that is devoid of any stigma, discrimination, victimisation or bias is billed to be published shortly.

The WAIPH is a Nigeria registered not for profit organisation that is limited by guarantee. And strives to provide much more service with less. The  Social Business Model Canvass below describes WAIPH's model.  

Key Partners

Key Activities

Value Propositions

Customer Relationships

Customer Segments

MOTIVATIONS FOR PARTNERSHIPS:  Providing more efficient Health services with less

ONE campaign/JPIEGO/Christian AID/White Ribbon Alliance/dRPC/HERFON/Vitamin Angels/CS-SUNN/UNFPA/WHO/UNICEF/ PACFaH@scale/AMP/Medicaid

Standards

Membership and Certification

Programme Implementation

Research

Consultancy and Advisory

Training , Education and Compliance

Networking

Delivery of innovations to address Health challenges

Efficient services

Grassroot community partnership

Experience in several domains of health service

Knowledge translation and dissemination network

CHARACTERISTICS: Innovation

Creative,

Very high value for money

Social responsible

Contextual

Efficient Performance, Customization,

Branding

Integration with communities

Collaboration and partnership with donors and other partners

Regular discussions

Formal and informal relationship

Interpersonal relationships

Local Communities

Donors and other grant givers

Government

Academy of learning

Key Resources

Channels

Human resources

Intellectual resources

Financial resources

Management system

Community support

Website

Emails

Telephone calls

SMS

Video conferencing

Physical visit

Cost Structure

Revenue Streams

Cost of project implementation

Operational cost (salaries, rent, utilities, consumables and likes)

Cost of social corporate responsibility

Grants from donors, research bodies and similar organisation

Funds from WAIPH members and certificate fees and voluntary contributions

Funds from WAIPH consultancy, Advisory, trainings and education courses

Currently, the sources of our income are grants, WAIPH academy members’ dues and voluntary contributions and fees paid by attendees of the Academy’s capacity building courses. We hope that without grants, adverts placed on the app will fund further scaling up plans of the solution.

The WAIPH is expanding, membership is growing and participants in the annual YPPH programmes are increasing and playing significant roles in the West African Public health space. All these are translating to more financial stability.

This year, the WAIPH Academy began to organise paid for courses for emerging public health issues such as One Health, Biosecurity, and Global Health Security. 

The annual voluntary members’ contribution has increased by at least 20% every year since 2019. Membership of the WAIPH Academy of Public Health has doubled over the last 4 years.  

Two paid for courses were organised by the WAIPH Academy so far in year 2022. The WAIPH with support from the Partnership for Advocacy in Child and Family Health at Scale (PACFaH@Scale/PAS) organised symposiums, conducted a scoping review and implemented community directed sensitisation for the scale up an extended (3 Month) celebration of the African Vaccination Week 2022.