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Implementation Process

NURHI Service Delivery Strengthening Step by Step Implementation Process

Step 1:     Define and select high volume health facilities and identify pharmacies, and patent medical vendors

To get the most out of available resources, NURHI concentrated its systems strengthening and quality improvement efforts on health facilities that served the largest number of clients.   In each city, NURHI identified and selected high volume sites (HVS), which are secondary level health care facilities and some primary health care clinics (PHCs). 

Under the NURHI project, HVS is defined as public or private health facilities that had the highest volumes of antenatal, delivery, and immunization clients. Most of the HVS found were tertiary or teaching hospitals, secondary level facilities or general hospitals, military hospitals and hospitals that provide free maternity services.

NURHI took three months to identify and select the 82 HVS in the first four cities: Ilorin, Ibadan, Kaduna and FCT. NURHI reviewed the public health facilities HVS annual utilization statistics of the State Ministry of Health (SMOH) of antenatal, delivery and immunization records.  Identifying the private sector HVS was challenging because the State Ministry Of Health (SMOH) lacked information about private sector patient load. Therefore, NURHI interviewed SMOH officials and other implementing partners to recommend popular private health care facilities. These facilities were then visited and the same utilization statistics were collected.  Most private facilities did not have organized records and had to estimate their client load

NURHI utilized this methodology for the HVS site selection and later utilized available data to refine the list. The Measurement Learning Evaluation (MLE) Baseline Assessment results validated the HVS selections, except in a few cases prompting the addition of two or three hospitals.  For the two expansion cities—Zaria and Benin City—NURHI requested the MOH Family Planning (FP) Coordinators for the names and locations of the largest hospitals, both public and private which became the high volume sites in those cities in order to identify sites.

Findings from the 2008 NDHS and the MLE Baseline Assessment results showed that pharmacies and patent medicine vendors are points where women access FP services and information outside the formal health care facilities.  Pharmacies and PMVs who participated in the NURHI Project were selected using the following criteria: 

  1. Must be located within NURHI HVS;
  2. Must be registered with a professional association, either the Nigeria Association of Patent and Proprietary Medicine Dealers (NAPPED)  or the Association of community Pharmacists in Nigeria (ACPN);
  3. Must have a valid practicing license; and
  4. Must be willing to be part of the Family Planning Providers Network (FPPN) and abide by its roles and regulations.

Step 2:     Conduct participatory assessments of high volume sites, pharmacies and patent medicine vendors

To serve as a baseline against which to measure progress, and to inform performance improvement plans for family planning services, NURHI conducted participatory facility assessments.  As a first step, NURHI developed facility assessment tools, which is designed to measure quality indicators that the project intends to address at the various high volume sites.  This Indicators were based on the “National Performance Standards for Family Planning Services for Nigerian Hospitals” developed by the Federal Ministry of Health in 2009.

The facility assessments included structured facility observations and interviews with health facility staff. All these were done in collaboration with the management team in the health care facility.  The questionnaires accessed issues such as hours of operation, personnel information as regards cadre, numbers and type of training received, service statistics, infrastructure, equipment, contraceptive stocks, record keeping, and other services for integration of FP.

A list of pharmacies and PMVs that met the criteria stipulated in step 1 was generated. From that list, 15 pharmacies and 20 PMVs were selected in each city.  A capacity assessment was then conducted for the selected pharmacies and PMVs.  Also the number and training of service providers, the types and volume of family planning methods provided, record keeping, infrastructure, contraceptive stocks, and willingness to join the Family Planning Providers Network (FPPN) were issues assessed

From the assessment, gaps that needed to be addressed including training and equipment needs, as well as cross-cutting issues such as supportive supervision and contraceptive supplies logistics were identified. NURHI then hosted meetings in each city to discuss key findings with SMOH, LGA and representatives of the health facilities assessed.  During these meetings, participants discussed strategies and approaches to improve family planning service provision at all levels and a consensus was reached that NURHI would be responsible for service provider training, provision of essential equipment, strengthening record keeping and FP commodities logistics management.  Some of those key suggestions were include in the project implementation plan.

Step 3:     Plan for Performance Improvement

After NURHI project start up, NURHI facilitated performance improvement planning sessions with staff in each of the 85 HVS.   NURHI engaged the State Ministry Of Health (SMOH) or Local Government Authority (LGA) FP Coordinator, health facility staff to facilitate one-day meetings. At the first meeting findings from facility assessments were reviewed addressing major gaps and plans were drawn.  

Site specific performance improvement plans (PIP) defined targets for each standard for family planning services, actions to be taken, and the investments required by NURHI, SMOH, LGA and the facility to achieve those targets. These finalized PIPs were shared with SMOH and LGA representatives to aggregate input and inform the project workplan and budget.

Step 4:     Support the implementation of performance improvement plans

NURHI supported the implementation of Performance Improvement Plans (PIPs) through a variety of key activities including: training, procurement and distribution of equipment, provision of guidelines, IEC and reference materials, continuous supervision and mentoring, integrating FP with other services, and family planning outreach services.

Training: NURHI assisted the State Ministry Of Health (SMOH) in  the project implementation sites to offer standardized family planning training courses tailored to the needs of service providers and their current level of family planning training.  NURHI supported master trainers in the four initial cities to provide these trainings.

  • Initial Family Planning Training for Nurses and Doctors. This 4-week course trains providers to offer a full range of family planning methods, including Long acting and permanent method (LAPM) IUDs and implants, and certifies them as family planning providers.
  • Family Planning Refresher Training.  This is a 5-day course for certified family planning providers who have completed the initial 4-week course in the previous three years.  It focuses on counseling skills, long acting and permanent method, side effects management, and addressing myths and misconceptions.
  • Post-partum IUD Training.  This is a 5-day on-site training for midwives and doctors.   During the training, trainees get experience inserting IUDs in the labor ward during the first 48 hours after delivery.  Trainees also get experience counseling and recruiting antenatal, postnatal, post abortion clients and mothers bringing their children for immunization.  
  • Family Planning Interpersonal Communication and Counseling Skills Training. This is a 5-day training course for CHEWs. It focuses on information on all family planning methods (natural and modern), interpersonal communication skills, counseling skills, referrals, record keeping and mobilizing for family planning outreaches.
  • Family Planning Interpersonal Communication and Counseling Skills Training for Non-Clinical Provider. NURHI also developed and offers a 3-day training course for pharmacists, pharmacy technicians/assistants and patent medicine vendors (PMV) on family planning counseling, provision of non-clinical family planning methods, referrals for clinical methods, and record keeping.
  • Contraceptive Logistics Management System (CLMS) Training.  This is a modified 2-day specialized training course for health workers who had completed family planning training to address gaps in record keeping, projecting contraceptive needs, tracking contraceptive stocks, and timely ordering of commodities.
  • On-Job-Training (OJT) curricula. NURHI assisted the FMOH to develop OJT curriculum manuals focusing on counseling, clinical service provision and contraceptive logistics management systems (CLMS) for use by trainers and supervisors to strengthen family planning service delivery skills.  This refresher training is done on-site in the health facilities.  The advantage of this approach is that it minimizes interruptions in services that occur when service providers attend classroom training elsewhere.
  • Distance Education Application for mobile phones. NURHI developed an innovative Distance Education Application to provide a platform from which providers can access relevant educational content and resources from Android based smart phones or tablets.  The Distance Education platform was developed in response to the need for the re-enforcement of skills post-training and is intended to supplement existing forms of traditional training and supportive supervision. The application is designed be a refresher of the three key components of the OJT curriculum.

Procurement and distribution of equipment. Based on site-specific PIP performance improvement plans, NURHI procured and distributed essential equipment to health facilities.   The project distributed equipment to facilities soon after it had trained service providers.  

Provision of guidelines, IEC and reference materials. In response to needs identified during the health facilities assessments, NURHI re-produced and distributed to all trained providers the WHO Medical Eligibility Criteria Wheel for Contraceptive Use, National Performance Standards for Family Planning Services for Nigerian Hospitals, the National FP/RH Service Protocols, the FMOH family planning flipchart and wall chart, the GATHER chart, Infection Prevention Materials, and FP Interpersonal Communication and Counseling Tools (IPCC), FP family planning integration chart and the NURHI Clinical Practical Record Booklet.

Continuous supportive supervision, mentoring and coaching, including on job training (OJT). The Family Planning Trainers conduct in-depth supportive supervision every two months, using national supervisory and monitoring tools, the NURHI Health Systems Strengthening Template and exit interviews with clients to identify weaknesses; then use the OJT training-manual to address gaps.  NURHI staff conduct monthly monitoring visits to health facilities. 

Outreach Family Planning Services. Reviewing monthly routine service statistics collected from HVS during supportive supervision and monitoring, NURHI realized that some of the HVS were under-performing in the provision of IUDs and implants.  To address this, in December 2011, the project embarked on a pilot in Abuja and Kaduna to test the feasibility of providing long-term methods through outreach services provided by a travelling team of trained providers managed by Marie Stopes International - Nigeria (MSIN).  During the pilot, NURHI Social Mobilizers promoted and referred women for the FP services two days prior and during the outreach services.  With promising results from the pilot, NURHI adopted the outreach services to low-performing sites in each NURHI LGA.

As result of the outreaches NURHI provided IUDs and implants to more than 7,000 women in six months.  Based on these impressive results, the project decided to scale up its outreach program.  For more information about the NURHI outreach programme, click here.

Integrating family planning with other services. In 2012, NURHI embarked on a program of “Active Referrals” for family planning services from HIV, post-abortion care, delivery and post-natal care, and child health services.   For more information about the NURHI approach to integration, click here.

The 72- hour Clinic Make-Over. To make family planning services more inviting for clients and address the dilapidated infrastructure and state of disrepair of the facilities that the PIP revealed,  NURHI  crafted a cost effective and efficient way of improving health care facilities.  

NURHI developed a unique 72- Hour Clinic Makeover approach to improve quality FP services without disrupting normal daily services. After NURHI trained health care workers and ensured good record keeping, provided materials for referrals, job aids SOPs, IEC etc., the project worked with facility management and community members to become involved in the “make-over” their facility. A process of assessment prioritization and cost effectiveness is ensured through direct labour, which brings about community involvement. The “make-over” exercise begins with a planning session with community members and service providers agreeing on what will be done in a chosen facility.   By the close of business on Friday, repairs, renovations and installing of equipment are carried out through the weekend, and by Monday morning the clinic reopens in a renewed state, ready to provide optimal family planning services.  The results of the makeover were highly positive.  Providers and FP coordinators were reinvigorated by their ‘new’ working environment and reported an increase in the number of clients. Additionally, this approach helped create community ownership of the health facility. In some communities leaders pledged their own money and resources to help with the renovations.

In the fourth year of the project, NURHI modified its 72-Hour Clinic Make-over concept to focus on the cleaning, repair and utilization of existing equipment in the facilities. NURHI altered its approach in response to the PIP findings that revealed that equipment in some facilities just needed minimal repairs, cleaning and refurbishing as opposed to purchasing brand new equipment. This modified clinic makeover approach helped to save time and money while yielding similar results.

Step 5:     Monitor and replan

To monitor progress on the implementation of the PIP and associated changes in family planning service utilization and quality, NURHI conducts service utilization reviews on a quarterly basis and collects monthly service statistics on FP services. See Research, Monitoring and Evaluation for more information. 

Data from the MLE midterm assessment was used by NURHI and the state teams to identify areas that needed to be refined, intensified and sustained to address realities on the ground and new gaps identified. In 2013, NURHI expanded successful approaches including trainings, integration, outreaches, clinic makeovers, and provision of equipment and materials into selected facilities in the two additional project cities of Benin and Zaria.