Covering a total population of approximately 19 million in four states of Northern Nigeria, the Partnership for Reviving Routine Immunization in Northern Nigeria / Maternal Newborn and Child Health programme (PRRINN/MNCH) was an innovative programme, combining health systems strengthening with Routine Immunization (RI) and Maternal, Newborn and Child Health (MNCH) interventions.
Working in states which have some of the world’s worst indicators for maternal, newborn and child health, PRRINN-MNCH aimed to revitalize Primary Health Care (PHC) and improve the availability, quality and utilization of maternal, newborn and child health services, including ante-, peri- and post- natal care, emergency obstetric and newborn care (EmONC), essential care for newborns and infants, young child feeding and nutrition, and routine immunization against preventable diseases.
Scope of work and key achievements:
A major aspect of PRRINN-MNCH was to mitigate the weakness and fragmentation of the health system. To address this Primary Health Care Under One Roof (PHCUOR) was rolled out to enhance coordination, collaboration, effectiveness and efficiency as well as eliminating constraints, fragmentation, managerial uncertainty and wastage of resources. Some key outcomes as a result of the roll out of PHCUOR were: increased efficiency and coordination of health services (reduction in duplication), decentralisation of health services (devolution and de-concentration) and increased confidence in and utilisation of services. At a programme level, indicators for immunization and maternal care as well as confidence in these services improved significantly across the four states. At national level, the positive results contributed to PHCUOR becoming national policy in 2011 and 23 states adopting the policy. At an international level, it has also attracted significant interest from several donors including the Gates foundation, GAVI, the EU, and the WHO.
PRRINN-MNCH also sought to improve access to financial resources in the health sector, which included major financing reforms with significant impact on government’s health budgeting and planning, particularly by bringing all financing under a single budget. To strengthen PHC delivery in Zamfara state a pooled fund (called the Basket Fund) was created. State, local government and development partners all contributed to the pool fund, which was used for tasks such as supervision, vaccine distribution and outreach services. Surveys before and after the pilot phase showed significant increases in many immunization indicators. The Basket Fund was endorsed by an assessment team from WHO. This contributed to an uptrend in the state health sectors budget and allowed for better access to financial data.
PRRINN-MNCH rolled out the District Health Information Systems 2 (DHIS2) across implementation states, in collaboration with Health Information Systems Program – Nigeria (HISP Nigeria) and also successfully pioneered the use of the mobile version of the software. At the end of the project all four PRRINN-MNCH states were using DHIS2, revolutionizing access to HMIS data not just in the four states but across the country.
PRRINN-MNCH developed and implemented a human resource information system (HRIS) that was used to capture baseline HR information, plan for equitable distribution of health workers within an affordable envelope and support administration of human resources. The HRIS empowered state managers to address problems such as ghost workers, absenteeism and maldistribution and shortage of health workers, especially female health workers.
Not only supply side barriers to health services were addressed, one of the largest and enduring community engagement and mobilization initiatives in Northern Nigeria was developed as part of the programme, resulting in large increases in demand for child immunization and MNCH services (ANC up from 25% to 51%, DPT3 up from 5 to 83%). The strategy for community engagement had three approaches:
- Increasing information access to participating communities (building capacity so that information can turn into
knowledge and be acted on).
- Supporting the establishment of sustainable community emergency schemes (blood donor schemes, emergency saving schemes, the emergency transport schemes, and a system of mother’s helpers).
- Monitoring MNCH-related activities and using this data to improve and increase understanding of and support for community-level response.
PRRINN-MNCH supported ongoing community engagement activities in 2,400 communities in 45 Local Government Authorities (LGAs) in three states, reaching an estimated population of 4.3 million. The establishment of Young Women Support Groups (YWSGS), which targeted the most vulnerable segment of the population, reached over 24,000 young women with the establishment of 2006 safe spaces or support groups YWSGs and as a result young women were empowered to access support and health services that were available to them.
In line with the WHO model for Emergency Obstetric and Newborn Care (EONC), PRRINN-MNCH adopted a cluster approach where states and local governments were supported to provide a continuum of care to a cluster of 500,000 people in which the recommended minimum coverage of 5 EONC was achieved including at least one comprehensive EONC. Innovations were piloted and evaluated within the programme to determine what works best in specific implementation contexts and how these innovations can be taken to scale. By the end of the programme, 19 clusters had been established in 3 states in which 95 functional EONC facilities and 152 functional 24/7 PHC facilities were established providing accessible EONC for approximately 9.5 million people and contributed to achieving the following impact across intervention sites:
- A doubling of percentage rates of women receiving antenatal care and delivering with a skilled birth attendant, from 25% to 51% and from 11% to 27 % respectively
- Dramatic reductions in child mortality, with a 41% reduction in the under-five mortality rate and a 44% reduction in the infant mortality rate
- A significant increase in fully immunisedimmunized coverage from 2% to 18% of 1 year olds.
A broad range of indicators provide strong evidence of value for money and lives saved by PRRINN-MNCH. The programme delivered a range of outcomes at an estimated cost per person of £0.43 in 2013, which equates to a cost of between £16 and £33 per child life saved. The programme’s comprehensive approach to health system strengthening contributed to positive change in one of the world’s most difficult settings.
Evidence, experience and learning is summarised in a set of publications: a Summary of output to purpose indicators, a Final Report, Factsheets and Technical briefs which are available to download. Together these publications provide an overview of key insights generated, with the aim of informing future program implementation and therefore development effectiveness by other health service providers, government agencies or cooperating agency partners and include evidence of a significant decline in child and infant mortality rates, which almost halved over the lifetime of the programme.
The PRRINN/MNCH programme was funded and supported by UK aid from the UK Government and the State Department of the Norwegian Government. The programme was managed by a consortium of Health Partners International, Save the Children and GRID Consulting, Nigeria. The consortium included the Mailman School of Public Health at Columbia University, Ahmadu Bello University, Liverpool Associates in Tropical Health and the Health Reform Foundation of Nigeria.
For more information about the programme visit the PRRINN-MNCH programme website.