12 June 2018

Nigeria: How 72-Hour "Makeovers" Are Transforming Primary Healthcare in Kaduna State

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How long does it take to transform a primary health centre, equip it and have it ready for business? The Nigerian Urban Reproductive Health Initiative (NURHI), a non-governmental organization, has come up with an approach that takes '72 hours'- starting at the close of work on a Friday and completing it by Sunday evening. At the end of a single weekend, the selected facility is completely transformed, so much so that when the facility is commissioned on Monday, it not only meets international best practice for delivery of family planning services, but the staff are better equipped with skills to meet the patient's needs.

An example of this transformation was carried out recently in Kamfanin Zango Primary Health Centre (PHC), in Igabi Local Government Area, Kaduna State. Hajiya Hadiza Bello, the officer in charge of this PHC spoke about how her facility was previously struggling to see five patients every month and how the story changed.

"When I came to this place initially, the place was completely dead, no work, no patients ... nothing".

In three days, the Kamfanin Zango PHC was completely revamped. Work on the facility started started on a Friday, as the clinic closed for the weekend and ended on Sunday evening. By the time the clinic opened on Monday morning, it had been given a face-lift that met international best practice for the delivery of family planning services. The goal of carrying out the 72-Hour Clinic Makeover on a single weekend was to provide rapid improvement to infrastructure and equipment in family planning clinics, without disrupting any services. As patients arrived at the clinic the next Monday, they could not believe the change that had taken place.

Hajiya Hindatu Adamu, who oversees another PHC in Kwarau has come to understand the impact that this change has brought. Suddenly, she has started enjoying her job and going to work. She now loves talking about her facility and how much it has changed, from what was previously a mediocre facility struggling to see 20 clients per month, to one that attends to over 300 clients a month.

The story behind the changes seen in Kamfanin Zango and Kwarau may hold the key to solving some of the problems with Nigeria's healthcare challenges, especially as it concerns increasing capacity at the neglected Primary Healthcare level to appropriately cater for healthcare needs. The Federal Government has severally referred to this as the focus of its interventions, yet progress seems to be slow at best. A large proportion of health care needs can be handled at the primary healthcare level, but because these needs are not being effectively addressed, patients are forced to take basic health problems to specialist hospitals.

Solutions with the end user in mind

The interventions described above, were developed by NURHI and is called the 72-hour Clinic Makeover. It is a process that ensures that beneficiaries' needs are considered from the very beginning. They are also an integral part of the change process from start to finish. Kabir Abdullahi who leads the Kaduna team said it takes a design thinking approach that is human-centred, involving everybody right from the system assessment to the overall development of services in each area. Community members are an integral part of the process from start to finish. This helps to guarantee sustainability by ensuring they take ownership after completion.

To get a project like this executed in three days requires exceptional expertise in areas that we do not often remember - in procurement practices, financial accounting and project management. The Service Delivery and Quality Improvement Team, Research, Finance Team and the Program Staff of the Kaduna office are all involved in ensuring that the project is delivered to the highest possible quality standards, despite the tight turnaround time of just three days. Every project starts with an assessment - a survey to determine if a facility meets the requirements for the intervention, especially to ensure that it is a potentially high-volume site. This is done by looking at data for deliveries and antenatal care, patients coming for HIV/AIDS care as well as, and immunisation data. The total volume of patients that are accessing services, provides an idea about the number of people that will potentially access family planning services by the time the makeover is completed. Once this is verified, facilities are chosen based on the assessed opportunity to deliver the most value to the most people in an equitable way.

A rippling outwards effect

The first phase of the project (NURHI I) began just after the 2008 National Health and Demographic Survey (NDHS). At that point, Kaduna state had a Contraceptive Prevalence Rate (CPR) of 9.6%. By 2013, just a year before the end of the project, Kaduna's CPR had risen to 20.2 according to the NDHS 2013. Kabir credits part of this increase to the work done by NURHI I, saying that they were able to build capacity within Kaduna State's primary health care system and use existing structures rather than creating a parallel intervention.

While NURHI's program focused on family planning, its impact on other service provision areas was evident during a site visit to five facilities in Kaduna state's Igabi LGA.

Hajiya Hindatu's clinic is located just opposite a busy market, off the Kaduna - Zaria road. There, she showed off her carefully kept monthly summary charts. She says that in January and February of 2016 her facility saw an average of 20 patients per month. After her PHC went through NURHI's makeover a year later, these numbers increased dramatically. "In January 2017, we had 58 patients, in February 32, and in March we had 139, thanks to a NURHI outreach," she said.

Advocacy and outreach are significant components of the makeover strategy, explains Khadijah A. Ibrahim-Nuhu, Senior Program Officer, Advocacy and Demand Generation at NURHI. The outreaches and community mobilization help to inform the community that a project is ongoing. She stated that they had mobilized over 300 volunteers in the LGAs where they work in Kaduna to help raise awareness and let Kaduna residents know where they can get quality primary health care services. This prepares the way for an increase in demand for services.

Embedded in the makeover process is also capacity building for staff of the primary health centre, primarily on administering family planning services. Hajiya Hindatu used to organize women, taking them to the Community Health Center in Jaji with her car or she would invite the Family Planning service provider to come to her facility to administer family planning services, especially Intrauterine Devices (IUDs). But after their training leading up to the makeover, she and her team are able to handle those tasks in-house, she says.

Taking ownership, ensuring sustainability and overcoming shortfalls

How government will take ownership and sustainability of projects established by development partners is always a big question. Kabir says Kaduna has developed a Costed Implementation Plan, a strategic document that provides tools and guidance to develop and execute multi-year family planning plans. Hajiya Bello recounted how community members at her facility had paid for family planning consumables on a certain occasion when the facility ran out of stock. The community is currently building a room laboratory for the healthcare centre, using their own resources.

Although training on appropriate information management and record keeping was done during the makeover, one of the challenges the project continues to face is poor record keeping. This makes it difficult for PHCs to account for the use of commodities, which means they may be unable to justify the need for more commodities. Other challenges include inaccessibility of some remote areas and commodity stockouts, Kabir says.

We all know that patients' lives are often put at risk because of the poor quality of service in many PHCs. So, NURHI's '72 Hour Clinic Makeover' not only carries out facility renovations and provide modern and new equipment at an affordable cost, it also helps service providers like Adamu and Bello develop more competencies to confidently render quality and better healthcare to meet the demands their patients. As Nigeria pushes closer to achieving Universal Health Coverage by the 2030 target, helping to ensure that Nigerians access quality care at the primary health care level without suffering financial hardship is critical. However, the poor state of PHC facilities in the country, remains a significant challenge and of great concern. If not adequately addressed, it risks holding Nigeria back in its ambitions to offer patients quality and affordable healthcare. Do you know of any PHCs in your area that would benefit from the 72-hour Makeover?

It would be great to hear your views on whether you may also know of organisations that may be willing to form partnerships to help revamp our PHCs.

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