Data is one of the most important drivers of development, from conceptualisation of interventions to design and implementation. It is what largely guides the policy direction of government and implementation plans of development partners. Data determines what investments will be made in particular areas, and highlights where the need is greater for a specific intervention. When policies are being implemented, data is used to track progress to see if the desired results are being achieved, and where changes are needed.
Every year, the government budgets for and releases funds for development sectors such as education, agriculture, and health. Data for these sectors, such as the number of students and teachers, the number of health facilities and health workers should be used when making budgetary decisions, however data collection systems needed to effectively plan and fund development projects have been lacking in Nigeria. To achieve positive changes in these sectors, especially health, details about health facilities are needed in budget planning and implementation. With such details, policymakers will go beyond budgeting for only personnel and running costs and start to focus budgets on the needs of specific facilities in terms of water, sanitation and hygiene services, beds, wards, ambulances and other critical equipment or amenities. Also, development partners will have more specific and tailored data when planning their interventions.
Health facilities are more than just structures and workers. Water, Sanitation and Hygiene (WASH) facilities, medication adequate human resources are some of the basic requirements of every healthcare facility. Hospitals and primary health centres are not the only places that provide health care services. Pharmacies and patent and proprietary medicine vendors (PPMVs) also do, but are most often not categorised as health facilities, which may limit the real-time planning and implementation of healthcare interventions.
Realising the need for data, the Kaduna State government boldly decided to do a comprehensive assessment of all health care facilities in the state, to determine their actual number, categories, services they provide, staff strength, infrastructure, capacities, needs and viability.
This culminated in the dissemination and launch of the Kaduna State Health Facility Analytics (HEFA) platform on July 9, 2020. HEFA is an online database of all health facilities in Kaduna state housed by the newly established Sustainable Development Goals (SDGs) Data Lab under the state Bureau of Statistics. Using results of the census and other national data such as the demographic health survey, the database provides real-time, all-inclusive information about all health facilities in the state with just a click, making it valuable for not just the policymakers, but for the citizenry as well.
Comprehensive health facility census
The journey started in January 2016 with the visit of Bill Gates, the co-chair of the Bill & Melinda Gates Foundation to Kaduna state to sign a Memorandum of Understanding (MoU) on strengthening routine immunisation (RI) with the state. The Aliko Dangote Foundation (ADF) and Bill & Melinda Gates Foundation had signed a similar MoU with neighbouring Kano State in 2012, which has helped improve RI system and coverage over the last few years. Knowing the importance of data for health care, the Kaduna State governor, Mallam Nasir el-Rufai during the ceremony requested that the Bill & Melinda Gates Foundation support the state in developing reliable data for the state health sector, to aid planning and implementing health care policies. With the support provided by the Bill & Melinda Gates Foundation, the Kaduna State Bureau of Statistics, ministries of health and budget initiated and conducted a census of the entire health facilities in the state, to get an understanding of the number and types of facilities, and their locations.
Driven by the Kaduna State Bureau of Statistics, the census was carried out in 2018, involving over 100 enumerators across the state. The results from the census showed that Kaduna State had 5263 health facilities with a staff strength of 30,172. More than 79% of the facilities were privately owned. Unsurprisingly, chemists and patent medicine stores constituted more than half of the health facilities at over 56%. Primary Health Centres (PHCs) constituted a little over 5%, health posts and maternity and child health clinics constituted 22% and 4.5% respectively.
In terms of basic infrastructure, the assessment showed that almost a quarter of health facilities in Kaduna State (24%) are not connected to electricity. This will undoubtedly pose a challenge to 24-hour service delivery by the facilities and will, among others, contribute to low facility delivery by pregnant women. Also, more than 60% do not have toilet facilities while over 15% have no source of water, two critical requirements for infection prevention and control (IPC) that will protect both the health workers and patients from infectious diseases.
On the distribution of facilities, the data showed a clear disparity in the number of health facilities between rural and urban areas, with the urban areas having more health facilities, especially private facilities, compared to rural areas, highlighting the inequality in access to healthcare and the urgent need for more investment in strengthening healthcare services in rural areas.
All-inclusive facility data
The Kaduna State HEFA platform is uncompromisingly detailed. The geospatial data system provides complete information about each facility in the state. This includes the type and location of the facility, whether it is public or private, the kind of services it provides, its staff strength according to cadre, whether it has an ambulance or not, whether it has an emergency contact number or not, the number of wards, number of inpatient, outpatient and maternity beds, number of toilets, source of water and electricity and other information. Also, by selecting any local government area (LGA) on the platform, the number of all categorised facilities in the LGA is shown with their location.
Information on basic primary health care services
Primary health care services form the basis for any standard health care system. Being closest to the people, PHC facilities not only provides curative treatment for basic illnesses, they also provide preventive services such as community sensitisation outreaches and maternal and child health services such as antenatal and postnatal care, immunisation and nutrition. The Kaduna State HEFA platform considers these basic services as it has data on the percentage of health facilities in the state providing them. For instance, 29% of health facilities in the state provide antenatal services while 26% provide postnatal services. Only 27% provide nutrition counselling while 19% carry out immunisation outreaches.
There is also data on facilities providing sexual and reproductive health services for adolescents and family planning services including outreaches, HIV testing and counselling, malaria rapid diagnostic test, tuberculosis treatment among others. In terms of equipment, the entire state has a total number of 2,428 maternity beds, 2,089 delivery couches and 268 incubators. With this data, more effort is needed to improve the provision of maternal and child health equipment and services at health facilities in the state. Percentages of facilities providing these services is obviously too low and equipment is at best inadequate. As Kaduna State uses the data to guide its policies, consideration must be given to expanding the capacities of existing health facilities to provide these basic services in addition to building new ones across the state.
Accessible tool for planning and regulation
"There is need to know every health facility, their location, capacities and whether or not they are adhering to the rules and regulations," says Dr Amina Baloni, the Kaduna State Commissioner for Health. According to her, in addition to aiding policy planning and deployment of resources, HEFA will help the state government regulate the health sector better, confront quackery and generate revenue from continuous registration and taxes from private facilities, in addition to making sure the services provided by the facilities are of high quality. She added that before the census was conducted, the majority of private health facilities were not registered with the state government and as such, regulating them was difficult. "Now we will make sure that every facility operates within their purview and do not render services they are not qualified to render", she added, insisting that regulatory visits will be carried out regularly to all the facilities in the state by various organs of her ministry to ensure adherence to standards and scope of service delivery.
A transparent basis for improving health care
For anything to be improved, its true state must be known. The fact that the Kaduna State health facility assessment provides seemingly unfavourable data about the state, shows sincerity of purpose on the side of the state government and partners and demonstrates political will and desire to be accountable for healthcare provision in the state. As Dr Baloni stated, for the state to drive towards achieving universal health coverage, it must be honest with itself on the state of its facilities. "We now know the gaps and we will develop plans to address them" she said. The platform will be updated periodically with a follow up census according to Mr Bashir Bature Ibrahim, the statistician general of Kaduna State Bureau of Statistics. This will not only help track progress but will also incorporate new health facilities that are established during the period. According to Mr Thomas Gyang, the Commissioner for Budget and Planning in the state, data from the assessment is already being used to guide the budgeting process of the second phase of primary health care revitalisation of the state. "In the first phase, we revitalised 255 primary health care facilities. We are now using data from the assessment to plan and budget for the second phase of another 255 so as we channel the resources where they are most needed", Gyang said.
The Kaduna State government, citizens and partners now have the data. What remains is its effective use to improve overall health care delivery in the state. As the data is available, citizens should be made aware of their existence through proper publicity. That way, they will also understand how it is used and be able to hold their local health officials accountable for healthcare delivery. They will also leverage it to provide feedback to the state government on their experiences accessing care from the facilities. The state government could make this more seamless if a phone number could be provided on the HEFA platform. For now, the data is available and this can only be the beginning of the journey towards better health care delivery for the people of Kaduna state.
"Without good data, we're flying blind. If you can't see it, you can't solve it" as stated by the late former UN Secretary General Kofi Annan. Geospatial data systems are an essential tool for accurately planning, funding and measuring health interventions and progress. Essential lessons will be learnt from the experience in Kaduna State and should provide strong evidence for the rolling out of similar systems in other states in Nigeria. At best, this will assist state governments in making better evidence-based budgetary decisions, ensuring that healthcare interventions are better targeted to where they are needed the most.
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