ZIFAS PROJECT MI/Nigeria

Transcription

1 ZIFAS Quarterly Technical Report to Micronutrient Initiative Oct 2014 ZIFAS PROJECT MI/Nigeria 31 October 2014

2 Table of Contents Acronyms... 3 Executive Summary... 4 Program Implementation review (Zinc Intervention) Introduction-Zinc Project Implementation review results-zinc Unanticipated activity/output achievements-zinc Revised PIP-Zinc Key deliverables achieved Constraints and lessons learned Annex 1: Progress in attaining the key results in Zinc intervention linked to CIDA PMF Iron and Folic Acid (IFA) Intervention Introduction-IFA Project Implementation review results-ifa Unanticipated activity/output achievements-ifa Major Program management activities- IFAS Status on implementation of the Risk Mitigation Strategy-IFA Revised PIP-IFAS Key deliverables achieved Constraints and lessons learned Annex 2: Progress in attaining the key results in Iron & Folic Acid intervention linked to CIDA PMF... 43

3 Acronyms CD Country Director CHAI Clinton Health Access Initiative CIDA Canadian International Development Agency. DDIC Drugs Distribution & Information Captured DHIS District Health Information System ESMPIN Expanded Social Marketing Program in Nigeria FLHW LFront line Health Worker FMOH Federal Ministry of Health FY Fiscal Year H2RA Hard-to-Reach Area IEC Information, Education and Communication IFAS Iron and Folic Acid Supplementation LGA Local Government Areas LO-ORS Low Osmolarity-Oral Rehydration Solution MDGs Millennium Development Goals MI Micronutrient Initiative MNCH2 Maternal Newborn and Child Health 2 MNCHW Maternal Newborn and Child Health Week MSS Midwifery Service Scheme NHMIS National Health Management Information System NMCP National Malaria Control Programme NPHCDA National Primary Health Care Development Agency PCN Project Concept Note PIP Project Implementation Plan PMF Performance Monitoring Framework Pos Program Officers PPMVs Private Patent Medicine Vendors PRRINN-MNCH Partnership for Reviving Routine Immunization in Northern Nigeria- Maternal Newborn and Child Health RD Regional Director RO Regional Office SAVI State Accountability and Voice Initiative SBCC Social and Behavioural Change Communication SFH Society for Family Health SMOH State Ministry of Health SPHCDA SURE-P State Primary Health Care Development Agency Subsidy Re-invested Programme TA Technical Assistance TBA Traditional Birth Attendance TBD UNICEF To Be Determined United Nations Children s Education Fund WINNN Working in Nutrition in Northern Nigeria

4 Executive Summary Background MI and PRRINN-MNCH had been collaborating to implement ZIFAS project, which is managed by HPI through NPHD and covers the 4 Northern States being supported by PRRINN-MNCH since the 1 st of December The objective of ZIFAS project is to increase the coverage and quality of ANC using low dose IFAS to reduce pregnancy related illnesses and deaths resulting from anaemia in pregnancy; it is also to increase the coverage and quality of diarrhoea treatment and prevention in under five year old children using zinc and low ORS and other preventive strategies. Phase 3 of the program started in full fledge in August 2014 with focus on: support FMOH on the development of revised draft of National Essential Medicine List (NEML); tracking of coverage of implementation at LGA level and monitoring of MI/DFATD required indicators; ensuring the continuous airing of radio and TV jingles, facilitating import clearance activities to take delivery of second consignment of IFAS that was procured in phase 2 and the distribution and use of ZIFAS commodities, using appropriate SBCC strategies to mobilise communities and policy makers; quarterly Joint state review meeting with stakeholders; other activities carried out included engagement with DFID and MNCH2 and fashion out collaborative mechanism similar to those with PRRINN- MNCH; to support to SMOH and LGAs to institutionalise the systems that will sustain the gains from the project and to track progress towards achieving the log frame indicators. This report builds on the last report produced in May 2014 but covers mostly the Phase 3 activities that were carried out July to October Progress Based on the contractual agreement, all the key deliverables for the period under review were achieved. Specifically, they include the following milestones: i) conduct of the joint quarterly review meeting with stakeholders, ii) Media Schedule of paid slots for airing of radio and TV jingles in all the 4 states, iii) tracking coverage of implementation at LGA level and monitoring of MI/CIDA required indicators in all the 4 states; iv) quarterly progress reports of joint state review meetings with Stakeholders from all the 4 states v) consultative meetings with FMOH to facilitate the review of the national essential medicines list and lobbying other development partners to support the process vi) Airing of radio and TV jingles in all the 4 states; vii) mount pressure to obtain approval and clearance documents from FMOH, NAFDAC, Federal Ministry of Finance and Nigerian Customs for the importation and sea port clearance of the second consignment of IFAS order that was placed in phase2, viii) used the existing HMIS in each state to track key project indicators and ix) collaboration with UNICEF, WINNN and other development partners through state level nutrition committee meetings and joint field supervisions activities Continued support to stakeholders at the state and LGA level to ensure wide distribution and use of the following documents printed through ZIFAS project support for all levels of the health sector in each state: training manuals, SBCC materials and HMIS tools. Follow up field monitoring and supervision was made in each state to ensure especially that the SBCC materials were properly distributed and used at the facility level and communities. The second memorandum of understanding between ZIFAS and the media for airing of the jingles in all 4 states ensured that jingles were aired for most of the months in phase 3. The media schedule of paid slots for airing of radio and TV jingles that was obtained in August

5 also ensured that airing of the jingles was continued in all 4 states. It is also worthy of note that radio monitors for the jingles do it on daily basis in all 4 states. Follow-up consultations with DFID Health Advisor in Nigeria and the MNCH2 program management team, the successor program to PRRINN-MNCH program, to establish similar collaborative arrangements ZIFAS had with PRRINN-MNCH. Favourable results were obtained as both DFID and the MNCH2 teams accepted to collaborate and support ZIFAS project to provide office accommodation in Kano and the four States, provide limited logistic support, carryout joint implementation of some field activities. State Procurement of low dose IFAS and Zinc and lo-ors The second order through UNFPA to procure IFAS was monitored and the commodity is on transit from manufacturers to Nigeria where it is expected to arrive Lagos sea port towards the end of November, 2014 for clearance and transportation to the four States.. Because IFAS is not yet approved by FMOH, approval for importation and duty exemption was sought and received through the appropriate government agencies. There was continued policy dialogue in all the four states for sustainable State procurement and management of IFAS, Zinc and lo-ors commodities during States 2014 annual planning exercise. This was to ensure that some budgetary provision for procurement of the commodities was made in each State. There are on-going efforts establish a harmonised system on the storage and distribution (supply chain management system) of these and other drugs in line with the medium term procurement and distribution guidelines of ZIFAS. These were produced in line with the PRRINN-MNCH program to ensure sustainable drug supply system for each state and ZIFAS medium term procurement and distribution plans were build on this system to ensure economy of scale and to ensure sustainability. The Jigawa State commissioner for health made attempts to procure the dispersible zinc and lo_ors commodities through SURE-P but bureaucratic bottlenecks could became an impassable challenge. This is mainly because the commodity is not yet manufactured in large quantities by national drug manufacturing companies. Collaboration with UNICEF, WINNN and other partners involved consultative meetings with national, zonal and state level partner officials and MI national officials. This facilitated reaching deeper understanding of each program to chart a common platform on the use of Zinc and low ORS in treatment of diarrhoea in under five children. All the four states have established or reactivated their state nutrition committees which are playing more strong coordinating role on the Zinc and lo-ors distribution and use at facility level, a key outcome of this collaboration. At a recent quarterly meeting with partners a general agreement was reached to include MNCH coordinators from the LGA level to such meetings so that such platforms will discuss not only nutrition and diarrhoea control issues but also ANC attendance and use of IFAS as well Three joint stakeholder meetings were carried out first was in January, second in April and the third one was in October to strengthen collaboration in program activities, At the October meeting there were about 52 participants. They include policy makers, health managers and service providers as well media organisations and community members and development partners from the 4 states and from the zonal and national levels. The objectives of the meetings included: to review progress on collaboration since the joint meeting in April 2014; to further strengthen collaboration among all stakeholders working on ZIFAS related issues;

6 to discuss challenges encountered in Partner Support/Collaboration; and to identify strategies for better outputs and to create more awareness of program interventions. A report on the proceeding and outcome of the October meeting has already been submitted to MI and other participants to the meeting Challenges Several challenges encountered in the field during the last reporting period still occurred during the current reporting period. There has been, as always, swift response by both MI and HPI/NPHD and ZIFAS team. Most of them were resolved in the best possible way. Some of the challenges include the following: i. Security challenges - The security situation in Northern Nigeria has not improved or even gotten worse during this period. In Yobe State, 2 LGAs are under the full control of insurgents so inaccessible to social services while in Zamfara and Katsina, banditry and cattle rustling affected several communities; Field supervision is therefore not possible in the 2 LGAs but we have been able to craft into the security arrangement of the state government to continue to offer support to stakeholder interventions. The commitment of stakeholders and government was however very impressive in supporting ZIFAS project even in security prone areas and this demonstrates the high level of local ownership of the ZIFAS interventions. ii. iii. iv. Collaborating with UNICEF - The importance of collaborating with UNICEF cannot be overemphasized and it was a challenge bridging the gap in communication to enhance better coordination. The communication gaps centered around the need to reduce fragmentation of the central storage and distribution of commodities from the State medical stores to facilities; the limited sharing of information of stock levels and facility level usage. At the recent quarterly review meeting, it was observed that zinc and lo-ors was almost out of stock and the available stock would expire on 31 st October this year, yet there was limited information what the available stock from UNICEF and when they will be delivered to States. Most state nutrition officers who are supported mainly by UNICEF are gradually appreciating the need for broad based collaboration but the communication gap is still wide between them and other stakeholders at the state level. Storage and distribution of ZIFAS commodities- Federal policy and guideline prescribes for a central storage and distribution point under the SMOH for drugs and commodities. Most states are yet to fully adapt and operationalize this policy and this has resulted in the establishment of several parallel distribution systems that create confusion and increase cost. Compared to the first half of the year, the situation is changing for example, Zamfara, Katsina and Yobe have moved most of their commodities to the central medical store under one management. All the IFAS procured through MI support is being distributed through the State Central Medical Stores which is easier to track. Deep-rooted problems and associated negative attitudes of parallel logistic management systems will take long to give away. Delay in effective take off of phase 3 occurred due to delay in the final signing of the contracts between HPI and MI. Funds were also not released on time and activities were slowed down in the first month of phase 2 even though our key engagement and capacity building activities were carried out during the period

7 v. Transition from PRRINN-MNCH to MNCH2. The PRRINN-MNCH program life span has ended in July 2014 and its activities have been taken over by MNCH2, another DFID supported program that will continue to support ZIFAS. The transition period to engage and build a strong relationship MNCH2 disrupted our staff s office arrangements in the four states. They have eventually been housed in the MNCH2 offices. In Kano, the MNCH2 office is yet to be fully established and our staff have to face the challenge to operate in locations. Building relationship with key technical officers from MNCH2 will also require time even though things have been resolved at their management level and potential areas of collaboration have been identified and agreed as outlined in the report of the joint stakeholder workshop vi. vii. viii. M&E data collection and data quality- Data quality has remained relatively low in most states as substantial time is required to strengthen the existing HMIS systems and its a price to pay in the short term on strengthening a routine data system; but this is gradually improving as more pressure for quality is being placed on the various data generated from the system. Procurement of IFAS commodities: HPI placed a second order for the procurement of WHO recommended low dose IFA supplements for the four states through UNFPA. This commodity is not yet approved in Nigeria so approval from NAFDAC, the federal regulatory body on drugs and food matters was complex delicate and protracted but it was eventually secured. Meanwhile the commodity is on the high seas and will arrive the Apapa Port in Lagos Nigeria towards the end of November Withdrawal of the conventional iron and folic acid tablets was a daunting challenge. It involved seeking policy change and local action for implementation by ensuring the retrieval of the conventional commodities and replacing them with low dose IFAS. It as quite a complex bureaucratic process but the challenges were eventually overcome and now low dose IFAS is offered free to all ANC facilities. Next steps The ZIFAS team with support from HPI and NPHD will work assiduously to: Continue to distribute the printed documents and tools as well as continue to engage and build confidence with stakeholders in each state on planned program activities Pursue with greater vigour, the equitable distribution of the first consignment of the low dose IFAS to all health facilities providing ANC services to avoid any stock outs at the facilities. Continue to support policy change and practice in the management of the States Central Medical Store to enhance their statutory role in the storage and distribution and use of Zinc and low ORS as well as IFAS and other commodities on a state wide basis Continue implementation of the communication strategy airing of radio jingles, distribution of posters and fact sheets and community dialogue sessions for care givers

8 Further strengthen collaboration with UNICEF, WINNN and other development partners using the ZIFAS project joint stakeholder meetings, States partners forum and States nutrition committee meetings as platforms to harmonise interventions and promote synergy Build stronger partnership with MNCH2 to ensure effective and efficient use of resources and enhance wider coverage and better quality of service intervention Continue to collaborate with the FMOH, CHAI and other partners to revise the national essential medicine s list and the standard treatment guidelines ensuring that it contain the appropriate formulation of zinc and low ORS as well and low IFAS Continue to collaborate on the National Essential Medicines Coordinating Mechanism a FMOH platform for coordinating the issues and management of childhood diarrhoea, pneumonia and malaria. Country experience is shared and lessons learnt among partners to ensure harmony to country approaches and sharing of resource materials and general information. Seamless implementation of all phase 3 activities as outlined Conclusion Overall, the collaboration between ZIFAS and MNCH2 is making steady progress as we continue to understand each other through improved communication and information sharing; there is also substantial build-up of cohesion and alignment of ZIFAS and other development partners and programs. The project enjoys seamless support from the MI country office as well. Confidence from policy makers to community members as well as their support and goodwill on program activities has also increased in all the states. This portends a positive signal of an emerging effective collaboration that will promote synergy for the health benefits of the women and children in Nigeria. And despite the security challenges in northern Nigeria especially in Yobe State, the program activities have continued to make progress because of the dogged commitment of the program staff and the ownership from stakeholders. Program Implementation review (Zinc Intervention) 1.1 Introduction-Zinc Name Start Date Bringing Zinc for Diarrhoea Treatment to Scale in Nigeria End Date Location Implementi ng HPI (PRRINN-MNCH) Area (Country) Annual Budget NIGER)A CDN$

9 Partners FY2012/13 Budget CDN$ 000s 1 FY2013/14 FY2014/15 Total Q 1 Q 2 Q3 Q4 FY 1 tot al Q1 Q 2 Q 3 Q4 FY 2 tot al Q 1 Q 2 Q 3 Q 4 FY 3 tot al CIDA Core CIDA Musk oka Total

10 1.2 Project Implementation review results-zinc Outputs and Activities (Zinc) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) Remedial actions to be undertaken by whom and when (including on the challenges outlined) Ref1 Ref2 Q1 Q2 Q3 Q4 110 Draft of revised WHO Diarrheal Treatment guidelines submitted for government approval; decision makers awareness raised; rapid revision conducted and disseminated by December, Expert Consultation of the drafting of the WHO guidelines Production, distribution and dissemination of approved draft guidelines and tools

11 Outputs and Activities (Zinc) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) Remedial actions to be undertaken by whom and when (including on the challenges outlined) 113 Conduct Review Meetings 114 Advocacy and sensitization of policy makers and health managers in 4 states X X X X Continued advocacy across the 4 states; the SBCC strategy & materials were used to support advocacy and deepen engagement with policy makers; similarly, the medium term procurement and distribution plans were handy tools for engaging state officials. All the four states factored these plans into their 2014 planning and budgeting process Most of the States are working towards including ZIFAS supported activities in their 2015 annual plans and budget. NPHD and ZIFAS program staff should continue to press for this actualisation of the proposals in states 2015 plans and budgets especially procurement of commodities with special emphasis on Zinc and Lo-ORS. 115 Advocacy and sensitization of stakeholders x X X X Ongoing and has deepened with the several meetings with UNICEF, WINNN and other partners; It has become more pronounced in the sharing and use of the SBCC materials including the radio jingles MI and NPHD should continue to advocate with the National Essential Medicines Coordinating Mechanism to share and promote the use of the SBCC and other materials on childhood diarrhoea

12 Outputs and Activities (Zinc) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) Remedial actions to be undertaken by whom and when (including on the challenges outlined) that have been produced by ZIFAS project 210 Forecasts and costings (for zinc+lo-ors for diarrheal treatment and health worker training) have been provided to all the four states and LGA health managers (SPHCDAs/SMOH) for inclusion in their costed integrated health plans by January, Provide TA to develop costed integrated health plan by each state of intervention. Concluded in phase Conduct meetings with Stakeholders x x X X Several meetings held with UNICEF in each of the program states and with their national officials together with the MI country team to deepen understanding and facilitate ZIFAS implementation. Joint stakeholder meetings MI support by lobbying for buy in from UNICEF Zonal and country offices

13 Outputs and Activities (Zinc) In all the four states, a medium term procurement and distribution plan for zinc and lo-ors supplies to all health facilities based on WHO guidelines developed and financed by March, 2013 Provide TA to SMOH for the development of a medium term procurement and distribution plan for Zinc/Lo-ORS. Dissemination of the medium term procurement and distribution plan for Zinc/Lo-ORS. x X FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) conducted in January, April and October to review field experiences, share lessons and improve program delivery. More stakeholders joined participated in the October meeting: SAVI, WINNN, SURE-P, NPHCDA & MNCH2 Completed in phase 1 The dissemination of the medium term procurement and distribution plan for Zinc/Lo- ORS was carried out in each state. This exercise became a platform to advocate and support states medical stores Remedial actions to be undertaken by whom and when (including on the challenges outlined) All partners to support states initiative to strengthen the drug supply chain management system with the State medical store as the coordinating unit for storage and distribution of all

14 Outputs and Activities (Zinc) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) to implement the national policy of central drug management, distribution chain and control. More States like Yobe, Katsina and Zamfara are buying into the national policy on supply chain management but capacity and bureaucracy and attitude are big challenges hampering progress Remedial actions to be undertaken by whom and when (including on the challenges outlined) commodities; DDIC should be encouraged by ZIFAS to continue with the support to Zamfara while and other partners to support the other 3 sates 223 Provide TA to SMOH for forecasting and quantification of Zinc/Lo-ORS. Completed in phase Procure WHO recommended Zinc and Lo-ORS. Not done; large stock was already available in Zamfara and Jigawa was redistributed to Katsina and Yobe States respectively. Stock available in the four states is small and all will expire by the end of October 2014; the challenge MI to lobby UNICEF for the procurement and distribution of zinc and lo-ors stock promised by them in April 2014; MI and NPHD to continue to mount pressure at the NEMCM forum where collaboration on broad based and sustainable

15 Outputs and Activities (Zinc) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) has been presented to the wider national stakeholder forum the NEMCM for broad based emergency action Remedial actions to be undertaken by whom and when (including on the challenges outlined) 225 Develop and produce Zinc/Lo-ORS stock management tools Completed in phase 1 Printed tools were distributed at state and LGA stores and at the health facility level by PRRINN-MNCH and ZIFAS team through the SMOH. Poor culture of record keeping remains a challenge measures are more likely to be put in place for the whole country ZIFAS team and other development partners like DDIC should monitor and support use of the tools at the central medical store and at the facility level. Partners should support their stakeholders to visit and learn from the Jigawa model PPP type medical store, known as JIMSO 230 M&E framework and monitoring tools developed, tested, adjusted and demonstrated to HMIS decision makers with advocacy for their adoption and incorporation into routine HMIS by March 2013 Completed in phase Provide TA to conduct baseline survey. Completed in phase 1

16 Outputs and Activities (Zinc) Printing of training manuals, HIMS monitoring tools i.e. facility register, community register and supervisory tools/checklists Training workshop at state level of M&E officers on HMIS monitoring and performance of Zinc/Lo-ORS x X Tracking of coverage of implementation at LGA level and monitoring of MI/CIDA indicators x FY 2013/14 X x X X x Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) Printed training manuals, additional HMIS monitoring tools for the 4 states was completed and distributed for use in all states through the SMOH. Katsina and Jigawa states were supported to adopt and use of the new NHMIS form 001 version Poor culture of record keeping though getting less has not abated This has been conducted for HMIS and M&E officers from the 4 states in attendance; follow up training of M&E officers in the LGAs also done Ongoing using the existing State HMIS. Using state systems will produce poor data quality in the short term. ZIFAS staff and other M&E officers from the four states were given Remedial actions to be undertaken by whom and when (including on the challenges outlined) WINNN, MNCH2 and ZIFAS should continue to monitor and support the use of the training manuals and HMIS monitoring tools to address poor record keeping culture, ZIFAS and partners to support and monitor regular compilation of HMIS data and use of the DHIS MNCH2 and ZIFAS to continue with support by random facility visits, regular & meetings to improve the tracking of coverage and monitoring of indicators through the state HMIS

17 Outputs and Activities (Zinc) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) a refrersher training on use of the tools on DHIS. Remedial actions to be undertaken by whom and when (including on the challenges outlined) Provide TA to SMOH/SPHCDA for the development of integrated supervisory plan for Zinc/Lo-ORS by each state of intervention. Training workshop at state level of Frontline workers on data collection and reporting of Zinc/Lo-ORS. x X No provision n phase 2 contract 484 Frontline workers trained (200 trained by December 2013 and 284 trained by April More health workers require training to address issues of staff attrition, leave etc ZIFAS staff will ride on the MNCH2 program structure to continue to use its existing integrated supportive supervision system to strengthen supervision of Zinc/Lo-ORS in each state MI, MNCH2 and other partners to support this 237 Midterm Process Evaluation 238 Provide TA to conduct End-line survey

18 Outputs and Activities (Zinc) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) Remedial actions to be undertaken by whom and when (including on the challenges outlined) 239 Half-yearly review meetings at State and LGA levels At least one frontline health workers in 80% of health Institutions/facilities in all the four targeted states have completed 2-3days training to improve their capacity and skills to deliver proper diarrheal treatment using zinc+lo-ors to children under-fives by February, Develop and print training manuals for Frontline Health Workers. x X X 200 front line health workers from the targeted 436 very busy facilities (45.8%)trained to improve their capacity and skills to deliver proper diarrhea by December 2013 Manuals developed in phase1. Printing of training manuals has been completed and are in use for training of the frontline health workers Manuals shared with other partners at state and national level e.g. the National Essential Medicines Coordinating Mechanism platform ZIFAS and MNCH2 should continue to use the training manuals; MI and NPHD should continue to advocate at the national level for other partners to use the manuals.

19 Outputs and Activities (Zinc) Training workshop at LGA level, state level of Frontline workers on data collection and reporting of Zinc/Lo-ORS. SBCC and IEC materials in place and in use to bring about attitudinal change of caregivers by June, 2013 x x FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) 484 Frontline workers trained (200 trained by December 2013 and 284 trained by April To address the issues of staff attrition, leave etc, more health workers require training in each facility SBCC and IEC materials produced in phase 1 have been printed and distributed; airing of jingles in progress but the air time is an expensive activity Remedial actions to be undertaken by whom and when (including on the challenges outlined) MI and other partners to fund this PRRINN-MNCH to contribute in paying for the airing of jingles 411 Provide TA to develop and test SBCC materials/fliers/posters for zinc/lo-ors (4 States). Completed in phase 1 ; 412 Production and distribution of developed SBCC materials for Zinc/Lo-ORS Concluded. Printing of the SBCC materials and additional printing to fill gaps completed and have been distributed in all states with partners at national level - e.g. the National Essential Medicines ZIFAS to monitor and support effective distribution and use from state to community level MI and NPHD to continue to lobby the national platform (NEMCM) on the use of these SBCC materials from ZIFAS

20 Outputs and Activities (Zinc) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) Coordinating Mechanism platform Remedial actions to be undertaken by whom and when (including on the challenges outlined) 413 Provide TA for production of radio and TV jingles promoting zinc/lo-ors. Completed in phase 1; airing of jingles supported and monitored to ensure value for money through most of phase 2. Airing of jingles has continued in phase 3 by ZIFAS who are also lobbying for government contribution to the airtime. Longer duration of airing is required to fully saturate the airwaves so more funding for this essential. Coverage is limited in Yobe due to security situation ZIFAS team should continue to monitor the airing of radio and TV jingles; ZIFAS to lobby for MNCH2 contribution to the airing and other partners to fund more air time ZIFAS and other partners to lobby for the radio stations and state government to contribute to the cost of airing

21 1.3 Unanticipated activity/output achievements-zinc Airing of the jingles and TV documentary have also increased awareness on the use of Zinc and lo-ors in diarrhea treatment of under 5 children to policy makers, stakeholder etc in all 4 states. Some of the radio stations like Yobe and Jigawa aired for longer durations beyond the contract period as their commitment to the process. A free one hour air time for phone program has been proposed for the ZIFAS activities by Yobe State government. The TV documentary was produced onto CDs as part of LGA health education tools at the community level as is still being used as a community mobilisation tool by the MNCH coordinators at the LGA level. The training and SBCC materials share with partners at the national level are being adapted by other States for example Bauchi State among others Development partners are gradually understanding the need to use harmonised monitoring tools and the HMIS tools and the NHMIS form 001 tool have provided a platform to translate this desire and knowledge into action. Eventually, this will be more sustainable and easier for the management of most program activities Major Program management activities-zinc Continued airing of the radio and TV jingles has enhanced awareness of ZIFAS activities to policy makers, health managers, frontline health workers and caregivers as well as the general public in all the states. Regular meetings were carried out between MI team andmnch2 and NPHD/HPI teams to introduce the program to MNCH2 and enhance collaboration between the two program. This has worked well generally and MNCH2 has offered ZIFAS program staff office space and limited logistic support when fully operational. Continued to hold frequent meetings between ZIFAS state officers and the States nutrition officers who are in-charge of state UNICEF nutrition and diarrhoea control activities. This has enhanced joint activities to address issues related to stock management and re-distribution of zinc and low ORS Distribution, monitoring and support for effective use of zinc and low ORS in targeted facilities Joint stakeholder meeting and collaboration with UNICEF, WINNN and other development partners on the use of Zinc and lo ORS commodities. Participation in weekly technical meetings organised by StateMNCH2 offices to share experiences and to resolve operational issues Two States have included ZIFAS State officers in the committee on integrated drugs and heath commodities logistic supply chain management Collaboration with DDIC program in Zamfara state to ensure the inclusion of all ZIFAS commodities in the list of DDIC items to be distributed and be monitored by that program. DDIC covers about 70% of targeted facilities using Zinc and lo_ors and about 50% of facilities providing ANC services. Regular internal ZIFAS program team meetings to discuss plans, share experiences and build capacity for better programme delivery

22 1.4 Status on implementation of the Risk Mitigation Strategy-Zinc Key Risks Update on Implementation of the Risk Mitigation Strategy Poor security situation Poor collaboration with other partners working on child health or drug supply Poor use of routine data and inherent poor data quality Other partners operating in our catchment states have a robust security management system and which the ZIFAS project staff aligned harness to their activities; these included the intelligence gathering and dissemination mechanisms, communication and transportation systems; good will from community groups and policy makers ZIFAS state officers are indigenes of their respective states and this enhances their ability to gather and use community intelligence, (a very useful security resource) fairly easily. Exploiting on the local ownership of ZIFAS project, the LGA MNCH Coordinators /Nutritional focal persons are involved in collecting and distributing of ZIFAS the commodities to the health facilities in security prone areas Postpone activities as and when due especially in Yobe Continued to engage other partners and work with SMOH to strengthen the weak collaboration mechanisms in each state. Build on gains from UNICEF and other DFID supported programs; participate, learn lessons and share information at the national essential medicines and commodities meetings to inform national policy and improve ownership and sustainability. More partners are participating in the ZIFAS joint quarterly stakeholder meetings with improved understanding of the core issues; most areas of disagreement are being resolved amicably. This platform has thus provided a powerful avenue to improve partner collaboration Provide intensive and sustained support to state M&E system and assisted Katsina and Jigawa to move from the NHMIS form 001 to NHMIS form 001 version 2013; monitor and support to front line health workers on the data they generate; MNCH2 supports has agreed to partner with ZIFAS on this issue by supporting regular conduct of data quality audits and the use of other approaches. 1.5Revised PIP-Zinc (Mention the part of activities you intend to reschedule the agreed implementation dates).

23 1.6 Key deliverables achieved Distribution of additional printed copies of training manuals, HMIS tools and delivery receipt sheets Distribution of additional copies of SBCC materials to SMOH, health facilities and other stakeholders in all states. Radio and TV jingles and media schedule of paid slot prepared and airing of radio and TV jingles in all 4 states Refresher training of M&E officers and ZIFAS staff on data tools, data collection and use of DHIS Progress reports of tracking coverage of implementation at LGA and facility level and monitoring of MI/CIDA required indicators in all the 4 states Tracking of coverage of implementation at LGA level and monitoring of MI/DFATD required indicators. Ongoing support to FMOH on the development of revised draft of National Essential Medicine List (NEML) A joint stakeholder meetings with participants from all the states and from zonal and national partner program offices including the MI Country Director and Program Officer was carried out on October 15. Key CIDA indicator target result by October.2014 in attachment F. 1.7 Constraints and lessons learned Security remains a key constraint in northern Nigeria and especially in Yobe following the declaration of state of emergency. Learning to work within and among the stakeholders and using other stakeholders robust security network system and good will has been very rewarding. The appointment of state ZIFAS officers from the respective states is a positive step to and good principle on how to work in fragile states The long time required to collaborate with UNICEF regarding the quantity and distribution of additional zinc and lo-ors which they had promised since April this year. The limited availability of the commodity in the four states is a real challenge This confirms the adage that effective collaboration takes time to mature. Harmonising the storage and distribution system for zinc and low ORS has continued to remain a major challenge. Harmonising logistic and supply chain system is key to ensuring value for money and greater and sustainable impact. The process however takes time in a chaotic supply chain management environment with lots of vested interests and negative attitude to such changes. The use of HMIS tools for record keeping at the facility level by frontline health workers is yet to reach the desired level. Continued support monitoring and supervisory visits by ZIFAS team has been helpful in improving the culture of record keeping. The visits in themselves act as motivating factors to health workers and improve their productivity and commitment Use of routine HMIS and DHIS platform for data management has continued to delay the provision of timely and good quality data and is also expensive. However, once institutionalised provides a platform for policy and advocacy on key health issues Airing of jingles long enough to saturate the airways is essential for behaviour change. This is however expensive. Engagement with media houses to support as been very positive in Yobe and Jigawa and recently in Katsina and Zamfara. This progress is possible due to the engagement and cordial relationship between the

24 radio houses and the ZIFAS team ensuring that the medial houses own the programs. Additional stock of Zinc is required as most of the existing stock will expire or be used up by the end of October Providing the actual stock levels has been a challenge because they are under the control of the nutrition officers and not state medical stores. Streamlining the supply and logistic chain management will ensure more accurate and faster information on stock levels at all levels 1.8 Annex 1: Progress in attaining the key results in Zinc intervention linked to CIDA PMF

25 Comments: Ultimate Result Area Result Area Annual Target for year under review Results Q1 Q2 Q3 Q4 Total Oct - jan - Apr - Jul - Dec 13 Mar 14 Jun 14 Sept 14 Will the annual results going to be achieved? Remedial action needed? (By who and when?) By 2015, to increase by 50% from baseline (TBD) the proportion of cases/episodes of under-five children in 4 states of Nigeria presenting with diarrhoea at public health facilities and community delivery sites treated for diarrhoea with a course of zinc supplementation for 10 days, in addition to lo-ors as an integral part of their diarrhoea management. Intermediate (1) Coverage: In states targeted by MI, the # of girls & # of boys aged 0-59m whose diarrhoea treatment included zinc. (2) Utilization: In states targeted by MI, the % of girls and the % of boys, whose diarrhea treatment included zinc, who consumed the minimum recommended quantity (10 tabs). 0% coverage by March, % utilization by March, ,103 76, , ,686 Based on HMIS data as at October 2014 To be reported after Midterm survey (MTS)

26 100: National health managers in FMOH & NPHCDA: champion (a) rapid revision and (b) wide dissemination among all stakeholders of National Diarrheal Treatment Policy Guidelines and National Essential Medicine List that that have been revised to include zinc and lo-ors based on WHO guidelines and recommended formulations. 200: State and LGA health managers in Four (4) State (SPHCDA/SMOH) : Plan for procurement/ requisition and arrange timely efficient distribution of guidelines and of sufficient supplies of Zinc and Lo-ORS to LGAs for all health facilities, coordinate state wide promotion of zinc+lo-ors treatment seeking (along with private sector counterparts), organize and oversee facility staff at LGA level, supervisor training, direct supportive supervision, oversee training, supervision and monitoring of the quality The extent to which decision makers are aware of the need to (a) Revise and adapt WHO guidelines for diarrheal treatment for the country. (b) ensure availability of new dispersible Zinc sulfate and Lo-ORS (3) Local supply adequacy: In states targeted by MI, the % of districts (LGAs) that had no stock outs of zinc supplements and ORS in at least over 80% of their service delivery points (health facilities). Medium awareness by March, 2013 Medium awareness by March, % by March, % 100% 100% 100% 100% To be reported after Midterm survey (MTS) To be reported after Midterm survey (MTS) This data is at LGA level.

27 of diarrheal treatment provided in facilities in all the LGAs. 300: Frontline health workers in facilities and community volunteers: Deliver correct treatments based on WHO guidelines for diarrheal treatment with zinc/lo-ors, counsel caregivers about diarrheal treatment and management and help promote it locally. In states targeted by MI, % of frontline health workers who are aware of the need to use Zinc and Lo-ORS for diarrhea treatment. In states targeted by MI, % of health facilities treating all diarrhea cases under-5 years with recommended dose of Lo-ORS/zinc. 30% by March, % of health facilities by March, 2013 To be reported after Midterm survey To be reported after Midterm survey

28 400: Caregivers: seek treatment for all under-five children with diarrhea based on raised awareness of the benefits and contact points. In states targeted by MI, % of diarrhea-cases under 5years treated with recommended dose (amount) of ORS/Zinc at CHWs Site (Community) by community/village Volunteers. # of caregivers of under-5 diarrhea cases who are referred to PHC centres or other higher health service institutions from CHW sites by community/village volunteers. (4) Beneficiary Awareness: In states targeted by MI,% of caregivers of children 0 to 5 who are aware of the need to use Zinc and Lo-ORS for diarrhea treatment. (5) Beneficiary knowledge: In states targeted by MI, % of caregivers who can 0% by March, % of all referable cases by March, % by March, % by March, 2013 To be reported after Midterm survey To be reported after Midterm survey To be reported after Midterm survey To be reported after Midterm survey

29 Outputs 210: Forecasts and costings (for zinc+lo-ors for diarrheal treatment and health worker training) have been provided to all the four states and LGA health managers (SPHCDAs/SMOH) for inclusion in their costed integrated health plans by January, : In all the four states, a medium term procurement and distribution plan for zinc and lo-ors supplies to all health facilities based on WHO guidelines developed and financed by March, identify benefits of treating childhood diarrhea with zinc and ORS, and describe how to obtain them. # of states with coasted state integrated health plan which includes Zinc/Lo-ORS for diarrhea. In states targeted by MI, the % of health facilities with no Zinc/Lo- ORS stock out. 1 of the states by March, % of health facilities by March, % 85% 82% 84% 82% Based on HMIS data. Figures were updated based on current available HMIS data. NB Data was wrongly reported in Q1 and Q2 as HFs with stockout instead od HF with No stockouts

30 230: M&E framework and monitoring tools developed, tested, adjusted and demonstrated to HMIS decision makers with advocacy for their adoption and incorporation into routine HMIS by March (6) National Supply adequacy: In state targeted by MI, % of targeted children 0-59m for whom zinc and lo-ors supplies were reported as available in-country per year % of health facilities which report timely data on diarrheal treatment. % of health facilities which report accurate data on diarrheal treatment. 0% of targeted children 6-59m by March, % by March, % March, % 81% 81% 80% 80% 81% 81% 81% 80% 80% based on available stocks of zinc Based on HMIS data as at Oct 2014 (data for previous quarters were also updated based on current DHIS2 data) Based on HMIS data as at Oct 2014 (data for previous quarters were also updated based on current DHIS2 data) 310: At least one frontline health workers in 80% of health Institutions/facilities in all the four targeted states have completed 2-3days % of health facilities with a frontline worker trained in the management of 5% by March, 2013 To be reported after Midterm survey

31 training to improve their capacity and skills to deliver proper diarrheal treatment using zinc+lo-ors to children under-fives by February, : SBCC and IEC materials in place and in use to bring about attitudinal change of caregivers by June, diarrhea including the use of lo-ors/zinc as part of IMCI refresher training. % of trained frontline health workers who scored positively on knowledge/use of lo- ORS/zinc in management of diarrhea during post- IMCI training. (7) Information disseminated: % of key intermediaries provided and caregivers with information on the importance and benefits of treating diarrhea with zinc and lo-ors, and on how to obtain them 40% by March, % by March, To be reported after Midterm survey To be reported after Midterm survey

32 Iron and Folic Acid (IFA) Intervention 2.1 Introduction-IFA Name Strengthening the Iron and Folic Acid Supplementation (IFAS) Program for Pregnant Women in Nigeria. Start Date End Date Location Implementi ng Partners CID A Mus koka Total Q 1 HPI (PRRINN-MNCH) FY2012/13 Q2 Q3 Q4 FY 1 tot al Q1 Area NIGERIA (Country) Annual Budget CDN$ 318,595 Q2 Budget CDN$ 000s 2 FY2013/14 Q 3 Q4 FY 2 tot al FY2014/15 Q1 Q2 Q3 Q4 FY 3 total Tota l

33 2.2 Project Implementation review results-ifa Outputs and Activities (IFAS) FY 2013/14 Status of Implementation (a. on activities for the quarter under review including challenges encountered in the implementation of planned activities b. are activities for the following quarter on track) Remedial actions to be undertaken by whom and when (including on the challenges outlined) Ref1 Ref2 Q1 Q2 Q3 Q Forecasts and costings (for IFA procurement and health worker training) have been provided to All four states for inclusion in their costed integrated health plans by January, 2013 Provide TA to develop costed integrated health plan by each state of intervention. Conduct meetings with Stakeholders x x x x X X Completed in phase 1 Dissemination plans carried out to enhance implementation and for developing 2014 health sector plans in phase 2. Inadequate, delayed or nonrelease of budget ZIFAS team worked with States incorporated activities in 2015 States Annual Operational plans Ongoing engagement and meetings with stakeholders in each state using existing platforms for support to improve implementation of program activities. Meetings also addressed ZIFAS and partners to advocate continuously for the release of budgeted funds for 2014 annual health plans and that 2015 States plans and budgets are approved as proposed for ZIFAS activities MNCH2 and ZIFAS to continue engagement; MI and NPHD to continue to pursue the issue of revision of the NEML and Standard Treatment Guidelines with IFAS included on the list States ZIFAS