To Identify Key Issues in the Kaduna State Government’s Financial and Policy Initiatives on Child and Family Health Policy

FAMILY PLANNING

REPORT OF STUDY
TO IDENTIFY KEY ISSUES IN THE KADUNA STATE GOVERNMENT’S FINANCIAL AND POLICY INITIATIVES ON CHILD AND FAMILY HEALTH POLICY

Published by:
The National Institute
Kuru, Nigeria
Email: info@nipsskuru.gov.ng
Website: www.nipsskuru.gov.ng
© 2018, National Institute for Policy and Strategic Studies, Kuru.

ISBN: 978-978-198-143-7
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form of or by any means, now known or thereafter invented, electronic, mechanical, photocopying, recording or otherwise without the prior written consent or permission of the publisher. Exceptions are allowed strictly in respect of research or private study, critique or review.

Team Leader/Principal Research
Prof. Habu S. Galadima
Director of Research, NIPSS, Kuru
Nigeria

Research Team, NIPSS, Kuru
Prof. Kursim L. Fwa, mni
Dr. Philemon Haggai
Dr. Ibrahim D. Choji, mni
Dr. Akeem M. Adeyanju
Dr. Musa E. Umar
Dr. Kingsley Ozele
Mrs. Egweye Egbodo
Dr. Fidelis Ikpe

Table of Contents

Introduction … … … … … 1

Aim and Objectives … … … … 2

Methodology … … … … … 3
Findings … … … … … … 4
Recommendations … … … ..15

FAMILY PLANNING (FP)
INTRODUCTION
Nigeria being the most populous country in Africa with a population of 198 million and growth rate of 3 percent (NPC 2018), has made Family Planning issues very important in the country. According to NURHI (2011) the use of family planning in Nigeria is very low where only 10 percent of married women use modern family planning methods. To address the health and social consequences such as high fertility, maternal and child mortality rates and low utilization of family planning services in the country, the Partnership for Advocacy in child and family health at scale (PACFaH@Scale) intervened in a health accountability project aimed at increasing State Government’s funding for 4 health issues. These are Family Planning (FP), Routine Immunisation (RI), Ending Childhood Killer Diseases and Primary Health Care Under One Roof (PHCUOR). This report is the outcome of a field research conducted by a team from the National Institute for Policy and Strategic Studies, (NIPSS) that assessed the nature and extend of the implementation of the PACFaH@Scale’s intervention on health accountability project in Kaduna State.

AIM AND OBJECTIVES
The aim of the study was to assess the nature and extend of the implementation of the health accountability project of PACFaH@Scale for Family Planning in Kaduna State. The objectives of the study are to:
a) Determine the causes for late and sub-optimal allocation and release of Family Planning funds in Kaduna State;
b) Examine the reasons for the low priority accorded to Family Planning amongst strategic policy makers in Kaduna State; and
c) Identify the persistence of barriers to expanded Family planning access in the regulatory agency in Kaduna State.
METHODOLOGY
This study utilized the qualitative method of data collection. Focus group discussions (FGD), key informant interviews and In-depth interviews were conducted with relevant stakeholders in the State’s Primary Health Care Development Agency, government officials working in family planning and others such as Finance, Administrative and M&E Officers. A total of ten respondents participated in the Key Informant Interview, which included two Desk Officers, one Finance Officer and one Administrative Officer. In addition, In-depth Interview was conducted with Donor Agencies (UNFPA, Save the Children, SOLINA, CHAI, PI), two respondents per agency. There was interaction with three PACFaH Champions. The interviews/FGD were all conducted in English, audio-taped, coded and transcribed and transcriptions saved in Microsoft Word documents.

The secondary data was sourced from relevant documents such as books, journals, National Demographic Health Survey Report, Sustainable Development Goals Report, policy documents from the State’s Ministry of Health, Budget and Planning, State Primary Health Care Development Agency and the internet.

Findings
Whether the allocation to FP in the 2018 budget increased over the 2017 allocation and if the 2017 allocation was released in full
The Kaduna State government appropriated N120 million as counterpart fund for Family Planning for the 2017 Action Plan, while United Nations Population Funds (UNFPA) provided N480 million (Abdullahi, 2017). This programme was to sensitise adolescent women in the use of contraceptives for child spacing. This was confirmed by a respondent in a key informant interview. According to the respondent in 2017 only N100 million was approved by State Assemble. The fund was released in two installments in July and November but there was no cash backing. Similarly, the appropriation for 2018 decreased by 25 percent to N75 million and no release has been done in the first quarter of the year. Respondent stated that the programme planned for the year 2017 suffered set-back because of lack of cash backing. However, the only programmes that were supported by the partners were completed before the end of the year. It was noted that the state government funding was for the procurement of consumables while the partners supported the provision of the commodities for Family Planning. According to Leadership Newspaper (2017), increasing public sector funding for family planning will enable Nigeria to meet its Family Planning Blueprint goal of 36 percent contraceptive prevalence rate by 2020. This would save 22,000 mothers and 101,000 children.
A general opinion expressed by most respondents in a focus group discussion, indicated that although there are Desk Officers in each MDA to plan and remind policy implementers on their quarterly activities, the problem of the cash backing has always hindered adequate implementation of FP activities.
As corroborated by a respondent, in 2017 the State Government budgeted Four billion, two hundred and seventy six million one hundred, and fifty two thousand and seven naira. However, what was released was one billion, nine hundred and seventeen million five hundred and eight nine thousand thirteen naira fifteen kobo which is 44.84 percent of the budget. This has made implementation of the activities and programmes of the Primary Healthcare sub-optimal.
Whether there is an FP strategy or plan for Kaduna State and if it is based on the FP Blueprint or any other FP planning document
The Partnership for Advocacy in Child and Family Health (PACFaH, 2017) in a research observed that priority given to provision of effective and efficient family planning services in Nigeria has been poor and inadequate, evident was shown in poor allocation of resources leading to a huge gap in family planning services. Further evidences are the complex public budgeting system that relies on little or no use of appropriate data to determine resource prioritization and allocation. There was also low prioritization of family planning programmes within the health sector as shown by consistent low allocation of resources and persistent non-release of allocated funds to the programmes of Family Planning in Kaduna State (PACFaH, 2017). Similarly, the Ministry of Local Government Affairs, Kaduna State, stated that prior to 2012 there was no specific policy in the state to create a budget line for family planning. It was left at the discretion of the local government to decide, indicating the low priority to family planning amongst strategic policy makers.
A respondent with the EPID affirmed that now there is Family Planning strategy or Plan in the State, the Costed Implementation Plan (CIP) where basically all activities of the FP programmes are drawn from. Thus the FP activities that were harmonized in the AOP are from the CIP strategic plan, which was based on the National Blueprint. This has changed the FP funding in the state from zero funding in 2010 to the creation of budget line of N1,000,000.00 in 2017. The significant improvement in the contraceptive prevalence rate in the state from 8.4 per cent to 18.5 per cent (Alayande et al, 2016) is a notable achievement in the C.I.P. Strategic Plan for Family Planning in the State.
The focus group discussion also confirmed that there was a state Strategic Healthcare Development Plan which was domesticated from the National Strategic Plan or Blueprint. It was domesticated for a period of 5 years (2017-2022). The different health sectors in the state draw their implementation plan from it for a three-year plan. From the sector implementation plan each Ministry, Department and Agencies (MDAs) draw her annual operational plan. The state strategic plan was strictly implemented for budgeting and for the activity and programme of each MDA involve with primary healthcare.
Release of funding for FP for the first quarter in 2018
According to a respondent, there has been a decrease in releases and no cash backing for the first quarter of 2018. The Family Planning funding for 2018 decreased by 25 percent from N100 million in 2017 to N75 million. The reasons might be based on the expected revenue for 2018 and the expected support from Foreign Partners who provided the State Family Healthcare services with commodities while the state government supplies the consumables. These might be the reasons that informed the State Government to cut down on its FP budget for 2018.
NGOs in the state working on monitoring the state government’s performance in FP and are they using score cards
According to the EPID Coordinators of the Kaduna State Primary Healthcare Development Agency, there are NGOs and CSOs in the state monitoring the state government funding of Family Planning. These are Family Health Advocacy Initiative (FHANI), and Civil Organisations such as MSCH, Nigeria Urban Reproductive Health Initiatives (UNRHI) and HERFON. According to the coordinators these NGOs and CSOs are the ones pursuing the cash backing for the 2017 released budget for Family Planning in the state. They are pushing for the revalidating of the 2017 released budget for Family Planning that was not cash backed. These NGOs and CSOs are using score cards in assessing state government performance in FP funding.
To increase the budget monitoring role of the NGOs, according to a respondent, is to cash back the releases of the FP, then the activities and programmes will be implemented creating wider scope of work for the NGOs in monitoring the activities and programmes of the FP. Basically, if there are no releases and cash backing their roles, will only stay at the level of advocacy for financial support.
The FGD indicated that there were active NGOs involved in monitoring the state government’s performance in FP and they were using score cards. The Kaduna Maternal Women and Child Health accountability mechanism have been very active in organizing review meetings. However, there were other coalition of civil society groups such as the Maternal Neo-natal and Child Health (MNCH), all performing monitoring of government budget implementation for public healthcare in the state.
The FP champions within government agencies and how they can be supported through leadership development training workshops
The FP champions within government agencies are the people and officers that are pushing or advocating for increase funding for family planning activities and programmes. These are Directors in the Budget and Planning Commission, Ministry of Finance and Women Affairs and the Kaduna State Primary Healthcare Development Agency. The respondents indicated that FP champions in the state were working hard to see that the FP budget releases are cash backed.
These FP champions will require in-depth capacity building in budget tracking and data collection and management for family planning. Although, the FP champions and some NGOs had had some level training in budget tracking in Abuja organised by Pathfinder International, they still required their capacities to be enhanced. Some areas of training need include advocacy for family planning and other reproductive health, data collation, analysis, interpretation and management.
Persistent Barriers to Expanded Family Planning Access in the State Family
One of the major barriers identified was insecurity in accessing family planning in the state. In the past, the state lost some FP providers and soldiers that were killed on their way for an FP outreach. Thus, even if the NGOs want to take the FP services to these communities, insecurity tends to be a major hindrance.
Lack of adequate data for planning the activities and programme of the FP was another barrier. The service providers lack the capacity to generate accurate and adequate data. For example, the State has 1,500 Primary Health Centres (PHC), but due to inaccurate and inadequate data, only 534 were provided with Family Planning services. There was a big gap in data generation which calls for capacity building of field officers.
Non-cash backing of releases which reduce the sufficient supply of consumables in the FP facilities in the state thereby limiting access was considered as a barrier. When the consumables are out of stock, the service providers sometimes asked the clients to pay a token. Thus, the women saw it as not providing FP services free thereby preventing many of them from accessing the facilities. Therefore, if government according to the EPID coordinator will be committed to cash-backing the funds for the procurement of the consumables and are then distributed to all the FP facilities, it will increase the number of women who can access the services.
Cultural and religious barriers were also identified by the EPID Coordinators. These were not considered as major barriers because some NGOs have been intensively working on the issues. For example, NURI has published a book on the perspectives of the two religions regarding family planning that has assisted in the acceptance of family planning and reproductive health and child spacing in many rural communities.
Another salient barrier was the inadequate training received by the healthcare providers as they find it difficult to implement some component of FP activities but only the ones they are familiar with. Therefore, there is the need for more capacity building and mentoring of service providers especially in skills and techniques of FP and data collection, analysis and interpretation.
Similarly, another salient barrier to FP access as indicated by a respondent is the non- harmonization of all the stakeholders rendering services such as the international and national partners, public and private service providers. This has not allowed for prioritization of resources and adequate data collection in the health facilities. For example, the PPMPs are providing services and the Kaduna state government does not have their data for proper planning, monitoring and evaluation.
The attitude of the service providers was identified by the respondents as another salient barrier especially in the choice of the Family Planning methods by clients. In Kaduna State, IUCD acceptance was high, but with the introduction of implant, the healthcare providers knowing that inserting IUCD requires many procedures and it is time consuming, usually shy away from introducing the women to it during counselling. For the implant where the insertion site is the arm, most women prefer it than exposing themselves to the healthcare providers to insert the loop in the case of IUCD. They find it more acceptable to insert the implant in the arm than the loop that can be sometimes discomforting.
Sourcing of data for FP in the State was generally a problem due to some deficiencies such as lack of capacity to generate accurate and adequate data by the staff, infrastructural gaps for data collection, analysis, and management. Similarly, other deficiencies are the mobility of trained staff in data collection, analysis and interpretation, who are moved to other assignments within the civil service.
The State government as indicated by some of the respondents was seriously committed to the provision of accurate data and has put an amnesty policy that ended in January 2018. After this dateline any staff caught falsifying any data will be punished according to the civil service rules. This policy was helping in addressing the gap between administrative data and the field survey data so that the quality of data can be improved. Presently the State Government has developed the Health Management Information System data tools for the generation of accurate data on Healthcare issues in the state. The HMIS data tools cover eight critical interventions.
The challenges healthcare providers were facing in completing the HMIS data form was due to inadequate staffing. Therefore, accurate and adequate data capturing were not always done. Similarly, Development Partners that invested in primary healthcare usually do have their data capturing tools different from the HMIS data tools to justify their investment, and these tools were usually handled by the same healthcare providers in the healthcare facilities. The data collected by the Development Partners hardly get to the state leaving a big gap in data collection. Therefore, to mitigate this there is the need to build the capacity of the healthcare providers on data collection in the state.
Recommendations
Based on the findings on FP, the following recommendations were made:
i. Kaduna State Government laudable efforts in increasing funding of Family Planning should be sustained;
ii. Kaduna State Government should ensure adequate and prompt release with cash backing of all budgeted funds for Family Planning in the state so as to provide adequate consumables that will meet the needs of the clients;
iii. Kaduna State Government should provide funding for the regular on-the-job training of Staff of KSPHCDA and, the primary healthcare centres and clinics throughout the state;
iv. The State Government and Development Partners should collaborate in enhancing the capacity of service providers in family planning activities specifically in data collection, analysis and implementation;
v. The Family Planning Champions in Kaduna State should strengthen its network and evolve effective strategies to further advocate for timely release of funds by the State Government for family planning activities.
vi. The collaboration between Kaduna State Government and NGOs should be further strengthened particularly in monitoring and evaluation to ensure that the goals of the Family Planning Blueprint are realised;
vii. Kaduna State Government and key stakeholders should discuss and address issues of family planning alongside reproductive health so that the two can be more effective and have a complete outcome in addressing child spacing, maternal and infant mortality and reproductive health issues;
viii. Kaduna State Government and Development Partners should collaborate to have a harmonised data on Family Planning in the State for purpose of effective planning;
ix. Kaduna State Government should strengthen the security of communities for family planning services to be effectively accessed.

REFERENCES
Braun V and Clarke V (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2). pp. 77-101. ISSN 1478-0887
Frequently Asked Questions on PHCUOR. Accessed online on 4th May, 2018.
Green J and Thorogood N (2009). Qualitative Methods for Health Research, 2nd ed, Sage Publications Ltd, London.
Health Partners International, HPI (2014). Bringing primary health care under one roof: 9 factsheets for implementation in Nigeria.
Sokpo E and McKenzie A. Primary Health Care Under One Roof. Policy to integrate management of Nigeria’s Primary Health Care Reflections from our experience in Jigawa state, Northern Nigeria. Accessed 4th May, 2018.

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