INTRODUCTION

Nigeria falls significantly short of the universal health coverage (UHC) targets set by the nation. Nigeria’s public health expenditure is sub-optimal, with out of pocket expenditure at 71.5%[1], a 0.2% decrease from the 2014 WHO Global Health Observatory for Nigeria. The relatively high levels of private out of pocket expenditure, does not reflect improvements in the health systems and the achievement of the goal of UHC. Access in Nigeria to lifesaving drugs for the poor and vulnerable is generally low, with only a proportion afforded adequate coverage. Two of such drugs in focus are Amoxicillin DT and Zinc-LO-ORS described by UNICEF and WHO as effective and cheap for the first line treatment for childhood pneumonia and diarrhoea, respectively.

It is on this premise that the Partnership for Advocacy in Child and Family Health at Scale (PACFaH@Scale) project, a social accountability project anchored by the development Research and Projects Centre (dRPC) sought to expand healthcare access to the poor and vulnerable by advocating for the inclusion of the WHO recommended treatment protocols and the subsequent increase in the implementation of the newly adopted policies to end childhood killer disease (Amoxicillin Dispersible Tablet and co-pack Zinc-LO-ORS for Childhood Pneumonia & Diarrhoea respectively) through the Primary Health Care (PHC) system and with community pharmacists (CPs) and patent proprietary medicines vendors (PPMVs) as private sector providers at National level and in Niger, Kaduna and Kano States. The Pharmaceutical Society of Nigeria (PSN), a civil society partner implemented the PACFaH@Scale project as one of the primary sub-grantees of the dRPC from 2014-2017; advocating for the mainstreaming of Amoxicillin DT as first line treatment for childhood Pneumonia and ORS-Zinc (co-pack) as treatment for childhood diarrheal diseases and for increase in the total health funding in Nigeria.

BRIEF OVERVIEW OF THE PROBLEM

In Nigeria, Pneumonia and Diarrhoea account for 14% and 9% of these preventable deaths amongst under- fives2. Together, these diseases are responsible for at least 23% of U-5 mortality; preventing Nigerian children from growing up to celebrate their fifth birthday. Due to poor access to life-saving drugs, 854,000 of the 7,028,000 annual live-births in Nigeria die before their fifth birthday[2]. Translating to one in every eight Nigerian child[3].

There was an urgent need for the government of Nigeria and other relevant stakeholders to place priority on mainstreaming this management of childhood Pneumonia and Diarrhoea. By addressing these two diseases alone, we would save over 196,000 deaths annually in Nigeria. The bar chart below highlights the pneumonia and diarrhoea profile of under-fives of select North-western States in Nigeria prior to initiation of intervention by the PACFaH@Scale project from the National Demographic Health Survey (NDHS) 2013.

[1] National Health Account 2016

[2] Nigeria National Demographic & Health Survey 2013

[3] Multiple Indicator Cluster Survey 2017

THEMATIC AREAS IDENTIFIED FOR PUBLIC PRIVATE PARTNERSHIP (PPP)

Embracing the heterogeneity of health systems, and adopting holistic strategies that combine public and private schemes will contribute to providing seamless coverage across social groups in Nigeria. Some thematic areas identified where strong PPP holds opportunities included:

• Leadership and Governance: Health systems depend on the quality of governance arrangements for the achievement of enhanced performance. Health-related PPPs can both target supporting general governance improvements and themselves offer strong governance.
• Policy and regulation: PPPs are often dependent on policies and regulations thus a regulatory actor has to exist to govern the PPP project.
• Advocacy: This seeks to keep the above two accountable on commitments. This role will be played by the CSO advocates and champions not just in the third sector but also in the public and private sectors.

INNOVATIVE APPROACH ADOPTED TO BREAK DOWN BARRIERS

PSN, under the PACFaH@Scale project, aimed to hold duty bearers in the executive and the legislative to account on funding and policy commitments as well as reducing administrative and regulatory barriers to child and family health via advocacy. Utilizing the concept of the PACFaH@Scale advocacy cycle in figure 2 below, PSN developed evidenced based advocacy messages, identified advocacy targets and formed media and other civil society organisation coalitions.

Figure 2: The Advocacy Cycle

Figure 3: The PACFaH project theory of Influence

The above advocacy strategies were deployed through evidence generation and dissemination; coalition building; advocacy visits/meetings; policy dialogues; media and CSO coalition capacity building; media dialogues; press-briefings and roundtable discussions on the backdrop of the theory of change and theory of influence in figure 2 above which highlights our intentions on how we aim to achieve results.

Key advocacy messages developed for ending childhood killer diseases:

• By mainstreaming the approved childhood Pneumonia and Diarrhea policies, the over 196,000 children who die every year in Nigeria from these diseases can be saved; and
• Implementation of the approved childhood Pneumonia and Diarrhoea policies is critical to ending U-5 mortality in Nigeria.

By advocating for increased implementation of the newly adopted policies to end childhood killer disease (Amoxicillin dispersible tablet and co-pack zinc-LO-ORS for childhood Pneumonia & Diarrhoea respectively) through the PHC system, and with CPs and PPMVs as providers at National and state level, strengthening the National Drug Formulary7 with Amoxicillin DT as first line treatment for childhood Pneumonia and ORS-Zinc as treatment for childhood diarrheal diseases; and by strengthening civil society organisation (CSO) and media coalitions in support of Amoxicillin DTA as first line treatment for childhood Pneumonia and ORS-Zinc as treatment for childhood diarrheal diseases, we can expand healthcare to the under-fives who are represented in the subset of the poor and vulnerable population.

Advocacy targets mapped and identified:

The primary advocacy target(s)-those with direct authority to make decision:

• National Council on Health;
• Honourable Minister of Health; and
• Honorable Commissioners for Health (Lagos, Kaduna and Lagos States).

The secondary advocacy target(s)-those in position to influence the primary advocacy target(s):

• National Standard Treatment Guideline (NSTG)/Nigeria Essential Medicines List (NEML) review committee;
• Registrar, Pharmacists Council of Nigeria (PCN);
• Directors, Family Health; Food & Drugs Services; Health Planning, Research & Statistics, Hospital Services; Nursing Services; Procurement; Budget FMOH; Executive Secretary-NPHCDA-National level;
• Directors, Pharmaceutical Services; Family Health; Health Planning, Research & Statistics; Hospital Services; Nursing Services; Procurement; Executive Secretaries-SPHCDA; SDMA-State level

The ultimate target group(s) – those in position to influence both the primary & secondary targets;

• Champions and change agents;
• Network of civil society organizations-including women, youth groups etc.;
• Health care service providers;
• Health care professionals; and
• Media

The beneficiaries of the advocacy efforts were: children aged (0-5years); Health care professionals; Child and family health decision-makers in government at National and State levels. The policy change when completed will enhance the work of the National and State level officials.

The Pharmaceutical Society of Nigeria (PSN) leveraged on the media and CSO coalitions established during the PACFaH (2014-2017) project. Among the CSOs in this coalition were professional associations, and youth and women groups, which were strategic secondary and ultimate advocacy targets for this project.

A rapid assessment (baseline) of the coalition members’ capacities was conducted prior to engaging them. The media and CSO coalition members who met the baseline assessment criteria then had an orientation program. The media and CSO coalitions were supported to develop and implement advocacy activities around thematic areas and geographies. For sustainability, the media and CSO coalitions were encouraged and supported to inculcate this scope of work into their respective organizations. Situational analysis on childhood pneumonia and diarrhoea were conducted in Kaduna, Kano and Lagos states, also conducted were knowledge, attitude, behaviour and practice to generate evidence of the gaps in the aforementioned states in Nigeria.

In achieving the advocacy goals assigned to PSN during the implementation of the completed PACFaH at Scale (PAS) in 2018, the PSN identified and formed coalitions with other civil society organisations. The Grantees in this group included Society for Family Health/IntegratE; AFP/Pathfinder; Albright Stonebridge Group (ASG); and John Snow Inc./Access Collaborative. The group held series of advocacy strategy review meetings and strategized on engaging relevant stakeholders on key advocacy deliverables.

SUCCESS STORIES FROM IMPLEMENTING INTEGRATION STRATEGIES

The PACFaH project supported the Federal Government of Nigeria through PSN to revise the Nigeria National Treatment Guidelines with the inclusion of the WHO recommended treatment protocol for childhood Pneumonia (Amoxicillin Dispersible Tablet) and Diarrhoea (co-pack Zn-Lo-ORS) between 2014 and 2016 after a series of multi-stakeholders engagement and advocacies to government ministries, departments and agencies (MDAs) and professional associations. In July 2017, the PSN-PACFaH project supported the Federal Ministry of Health (FMOH) to launch the revised national treatment guidelines in Abuja, Nigeria[1][2].

FMOH launch of the National Treatment Guidelines July 2017

[1] https://sundiatapost.com/2017/07/21/stakeholders-urge-fg-to-check-arbitrary-hike-in-sale-of-drugs/; https://drive.google.com/file/d/0B_t3eX_XN9jLWmRra2lvZWNSZHhnX09RdklwNzZ2OHd4ODdn/view

[2] http://leadership.ng/2017/07/24/health-ministry-launches-stg-eml-harps-compliance/

After the policy launch, further situational analysis and knowledge, attitude, and behaviour assessment by PSN revealed that there was inadequate childhood killer disease (CKD) policy dissemination among key Directorates within the Federal Ministry of Health (FMOH). This has led to non-integration and collaboration in the rolling out of the policy nationwide. Only the Departments of Food & Drug Services and Family Health (Child Health Division) were actively mainstreaming the CKD policy at FMOH slowing the pace of implementation.

To mitigate this challenge, the PSN-PAS project proposed collaboration with the Food & Drug Services and Family Health Departments of FMOH to organize a one-day event where all the Directors and senior officers of ALL the departments in FMOH will be engaged to understand the newly adopted CKD policies as well as the National Essential Medicines List (NEML) and National Standard Treatment Guidelines (NSTG). This increased knowledge, roll-out, support and implementation of not just the CKD policies but other key child and family health policies in the NEML and NSTG.

PSN-PACFaH@Scale worked with other PAS sub-grantees to support the government in disseminating the new national Childhood Killer Disease protocols through a series of zonal meetings. PSN worked with Centre for Communications and Reproductive Health Services (CCRHS-PAS) to disseminate the protocols in the South and North Central Zones on the 24^th July 2018 in Lagos state. Key stakeholders included UNICEF and CHAI representatives as well as government bureaucrats drawn from the FMOH, Lagos, Osun, Ogun, Ondo, Oyo, Ekiti, Niger, Kwara, Nasarawa, Benue, FCT, Plateau and Kogi States, in attendance.

PSN-PACFaH@Scale also worked with Aminu Kano Centre for Democratic Studies (AKCDRT-PAS) to disseminate the protocols in the North-West and North-East zones on the 27^th July 2018 at Tahir Guest Palace, Kano State. The government officials were drawn from FMOH, Kano, Kaduna, Katsina, Sokoto, Yobe, Borno, Bauchi, Jigawa, Zamfara, Adamawa, and Kebbi States alongside WHO.

In collaboration with Rural African Health Initiative (RAHI-PAS) they disseminated the protocol in the South-South and South-East zones. This strategic activity was conducted on Tuesday 11th September 2018 at Sparklyn Hotel, Port Harcourt, Rivers State. Directors from the Federal Ministry of Health and the chairman/members of the NDF/EDL review committee were present. Other key delegates at the meeting were Directors Medical/Hospital/Pharmaceutical Services from Rivers, Akwa Ibom, Bayelsa, Edo, Enugu, Ebonyi, Abia, Imo, and Anambra State Ministries of Health. Professional Associations-Nigerian Medical Association, Pharmaceutical Council of Nigeria, National Association of Nigerian Nurses and Midwives, National Association Patent Proprietary Medicines Dealers (NAPMED), as well as development partners Clinton Health Access Initiative (CHAI) and media were in attendance.

The government officials from the different geographical zones of Nigeria committed at the end of the event to domesticate and implement (by procuring, and utilizing AMX DT and co-pack Zinc-Lo-ORS) the revised treatment guidelines for the management of Childhood Pneumonia and Diarrhoea in their respective States[1] [2] [3].

[1] https://leadership.ng/2018/08/04/why-pneumonia-diarrhoea-persist-in-nigeria/ & https://www.vanguardngr.com/2018/07/stakeholders-call-for-rational-use-of-essential-medicine-in-nigeria/

[2] https://www.dailytrust.com.ng/fg-presents-guidelines-on-reviewed-essential-medicines-lists-263289.html, https://www.vanguardngr.com/2018/08/psn-to-state-govts-domesticate-new-treatment-guidelines-for-pneumonia-diarrhoea/ and https://leadership.ng/2018/08/09/child-killer-diseases-northern-govs-charged-to-domesticate-treatment-guidelines/

[3] https://www.nan.ng/health/ngo-tasks-govt-on-health-sector-funding/amp/

https://www.vanguardngr.com/2018/09/why-states-should-domesticate-neml-policy-ngo/

South-East/South-South Zones (Rivers State)

North-West/North-East Zones (Kano State)

South-West/North-Central Zones (Lagos State)

Building on the momentum generated at the dissemination meetings, the PAS-NGOs in Niger, Kano and Kaduna mapped the CSOs and coalitions working on CKD to empower them to monitor the elimination of CKDs over the life of project.

Integrating Public Private Partnership Approach for Breaking Down Barriers for The Expansion of Healthcare Services and The Resulting Impact

There were issues highlighted during the roll-out of the CKD policies at the community level through the critical private health care providers (CPs and PPMVs). While FMOH had approved the use of Amoxicillin DT and co-pack Zn/Lo-ORS at the community level in the NEML and NSTG, the Pharmacists Council of Nigeria (PCN) and NAFDAC who jointly regulate private providers’ practice at the community level, were yet to adopt and revise their guidelines to align with FMOH. Having identified the thematic area Policy and regulation, with an understanding that PPPs are often dependent on policies and regulations thus, a regulatory actor has to exist to govern the PPP. The PSN-PACFaH@Scale conducted advocacies to and workshops with the regulatory body (PCN) on supporting this critical government agency to review the PPMV List with the inclusion of all the recommended policies (CKD inclusive) for child and family health at the community level by PPMVs to align with FMOH. The pre-advocacy status of the PCN PPMV List prevented PPMVs from stocking and selling of these life-saving commodities at the community level, as they faced harassments and detention by the PCN and National Administration for Food and Drugs (NAFDAC). The PSN-PACFaH project from 2015 to 2017 supported to revise the State Essential Medicines List (EML) with the inclusion of the recommended Childhood Killer Diseases (CKD) protocols (Amoxicillin DT for Pneumonia and co-pack Zinc/Lo-ORS for Diarrhoea). The PSN-PACFaH project also supported at State level to develop a draft Costed Implementation Plan (CIP) for CKD and advocated for States to commence procurement of Amoxicillin DT and co-pack Zinc-Lo-ORS. The inclusion of the private sector (CPs and PPMVs) by revising the PPMV list expanded access to these life-saving drugs for hard to reach areas. Through the innovative efforts of the PACFaH@Scale project, there was a policy change. Achieving this policy change to include these live saving drugs into the treatment guidelines was a big win for the project and the communities that had high prevalence of the childhood killer diseases with low or no access to life-saving drugs for treatment, because now the private providers are now able to stock and provide these drugs.

The Impact Of PACFAH@Scale’s Work and The Resulting Policy Change

Figure 4: Prevalence Of Diarrhoea And Acute Respiratory Infections In Under 5’s (National Demographic Health Survey 2018)

The PACFaH@Scale project’s efforts in the updating of the essential medicines list and the patent proprietary medicines lists to include these drugs resulted in the expansion of access to these drugs especially to the hard to reach areas, as the private sector could now stock these drugs. The bar chart above (figure 4) highlights the resulting reductions in prevalence of diarrhoea (NDHS 2108) when compared to (NDHS 2013) figure 1. With Kano state witnessing a 13.9% decrease in prevalence and Kaduna state, a 12.9% decrease amongst other states highlighted in this region.

CONCLUSION

The burden of many low and middle income countries health systems is that of under resourcing and non integration which leaves many without access to quality basic health services including life-saving drugs. PSN-PACFaH@Scale, through advocacies to policy makers and stakeholders, partnerships with media and civil society organisations and integration of the private sector are changing the narrative having managed to expand the reach of life saving commodities through our work in policy change in a bid to reducing the incidence, prevalence and ultimately the mortalities of under-fives from childhood pneumonia and diarrhoea in Nigeria. The problem of non-inclusion of relevant stakeholders can mar the success of advocacies for policy change at different level. It is our recommendation that for further works on advocating for policy change for healthcare services, it is pertinent to place high priority on mapping of strategic stakeholders and coalitions for reduced resistance by all parties involved and/or affected by the policy change and for the sustainability of the said policy.