Introduction

Primary health care under one roof (PHCUOR) otherwise known as Integrated PHC Governance, is a primary health care (PHC) reform promoted by the Government of Nigeria to integrate the PHC structures and programs at sub-national levels, under one State-level body – the State Primary Health Care Development Agency or Board (SPHCDA/B) within the framework of a decentralized health system. The policy is based on the principle of “Three Ones”: One Management, One Plan and One Monitoring & Evaluation System.

The PHCUOR was initiated with support from DFID funded projects- Partnership for Transformation of Health Systems (PATHS 2005-2008) and Partnership for Reviving Routine Immunization in Northern Nigeria: Maternal Newborn and Child Health Initiative (PRINN-MNCH 2008-2014), became a national policy agenda following its endorsement by the 56th National Council on Health (NCH) in May 2011. The Council in its 58th Session in 2013 further approved the national guidelines and the policy document, for implementation, through its Resolution 29. The guidelines identify a conceptual framework for implementing the policy which consists of nine specific domains- Governance, Legislation, Minimum Service Package, Repositioning, Systems Development, Operational Guidelines, Human Resources, Funding Sources & Structure and Office Setup-and outlines specific steps and approaches involved in establishing a functional SPHCDA/B. In spite of the adoption of the Policy by the NCH, progress with implementation has been slow with States making varying degrees of progress on each domain.

In September 2012, a national stakeholders’ workshop organized by the NPHCDA with technical support from PRRINN-MNCH resolved that partners should work with the NPHCDA to support the States in the implementation of PHCUOR in line with the national guidelines. In line with this, the National Steering Committee (NSC) for PHCUOR was established in 2012 for the purpose of supporting and monitoring the implementation of PHCUOR in States. The same year, the NPHCDA (with support from HERFON and PRRINN-MNCH) developed a checklist for monitoring PHCUOR implementation progress. This led to the development of PHCUOR Scorecard 1 in 2012. In October 2013, the NPHCDA (with support from IVAC, HERFON and PRRINN-MNCH) expanded the existing checklist into an assessment tool which was used in all States to develop a National Scorecard 2. In 2015, the PHCUOR NSC commissioned the development of Scorecard 3 and the assessment tool used in Scorecard 2 had to be revised to increase sensitivity and expanded to include a qualitative questionnaire for better understanding of the implementation process in the States. These assessment tools have been administered in all the States and FCT, its findings analyzed and the latest Scorecard 3 developed. Assessments of States were conducted by NPHCDA supported by partners – HERFON, IVAC, UNICEF, SCI and PACT.

Background

Niger State is located in the North Central geopolitical region of Nigeria with a land mass of 76,481.1km2 equivalent to about 10% of the total land area in Nigeria. It was formed in 1976 when the then North-Western State was separated into Niger State and Sokoto State. It is considered as the state with the largest land area in Nigeria. The State is bordered to the north by Zamfara State; to the northwest by Kebbi State; to the south by Kogi State; to the southwest by Kwara State; while Kaduna State and the Federal Capital Territory border the state to the northeast and southeast respectively. Furthermore, the State shares a common international boundary with the Republic of Benin at Babanna in Borgu Local Government Area in the North West of the State. Niger State’s projected population for 2017 based on an annual growth rate of 3.4% is 5,706, 245 of which approximately 1,255,374 (22%) are women of reproductive age.

The state is named after the River Niger. Two of Nigeria’s major hydroelectric power stations, the Kainji Dam and the Shiroro Dam, are located in Niger State, The famous Gurara Falls is in Niger State, and Gurara Local Government Area is named after the Gurara River, on whose course the fall is situated. Also situated there is Kainji National Park, the largest National Park of Nigeria, which contains Kainji Lake, the Borgu Game Reserve and the Zugurma Game Reserve ¹

The state is made up of 25 Local Government Areas, 274 political wards spread across the 3 senatorial districts and 6 health zone. The 25 Local Government Areas are Agaie, Agwara, Bida, Borgu, Bosso, Chanchaga, Edati, Gbako, Gurara, Katcha, Kontagora, Lapai, Lavun, Magama, Mariga, Mashegu, Mokwa, Munya, Paikoro, Rafi, Rijau, Shiroro, Suleja, Tafa, and Wushishi. The current projected population from the National population commission is 5,900,257 and the women of Child bearing age is 1,255,374. See the table below for summary of Niger State Statistics as follows;

No of LGAs	25
No of Political Ward	274
Total No of Health Facilities	1,676
Total Population	5,900,257
Total No Women of Reproductive Age	1,298,057
Population of U5 Children	1,255,374
Total No of Settlements	16,788
Total No of Hard-To-Reach Communities	3,628
Maternal Mortality Ratio	352/100,000
Infant Mortality Rate	100/1,000
Under Five Mortality Rate	149/1,000

Fig1; The summary of Niger State Statistics⁴

PHCUOR implementation and its challenges in Niger state

Niger State Primary Health Care Development Agency (SPHCDA) was established in 2012 following passage of its bill by the State House of Assembly and assented by the Executive Governor of the State. It has a management team, with clear lines of accountability, led by an Executive Director who reports to the Governor through its Honourable Commissioner for Health. Part of the objectives of establishing the SPHCDA was to further reach the criteria for the fulfillment of the PHCUOR in the state.

Following the commencement of the Implementation of PHCUOR in Nigeria, Niger State also commenced the processes towards actualization of PHCUOR, hence the fulfillment of the criteria for her consideration as one of the states to assess the Basic Health Care Provision Funds in Nigeria.

Scorecard Three & HSDF Assessment Findings

In 2015 level of Implementation of PHCUOR was assessed in Nigeria with the use of a scorecard tool. The toll looked through level of performance in percentage of the nine pillars or domain of PHCUOR. Findings from the National scorecard 3 revealed that Niger state scored 61% overall in implementation of PHCUOR, ranking 6^th nationally and 1^st in the North Central geopolitical zone of Nigeria. The state scored high performance in Governance and Ownership domain (88%) and its lease performance in MSP domain (11%). Below is the National Scorecard presenting Niger State score from the assessment

Fig2: National Scorecard 3 Assessment of PHCUOR in Niger state¹  

Following the findings from the National Scorecard 3 of 2015 on Implementation of Primary Health Care Under One Roof in Nigeria which revealed some of the gaps on the level of PHCUOR Implementation in Niger State; topmost of which was the poor performance in the Minimum Service Package (MSP) domain with the score of 11%¹.  Health Strategy Delivery Foundation (HSDF), one of the partners working on health system strengthening in Niger State supported the state to undertake the costing of MSP.

The scorecard three assessments was followed by an independent assessment by HSDF in 2017 of PHCUOR implementation in Niger State. The assessment by HSDF also revealed as part of its findings, challenges around Implementation of PHCUOR in Niger State. These challenges were prior to intervention of PAS project by CCRHS PAS.

The challenges from the findings of HSDF assessment in Niger State are:

• Non-replacement of the Board to SPHCDA since its dissolution
• Staffs are currently operational at the facilities. However, the staff database is not automated
• The contributors of finance to the Agency are mainly the State and Donor Partners. However, the LGA currently fund the payment of salaries. Though the offices are equipped, the space to accommodate the current and expected staff of the Agency is grossly inadequate.
• 15% agreed support from the Ministry of Local Government and Chieftaincy Affairs not fulfilled
• No dedicated budget line for PHC system strengthening

To re-emphasize, the three key major challenges of the Implementation of PHCUOR in Niger State prior to intervention of PAS project were Lack of Board to SPHCDA, Lack of repositioning of PHC Staffs from Ministry of Local Government to SPHCDA and Lack of effective or Inadequate funding to the SPHCDA. Niger State does not have a functional board for the SPHCDA, resulting to slow pace of the agency to function as an independent body. The Coordination, monitoring and payment of staffs of the PHCs across the LGAs are being done by the Ministry of Local Government and Chieftaincy Affairs which do not allow effective coordination and monitoring of the HCW across the PHCs by the Primary Health Care Development Agency. Finally, SPHCDA is not adequately funded by the state and even the constituted support from the Ministry of Local Government and Chieftaincy affairs is not being fulfilled.

Score Card Four Main Findings

Another assessment on PHCUOR Implementation in Nigeria was carried out in 2018 with the use of scorecard 4. Findings from score card 4 revealed that Niger State scored 73% in the PHCUOR Scorecard 4 assessment placing it in the 2^nd position nationwide. Its best performing pillars include MSP 83%, Human Resources 83% and Office Setup 100% with good performance in other pillars³.

Fig3: PHCUOR Implementation scorecard 4 assessment of Niger State³

Summary of Findings Scorecard 4 from the figure above:

• Niger SPHCB has a governing board and a management team but no LGHAs established in the 25 LGAs of the State.
• Niger SPHCB has a Law establishing it but No regulations for the operationalization of the SPHCB Law.
• Niger SPHCB has a draft costed MSP that is not yet approved.
• There is no investment or service delivery plan. Investment/service delivery plan is not captured in the annual budget.
• There is a decreasing trend in the number of institutional maternal deaths, still births, neonatal deaths, Under 5years deaths.
• PHC department programmes (FP/MCH/Nutrition and Immunization) and staff in the SMoH have moved to the SPHCB. The SMoH has restructured its departments in line with the SPHCB reform and has conducted an orientation for the staff on the new roles and responsibilities of the SMoH.
• Malaria, HIV/AIDS and TBL are yet to be transferred to the SPHCB.
• LGA PHC departments have not been transformed to LGHAs with definite reporting lines to the SPHCB.
• The SPHCB has developed key strategic documents including strategic health development plan, ISS checklist, list of ISS team (including State and LGA members) and supervisory schedule. Performance review has been conducted on the SPHCB in the last year. State has functional data quality assurance system and has conducted a State-wide DQA in the previous year. Its HMIS facility reporting rate for the last 12 months is >80%.
• SPHCB has no PHC annual operational plan and no M&E /results/performance framework with clear milestones and targets.
• PHC staff in the LGAs, SMoLG and LGSC have moved to the SPHCB and on-boarded. There are job descriptions for all SPHCB staff and positions. SPHCB has staff nominal roll.
• There is no HR plan or HRIS for the strategic management of PHC HRH.
• SPHCB has dedicated bank accounts. SPHCB staffs are on the SPHCB payroll. PHC budget performance is periodically tracked and annual audit of the PHC income and expenditure for the preceding year was conducted.
• SPHCB has no dedicated budget line.
• None of the PHC facilities received regular operational funding in the last three months.
• There is administrative manual to standardize the administrative processes in the SPHCB.
• SPHCB-wide orientation has not been conducted to familiarize staff at all levels with the mandate of the SPHCB.
• The SPHCB has a physical office with requisite amenities and equipment such as power, water, computers, furniture, internet access and printer.

Recommended Areas of Improvement as Scaled out in the Scorecard 4

• Include women and key stakeholders in the governing board as recommended in the national guidelines
• Establish LGHA in all 25 LGAs of the State
• Need for the Review and Amendment of the SPHCB Law
  • To reflect clear oversight function of the SMoH on the SPHCB
  • To make provision for the movement of PHC departments, programmes and staff in all LGAs to the SPHCB
  • To provide clear definition of repositioning and 15% allocation by LGAs Councils to SPHCDA.
• Develop regulations for the operationalization of the SPHCB Law
• Develop a costed and approved MSP document for PHC facilities in the State and MSP should incorporate any free health services offered in the State
• MSP should be used to classify health facilities in the State and classification report should be documented for reference purposes
• Incorporate investment plan in annual budget to address services, infrastructural and HRH gaps required to meet the MSP for PHC facilities
• Transfer Malaria, HIV/AIDS and TBL programmes to the SPHCB
• Transform LGA PHC departments into LGHAs with established reporting line to the SPHCB
• Commencement of payment of staff salaries by the SPHCDA
• Develop PHC annual operational plan incorporating the LGA PHC annual plans
• Develop M&E /results/performance framework with clear milestones and targets for the SPHCB
• Develop HRH strategic plan comprising of recruitment forecasting, redistribution, production, succession planning, capacity building, performance management including rewards and recognition
• Develop functional HRH-IS to guide HRH strategic plan
• Establish dedicated budget line for PHC in the State annual budget
• Provide regular funding for health facilities to cover operational expenses and provide integrated PHC service delivery
• Conduct SPHCB-wide orientation to familiarize staff at all levels with the mandate of the SPHCB

The Outstanding Key Challenges on the Implementation of PHCUOR in Niger State Following the Scorecard 4 and findings through CCRHS PAS project Implementation in Niger State.

• Lack of effective functioning of the constituted and inaugurated Board of Niger State Primary Health Care Development Agency (SPHCDA)
• Incomplete repositioning which includes transfer of Salaries and payment of PHC staffs across the LGAs from Ministry of Local Government and Chieftaincy Affairs to Niger State Primary Health Care Development Agency leading low and ineffective Monitoring and coordination of PHCs staff by SPHCDA.
• Task shifting in Niger state is concerned as an interim measure, and will have to be implemented alongside other efforts to increase the numbers of skilled health workers and this will ensure a true assessment and consider using existing health workers.
• Inadequate funding to SPHCDA from the State budget
• Lack of dedicated budget line for PHCs strengthening in the state annual budget
• Lack of fulfillment of 15% counterpart support from Ministry for Local Government and Chieftaincy Affairs to SPHCDA.
• No HRH-IS in place to inform decision making on HRH strategic planning that includes recruitment forecasting, redistribution, production, succession planning, capacity building, performance management.

Recommendations:

• There is need for a dedicated budget line for PHC for sustainable health funding to strengthen PHC facilities.
• Complete repositioning of SPHCDA to include Ministry of Local Government and Chieftaincy Affairs (MoLGCA) to move all PHC staff to State Primary Health Care Development Agency (SPHCDA) and the payment of PHCs staff salaries by SPHCDA.
• Effectiveness of SPHCDA Governing Board through regular meetings of the board to discuss PHC strengthening specific and PHC service delivery sensitive issues.
• There is need to secure full commitment of the 25 Local Government Councils to commit and remit 15% of their annual budgetary allocation to SPHCDA as counterpart support to SPHCDA.
• State Government to improve funding and ensure prompt fund release to SPHCDA on annual basis through state appropriation.
• There is need for full implementation of Task Shifting Policy implementation across the PHCs in the state to strengthen integrated PHC service delivery.
• It is recommended that the agency should develop HRH-IS data base and HRH strategic plan that would comprise of recruitment forecasting, redistribution, production, succession planning, capacity building, performance management including rewards.
• Need for an accountability platform to foster accountability and transparency in the PHC setting

References:

1. Primary Health Care Implementation in Nigeria Scorecard III, 2015
2. Assessment of PHCUOR in Niger State by HSDF
3. Implementation status of Primary health care under one roof (PHCUOR): scorecard 4 – October 2018
4. National Nutrition and Health Survey (NNHS), 2018
5. Niger State Budget documents of 2015, 2016, 2017 & 2018.