Development policy planning & analysis 2

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MDS 8305: Development Policy Planning and Analysis

BAYERO UNIVERSITY,

KANO

FACULTY OF ARTS & ISLAMIC STUDIES

Department of History

COURSE TITLE:

DEVELOPMENT POLICY PLANNING &

ANALYSIS (MDS 8305)

Assignment submitted to:

Dr. Abdulmalik Auwal

Written by:

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ALIYU ADAMU TSAFE

REG No: SPS/MDS/13/00022

Question: Community Participation in Health Sector Development, A Review of

2012/2013 Community Score Card in Kano State

Outline:

Title Page/Outline:…………………..…….1 Abstract:………………………………….…….2 Introduction:………………………………….2 Interventions that Involves

Community Participation:………………3 Community Participation Check list:.4 Community Score Card:…………………5 Justification for CSC as Evidence

Based Tool:………………………………….…6

CSC Goal and Objectives:……………….6 CSC Implementation Principles:……..7 The Use of Manual:………………………..7 Methodology:……………………………….7 Implementation and Findings:……….8 Conclusion:…………………………………..19 Recommendations:………………………20 References:………………………………….22

Abstract

Participatory community development has evolved in the past 60 years as a development process

and discourse that should encapsulate a wide range of views, voices and stakeholder

contributions. How has this approach been followed in Nigeria’s community development

practice? This paper reviews the practical application of “Community Score Card in Kano State” as

a tool used in assessing community participation in health sector development from 2012 and

2013 rounds. The paper observes that community participation health issues started receiving the

desired attention in real sense of the concept in community development, hence resulting to

effective planning, policy formulation and implementation in Kano state.

Introduction:

Community participation is about ensuring meaningful engagement with our communities.

For health promotion to work well, it must be carried out by and with people, not on or to

people. This means that at all stages of the health intervention communities are involved with

and retain ownership of any health action.

In the context of the subject matter, the term community participation refers to working with

communities in order to define their own goals and address collective issues that includes;

community action, community participation and community engagement.

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The community action for health is the collective efforts by communities directed towards

increasing community control over the determinants of health, and thereby improving health

conditions of their people. While, community engagement is where the community is

empowered to apply its collective skills and resources to increase its level of influence and

control in order to improve their health needs and address the local determinants of health.

Community participation relies on us having a good understanding of the communities,

groups and individuals we work with. Effective interventions rely on community participation.

Effective interventions are achieved when the community supports the identified health need

over priorities, capacity and any barriers to action.

The second round of the CSC covers 17 LGAs and with a total population of 5,393, 264 (43%)

with a total of 523 (40%) of 1,305 functional health facilities in Kano State with indices

enlisted in the table below:

No. of LGAs 44

No. of Political Wards 484 State Population (2014 projection) 12,166,853 CSC Population Coverage (17 LGAs) 5,393, 264 (43%)

No. of Tertiary Health Facilities 2 No. of Public SHCs 33 No of Private SHCs 2

No of Private PHCs 165 No. of Public PHCs 1103 No of HF in 17 LGAs 523 (40%) (Sources: SMoH, PHCMB and HMB, Kano 2013)

LGAs for Second Round of Community Score Card in Kano State

SN LGA 2006 Census

Population Projection (3.2 AGR) 2007 2008 2009 2010 2011 2012 2013 2014

1 Albasu 190,153 202,910 209,606 216,523 223668 231,050 238,675 246,552 254,689

2 Bichi 277,099 295,689 305,447 315,527 325939 336,696 347,807 359,285 371,142

3 Bunkure 170,891 182,356 188,374 194,590 201011 207,645 214,498 221,577 228,890

4 Dawakin-

Kudu

225,389 240,510 248,447 256,646 265115 273,864 282,902 292,238 301,882

5 Garko 162,500 173,402 179,124 185,035 191141 197,450 203,966 210,697 217,651

6 Garum-

Mallam

116,494 124,309 128,412 132,649 137027 141,549 146,221 151,047 156,032

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7 Kabo 153,828 164,148 169,565 175,161 180941 186,913 193,082 199,454 206,036

8 KMC 365,525 390,048 402,919 416,216 429951 444,140 458,797 473,938 489,578

9 Kiru 264,781 282,545 291,869 301,501 311450 321,728 332,346 343,314 354,644

10 Kumbots

o

295,979 315,836 326,259 337,025 348147 359,636 371,504 383,764 396,429

11 Kunchi 111,018 118,466 122,375 126,414 130586 134,895 139,347 143,946 148,697

12 Makoda 222,399 237,320 245,151 253,241 261598 270,231 279,149 288,361 297,877

13 Nasarawa 596,669 636,699 657,710 679,414 701835 724,996 748,921 773,636 799,166

14 Tarauni 221,367 236,218 244,013 252,066 260384 268,977 277,854 287,024 296,496

15 Tofa 97,734 104,291 107,732 111,288 114960 118,754 122,673 126,722 130,904

16 Ungongo 369,657 394,457 407,474 420,921 434811 449,160 463,983 479,295 495,112

17 Wudil 185,189 197,613 204,134 210,871 217830 225,018 232,444 240,115 248,039

Total

4,026,672 4,296,817 4,438,612 4,585,087 4736394 4,892,702 5,054,169 5,220,965 5,393,264

Interventions that Involves Community Participation:

In order to promote community participation and involve them in planning and design of

health related interventions including policy formulations as well as implementation of such

programmes and policies, the Kano State Ministry of Health approved and ensures

strengthening of the following:

1. Emergency Transport Scheme (ETS) through collaboration with NURTW and

communities, rural poor women with maternal complications are transported through

ETS to health facilities. The scheme is helping in overcoming 3 delays that cause

maternal deaths. From January to July 2014 a total of 1,314 women with pregnancy

related conditions transported through the Emergency Transport Scheme (ETS) in Kano

State.

2. The development and institution of Facility Health Committees (FHC), sometimes also

known as Local Health Committees (LHC) or Ward Health Committees (WHC), as a

mechanism to promote citizen voice and enable greater accountability of Government

and health providers to service users. In Kano, State a total of 152 Facility Health

Committees (FHCs) have been established through collaborations with a donor agency

from 2009 – July, 2014. The state government concluded plan to scale up in 985 public

health facilities.

3. CSOs/FHC Advocacy initiatives to pressure government to improve service delivery, and

4. Pushing the agenda of participatory policy/strategy development and resource tracking

to improve government responsiveness, improve allocation and expenditure of health

sector resources.

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5. Strengthening of Civil Society Organisations to be able to voice out people concerns on

health related issues.

6. Conduct of rounds one and two Community Score Card

7. Quarterly Review of LGA Annual Operational Plans in Kano State

Community Participation Check list:

The Community Participation Check list includes but not limited to the following:

What issues are important for the community, group or individual? How do we know

these are important?

How can we give ownership to communities, groups or individuals so that they feel in

control of their own health endeavours?

What is needed to engage community members in a meaningful way?

How will we involve community members, in a representative manner, in deciding

what to implement?

What will our role be? Are we skilled in enabling, facilitating and mediating?

Do we have the capacity to address the health issue? Does the community, group or

individual have the capacity?

What factors help or hinder people becoming involved in action (for example, timing,

physical access, English fluency, information, formats, family and work commitments,

level of experience in community participation)? How are we addressing these?

Do we need further skill development in supporting/facilitating community

participation?

In order to established health practice that is guided by the best research and information

available, however, an evidence informed practice means was adopted that identifies the

potential benefits, harms and costs of community participation in health seeking behiaviours

as well as barriers to effective interventions, hence the design and implementation of CSC in

Kano State. A number of tools and cutting-edge processes, over time, has been adapted (and

adopted) or developed, reviewed and refined by the PHCMB team and FHCs team for this

purpose. The Community Scorecard (CSC) tool is one of the front-line tools used to monitor

and improve service delivery as well as promotes citizens’ voices in the State.

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The Community Score Card

The Community Score Card (CSC) is a two-way participatory community-level monitoring tool

that brings community members and service providers together to provide insightful

perceptions and feedback on service delivery. It solicits community perceptions and assigns

perceived scores against the quality, accessibility and relevance of various public services.

There are three main tools used during the CSC process which together gives a better picture

for evidence based planning and participatory monitoring at the local level. The tools are

1. An input tracking scorecard

2. A service provider self-evaluation scorecard

3. A community scorecard

The CSC process is neither an auditing process, nor a fault finding mission. Instead it is a tool

that points out which aspects of the health services are delivered well, which aspects require

improving and what level of collaboration is needed to bring about these positive changes in

the provision of services. It is a powerful tool to increase participation, accountability and

transparency between community members, service providers and policy makers.

Justification for CSC as Evidence Based Tool:

The quality of governance is recognized as one of the central factors affecting development

prospects in developing countries. Citizens' voice and government accountability are

important dimensions of governance. Citizens' capacity to express and exercise their views

effectively is believed to have the potential to influence government priorities and processes,

including a stronger demand for responsiveness, transparency and accountability.

Governments that can be held accountable for their actions, for their part, are assumed to be

more likely to respond to the needs and demands articulated by their population.

The CSC approach is community driven and it institutes mutual accountability and co-

responsibility between citizens and their governments and demonstrates to citizens that they

have critical roles to play in promoting service-delivery improvements, thereby serving as a

strong instrument for community participation in health and empowerment.

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Compared to other forms of social audits, the CSC technique is further unique not only

because it also greatly allows for citizens to directly interface or dialogue with the local service

providers and policy makers, but also because it allows citizens to instantly assess, openly air

perceptions, criticize and or recommend ways to improve the integrity of the processes (not

people) put in place to deliver quality health services at the grass root level.

CSC Goal and Objectives:

The goal of the CSC is to achieve wide representative community participation in defining and

identifying issues affecting quality of health services, while jointly making decisions to solve

them. The main objectives of the process are to:

Assess the quality of health services, facilities and other innovations from the

community and user perspective.

To probe in-depth and provide analytical insights into challenges identified in quality of

services in the facility and patterns observed in supported communities

Improve feedback and accountability loops between health providers, communities and

users around supported communities;

Strengthen citizens’ voice and community empowerment.

CSC Implementation Principles:

The principles that guided the conduct of a CSC process are as described below.

Ethical

Flexible and adaptable qualitative methodologies

Community centered and driven

Participatory

Non-discrimination, equality and inclusiveness

Coordination, cooperation and harmonization with local health planning and

monitoring systems

Value for money

The principles described are predicated upon the World Bank’s rights based approach to

development of 2005, which emphasizes a community focused approach to development.

The Use of Manual:

Though this manual is developed specifically for Kano state, it can be adapted and used by

other government institutions and agencies on various levels, Non-governmental

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organizations (national and international) operating in various sectors particularly health,

Community-based structures, e.g., Facility Health Committees, Village Development

Committees, Ward Health Committees and Community-based organizations such as women

groups and home-based care groups that the CSC was structured and also assessed.

Methodology:

The quality of governance is recognized as one of the central factors affecting development

prospects in developing countries. Citizens' voice and government accountability are

important dimensions of governance. Citizens' capacity to express and exercise their views

effectively is believed to have the potential to influence government priorities and processes,

including a stronger demand for responsiveness, transparency and accountability.

Governments that can be held accountable for their actions, for their part, are assumed to be

more likely to respond to the needs and demands articulated by their population.

The CSC approach is community driven and it institutes mutual accountability and co-

responsibility between citizens and their governments and demonstrates to citizens that they

have critical roles to play in promoting service-delivery improvements, thereby serving as a

strong instrument for community participation in health and empowerment.

Compared to other forms of social audits, the CSC technique is further unique not only

because it also greatly allows for citizens to directly interface or dialogue with the local service

providers and policy makers, but also because it allows citizens to instantly assess, openly air

perceptions, criticize and or recommend ways to improve the integrity of the processes (not

people) put in place to deliver quality health services at the grass root level.

Community Score Card Implementation and Findings:

The scorecard was developed during October and November 2012 through a series of

consultations by Facility/ Ward Health Committees, state and local government officials,

health workers and community members in Kano State. Subsequently, implementation of

round 1 took place at the beginning of 2013 having covered 20 communities across 5 LGAs in

the States. Following this first score card round, lessons learned were incorporated and some

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minor revisions were made to the score card that was used in Round 2 which started in

November 2013:

Some changes were made to the Score Card wording and order of score card

indicators;

The rating scale was changed. Whereas the initial score card allowed respondents four

options when providing their opinion about the indicator (‘good’, ‘fair’, ‘bad’, ‘don’t

know’) the second round provided five (‘very good’, ‘good’, ‘bad’, ‘very bad’, don’t

know’). These changes were made to ensure there was clear differentiation between

positive and negative responses, since ‘fair’ could be interpreted either way.

Community selection was undertaken through random sampling in Round 2, rather

than using communities living close to the health facility as had occurred in Round 1.

This meant that there was a greater diversity of access to some of the health facilities

compared to others, depending on how far different communities were from the

facility they were being asked their opinions about.

Family Planning was added to the score card to ensure that people give their opinion

about this service.

Though the first and second round of community score card administration followed the same

pattern, there were a few of notable differences between the two. These differences,

especially in terms of selection and rating options, are likely to affect any comparative analysis

between the results of these two different rounds, and so comparisons must be treated with

caution.

Focus groups: Four different focus groups continued to be held in each community,

comprised of older men and older women (aged above 45) and younger men and younger

women (aged 45 and below).

Traffic light scores: To facilitate easy interpretation of the scores provided to the indicators in

the score card, each score was given a colour. Each community and facility that participated

in the score card exercise was given their individual traffic light scores.

Score Thresholds:

The score thresholds, colours and definitions were agreed in discussion with communities,

PHCMB and SMOH staff and are as follows:

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Score thresholds Colour Definition

85% - 100% Dark Green The service/indicator is perceived to be very good – keep it up

70% - 84% Light Green

The service/indicator is perceived as good, but with more effort

could be very good

40% - 69% Yellow

The service/indicator is seen as below average and needs

improvement

0% - 39% Red

The service indicator is seen as inadequate and in urgent need

of attention

When setting these thresholds, the following was considered:

What colours and thresholds are used in existing traffic light score cards applied in other

state and beyond Nigeria?

What colours and thresholds would give the right message in the context of the state?

What is likely to be accepted by stakeholders? If people don’t accept the results, the

exercise has failed. For example, though some considered the threshold for ‘light green’

be rather low, 70% is the threshold for a satisfactory result in Nigeria’s educational

system. Therefore, government staff, facility staff and people in communities felt this

threshold would be appropriate.

Community Score Card Findings:

The first implementation round of community score cards in Kano was completed in February

2013, covering 22 communities in 13 LGAs. This time the exercise was completed for 23

communities in 17 LGAs held in November, 2013.

The table below provides an overview of the selection of communities, by LGA and LCDA. A

total of 24,126 community members and 1,721 providers participated in the second round

community score card.

LGA Community Service providers

Dawakin Kudu Gano Gano PHC

Yar Gaya Yar Gaya PHC Kabo Tudun Mai Zabi Garo Tundun Maizabi PHC

Ungogo Jan Garo Jan Garo PHC

Dausayi Dausayi PHC Nassarawa Dakawin Dakata Dakawin Dakata PHC

Giginyu Giginyu PHC Garko Turku Turku Garko PHC

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Sabon Garin Roba Sabon Garin Roba PHC Tarauni Hausawa Hausawa PHC

Bunkure Gambo Shugaba Gambo Shugaba PHC Makoda Dutsen Gima Dutsen Gima PHC

Kumbotso Chiranchi Tudu Chiranchi Tudu PHC Tofa Lambu Cikin Gari Lambu Cikin Gari PHC

GurunMallam Yashi Yashi PHC

Albasu Jemu Jemu PHC Kiru Kotoko Kotoko PHC

Bichi Danzabuwa Danzabuwa PHC Wudil Achika Achika PHC

Dagumawa Dagumawa PHC Kunchi Shuwaki Shuwaki PHC

Unguwar Gyattai Unguwar Gyattai PHC Kano Municipal Kududdufawa Kududdufawa PHC

Scores that were given to facilities varied greatly, though Immunization services consistently

received a good score. Some facilities in Kano, such as Garo, Tudun Maizabi PHC , Jangaro and

Ungogo PHC, were given exceptional scores against almost all indicators from their

communities. It may be worth identifying if lessons can be drawn from these facilities.

It is worrying that scores for some PHCs have reduced since the last score card round. This

may have been caused by the differences in scoring criteria, as explained earlier in this report.

However, it is something that needs to be looked into by the government. Particularly

perception of health services seem to have become more negative, including ANC and

Delivery services.

Health Services:

Although there were some exceptions, health services were rated quite positively by

community members. Particularly, Immunization services were perceived positively by all

communities. Delivery and Family planning services provided by some facilities seem to

require attention.

Indicators Kano State CSC results community

Kano State CSC results service providers

ANC 80% 96% Delivery 57% 68%

Immunisation 90% 97% Family Planning 42% 85%

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Malaria 77% 93% Diarrhoea 73% 96% Other health services 80% 94%

Service providers tend to have a much more positive view about their services. As in most

other LGAs, they most tend to give Delivery services the lowest score. The scores reflect quite

a difference in service providers’ perception of Family Planning services compared to the way

in which the community sees these services. Although it is true that service providers tend to

rate Family Planning services more positively, some of this difference is caused by the fact

that many community members (37%) say they ‘don’t know’ about these services. It is

interesting that, as in other LGAs, it is mostly young men that say that they are unaware about

the family planning services provided at the facility (51%). Women of reproductive age seem

to be much more aware of these services, although the scores may also indicate that they are

more willing to talk about these. They also tend to give this service a more positive score

compared to other groups. When giving Family Planning services a bad score, community

members often say that this is because these services are not available at the facility.

According to the reports that we received, community members did not comment on the way

in which the service itself was provided.

Where these were perceived negatively, Delivery services were often reported not to be

available. It may be worth investigating why community members report that Delivery

services are not available at the following PHCs: Yar Gaya PHC, Dausayi PHC, Unguwar Gyattai

PHC, Dagumawa PHC, Achika PHC, Danzabuwa PHC, Dutsen Gima PHC, Kotoko PHC, Lambu

Cikin Gari PHC. In some facilities, the reason why Delivery services are not provided is because

there is no labour room. Perhaps CSOs can support FHCs for these facilities in their advocacy

efforts for a labour room and equipment. Some communities provide a negative score to

Delivery services because these are only provided during daytime, or because the health

workers are not skilled enough to provide these services.

ANC services are perceived positively by many communities. Some communities, such as

Gano PHC, report that facilities provide good ANC services, although these are available one

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day a week. Similar to other health services, ANC services are sometimes affected by a lack of

staff.

Malaria is seen as good and in most communities. Malaria drugs are available and bed nets

are provided. Although Malaria services in Yashi PHC, Lambi Cikin PHC and Kotoko PHC seem

to have been affected by poor availability of drugs.

Diarrhoea services were perceived to be very good by many communities. Though the score

has been negatively affected by the fact that 24% of young men indicated that they did not

know about these services, many community members mentioned that diarrhoea services

were very good. Some commented that drugs to treat diarrhoea were freely available. The

reason behind negative ratings was mostly related to the lack of sufficient staff to provide the

service.

Other health services’ provided at the facility was perceived positively by most communities,

with people reporting that minor ailments were treated. Negative scores were sometimes

given because of lack of electricity and privacy, as was the case for Gano PHC. At other PHCs,

such as Chiranchi Tudu PHC and Lambu Cikin Gari PHC, these services seemed to be affected

by a lack of available health workers.

Indicators

Group

Scores (percentage of respondents)

Good Bad I don't know

ANC

Old women 89% 9% 2%

Old men 79% 17% 3%

Young women 84% 15% 2%

Young men 76% 14% 10%

Labour and Child Birth Services

Old women 43% 50% 7%

Old men 49% 50% 1%


Young men 44% 47% 10%

Immunization

Old women 95% 0% 5%

Old men 88% 8% 3%


Young men 96% 0% 4%

Family Planning

Old women 45% 22% 33%

Old men 32% 28% 40%


Young men 35% 15% 51%


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Malaria Old men 81% 10% 9%


Young men 79% 11% 10%

Diarrhoea


Old men 78% 14% 8%


Young men 63% 13% 24%

Other Health Services


Old men 89% 8% 3%


Young men 78% 14% 8%

As mentioned earlier in this report, it is worrying that for the three PHCs which participated in

round 1 and 2 of the Community Score Card exercise, most health services have received

lower scores. Though scores may have been affected by changes in the scoring system, it is

recommended that PHCMB staff visits these communities to find out the reasons for this.

Scores for ANC services at Dausayi PHC seem to have been affected by the fact that older men

were not aware that these services were available at the facility, as other groups report

positively about this service. Therefore, there seem to be no reason to worry about this

declining score.

Labour and Delivery services are not available at Dausayi and Unguwar Gyattai PHCs. At

Giginyu PHC Delivery services are available, but affected by lack of staff and the fact that

these are only available during the day.

Unguwar Gyattai PHC is one of the very few facilities that received negative scores for

Diarrhoea services as all groups, except women of reproductive age; report that these

services are not available. Scores for health services provided at this facility generally seem to

have been affected by insufficient staff and drugs are reported to not be available.

Family planning was added as an indicator for the second round of Community Score Card

implementation. Therefore no comparison is possible for this indicator.

No particular reasons were given behind improvements to some health services, such as

‘Immunization’ and ‘other health services’ at Unguwar Gyattai PHC.

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Ungogo LGA Nassarawa LGA Kunchi LGA

Dausayi Giginyu U/Gyattai

R1 R2 R1 R2 R1 R2

ANC 82% 41% 100% 86% 33% 43%

Labour and Delivery 33% 25% 83% 67% 33% 25%

Immunisation 92% 68% 100% 94% 64% 78%

Family Planning No data 36% No data 44% No data 30%

Malaria 100% 78% 98% 81% 58% 50%

Diarrhoea 92% 78% 100% 60% 45% 34%

Other Health Services 92% 78% 99% 75% 46% 77%

Conditions at the facility:

Although service providers in Kano feel more positively about conditions at their facility then

communities that are living close to these, both communities and service providers seem to

feel that there is room for improvement. At many facilities, both facility staff and

communities feel that either the availability or quality of water is insufficient.

Services Kano State CSC results community


Water 63% 66% Toilets 60% 77%

Sanitation 70% 82% General Conditions 73% 84%

Of all facilities, both community members and staff Kotoko PHC (Kiru LGA) are most

dissatisfied about conditions around this facility, which is apparently in need or urgent

attention. At Gambo Shugaba PHC, all conditions are perceived to be very good.

As is the case for some other States, the way conditions at facilities are viewed by women and

men of different ages tends to quite similar.

Services

Group



Water


Old men 44% 52% 4%



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Toilet Facilities

Old women 49% 37% 14%

Old men 57% 34% 9%


Young men 46% 37% 17%

Sanitation Facilities


Old men 59% 30% 10%



General Conditions at the Clinic


Old men 71% 28% 2%



At Unguwar Gyattai PHC the community reports that there are not facilities to dispose waste.

It is likely that this was also the case during the last score card round. Therefore, it can be

concluded that sanitation facilities at this facility have not improved, rather than these

deteriorating. The same seems to be the case for its water which is available from a well, but

is seen to be of poor quality.

The community at Giginyu reports that there is no water at the facility, which is something

that requires urgent attention.

No clear reasons have been provided that can explain improved perception of Sanitation

facilities at Dausayi PHC.

Services Ungogo LGA Nassarawa LGA Kunchi LGA


R1 R2 R1 R2 R1 R2

Water 72% 60% 58% 35% 76% 59%

Toilets 55% 53% 83% 62% 52% 54%

Sanitation 33% 75% 45% 55% 69% 29%

General Conditions 63% 79% 83% 76% 47% 45%

Health workers:

Many community members in Kano agree with their service providers that facility staff have

good attitudes. However, especially community members indicate that often health workers

are not available.

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Services Kano State CSC results community


Availability of HW 66% 73% Attitude of HW 85% 95%

Of all communities in Kano, those around Kotoko PHC, Yashi PHC and Sabon Garin Roba PHC

were most dissatisfied about availability of health workers at the facility. Community

members that live around these facilities often indicate unavailability of health workers at the

facility is negatively affecting health services.

Although some groups report more positively about the attitude of health workers then

others, there is no community in which the majority of groups have a negative perception of

the attitude of health workers at the facility. It should be noted that, although Kotoko P HC

scores poorly against many indicators, their health staff received an exceptional (100%) score

for their attitude. This appears to indicate that health staff at this facility tries to provide

services despite difficult circumstances at the facility.

The way in which groups perceive the availability of health workers tends to be similar. Older

men and women tend to perceive attitudes of health workers at their facility more positively.

Indicator Groups Scores (percentage of respondents)


Availability of HW


Old men 77% 18% 5%



Attitude of HW

Old women 91% 5% 4%

Old men 94% 1% 4%



The qualitative data that was made available as a result of this Score Card exercise in Kano,

did not indicate reasons behind either more positive or negative views relating to the

availability or attitude of health workers. Availability of Health workers was seen as

inadequate at all three PHCs where two Community Score Card rounds were conducted.

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Ungogo LGA Nassarawa LGA Kunchi LGA

Indicator Dausayi Giginyu U/Gyattai R1 R2 R1 R2 R1 R2 Availability of HW 57% 63% 75% 64% 63% 57% Attitude of HW 100% 91% 98% 77% 51% 71%

Facility operations:

Communities in Kano tend to feel less positive about facility operations than facility staff,

though both often agree that security needs to be improved.

Indicator Kano State CSC results community


Availability of drugs 71% 81%

Security 75% 72%

Opening Hours 69% 83%

Community Mobilisation 76% 92%

According to community members, availability of drugs tends to vary per facility. Though

many communities are satisfied with the drug availability at their facility, most indicate that

there is room for improvement. Communities around Dakawin Dakata PHC and Shuwaki PHC

say that drugs are always available.

The four communities with the most negative perception of drugs availability are Kotoko PHC,

Sabongarin Roba PHC, Yashi PHC and Jemu PHC. These facilities also report insufficient

availability of staff members. Therefore it is possible that the poor availability of staff

members is affecting drug management, but this needs further verification. Again, scores for

health services at these facilities are affected by these indicators.

Many communities report that facilities are only open during the day, which seems to be

related to poor security at the facility. This is affecting Delivery Services in particular. It is

possible that at some facilities, health worker do not wish to stay at the facility at night ,

because of insufficient security. The low score that communities in Kano provide for opening

hours is not surprising considering that according to other data sources, such as the health

facility survey in 2012, the percentage of facilities that provide 24-hour emergency services is

18% in the State

Many facilities in Kano do excellent outreach work. Communities around the following

facilities are particularly satisfied: Garo Tundun Maizabi PHC, Jan Garo PHC, Dausayi PHC,

Dutsen Gima PHC, Chiranchi Tudu PHC and Lambu Cikin Gari PHC. For most of these facilities,

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outreach work appears to have had a positive effect on Delivery and ANC services. In many

cases, older men were less happy with outreach efforts by the facility.

Indicator

Groups



Availability of drugs


Old men 78% 15% 8%



Security


Old men 79% 18% 3%


Young men 66% 32% 2% Consistency of Opening Hours


Old men 74% 19% 7%


Young men 57% 32% 11%

Community Mobilization and Outreach

Old women 88% 12% 0% Old men 69% 24% 6%



When comparing round 1 to round 2, it seems that little of no improvement was made for the

three facilities that participated in round 1 and 2. Particularly Unguwar Gyattai shows a

significant reduction in its outreach efforts. According to PHCMB staff this may have been

caused by the fact that the facility is limiting its outreach efforts to one area in the

community, which was covered during the first score card round. The negative consequence

of this is reflected in the second community score card round, which was implemented in a

different part of the community. Government has already advised the facility to rotate its

outreach efforts among different sections of its community.

Indicator Ungogo LGA Nassarawa LGA Kunchi LGA


R1 R2 R1 R2 R1 R2

Availability of drugs 92% 70% 70% 72% 48% 52%

Security 70% 73% 100% 75% 64% 60%

Opening Hours 75% 70% 96% 70% 57% 57%

Community Mobilisation

75% 87% 67% 62% 80% 33%

20


Conclusions In conclusion, it is a wide practice that community participation that could led to development

practice in Nigeria over the years has been a one-way practice still centrally packaged by

public officials and development agents, and handed down to the people who become passive

recipients of such public development benefits and such top-down community development

perspectives are still very much common even in the current democratic experiment.

However, this paper explained with reference the basic capability on the part of the citizens to

participate and negotiate in the processes that are intended for their own development

benefits on health matters. In Kano state as case, improved capacity of well informed citizens

has led to active community participation in health governance as in the case of CSC and

results was used by the FHCs who represent their local content to advocate to government on

series of health related issues and government have already resolved some of the issues

raised by the communities that includes but not limited to the following:

Approved scale up of Free Maternal and, Neonatal and Child Health (FMNCH) services

in 484 health facilities. This intervention will reach every ward in the state. Prior to this

approval only 22 Secondary health facilities provides FMNCH services with rural areas

neglected.

Approved recruitment of Human resource for health to ensure attainment of a

minimum HR requirement of 5/10,000 populations. So far from January-July, 2014, a

total of 177 doctors and midwives have been recruited by the SMOH , hence leading to

increased number of skilled manpower to provide quality MNCH services from 0.8 to

1.9 per 10,000 population

612 health facilities capitalized with Drugs Revolving Funds (DRF). Established 38 D&E

centres including in rural PHCs

Development of PHC staff distribution plan and posting to various health facilities for

equity. The posting consider indigenes of each staff and post them to their respective

LGAs.

Prompt payment of monthly allowances of MSS and SURE-P Midwives and CHEWS

53 additional health facilities were renovated as at July, 2014. Prioritize health facilities

for refurbishment and provision of equipment and supplies

6 CSOs and 40 FHCs chairmen participated in the development of the 2014-2016 Kano

MTSS.

Recommendations:

21


Poverty is the main structural driver of high maternal and child mortality which creates a

double burden by compromising the overall health and nutritional status of women and

children and then compounds the problem by preventing access to health services for those in

greatest need. The people spend at least three quarters of their income on food and yet, for

the very poor it is insufficient to provide a nutritious diet. As a result pregnant women are iron

and vitamin A deficient during pregnancy, which leads to inadequate foetal nutrition, birth

complications and low birth weight babies. Undernourished infants and children are

predisposed to infection and stunted in growth and mental development.

Of the leading barriers preventing access to health services, 56% of women stated “getting

money for treatment” was the leading problem. Maternal and child health services are, in

principle, free. Yet, all basic drugs, dressings and even immunisation and antenatal records

have associated costs, as well as the transportation to and from facilities.

Socio-cultural barriers to attending health services A number of other factors such as cultural

and religious beliefs, education levels and gender also affect the health outcomes of women

and children by reducing access to services. The effects on health are varied and often not

quantified. Hence the following recommendations are in evitable:

CSC to be conducted in each quarter and its findings implemented by appropriate quarters;

Ensure 100% implementation of Free-MNCH packages with zero associated cost as a strong primary health care system is a prerequisite to deliver comprehensive maternal,

newborn, child and routine immunisation services and community buy-in is the key to acceptance and access to health the services;

Expand community involvement in the initial design, implementation and evaluation of public health interventions in the state;

More research is needed to understand the drivers of these behaviours to develop appropriate communication and social mobilization;

Ensure availability of General Hospitals at least one in each LGA for effective provision of comprehensive emergency obstetric care services and for referral from lower feeder

facilities (PHCs);

Scale up of DRF services to the remaining 693 health facilities in the state in order to sustain the availability of qualitative drugs and medicines.

Finally, in order to enhance further positive community participatory on all related

development matters, the paper recommends that massive public investments and spending

should be at a scale in order to improve social opportunities such as education, healthcare

and economic empowerment. Such investments in social and economic opportunities will

contribute in improving the basic capabilities of the rural populace and will contribute in

guaranteeing effective participation in any development process.

22


References

National Population Commission Federal Republic of Nigeria and ICF International

Rockville, Maryland, USA, (June 2014) “Nigeria Demographic and Health Survey (NDHS),

2013

Kano State Ministry of Health (2014), “2013 Health Sector Achievements” Factsheet

Primary Healthcare Management Board (2013), “Report of Health Community Score

Card covering 17 LGAs in Kano State”

Ghai, D. (1988) “Participatory development: some perspectives from grassroots

experiences”, Discussion paper No. 5, Geneva: UNRISD: IFAD (2011) “Rural Poverty in

Nigeria”, http://www.ruralpovertyportal.org/web/guest/country/home/tags/nigeria.

Javan, J. (1998) “Empowerment for community development: a multivariate

framework for assessing empowerment at the community level”, Department of

Psychology, North Carolina State University Marcellus,

O. Eze (2009) “Development planning in Nigeria: reflections on the National Economic

Empowerment and Development Strategy (NEEDS), 2003-2007”, J. Soc Sci, Vol. 20(3),

pp. 197-210.

23


WHO, 1986, Ottawa Charter for Health Promotion, First International Conference on

Health Promotion, Ottawa, 21 November 1986.