ESMPIN
Expanded Social Marketing Project in Nigeria
ESMPIN Integrated Health
Implementation Report
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E S M P I N Integrated Health Implementation Report
FOREWORD
The ESMPIN Project is a social marketing project implemented by Society for Family Health (SFH) along with the Association for Reproductive and Family Health (ARFH), BBC Media Action (BBCMA) and Population Services International (PSI). The goal of the project is to improve the health of women and children in Nigeria by increasing use of modern family planning methods and child health. To achieve this, the team worked to increase access to family planning (FP), reproductive health (RH) and child health products; increase use of health products and practice of health behaviors; generate support from all sectors for social marketing as an important part of a total market approach; and improve the viability of local manufacture of key health products. As an integrated project, ESMPIN had quality and scale as its implementation focus. The project therefore used several distinct channels to promote healthy practices among separate target groups in the areas of family planning, malaria, diarrhea and nutrition. The intervention strategies were implemented one at a time or together over a period of time with the aim of changing behavior. The project also used approaches proven over time to design and deliver these messages to the target groups. To achieve scale, ESMPIN designed and implemented several approaches, some with a nationwide spread, while others focused on 22 states in Nigeria (including the Federal Capital Territory). This document therefore provides a brief outline of specific approaches used by ESMPIN as well as some program outcomes recorded during and after field implementation.
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SIR BRIGHT EKWEREMADU, Managing Director, Society for Family Health
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Acknowledgement
This document is a product of Expanded Social Marketing Project in Nigeria (ESMPIN) consortium partners led by Society for Family Health (SFH). The Federal Ministry of Health (FMoH), along with the various State Ministries of Health (where ESMPIN was implemented), were resourceful in providing support and access to relevant stakeholders and sharing relevant information and data that informed the strategy design. Their efforts are much appreciated. Local government departments of health were beneficial and physically available to support actual field interventions. We are grateful for all their guidance and active involvement during the project implementation. We acknowledge the effort and contribution of the staff of SFH, BBC Media Action (BBCMA), Association of Reproductive and Family Health (ARFH) and Population Services International (PSI) for their relentless drive to achieving impacting results and also for taking time to document the processes involved. Finally, we acknowledge the technical support received from PSI as well as content input from SFH, BBCMA and ARFH staff (both field and program). ďƒš
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DR. JENNIFER ANYANTI, Chief of Party, ESMPIN Project
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INTRODUCTION
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Although family planning remained the focus for the ESMPIN project, other major objective components were the promotion of child survival interventions. It paid particular attention to nutrition (exclusive breastfeeding), malaria prevention and treatment and diarrheal management (point of use water treatment, hand wash with soap and water and diarrhea treatment with oral rehydration salts and zinc) in an integrated manner and specifically for the wholesome benefit of women and children.
The project’s key objectives were:
To significantly expand access and availability to family planning and child survival products
Increase knowledge, attitudes, perception and practices towards child spacing and survival
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Engender a sustainable partnership with key stakeholders Enhance the capability of the commercial sector in Nigeria to provide maternal and child health products
The different activities designed to achieve these objectives under the ESMPIN project are classified under the following subsections:
Capacity-Building
Demand Creation
Service Provision
Advocacy & Collaboration
ORS & zinc Promotion
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“The balanced counseling sessions conducted by ESMPIN have helped my providers to have a better insight to what method the client should take. ... and the client goes home more aware of what experiences they may go through with the method they have chosen. This makes the client feel safer using an FP method and stay longer on it.” M R S . A R O G U N DA D E FP coordinator, Epe LGA, Lagos State.
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CAPACIT Y BUILDING STRATEGY The ESMPIN capacity building activities focused on providers and field agents. Capacity building activities were designed to bridge the knowledge gap and address myths and misconceptions around the child spacing and survival health areas of ESMPIN. In some cases, the activities addressed Family Planning (FP), Malaria, Diarrhea and Nutrition objectives at a sitting or separate meetings. The objectives of these activities were to empower agents and providers with adequate knowledge and skills. For agents, capacity building activities helped persuade specific target groups to adopt ESMPIN health behaviors. For providers, it helped them provide a wide range of FP and Maternal and Child Health (MCH) services in line with quality standards. Types of capacity building activities for providers (such as PPMVs, nurses, pharmacists and physicians) included PPMV training, clinical presentations, BCS update and provider quarterly meetings. For agents (such as IPCAs, CBDAs and radio station personnel) it included IPCA training, CBDA training and monthly review meetings.
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PPMV training sessions are instruction classes for PPMVs on the ESMPIN health areas. It was either a one-day training on FP, malaria and diarrhea or a six-day iCCM training on malaria, diarrhea or pneumonia. Both had curricula developed in line with the FMoH guidelines. The trainings improved their capability to better handle (diagnose, treat or refer) health cases commonly seen by these cadre of health staff. Clinical presentations under the ESMPIN program were typically aimed at professional healthcare providers (physicians, nurses and pharmacists) and focused on one or more specific child spacing or child survival products at a time. These sessions reviewed these products with the aim of motivating the providers to offer quality services. The BCS updates, on the other hand, built the counseling skills of providers in offering quality FP services. The ESMPIN IPCA and CBDA training were threeday trainings where agents learned how to create demand on ESMPIN objectives. The agents learned the correct information on the ESMPIN health areas, ways to dispel myths and misconceptions around the same and requisite skills to motivate
contacts to change or adopt positive behavior. For the CBDAs, the training curriculum included learning sales skills designed to better persuade contacts to make an immediate purchase of non-ethical products. In addition, the CHEWs training included an additional two days on short and intermediate acting FP method service provision. Various radio stations partnered with the program, and their staff also received training to develop ESMPIN programs. In return, the stations received donations of work tools to aid their services. Furthermore, the ESMPIN project held monthly review meetings with its field agents (IPCAs and CBDAs) to build capacity and address other administrative and logistic issues. Generally observed gaps from the field (both knowledge and skills) were addressed during these meetings. Similarly, the project hosted quarterly provider meetings where knowledge and administrative issues were addressed based on unique gaps observed during implementation.
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S t a t is t ics As a result of these capacity building sessions, health care providers were able to improve stocking practices for essential health commodities. GOLD CIRCLE RECORDED AN
81%
Shelf Presence Across SDPs Surveyed in Nigeria COMBINATION 3 RECORDED
82% STOCKING NORISTERAT 74% DEPO-PROVERA 74% CYCLEBEADS 72% POSTINOR 2 66% FEMALE CONDOM 74% The stocking findings for child survival products recorded were:
31% FOR ORS/ZINC (Chi Co-packed ORS/zinc)
52% FOR P&G WATER PURIFIER OF ALL OUTLETS SURVEYED
49.4% Sell other brands of MCH products (2016 MAPS)
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Total Number of Providers and Agents with Capacity Built Under the ESMPIN Project: S/N
C A PA C I T Y B U I L D I N G A C T I V I T Y
PPMV Training
Monthly
21,580 32,167 53,747
Clinical Presentation & BCS Update
Monthly
10,240 6,570 16,810
3
IPCA training
6-Monthly
3,044 1,668 4,703
4
CBD Training
5
CHEW Training
1
2
F R E Q U E N C Y
Twice in LOP Once (in Cycle 10)
FEMALE
MALE
T O TA L
1,454
726
2,180
433
123
556
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C A PAC I T Y B U I L D I N G S T R AT EGY
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SUCCESS STORY
Empowered to Take FP to the People Hamzat Kikelomo is a CHEW employed by the ESMPIN project as an interpersonal communication agent (IPCA) in the Odorangushin community of Epe LGA in Lagos State. Here, the implementation of the Cycle 10 IPC program (between July–December 2016) took place. The Mojoda PHC is one of the only health facilities in the community which offers quality and discounted FP services. Nevertheless, the facility had recorded relatively low patronage due to proximity. Additionally, community members were mostly civil servants or traders and had little time to seek FP services. Hamzat and her colleagues created demand for FP and other ESMPIN child survival objectives within the community by offering injections and pills to those who were unable to access FP due to distance and time constraints. During the implementation phase, Hamzat’s motivation for work was her monthly allowance, the mark-up on sales of products and her passion for helping her community members. Hamzat
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had this to say at the end of the cycle: “I was unemployed for three years since I finished my health education training. ESMPIN came and trained me to better practice my profession. I’m so excited that I was introduced to house-to-house FP service provision. Our LGA FP Coordinator for Epe worked together with our SFH supervisor in training us to confidently talk to people. They worked with us all the time in the community while we provided these services and corrected us with love. I’ve gathered a customer base through the work period as well as all the prospective customers I’m yet to meet. I hope to continue in this business for a long time until I can get a formal hospital job.”
I was unemployed for three years since I finished my health education training. ESMPIN came and trained me to better practice my profession.”
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C A PAC I T Y B U I L D I N G S T R AT EGY
SUCCESS STORY
Building Local Community Distribution Networks Sustainability Element The ESMPIN project developed training curricula that partners or stakeholders can leverage. In addition, there are leave-behind reference materials for providers which will remain in circulation. Some of these materials can also be made available on request or put on the online public domain.
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Aisha Hassan was a house wife in Gwaram LGA of Jigawa State before she was selected as a community- based distribution agent (CBDA). ESMPIN built her capacity to conduct one-onone and group interpersonal communication (IPC) sessions on child spacing and child survival products. She was also taught how best to resupply and sell the nonethical products, as well as refer persons for the ethical methods and services. While creating and meeting these demands within her community, she was soon regarded as a ‘community doctor.’ The knowledge gained from the CBD training also elevated her social standing among her peers. She received supportive supervisory visits both from program staff as well as select community members (such as members of the ward development committee, WDC). The visits strengthened the delivery of qualitative information and provision of services. She also participated in the ESMPIN monthly review meetings which served the dual purpose of product restock and skills and knowledge improvement. Currently, Aisha and her other CBDA colleagues
have formed a cooperative called CBD networks. These are formally registered networks with bank accounts, office accommodation and constitution/policies. With Aisha serving as the treasurer of her CBD network, she has further built her capacity to source commodities and continue to better empower herself, her network and her community.
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LESSONS LEARNED
A major lesson learned for the capacity building of providers and field agents is the need to work closely with relevant stakeholders (such as policy makers, community leaders, leaders of relevant health associations) for support in seeking approvals, selecting participants and participating in the actual capacity building exercise. Other lessons include: more group work, games and field practice sessions, an objective approach to screening participants nominated by community stakeholders as prospective field agents; and uncovering provider concerns before engaging them in groups.
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“So many of our women die daily from poor reproductive and maternal and child health. I am grateful to USAID for their investment through the ESMPIN project that employs our people to educate community members. I implore all traditional and community leaders to join in mobilizing their people at community gatherings, religious gatherings and other channels to educate them on the benefit of child spacing as well as the correct prevention and treatment of diarrhea and malaria.” A L H A J I S A N I U M A R J A B B I , The Sarkin Yakin-Gagi (leader in charge of health affairs under the Sultanate).
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DEMAND CREATION ACTIVITIES Demand creation activities under the ESMPIN project focused on providers and men/women of reproductive age (MWRA). Activities were designed to address all ESMPIN health themes, either one at a time or altogether. Several factors were considered in developing the nature and content of activities, such as length of sessions, important research findings and community structures to harness positive outcomes. The aim of the ESMPIN demand creation activities were primarily to increase uptake of modern child spacing and child survival products. Examples of demand creation activities targeting providers are product detailing and provision of IEC materials. Product detailing, which used provider behavior change communication (PBCC) techniques, helped to uncover and address provider concerns over child spacing and child survival products promoted by the ESMPIN project. After these sessions, providers were motivated to offer services with these commodities. For men and women of reproductive age, demand creation activities included routine house-to-house and marketplace IPC, special male involvement sessions, special HF sessions at ANCs and CWCs, town hall meetings, bulk SMS, community drama shows, community gathering sessions, IEC materials and mass media.
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Brief Description of Demand Creation Activities S / N AC T I V I T Y
DESCRIPTION
01
IPC Sessions
Typical 1:1 or 1:G IPC sessions to MWRA across ESMPIN health themes. Contacts who change behavior are offered direct services or referred to appropriate health facilities or SDPs
02
Male Involvement Sessions
Special IPC sessions with organized group of men within intervention communities engaged monthly on various topics with the sole aim of gaining greater male participation in family health
03
ANCs and CWCs Special Sessions
Group IPC sessions targeting expectant and nursing mothers at special clinics on adopting healthy behaviors around the ESMPIN health areas
04
Provider Town Hall Meetings
A meeting of healthcare providers with key community stakeholders for the purpose of persuading providers to offer quality cost effective care and encouraging stakeholders to become advocates for promoted ESMPIN behaviors
05
Bulk SMS
Framed messages sent out on monthly basis designed to reinforce key messages learned by IPC contacts and providers during the call or meeting sessions
06
Movercado
Use of free SMS services (free to community participants such as IPCAs, IPC contacts, healthcare providers and FP clients) employed in exit intervention communities to track outcomes of IPC contacts and health facility referral outcomes
07
Community Drama Shows
Drama shows that depict typical community experiences and how adopting ESMPIN-promoted behaviors can improve situations
08
Community Gathering Sessions
Special IPC sessions on ESMPIN health themes targeting community gatherings such as churches, mosques, community or family festivals
09
IEC and Promotional Materials
Posters (placed at HFs and SDPs), leaflets and fliers (shared to IPC contacts and handed to providers for their clients) and promotional materials supporting specific ESMPIN health behavior or products
10
Wall Murals
Wall paintings at strategic locations of intervention communities serving as reminders to its members to uphold the healthy behaviors promoted by the project during implementation
11
Mass Media
A 15-minute radio drama series aired twice weekly in four Nigerian languages that covers all ESMPIN health areas across Nigeria; a 15-minute radio magazine program called “Ya ta kene Arewa� in the northern Hausa speaking part of the country; and a 60-minute radio spot aired in four Nigerian languages across all ESMPIN health areas across the country
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S t a t is t ics
A one-off analysis of the impact of demand creation on malaria objectives was conducted in Bauchi (IPT uptake trend) and Akwa Ibom (RDT use) states, respectively. The comparison was for six months (before a select intervention period) and six months into the intervention period. The HF IPT uptake results from Bauchi showed an average 34% INCREASE in IPT1 uptake and 61% INCREASE for IPT2 uptake. RDT use in Akwa Ibom recorded an average increase of 391% within the intervention period. The periodic impact survey of the ESMPIN radio mass media campaigns showed an average recall of
(NIGERBUS, 2016)
FP MESSAGES
47%
MALARIA MESSAGES
44%
EBF MESSAGES
39%
DIARRHEA MESSAGES 38%
A total of 15,123,844 IPC contacts were recorded through the entire Cycle 1-10 of the ESMPIN program (at 102% of planned target) along with 598,037 redeemed FP referrals (at 80% of target).
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SUCCESS STORY
Using Radio to Prevent Diarrhea Mass media is one of the ways the ESMPIN projects disseminate health messages to sensitize people on adopting healthy behaviors. The project used a 60-second advert, 15-minute radio dramas and 15-minute radio magazine programs. These complementary forms of communication helped reinforce health messages and promote behavior change. “I am a proud beneficiary of an SFH intervention through a radio drama called ‘One Thing at a Time.’ My wife and I had almost lost our son to diarrhea, despite several treatments from his doctor including ORS. Unfortunately, these yielded little result, and my son was gradually “drying up” day by day despite the medical attention. One morning, I took a drive from home tuned my radio. I heard the radio program sponsored by SFH, and the discussion was on diarrhea prevention and treatment. For the first time, I heard of the complete treatment of diarrhea with ORS and zinc. I quickly spoke to my wife and we purchased ORS and zinc (co-packed) which worked like magic. Indeed, that experience was a life-transforming moment, because we learned how to handle diarrhea at our home which saved my son’s life; we
Mr. Jimmy Aninege, a father of three and secretary of Ogoja LGA, Cross River State
also learned ways to prevent diarrhea. Now, my son and his siblings live diarrhea-free because we tuned to this SFH drama titled ‘One Thing at a Time’.” Jimmy Aninege, a father of three children residing in Ogoja LGA of Cross River state, recounted this story to SFH. As the secretary of Ogoja LGA, he shared this at the ESMPIN town hall meetings he attended as a policy maker. He explained that the program gave him a comprehensive answer to diarrhea management. He is now an advocate for correct diarrhea treatment and uses his office to promote it. ESMPIN radio dramas were designed to appeal to all men and women of reproductive age across major Nigerian languages. They were also designed across all ESMPIN health areas including child spacing, malaria and exclusive breastfeeding.
Now, my son and his siblings live diarrhea-free because we turned to the SFH drama ‘One Thing at a Time.”
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D E M A N D C R E AT I O N AC T I V I T I E S
LESSONS LEARNED
To create demand efficiently among specific target groups, a good understanding of both the language and culture is critical for success, both in the design of materials as well as during message delivery. At each point, the project sought to recruit agents who were community locals, residing within and nominated by community stakeholders. In addition, PPMVs, which serve as first port of health call, are an effective means of changing behavior.
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 Sustainability Element The ESMPIN project leaves behind a pool of trained agents who work with other local organizations to continue demand around its health objectives. Similarly, personnel for several radio stations build capacity to develop programs across these health objectives. In addition, community stakeholders (policy makers, community leaders and other local partners) were motivated to support demand creation activities at project close out. Finally, IEC materials, like posters and leaflets for clients who visit health providers ,would continue to be made widely available, particularly across SDPs.
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“The ESMPIN CHEW strategy has been a tremendous success. The highlight for me is seeing the CHEWs take FP services to the people, especially in very rural communities and at discounted rates , without compromising quality. This is why we are buying into the project’s strategy to make sure that the gains to the people in the past six months does not end. We therefore plan to engage some of the same faces (i.e. the CHEWs) whom the people have come to trust to continue offering services.” MR. FRANCIS ILOK MODE
Primary Health Coordinator, Ogoja, Cross River state
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SERVICE PROVISION ACTIVITIES ESMPIN Service provision refers to the direct offer of family planning (FP), as well as to health workers engaged in maternal and child health (MCH) services during the project’s implementation phase. Service provision under the project covered all health areas of FP, diarrhea, malaria and pneumonia. The ESMPIN service provision strategy addressed certain gaps identified during project design and implementation. Some of these include: dearth of service delivery points (especially in northern Nigeria); inadequate number of trained FP service providers; frequent product stock-outs (due to poor stock requisition system especially for the public sector and inadequate cash base to ensure consistent shelf presence for the private sector); a high number of IPC contacts not completing their referrals (largely due to perceived high service cost at health facilities, proximity to healthcare facilities and the consequent high cost of transportation to these facilities). Therefore, the direct service provision activities were designed and implemented to bridget the gap between inadequate staff strength, inconsistent product availability and perceived high cost of services at the public and private sector. The strategies employed herein include the CBD, iCCM and CHEWs approaches.
A door-to-door field IPC session.
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S t a t is t ics The ESMPIN CBD Approach
Unit Sales of Commodities under the CBD Approach
Service provision under the community-based distribution approach was implemented in four (4) northern states. It was aimed at improving access to child spacing and child survival products by addressing issues around insufficient public and private sector outlets. The approach prioritized unethical FP commodities such as male and female condoms, CycleBeads and oral pills (Combination 3). The other MCH products promoted by the approach include ORS and zinc, P&G Purifier of Water (PUR) and WaterGuard Plus. There was a significantly higher level of awareness on the ESMPIN promoted health objectives within CBD intervention communities, compared to the non-intervention communities. Awareness
CBD: 56% Non-CBD: 32%
Ever used an FP method
CBD: 17% Non-CBD: 5%
Currently use an FP method CBD: 10% Non-CBD: 3%
PRODUCT
Condoms
34,926 192,157 781,178 813,651 572,226
Cycle Beads
23,494 59,563 203,170 190,794 103,046
Cycle Beads
3,323 8,740 16,381 6,889 16,967
P&G Purifier of Water
CBD COMMUNITIES
60%
NON-CBD COMMUNITIES
45%
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746 178,856 450,124 320,004 137,177
WaterGuard + WaterGuard Plus
17,269 6,257
ORS and zinc
0
10 1,286 1,138
1,795 44,940 119,106 98,711
THE ESMPIN ICCM PILOT The iCCM pilot (integrated community case-management of childhood killer diseases) in 2 Ebonyi state LGAs focused on addressing malaria, diarrhea and pneumonia through the private sector (i.e. through PPMVs). These PPMVs were trained to identify and properly diagnose these ailments, treat them with correct medications and dosages, and identify severe cases that required referral. A total of 295 PPMVs participated in the six-month pilot with constant supervision and product resupply.
Cases Treated Under the 6 months iCCM Pilot for Ebonyi State A R E A
The percentage of children under five who had an episode of diarrhea and were treated with ORS/zinc combination was higher in the CBD communities
2012 2013 2014 2015 2016
JAN
FEB
MAR
APR
M AY
JUN
T O TA L
Malaria
1,246
1,087 1,447
2,090
2,440
Diarrhea
1,573
1,505 1,065
956
699
569
308
304
382 1,856
Pneumonia
277
266 319
2,692 11,002 6,367
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SERVICE PROVISION ACTIVITIES
SUCCESS STORY
Offering Improved Quality Child Health Services Through iCCM The private sector-focused iCCM pilot in Ebonyi state improved the practices of PPMVSs to implment this objective. Select PPMVs were trained to assess, classify and treat children who have malaria, pneumonia, diarrhea or malnutrition and refer critical cases to public and private health facilities. Specifically, they learned to diagnosis malaria fevers with RDTs, probe for diarrheal history and monitor respiratory rate for pneumonia diagnoses. They were also taught to treat using ACTs for positive RDTs, ORS and Zinc for diarrhea and Amoxicillin for positive pneumonia cases. Mr. Ogbonna Alex, a PPMV from Umudomi community of Onicha LGA within the state expressed his excitement: “Before now, we were seen as unable to take care of children. We were called quacks. But now the community believes in us. Before the training, all fever cases were treated as malaria. But now, if a child has fever, I carry out an RDT. And if positive, I give the child an ACT according to the age of the child and advise the parent to bring the child back in three days for follow up. But if it is negative, we refer for further tests and follow up.”
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A PPMV trained on the EXMPIN iCCM pilot.
THE ESMPIN CHEW APPROACH This approach was implemented alongside the IPC program and leveraged the task-shifting policy to engage CHEWs as interpersonal communication agents (IPCAs). ESMPIN , with the support of policy makers and other stakeholders, carefully selected unengaged CHEWs , trained them on the ESMPIN health areas and built their capacity on quality FP services within their scope. The product of focus included: Noristerat, Depo-Provera and Combination 3 while referring clients with LARC needs to referral facilities. The CHEWs were trained to create demand on child spacing, malaria, diarrhea and exclusive breastfeeding but offered FP services only to wiling contacts.
Services Provided by CHEWs Through the Six-Monts Cycle 10 Period (UNIT SALES) METHOD
JUL
AU.
SEP
OCT
N OV
DEC
T O TA L
CYP
Depo-Provera
2,367 7,589 10,291 9,202 8,617 6,758 44,824 11,206
Noristerat
1,724 5,338 6,221 4,689 4,776 5,813 28,561 4,760
Combination 3
4,407 10,174 13,724 14,969 11,541 9,509 64,324 4,948
The project achieved a combined total of 20,914 CYPs with 349 CHEWs through the Cycle 10 six-month period.
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SERVICE PROVISION ACTIVITIES
SUCCESS STORY
Offering Quality FP Services through CHEWs Sustainability Element The ESMPIN service provision activities recorded some sustainable outcomes. For instance, under the CBD implementation, agents joined together to create registered CBD Networks to access and sell the commodities they promoted during the implementation phase. Similarly, CHEWs who were engaged as IPCAs organized themselves across various communities even after exit, with the aim of sustaining sales or service provision. Furthermore, some states such as Cross River and Edo are currently working to continue offering similar services using the CHEWs under the payroll of the state.
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Proximity to health facilities (and the corresponding transport cost), inadequate staffing (with consequences such as long wait times and unfavorable provider attitudes) and relatively high cost of FP services remain a challenge to access of FP (and MCH) products and services. As a result, most community members resort to services from unqualified sources such as PPMVs, who often offer services beyond their scope. The ESMPIN project recruited
and trained CHEWs who created demand for FP within intervention communities and offered FP services as appropriate afterwards. In this way, they offered subsidized FP services to bridge the gap on proximity and cost. Modupe Adejo is a beneficiary of such FP services. She lives in Chokocho community of Rivers state with her three children. Before the ESMPIN intervention commenced in her community, she was receiving Depo-Provera (a family planning method) from a PPMV. Nevertheless, she reported wrong dosing: Modupe Adejo the PPMV administered a (seated in chair) double dose (i.e. 2 ampoules) benefiting from to last for a six-month CHEW services period, instead of one every three months, with no proper follow-up. When she participated in an IPC session with one of the ESMPIN trained CHEWs, she learned the correct information. She then opted for another method, which the CHEW provided. She says, “I thank you for correcting the mistake from the Chemist (PPMV). I plan to have another baby three years after my last issue. I am now more confident that I will have one again.”
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LESSONS LEARNED
Although policies are in place encouraging task shifting, as well as engagement of other lower level healthcare providers such as PPMVs, there is still a need to gain the support and active participation of all relevant groups such as the government, regulatory authorities, health association groups and community leaders. Planning for interventions must also include minor issues such as provision of consumables required for offering services or waste disposal strategy for mobile agents.
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ďƒ˜ A Health Communicaitons Coordinator providing guidance to a CHEW-IPCA on service provision
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“ORS and zinc is the magical medicine that stopped my child’s diarrhea within 12 hours of starting treatment.” M R S . S U WA I B A S U L A I M A N
Caregiver of three children who had lost two to diarrhea. She is now an advocate for ORS and zinc in her Tsakuwa community of Katagum LGA of Bauchi state.
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ORS & ZINC
A Winning Diarrhea Response
Diarrhea remains a major cause of illness and death for children under the age of five in Nigeria, although it is preventable and treatable with low-osmolarity ORS and zinc tablet. ORS/ zinc is a combination therapy recommended by the World Health Organization (WHO) for management of diarrhea in children. At a prevalence rate of 10.2%, only 33.7% of children receive any form of ORS and only 2.3% receive zinc during an episode of diarrhea (NDHS, 2013) due to lack of access and availability. SFH, through the Expanded Social Marketing Project in Nigeria (ESMPIN), embarked on making the products readily available and accessible to save the lives of children in rural, hard-to-reach areas and urban Nigeria. ESMPIN was committed to increasing the use of ORS and zinc to improve child survival and elminate childhood death from diarrhea in Nigeria. The project used a a three-pronged approach: 1. Building demand for ORS and zinc among caregivers using generic mass media campaigns and strategic community mobilization.
2. Training, detailing and supporting health care providers including PPMVs to promote the use of ORS and zinc. 3. Engaging and supporting private sector manufacturers in the local production of ORS and zinc. In supporting local manufacturers of ORS and zinc, SFH commits to opening up the market and providing these manufacturers with linkages to our extensive wholesale and retail networks across the 36 states of Nigeria (and the FCT). This potentially catalyzes and accelerates access to ORS and zinc. With support from USAID, ESMPIN promoted local production of ORS and zinc through its partnership with CHI pharmaceuticals. CHI Pharmaceuticals is a Nigerian company which launched the first co-packed low osmolarity ORS/ zinc tablet within the country. This has meant that caregivers could receive a combination of ORS and zinc in one pack to treat diarrhea. Additionally, a capacity assessment of several pharmaceutical companies in Nigeria revealed that there is good capacity in-country, and with adequate support, they are able to locally produce the commodities.
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S t a t is t ics
Some gaps that have been addressed through ESMPIN’s intervention in promoting ORS/zinc:
ORS & ZINC
M A NUFA C T URE Facilitated engagement and support for local production of ORS and zinc.
DIS T RIBU T ION SFH committed to providing the manufacturers with linkages to our extensive wholesale and retail networks across the 36 states of Nigeria (and the FCT), thereby creating the potential to catalize and accelerate access to ORS and zinc.
P OL IC Y Strengthened national policy implementation on use of ORS/ zinc combination in management of childhood diarrhea. Through the NEMCM platform, facilitated inclusion of ORS and zinc in the national essential medicines list.
DEM A ND GENER AT ION Built demand for ORS and zinc among caregivers through generic mass media campaigns and strategic community mobilization.
P RO V IDER C A PA CI T Y Trained, detailed and supported health care providers including PPMVs to improve provider knowledge and promote the use of ORS and zinc.
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Creating the ORS & Zinc Market Before the ESMPIN intervention, the combined use of ORS/zinc in Nigeria was practically nonexistent. despite the WHO recommendation. ESMPIN intervention with government, manufacturers, healthcare providers, other partners and local communities sparked and created the now increasing demand for the products use in the treatment of diarrhea. This landmark initiative enabled the growth of the market for locally produced ORS/zinc and has since seen the inclusion of four other local manufacturers. The project’s interventions also strengthened implementation of the national policy on use of co-packed ORS/zinc for diarrhea management. Collaboration with federal and state ministries of health achieved this goal. Similarly, through SFH’s vast distribution networks, the product now enjoys nationwide demand and availability in the private sector (pharmacies, hospitals and PPMVs).
Demand Generation ESMPIN conducted nationwide demand generation through mass media campaigns to increase caregivers’ knowledge and awareness on proper diarrhea treatment using the ORS/zinc tablet. In addition, IPC
agents worked in communities across 22 states in Nigeria conducting door-to-door and group sessions with caregivers to promote diarrhea treatment practices. In this way, the ESMPIN project recorded 8,819,725 IPC contacts on diarrhea management. SFH worked with national committees such as the National Essential Medicines Coordinating Committee (NEMCM) and other partners to expand demand generation and product redistribution. The collective effort of NEMCM partners brought about both an increase in awareness and product penetration to rural and hard-to-reach communities through the government and private sector channels. Similarly, ESMPIN leveraged on the SFH nationwide distribution networks to promote product distribution within the private sector. SFH detailers and sales representatives also conducted capacity building sessions with pharmacists, doctors and PPMVs to improve knowledge and understanding of the product. The demand generation activities resulted in an increase in knowledge and utilization with about 50% (NIGERBUS, 2016) of caregivers who understand that use of combination of ORS/zinc is appropriate treatment for diarrhea in children under 5.
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SUCCESS STORY
Collaborative Partnership Improving Local Production of ORS/Zinc Mr. Steve Onya is the managing director of CHI Pharmaceuticals Limited and says the experience of pioneering the local manufacture of ORS/zinc in Nigeria is one of mixed feeling. “There is that feeling of joy and satisfaction in being the pioneer of an important medicine intervention relevant to child healthcare. There is also the joy of meeting the desire of the world health community to see locally manufactured quality essential medicine in Nigeria which remains the most populous nation in Africa. The flip side of the feeling is in the business part, reflected by the poor return on huge investment. We believe that better government and other relevant agencies’ support would make a big difference.” The CHI Pharma brand of dispersible zinc sulphate tablets and low-osmolarity ORS have always met quality specification in all tests carried out locally and internationally. CHI pharmaceutical is currently producing at 45% capacity and has an installed capacity to produce 1.2 billion tablets of zinc and 925 million sachets of ORS per annum. They currently export the products to other African countries.
LESSONS LEARNED
A major lesson learned through the promotion of ORS/zinc use is that to further strengthen the local market and improve local production, the Nigerian government must actively participate along with development partners and providers. Together, they must prioritize procurement of locally manufactured ORS/zinc by federal and state governments to further stimulate the market for local production.
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“The ESMPIN project has done a lot for the state through demand generation. What is of interest to me is seeing women in the communities walk into the health facility with a referral form to demand for FP service. The work of ESMPIN interpersonal communication agents in mobilizing clients makes work easy for the provider. Your support with consumables to referral health facilities has been helpful in addressing some of the challenges of these facilities.” M R S . J OYC E A M A E W H W E Rivers State Family Planning coordinator.
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ADVOCACY & COLL ABORATION
Advocacy and collaboration was prioritized on the ESMPIN project with focus on the government, funders, peer organizations, private sector stakeholders and community stakeholders all with the aim of achieving its objectives. Advocacy was continuous under ESMPIN and events were held with all stakeholders to inform, build buy-in and support, gain active participation on activities, receive their contribution in addressing challenges and share outcomes of project activities to stimulate ownership. ESMPIN engaged in numerous collaborations and partnerships with government agencies at the state and local levels. Traditional/ religious institutions and other implementing partners proved beneficial in leading family planning, malaria and diarrhea community-level interventions across 22 intervention states. All project activities, including selection of intervention communities and field agents, were done in collaboration with local authorities.
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S t a t is t icsIntegrated Health Implementation Report
Mass Media The ESMPIN project used mass media to reach audiences everywhere in Nigeria. ESMPIN aired media jingles and provided equipment to select media organizations to improve their capacity to produce and air FP and child survival programs through a collaborative arrangement. Producers and presenters of health programmes and popular programmes participated in ESMPIN training and in-house mentoring conducted by BBC Media Action.
10:
465:
Beneficiaries of the project are grateful for the opportunity.
Media practitioners attended workshops on thematic and production issues.
72:
Media practitioners received specialized training on production for improving reproductive, maternal, neonatal and child health (RMNCH).
62:
Chief executive officers took part in master classes.
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New programs were introduced in different partner stations on RMNCH .
5: Existing MCH programs in different partner stations improved their content and production and all partner stations now have health programmes that address RMNCH issues.
BLESSING LAWYER RADIO RIVERS:
“I learned interview skills because I know that was my major problem. I learned how to get to the heart of my listener and I learned how to get to the heart of my interviewee.” VIVIAN OSAGIE CITY FM, LAGOS:
“I got one special tool, a zoom recorder. I take it everywhere with me, it makes my job easier. Basically, this tool has helped me, this has helped me with my interviews.”
Policy Change Through iCCM ESMPIN worked with MalariaCare in collaboration with the Federal Ministry of Health (FMoH) and Ebonyi State Ministry of Health (ESMoH) to implement the ICCM pilot in Ebonyi. ESMPIN trained 295 PPMVs on case management (diagnosis and treatment) of uncomplicated malaria, pneumonia and diarrhea. They were trained to identify malnutrition in children and to refer all complicated cases to a health facility. ESMPINs collaboration with the FMoH and MalariaCare to implement the iCCM pilot will provide evidence required for wide scale training of lower cadre health workers (such as PPMVs) on proper diagnoses and treatment of serious childhood illnesses such as pneumonia and malaria. Local Manufacture of ORS/zinc ESMPIN facilitated engagement and support of local production of ORS/zinc in Nigeria through its partnership with CHI Pharmaceuticals. The partnership led to the pioneer production of locally manufactured co-packed ORS/zinc, making it easy for caregivers to access the product in one pack for the treatment of diarrheal episodes. Prior to ESMPIN’s intervention, the use of ORS/zinc in Nigeria was low, as 2.3% of children who had diarrhea received zinc and only 33.7% received any form of ORS.
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A DVO C AC Y & C O L L A B O R AT I O N
Customer buying child survival products from a PPMV
A male involvement session in Southern Nigeria
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ESMPIN’s intervention with government, manufacturers, healthcare providers, other partners and local communities created a growing demand, building capacity for the local production of ORS/zinc. At the end of the ESMPIN project, four other local manufacturers joined in. CHI Pharmaceuticals, which is the pioneer local manufacturer, has an installed capacity to produce 1.2 bilion tablets of zinc and 925 million sachets of ORS per annum.
Special Events with States & Federal Government ESMPIN worked closely with state and federal government ministries of health to host special events that aimed at improving women and children’s health. The 2015 child spacing day event in Zamfara State is an example of such special events. Prior to the event, advocacy visits were held with religious and traditional leaderships who helped with community mobilization and sensitization. On that single day 568 women willingly accepted different types of FP methods.
Male Involvement In most Nigerian communities, men hold decision-making power and their influence impacts choice and use of maternal and child health commodities. However, these men are often excluded from FP programmes and interventions. Lack of spousal support is a barrier to acceptance and uptake of FP counselling and services. The ESMPIN project prioritized male involvement to increase support among men for family planning and greater participation in women’s health. The male involvement sessions were held in 22 priority states. The project conducted planned interactions with male groups designed to change social norms and improve male participation in women’s health. Studies showed that the intervention strategy contributed to higher spousal communication on family planning in the communities where ESMPIN worked (IPC & CBD Evaluation, 2016).
Method Uptake at Zamfara Child Spacing Day Event S/N
METHOD PROVIDED
Q U A N T I T Y
1 Implanon
301
2 Jadelle
58
3 IUCD
15
4 Depo-Provera
04
5
Oral Pills
6 Condoms
120 70
ESMPIN also collaborated with the SMoH across
all its priority states to support and participate in organizing special health day celebrations amidst specific technical working groups.
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SUCCESS STORIES
FP Training Impact on Outcomes of Demand Creation Activities ESMPIN collaborated with other implementing partners with to provide complete FP training for providers. This is because ESMPIN focused on demand generation, its core strength. FH+, a project implemented by Marie Stopes International Organisation Nigeria (MSION), collaborated with the ESMPIN project across various states where ESMPIN implemented community level intervention, such as in Imo state. In Imo, uptake of modern FP methods, especially LARCs , was very low. During their collaboration, MSION conducted training of providers on LARCs while ESMPIN generated demand for services. As a result of the collaboration, service uptake jumped from five in January 2016 to 834 by June 2016. In addition, the method acceptance mix changed to more LARCs from zero to 68.
The Onuh of Obocho Community in Kogi State and Celest Carr, Senior Planning and Program Advisor, USAID during a USAID/ ESMPIN field visit
LESSONS LEARNED
Advocacy works. Through advocacy, doors of opportunity opened for the project. We gained trust, acceptance and active participation of stakeholders on project activities. Collaboration brings leverage. Through collaboration, ESMPIN leveraged the strengths of other partners to achieve its mandate, while contributing its strength to these organizations, resulting in a win-win situation for all parties.
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Integrated Health Implementation Report A  cross E S M Psection I N 31 of the ESMPIN team with the Kogi State Commissioner of Health and SMoH officials
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ESMPIN PARTNERS USAID We partner to end extreme poverty and promote resilient, democratic societies while advancing our security and prosperity.
Society for Family Health (SFH) SFH is an indigenous, non profit, non-political, non governmental organization in Nigeria with a mission to empower Nigerians particularly the poor and vulnerable to lead healthier lives. Working with private and public sectors, SFH uses social marketing and evidence-based behavior change communication to improve access to essential health information, services and products to motivate the adoption of healthy behaviors. SFH implements and demonstrates significant impact in various health fields including maternal and child health, malaria prevention and treatment, HIV & AIDS prevention, reproductive health, family planning and safe water systems. SFH also provides health products and clinical services to Nigerians in urban and rural areas, especially among the most vulnerable. SFH in collaboration with Population Services International (PSI) embraces opportunities for furthering its mission through
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partnerships with several international donors, Ministries of Health and other organizations to create health solutions that are built to last.
The Association for Reproductive and Family Health (ARFH) ARFH, established in 1989, is a leading fully indigenous non – profit and Non- Governmental organization in Nigeria, committed to improved quality of life of individuals and families by promoting and increasing access to quality health information and services. ARFH has a multi-skilled workforce of 170 staff with the capacity to design, implement and evaluate model initiatives, many of which have gained national and international recognition and are being replicated. Within the 28 years of existence, the organization has successfully managed and implemented over 150 innovative reproductive health and development projects across the 36 states and the FCT and other neighbouring countries most of which have gained national recognition, shaped national responses to public health challenges and a number are presently replicated nationwide.
BBC Media Action Established in 1998, BBC Media Action is the international charity of the BBC. Working with media and communication to help reduce poverty and support people in claiming their rights, our aim is to inform, connect and empower people around the world. BBC
Media Action reaches some 200 million people through local broadcast partners, BBC channels (especially the BBC World Service), online, mobile and print platforms and through interpersonal communication. In Nigeria, we work in partnership with more than 300 radio and TV broadcasters – more than any other development organization in the country. Since 1999, we have delivered more than 16 health governance projects reaching and engaging Nigerian across all 36 states and the Federal Capita Territory. About 8.6million Nigerians listen to Ya Take Ne Arewa in the north, a Hausa radio programme produced under the Expanded Social Marketing Project in Nigeria (ESMPIN).
Population Services International (PSI) PSI makes it easier for people in the developing world to lead healthier lives and plan the families they desire by marketing affordable products and services. A global health network of more than 50 local organizations, PSI focuses on serious challenges like a lack of family planning, HIV and AIDS, barriers to maternal health, and the greatest threats to children under five, including malaria, diarrhea, pneumonia and malnutrition. A hallmark of PSI is a commitment to the principle that health services and products are most effective when they are accompanied by robust communications and distribution efforts that help ensure wide acceptance and proper use. PSI works in partnership with local governments, ministries of health and local organizations to create health solutions that are built to last.
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Go Deeper For more ESPMIN project resources, please find the following online briefs: SUCCESS STORIES
http://bit.ly/2mhWcgb BOOK OF ABSTRACTS
http://bit.ly/2mlclSL BOOK OF STANDARDS
http://bit.ly/2mNtaD9 TECHNICAL BRIEFS
http://bit.ly/2mldoSC GUARD BOOKS
http://bit.ly/2mSLIBb POLICY BRIEFS
http://bit.ly/2m2FoHX
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ESMPIN
Expanded Social Marketing Project in Nigeria
8 P O R T H A R C O U R T C R E S C E N T A R E A 11 , G A R K I , A B U J A • T E L : +2 3 4 (0) 70 9 8 22 1 4 4 0 , 70 9 8 22 1 4 4 5, 70 9 8 22 1 47 • E M A I L : I N F O @ S F H N I G E R I A . O R G
www.sfhnigeria.org
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