Read the assessment report - UNFPA Nigeria

Lagos State ReportHEALTHCARE SERVICES IN UNFPA ASSISTED STATES OFNIGERIAPREPARED BYUNFPA NIGERIA COUNTRY OFFICENOVEMBER 20101

TABLE OF CONTENTSPageCover Page 1Table of contents 2List of Acronyms 4List of Tables 5List of Figures 61. INTRODUCTION 81.1 STATE CONTEXT 81.2 BACKGROUND TO THE ASSESSMENTS 91.3 AIM AND OBJECTIVES OF THE ASSESSMENTS 102. METHODOLOGY 102.1 SAMPLE SELECTION 102.2 QUESTIONNAIRE DEVELOPMENT AND ADMINISTRATION 102.3 LIMITATION OF THE ASSESSMENTS 113. RESULTS OF THE ASSESSMENTS 113.1 BACKGROUND INFORMATION 113.1.1 Designation of respondents 113.1.2 Types of facilities 123.1.3 Residential status of facilities 133.1.4 Physical status of facilities 133.1.5 Methods of Waste Management 193.1.6 Common RH problems 193.2 HUMAN RESOURCES 193.2.1 Availability of health workers 193.2.1.1 Skilled Health Workers 223.2.1.2 Unskilled Health Workers 283.2.1.3 Other Health Workers 313.3 TYPES OF TRAINING ATTENDED BY HEALTH WORKERS 373.4 HEALTHCARE SERVICES PROVIDED BY FACILITIES 393.3.1 ANC, Delivery Care and PNC Services 403.3.2 Child Welfare and Immunizations Services 413.3.3 Family Planning Services 423.3.4 STIs, HIV Counseling and HIV Testing Services 423.3.5 Obstetric Fistula Repair 433.3.6 Treatment of Minor Ailments 443.3.7 Referral Services 442

3.3.8 Demand creation activities 443.3.9 Other Services 453.5 PROVISION OF SERVICES IN THE LAST THREE MONTHS 453.5.1 Total Attendance for Services 453.5.2 Family Planning Services, Contraceptives and Stock outs 473.5.2.1 Number of new FP acceptors 473.5.2.2 Number of FP revisits 473.5.2.3 Stock out status 483.5.2.4 Type and number of Contraceptives 493.5.2.5 Number of FP complications referred 503.5.2.6 Availability and Adequacy of FP Rooms 503.6 AVAILABILITY OF INTEGRATED SRH AND HIV SERVICES 503.7.1 Provision of Integrated SRH/HIV care and Services 513.7.2 Types of Integrated SRH/HIV care and Services 513.7 EMERGENCY OBSTETRIC AND NEW BORN CARE SERVICES3.7.1 Basic Emergency Obstetric and New Born Care Services 523.7.2 Comprehensive Emergency Obstetric and New Born Care Services 523.7.3 Total obstetric complications in the last three months 563.7.4 Other requirements for EmONC services 573.7.4.1 Availability and utilization of Referral Forms 573.7.4.2 Provision of Birth Preparedness Services 583.7.4.3 Functional Means of Transport for Emergencies 593.7.4.4 Availability of Maternity Beds and Delivery Equipment 603.7.4.5 Availability of Essential Drugs and Consumables 613.7.4.6 Methods of Styerilisation. 623.8 DATA COLLECTION FORMS, SUPERVISION AND SUPPORT3.8.1 Availability, utilisation and transmission of RH/FP data forms 633.8.2 Other statistical data forms 633.8.3 Supervision of facilities by LGAs 633.8.4 Types of IEC Materials 643.8.5 Village Health Committees 654. RECOMMENDATIONS 663

LIST OF ACRONYMSANCCPAPCPRFCTFPHIV/AIDSM&EMDGMICSMMRMNCHNDHSRHRSRHTFRUNUNFPAZOAntenatal CareCountry Programme Action PlanContraceptive Prevalence RateFederal Capital TerritoryFamily PlanningHuman Immunodeficiency Virus/Acquired Immunodeficiency SyndromeMonitoring and EvaluationMillennium Development GoalsMultiple Indicators Clusters SurveyMaternal Mortality RateMaternal and Neonatal Child HealthNational Demographic and Health SurveyReproductive Health and RightsSexual Reproductive HealthTotal Fertility rateUnited NationsUnited Nation Population FundZonal Office4

LIST OF TABLESTable 3.1: Frequency Distribution of Respondents by rank and professionTable 3.2: Frequency Distribution of Respondents by Nature of ResidenceTable 3.3: Indicators of the Physical Status of HCFs in the StateTable 3.4: Common RH problems in the StateTable 3.5: Frequency distribution of health workers by types of health care facilitiesand nature of residenceTable 3.6: Frequency distribution of skilled health workers by types of health carefacilities and nature of residenceTable 3.7: Frequency distribution of Doctors by types of health care facilities andnature of residenceTable 3.8: Frequency distribution of Nursing and Midwifery Professionals by types ofhealth care facilities and nature of residenceTable 3.9: Frequency distribution of unskilled health workers by types of health carefacilities and nature of residenceTable 3.10: Frequency distribution of pharmaceutical health workers by types ofhealth care facilities and nature of residenceTable 3.11: Frequency distribution of laboratory health workers by types of healthcare facilities and nature of residenceTable 3.12: Frequency distribution of other health workers by types of health carefacilities and nature of residenceTable 3.13: Number of health workers trained by the types of trainingTable 3.14: Percentage Distribution of the Types of Services by the Types ofsupported Facilities and how frequently the services were providedTable 3.15: Frequency distribution of attendance for healthcare services in the past 3months (June-August 2009) by type of facility and nature of residence.Table 3.16: Frequency Distribution of FP clients in the last three months by the typesof acceptors, residence and types of facilities.Table 3.17: Distribution the types and numbers of contraceptives availableTable 3.18: Number of FP complications referred by residence and type of facilityTable 3.19: Types of Integrated SRH, HIV&AIDS services provided by Type of HCFsTable 3.20: Availability of Basic Emergency Obstetric and Newborn Care Services inthe selected HCFsTable 3.21: Summary of reasons for not providing BEmOCTable 3.22: Provision of CEmONC service in the supported HCFs in the StateTable 3.23: Summary of reasons for not providing CEmONC servicesTable 3.24: Number of Obstetrics Complications.Table 3.25: Types of obstetric complicationsTable 3.26: Names of Health Facilities where referrals are made in the StateTable 3.27: Provision of Birth Preparedness Services by the Types of HCFsTable 3.28: Availability of Functional Means of TransportTable 3.29: Type of, who provided and maintained the functional means of transportTable 3.30: Availability of maternity equipment in health facility by types of beds,residence and facility typesTable 3.31: Availability of RH/FP data forms by the Types of HCFs and where data issent toTable 3.32: Distribution of IEC materials available in the facilitiesTable 3.33: Supervision of HCF by officials of the LGA departmentTable 3.34: Existence, Functionality and Meetings of VHCs5

LIST OF FIGURESFigure 1.1a: Map of Nigeria showing the LGAs of Lagos StateFigure 3.1: Percentage distribution of respondents by professionFigure 3.2: Percent Distribution of Supported Health Care Facilities by TypesFigure 3.3: Percent Distribution of Respondents by Nature of ResidenceFigure 3.4: General Cleanliness of the FacilityFigure 3.5: Availability of Curtain in the Maternity Ward or Delivery RoomFigure 3.6: Condition of the floor of the Labour RoomFigure 3.7: Percent Availability of Amenities in supported HCFs in the StateFigure 3.8: Percent Availability of Toilets and Bathrooms in supported facilitiesFigure 3.9: Main source of water within the premises of supported facilitiesFigure 3.10: Sources of Light in the supported FacilitiesFigure 3.11a: Frequency distribution of skills workers by types of facilityFigure 3.11b: Frequency distribution of skills workers by residenceFigure 3.12a: Frequency distribution of Doctors by types of health care facilitiesFigure 3.12b: Frequency distribution of Doctors by nature of residenceFigure 3.13a: Frequency distribution of Nursing and Midwifery Professionals by typesof health care facilitiesFigure 3.13b: Frequency distribution of Nursing and Midwifery Professionals bynature of residenceFigure 3.14a: Frerquency Distribution of unskilled health workers by the types offacilitiesFigure 3.14b: Percent Distribution of unskilled health workers by ResidenceFigure 3.15a: Frequency distribution of pharmaceutical health workers by types ofhealth care facilities and nature of residenceFigure 3.15b: Percent distribution of pharmaceutical health workers by residenceFigure 3.16a: Frequency distribution of laboratory health workers by types of healthcare facilitiesFigure 3.16b: Percent distribution of laboratory health workers by residenceFigure 3.17a: Frequency distribution of other health workers by types of health carefacilities and nature of residenceFigure 3.17b: Percent distribution of other health workers by residenceFigure 3.18a: Number of health workers trained by the types of training and facilitiesFigure 3.18b: Percent distribution of health workers trained by residenceFigure 3.19: Percentage of the Types of facilities that offered ANC, Delivery care andPNC servicesFigure 3.20: Percentage of the Types of Facilities that Provided Child Welfare andImmunisation ServicesFigure 3.21: Proportion of the Types of Facilities That Offered FP servicesFigure 3.22: STIs management, HIV counseling and HIV testingFigure 3.23: Obstetric Fistula RepairsFigure 3.24: Referral ServicesFigure 3.25: Demand Creation ServicesFigure 3.26a: Frequency distribution of attendance for healthcare services in the past3 months by type of facility and nature of residence.Figure 3.26b: Frequency distribution of attendance for healthcare services in the past3 months by type of facility and nature of residence.Figure 3.27: Percentage availability of FP Services by the Types of Facility6

Figure 3.28: Percentage availability of Contraceptives by Types of FacilityFigure 3.29: Percentage of Facilities Providing Integrated SRH/HIV Services by theTypes of FacilityFigure 3.30: Availability of Basic Emergency Obstetric and Newborn Care Servicesin the selected HCFsFigure 3.31: Provision of CEmONC service in the supported HCFs in the StateFigure 3.32: Percentage distribution of Facilities that utilised Referral Forms by theTypes of HCFsFigure 3.33a: Number of the Types of Beds in the selected Facilities.Figure 3.33b: Percent distribution of Beds in the selected Facilities by residence.Figure 3.34: Percent Distribution of selected HCFs by Methods of SterilisationFigure 3.35: Availability of other statistical data by the Types of HCFS7

1 INTRODCUTION1.1 STATE CONTEXTLagos State, Nigeria was created on May 27, 1967 by virtue of State (Creation andTransitional Provisions) Decree No. 14 of 1967, which restructured NigeriaFederation into 12 States. Lagos State lies to the south-western part of theFederation. It shares boundaries with Ogun State both in the North and East and isbounded on the west by the Republic of Benin. In the South it stretches for 180kilometres along the coast of the Atlantic Ocean. The smallest State in theFederation, it occupies an area of 3,577 sq km. 22% or 787sq. km of which consistsof lagoons and creeks.The state government recognizes that health is the basic ingredient for socioeconomic,technological and sustainable development. As part of its commitment toensuring that the people attain high standards in health; the State Government hassigned LoU with UNFPA in the 6 th Country Programme. Under the programmeUNFPA provides support to 10 designated as focal project LGAs partly increase thelow political commitment and community support for population, RH and genderissues; and reduce the wide gender gap. Figure 1.1a below shows the Map ofNigeria showing Lagos State, while Figure 1.1b is the Map of Lagos.Figure 1.1a: Map of Nigeria showing the LGAs of Lagos State8

1.2 BACKGROUND TO THE ASSESSMENTUNFPA Nigeria signed a Memorandum of Understanding for the 6 th CountryProgramme Action Plan (CPAP) with the Federal Government of Nigeria in August2008. The CPAP document specifies the nature of broad development assistanceframeworks of UNFPA for Nigeria in the mandate areas of UNFPA. The developmentassistance frameworks of UNFPA to 12 States and the FCT are essentially in thethree thematic areas including Reproductive Health and Right (RHR), Population andDevelopments (P&D) and Gender Equality (GE).The RHR component has two outcomes and four outputs. The two outcomes are asfollows:a. Federal, and 12+1 States’ institutions, and sectors are able to plan, implementand monitor the delivery of quality Reproductive Health/Family Planning and HIVPrevention services by 2012b. Communities in 12+1 supported States are able to demand for and use qualityreproductive health/family planning and HIV prevention services by 2012.Meanwhile, the four specific outputs expected to deliver on the two outcomes are:a) Improved gender responsive and equitable HIV preventive services forwomen and youth in 12+1 states and at the Federal level.b) Strengthened institutional capacity to ensure reproductive health commoditysecurity and deliver gender sensitive and equitable family planning services atFederal level and in 12+1 supported States’ institutions and NGOs.c) Increased gender sensitive and culturally appropriate quality maternal healthservices, including Emergency obstetric and neonatal care in 360 facilities in12+1 supported States .d) Enhanced knowledge, skills and mechanism to demand for, and accessquality gender sensitive and equitable RH/FP and HIV/AIDS preventionservices in selected communities in 12+1 supported States.In order to achieve these outputs, UNFPA planned to support 30 health facilitiescarefully selected to achieve a model of four primary health facilities to feed into asecondary facility in the 12+1 supported States with view to scale up servicedeliveries, increase access and utilisation of health care in the supported states, andensure that a model of continuum of care is available and the scale up of EmONCand family planning in the selected local government areas. The supported healthfacilities will be used as model for best practise in the provision of quality maternalhealth services in these 12+1 supported State.UNFPA Nigeria’s programme implementation adopts the principles of nationalexecution as prescribed by Paris Declaration. This informed the decision to embarkon the assessment of selected health facilities in the states to identify theweaknesses and strengths of health system especially as relate to the delivery ofhigh quality maternal health services. This will among other things highlightstechnical assistance required and the specific intervention requirement in the statesto achieve the Reproductive Health and Right (RHR) outcomes and outputs.UNFPA collaborated with the State Ministry of Health in the supported states toconduct the assessments of capacities of health facilities to deliver on thereproductive health outputs in the states. The results will serve as baselines for9

UNFPA interventions, particularly in the selected facilities and in the states ingeneral. This report presents the State summary of the health facilities capacityassessments with the view to examine the status of the EOC, family planning,HIV/AIDS services in the facilities and highlight the nature of intervention andresource requirements to improve maternal health services at the grassroots.1.3 AIM AND OBJECTIVES OF THE ASSESSMENTThe main objective of the assessment was to provide baseline data on theavailability and utilization of Reproductive Health services in the selected states andthus provides the nature of specific interventions in line with UNFPA 6 th countryprogramme in Nigeria. The specific objectives were: To determine the availability of Emergency obstetric services in the selectedhealth facilities To determine the availability and the quality of family planning services in theselected health facilities To identify the quality of youth focus services in the health facilities To identify the nature and types of problems associated with accessibility,utilization and service delivery of maternal health care in the selected healthfacility To identify and document areas for improvement in the provision of maternalhealth care delivery in the selected states To identify gaps, strength and weaknesses in the maternal health care in theselected states2 METHODOLOGY2.1 SAMPLE SELECTIONHealth facilities were selected through purposive sampling approach with theparticipation of the stakeholders and the programme coordinators in the State. TheState team identified six focus local areas councils from where health facilities werechosen. Four primary health facilities and one secondary health facility were selectedfrom each local government area to form a module of referral health care in the localgovernment. Thus, 30 health facilities were selected comprising 24 Primary HealthCenters and 6 referral hospital or secondary health facilities. This report presentsresults of data from 28 supported health facilities in the Lagos State. This sample isrepresentative of the condition of maternal health care especially in the public healthfacilities in the selected states2.2 QUESTIONNAIRE DEVELOPMENT AND ADMINISTRATIONA structured questionnaire was developed featuring various questions includingEmONC, Family Planning, medical human resources, and facilities for maternal andneonatal health care, training needs of personnel and the access and utilization ofservices in the facilities. A team of field enumerators were trained in each statethrough UNFPA Technical Assistance and were deployed to the health facilities.Enumerators were sourced from the state ministry of health and were trained on howto complete the questionnaire. They were also instructed to ensure that responses tothe featured questions are obtained from the most senior person in the health facility.On the average data collection exercises were completed in 2 weeks in most states,10

however where poor terrain and long distance were major challenges the exerciseslasted longer. The survey was conducted between October and December 2009.2.3 LIMITATION OF THE ASSESSMENTThe major challenge encountered during the survey was poor accessibility to somehealth care facilities (HCFs). In some cases enumerators had to disembark from theproject vehicle to visit HCFs on foot or through commercial motor-bike. On the otherhand, the selection of HCFs in accordance with the prescribed referral module isanother challenge encountered. Some of the selected HCFs were found to bedysfunctional and do not meet the requirements of the planned interventionprogramme of UNFPA. Such HCFs were dropped and the States were requested torevise their list and provide substitute.Data collection tools did not facilitate disaggregation of data by the characteristic ofthe HCFs. Data collection on personnel, including issues of training did not reflectthe core UNFPA mandate of gender sensitive data; hence, the information humanresources could be disaggregated by sex.3 RESULTS OF THE ASSESSMENTS3.1 BACKGROUND INFORMATION3.1.1 Designation of RespondentsData on health facilities were collected from the staff in-charge of the health facilities.The designations or cadres of respondents to the questionnaire are shown in Table3.1 and Figure 3.1 below.Table 3.1: Frequency Distribution of Respondents by rank and professionS/N Cadre Frequency %1 Distribution by rank of respondentsChief Matron 4 14.3CNO 10 35.7ACNO 6 21.4PNO 2 7.1Hospital Administrator 1 3.6CHO 1 3.6RNM 1 3.6Staff Nursing Officer 1 3.6Unstated 2 7.1Total 28 100.02 Distribution by profession of the respondentsNursing and Midwifery 24 85.7Community Health Workers 1 3.6Hospital Administration 1 3.6Unstated 2 7.1Total 28 100.011

Figure 3.1: Percentage distribution of respondents by professionThe data in Table 3.1 and Figure 3.1 show that almost all respondents (85.7%) wereof the Nursing and Midwifery profession. The balances of 3.6% each wereCommunity Health Workers and Hospital Administration. In the mean time, 7.1% didnot state their rank or profession. The results suggest that data for the facilityassessment in the State were likely collected from health workers in-charge of thesupported facilities.3.1.2 Types of supported HCFsA health care facility (HCF) is any place where medicine is practiced regularly.Overall, the types of HCFs ranges from small and relatively simple medical clinics(such as dispensaries, dental offices, out-patient surgery centres, birthing or deliverycentres, and nursing homes and personal care facilities) to large, complex, andcostly hospitals (General, Specialist, and Teaching and Research). In between thetwo extremes are the Comprehensive Health Centres (CHC), Maternity Centres andHomes, and Primary Health Care Centres (PHCs). In this survey, information wascollected on the types of HCFs supported by UNFPA in the State, and the results ofthese are highlighted in Figure 3.2.Figure 3.2: Percent Distribution of Supported Health Care Facilities by TypesThe information in Figure 3.2 shows that the 28 facilities were Primary HealthcareFacilities at 64.3% and secondary healthcare facilities at 21.4%. The CHCs and12

PHCs were the primary type of HCFs that are the closest to the grassrootspopulation in the rural communities while the GHs constituted the secondary HCFsthat usually represent referral centres to the primary facilities in the third tier of healthcare in the country.3.1.3 Residence status of the supported facilitiesFacilities reside or locate in either urban or rural areas. Table 3.2 and Figure 3.3present data on the types of selected health care facilities by location or residentialstatus.Table 3.2: Frequency Distribution of Respondents by Nature of ResidenceFacility Rural Urban TotalType Frequency % Frequency % Frequency %CHC 0 0 3 10.7 3 10.7PHC 4 14.3 15 53.6 19 67.9GH 1 3.6 5 17.9 6 21.5Total 5 17.9 23 82.1 28 100Figure 3.3: Percent Distribution of Respondents by Nature of ResidenceOut of a total of 28 supported healthcare facilities in the State, 22 (78.6%) wereprimary healthcare facilities as against 6 (21.4%) secondary facilities; and 23(82.1%) were located in the urban areas; co0mpared 5 (17.9%) that were located inrural areas. Almost all the secondary facilities at 83.3% were located in urban areasagainst 16.7% in rural areas. Similarly, 18 of the 22 primary facilities representing81.8% were located in the urban areas compared to 18.2% in the rural areas.3.1.4 Physical Status of the supported HCFsInterviewers were asked to observe the physical status of the selected HCFs in theState with respect to general cleanliness, availability of curtains in theMaternity/Delivery Rooms, and the status of the floor of the labour room. The dataon these indicators of the physical status of selected HCFs are displayed in Table3.3 and Figures 3.4 to 3.10 below.13

Table 3.3: Indicators of the Physical Status of HCFs in the StateS/N Physical status Indicator Freq %1 General facility status Very clean 2 7.4Clean 24 85.7Dirty 1 3.6Very dirty 0 0Unstated 1 3.628 1002 Curtains Available 11 39.3Not available 9 32.1Unstated 8 28.628 1003 Floor of the maternity/deliveryroom/wardVery Dirty 0 0.0Dirty 1 4Clean 21 75Very clean 2 7Unstated 4 1428 1004 Water Available 11 39.3Not available 9 32.1Unstated 8 28.628 1005 If available, what is the source of water? Borehole 23 82.1Well 3 10.5Water mains 2 7.428 1006 Source of light PHCN andGenerator(Functional)14 50PHCN 12 42.9Generator 1 3.6Unstated 1 3.628 1007 Toilet Available 23 82Not available 2 7Unstated 3 1128 1008 Bathroom Available 21 75.0Not available 2 7.4Unstated 5 17.628 1003.1.4.1 General CleanlinessThe data on the general cleanliness of HCFs are also shown in Figure 3.4 below.The results in Table 3.3 and Figure 3.4 reveal that majority (85.7%) of the supportedfacilities in the State was clean and 7.4% were very clean. However, the balance of3.6% was dirty, which may require renovations to make attractive to clients.14

Figure 3.4: General Cleanliness of the Facility3.1.4.2 Availability of Curtains in the Maternity and Delivery RoomsCurtains in the maternity or delivery room provide confidence and privacy to womendelivering in HCFs. The status of Curtains in the maternity or delivery rooms arepresented in Table 3.3 above and Figure 3.5 below.Figure 3.5: Availability of Curtain in the Maternity Ward or Delivery RoomAccording to the data, the percentage distributions by availability of curtain in thematernity or delivery room were unevenly distributed between available (39.3%) andnot available with 32.1%. This suggests that women who attended one-third of thefacilities without curtain in the maternity room did not have the rights to privacy andcomfort during delivery. However, many of the 28 facilities assessed at 28.6% didnot provide information on the status of curtain in the maternity ward.3.1.4.3 Status of the Floor in the Labour RoomTable 3.3 above and Figure 3.6 below present the results on the status of the Floorin the Labour Room in the State, which are required to make them attractive fordelivery services and to minimize any accidents.15

Figure 3.6: Condition of the floor of the Labour RoomThe results show that many of the supported facilities in the State were clean with75% and very clean with 7%. None the less, 4% of the facilities in the State weredirty. These findings suggest that some of the HCFs in the State require some ofrenovations to make facilities more attractive to clients, minimize accidents and toaccelerate service delivery.3.1.4.4 Availability of AmenitiesAmenities are any provisions in the HCFs that enhance its benefits including access,patronage and performance of service delivery, as well as the sanitary conditions.Amenities in this context are toilets, water, light, bathroom, waste disposal system,and sterilization system, wards, and labour or delivery rooms. Figure 3.7 provideinformation on the status of amenities in the supported HCFs in the State.Figure 3.7: Percent Availability of Amenities in supported HCFs in the Statea) Availability of Toilet and Bathroom amenitiesAvailability of toilet facility in the HCFs offers safe sanitation facilities and opportunityfor healthy habits for the clients. The results in Figure 3.8 present data on availabilityof Toilets and Bathrooms in the Facilities.16

Figure 3.8: Percent Availability of Toilets and Bathrooms in supported facilitiesThe results reveal that most facilities with 82% had Toilets while three-quarters hadBathrooms within their premises. But 7.4% each of the facilities did not have anyToilets and Bathrooms. Information also indicates that majority of the facilities(91.3%) that had Toilets also had Bathrooms. Meanwhile, some facilities did notindicate the status of Toilets and Bathrooms. However, information on the type andsanitary conditions of the toilets was not obtained by the survey. None the less, oneof the 28 facilities did not indicate the status of its Toilets, which show that a numberof clients and staff would resort to other methods including bush to defeacate withimplications for environmental sanitation in the HCFs. Lack of toilets within thepremises of HCFs promotes open space or nearby bush defecation, which in turnpromotes rapid growth of fungi and other germs that spread diseases. It is also asource of air pollution and contamination of open water sources.b) Availability of Safe Water SourcesAccess to safe water sources by 2015 is one of the indicators of the MDGs 7 -ensure environmental sustainability. Inadequate access to safe drinking water leadsto widespread water borne diseases and is a major cause of death in manycountries. Poor sanitation, water and hygiene have many other seriousrepercussions. Staff are denied the right to good healthy working environmentbecause their HCFs lack sanitation facilities. Staff also spend parts of their workinghour fetching water for sanitary purposes in the HCFs. Hence, availability of water inHCFs enhances healthy, effective and efficient medical practices that guaranteegood health of clients and other stakeholders. The study investigated the availabilityand sources of safe water in the selected HCFs. Table 3.4 and Figure 3.9 belowpresent the source of water in the HCFs.17

Figure 3.9: Main source of water within the premises of supported facilitiesThe results presented in the Table 3.4 and Figure 3.9 indicates that 82.1% of thefacilities in the State relied on Borehole for water, distantly followed by Water mainsat 10.5%. The least proportion of 7.4% obtained water from Water Main. Boreholeand Water main are acclaimed safe sources, while Rivers and Well are acclaimedunhygienic sources of water.c) Main Sources of LightSources of light include electricity, lambs, gas, lanterns, candles torches andgenerator sets. Some of these sources, especially electricity is used to operateequipment and apparatuses in HCFs such as computers, television, washers; as wellas to light, heat, and cool buildings, cook food, boil water, wash clothes, provideentertainment, and power transportation system. Table 3.3 and Figure 3.10 indicatethat out of the 28 assessed HCFs, 27 (96.4%) had some form of light.Figure 3.10: Sources of Light in the supported FacilitiesThe distribution of the facilities by sources of light, found that 50.0% of the 28supported HCFs had supply of electricity from both PHCN and Generator, while42.9% of these supported HCFs depend on light from public supply from PHCN.18

However, 3.6% obtained electricity from Generator, but 3.6% did not indicate theirsource of light at all.3.1.5 Methods of Waste ManagementWaste disposal is the process of getting rid of unwanted, broken, worn out,contaminated or spoiled materials in an orderly and regulated fashion; with a view toreduce their effect on health, the environment, aesthetics; and/or to recoverresources. Health-care activities generate wastes that may lead to adverse healtheffects. Some types of health-care waste represent a higher risk to health. Theseinclude infectious waste (15% to 25% of total health-care waste) among which aresharps waste – needles, syringes and blades (1%), body part waste (1%), chemicalor pharmaceutical waste – laboratory solvents, expired drugs and cleaningchemicals (3%), and radioactive and cytotoxic waste or broken thermometers (lessthan 1%). Sharps waste, although produced in small quantities, is highly infectious. Ifpoorly managed, they expose healthcare workers, waste handlers and thecommunity to infections. Contaminated needles and syringes represent a particularthreat and may be scavenged from waste areas and dump sites and be reused withserious health implications. The supported HCFs in the State generate and disposeof waste in different ways, however data was not collected on the types andmanagement of waste for possible strengthen, as part of baseline for trackingimprovement waste management.3.1.6 Common RH problems reported at FacilitiesThe most frequency occurring RH problems reported by the supported facilities wereearly marriage, Miscarriages/induced abortions, STIs, and Teenage pregnancy(Table 3.4).Table 3.4: Common RH problems in the StateType of RH problem Frequency %Late referrals of complications by TBAs 1 3.6Referral of under-aged parents 1 3.6Early marriage 19 67.9Teenage pregnancy 2 7.1Miscarriages/Induced abortions 4 14.3STIs 3 10.7HIV 1 3.63.2 HUMAN RESOURCES IN THE SUPPORTED FACILITIES3.2.1 Availability of health workersThough Nigeria has the largest number of health human resources in Africa, healthpersonnel are unevenly spread across the six geopolitical zones and between therural and urban areas of the country. There is also uneven distribution of healthworkers between the few secondary HCFs that provide CEmONC services, therebycreating acute shortage of health personnel in the primary healthcare facilities thatprovide BEmONC services. The other issue is the preponderance of unskilled healthworkers in the healthcare sector. Yet, availability of adequate health worker and rightmix are critical to the delivery of quality reproductive health services in the health19

facilities. On the basis of this, the study examines the level of health humanresources in the selected HCFs in the State, and this section present and discussesdata on skilled (doctors, nurses and midwives), unskilled (CHOs, CHEWS andAttendants) and other categories of health workers, including issues of trainings.Table 3.5 displays the frequency distribution of health workers in the supportedfacilities by categories and type of HCFs. It also shows the rural-urban dichotomy inhuman resource distribution.Overall, the results in Table 3.5 reveal that the 28 supported facilities in the Statehad a total 2,073 health workers. Out of this total, 1,919 (92.6%) were in urbanfacilities compared to 154 (7.4%) work in rural facilities. The distribution by the typesof facilities indicates that 1,133 (54.7%) worked in GHs, while 940 (454.3%) workedin primary facilities.In terms of the distribution by the types of health workers, RegisteredNurse/Midwives recorded the highest number with 588 (28.4%, distantly followed byWard Assistants with 411 (19.8%). Health Educators at 3 (0.1% reported the least.20

Table 3.5: Frequency distribution of health workers by types of health care facilities and nature of residenceResidenceFacilitytypeStaff Strengths by categories and typesMO OG OS Ph PA NM RN RM NA HO CHE JCH MLT MLA WA Wm Lb HE SW OthTotal %Rural/urban CHC 17 1 2 9 8 16 3 1 1 4 2 3 3 1 8 12 2 0 1 4 98 4.7PHC 75 3 16 19 31 121 185 4 4 31 35 18 17 19 186 44 11 3 7 13 842 40.6GH 127 15 13 39 30 451 1 2 4 5 2 1 24 13 217 31 19 0 13 126 1133 54.7Total 219 19 31 67 69 588 189 7 9 40 39 22 44 33 411 87 32 3 21 143 2073 100.0% 10.6 0.9 1.5 3.2 3.3 28.4 9.1 0.3 0.4 1.9 1.9 1.1 2.1 1.6 19.8 4.2 1.5 0.1 1.0 6.9 100.0Rural CHC 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0.0PHC 2 0 0 0 0 11 2 1 0 2 7 0 0 0 33 5 4 0 0 1 68 3.3GH 16 2 0 3 4 32 0 0 0 0 2 0 2 2 14 4 4 0 1 0 86 4.1Sub‐Total 18 2 0 3 4 43 2 1 0 2 9 0 2 2 47 9 8 0 1 1 154 7.4% rural 0.9 0.1 0.0 0.1 0.2 2.1 0.1 0.0 0.0 0.1 0.4 0.0 0.1 0.1 2.3 0.4 0.4 0.0 0.0 0.0 7.4Urban CHC 17 1 2 9 8 16 3 1 1 4 2 3 3 1 8 12 2 0 1 4 98 4.7PHC 73 3 16 19 31 110 183 3 4 29 28 18 17 19 153 39 7 3 7 12 774 37.3GH 111 13 13 36 26 419 1 2 4 5 0 1 22 11 203 27 15 0 12 126 1047 50.5Sub‐Total 201 17 31 64 65 545 187 6 9 38 30 22 42 31 364 78 24 3 20 142 1919 92.6% urban 9.7 0.8 1.5 3.1 3.1 26.3 9.0 0.3 0.4 1.8 1.4 1.1 2.0 1.5 17.6 3.8 1.2 0.1 1.0 6.8 92.621

3.2.1.1 Availability and deployment of skilled health workersDoctors and Nursing and Midwifery professionals were regarded as the skilled healthworkers. Table 3.6 and Figure 3.11a and 3.11b below show the availability anddeployment of skilled health workers in the supported facilities.Table 3.6: Frequency distribution of skilled health workers by types of healthcare facilities and nature of residenceResidenceFacilitytypeStaff Strengths by categories and typesMO OG OS NM RN RM NATotal %Rural/urban CHC 17 1 2 16 3 1 1 41 3.9PHC 75 3 16 121 185 4 4 408 38.4GH 127 15 13 451 1 2 4 613 57.7Total 219 19 31 588 189 7 9 1062 100.020.6 1.8 2.9 55.4 17.8 0.7 0.8 100.0Rural CHC 0 0 0 0 0 0 0 0 0.0PHC 2 0 0 11 2 1 0 16 1.5GH 16 2 0 32 0 0 0 50 4.7Sub‐Total 18 2 0 43 2 1 0 66 6.2% rural 8.2 10.5 0.0 7.3 1.1 14.3 0.0 6.2Urban CHC 17 1 2 16 3 1 1 41 3.9PHC 73 3 16 110 183 3 4 392 36.9GH 111 13 13 419 1 2 4 563 53.0Sub‐Total 201 17 31 545 187 6 9 996 93.8% urban 91.8 89.5 100.0 92.7 98.9 85.7 100.0 93.8Figure 3.11a: Frequency distribution of skills workers by types of facility22

Figure 3.11b: Frequency distribution of skills workers by residenceThere were a total of 1,062 skilled health workers in the supported facilities, out ofwhich 55.4% were NM, 20.6% were MOs and the least proportion of 0.7% were RM.However, 57.7% of the skilled personnel worked in the secondary facility while42.3% were in primary facilities. Most of the skilled health workers (93.8%) worked inurban facilities against only 6.2% in the rural areas.a) Availability Medical Doctors in the supported HCFsFor the purpose of this health facility survey, medical doctors were categorised intothree, namely medical officers, OG specialists and other specialists. A medicalofficer applies medical knowledge to properly diagnose a patient's ailment,prescribes medication for a patient’s treatment, provide healthier lifestylerecommendations, and/or refers the patient to a doctor who specializes in a specificareas such as an OG specialist, or other specialists (Paediatrician, Internist, orSurgeon), if a patient’s health concerns are beyond a his scope of practice. AnObstetric Gynaecologist (OG) is a medical doctor who has specialized training inissues of a woman’s reproductive system (ovaries, uterus, vagina) and urinary tracthealth, such as stress incontinence. OG specialists are trained to evaluate,recognize and treat potential disease of the reproductive system, and to surgically toperform surgeries like hysterectomies, (removal of the uterus). Data on the visibilityof Medical Officers, OG specialist and other specialists in the selected HCFs in theState are shown in Table 3.7 and Figures 3.12a and 3.12b.23

Table 3.7: Frequency distribution of Doctors by types of health care facilitiesand nature of residenceResidenceFacilitytypeStaff Strengths by categories and typesMO OG OSTotal %Rural/urban CHC 17 1 2 20 7.4PHC 75 3 16 94 34.9GH 127 15 13 155 57.6Total 219 19 31 269 100.081.4 7.1 11.5 100.0Rural CHC 0 0 0 0 0.0PHC 2 0 0 2 0.7GH 16 2 0 18 6.7Sub‐Total 18 2 0 20 7.4% rural 8.2 10.5 0.0 7.4Urban CHC 17 1 2 20 7.4PHC 73 3 16 92 34.2GH 111 13 13 137 50.9Sub‐Total 201 17 31 249 92.6% urban 91.8 89.5 100.0 92.6Figure 3.12a: Frequency distribution of Doctors by types of health carefacilities24

Figure 3.12b: Frequency distribution of Doctors by nature of residenceAccording to the results, there were a total 249 medical doctors providing healthcareservices in the State. Of this number, 201 medical officers (91.8%), 19 Specialist(O&G) accounting for 7.1% and 31 Non-Specialist Doctors (11.5%) available in thesupported HCFs. Most of the medical doctors (92.6%) worked in urban areascompared to only 7.4% in the rural areas. Also, 57.6% worked in the secondaryfacilities against 42.3% that provided healthcare services in the Primary Facilities.These results suggest the GHs had many MOs, Specialist Doctors (O&G) and OtherSpecialist Doctors to support CEmONC services, including Pediatrics issues.However, only 2 MOs (0.7%) of the 269 Medical Doctors were available in theprimary facilities in the rural areas. The non-availability of medical officers in thePrimary Facilities in the rural areas places constraints on the ability of these facilitiesto provide BEmONC services, which imply the Primary facilities in the rural areas ofthe State should be strengthened with strong referral system to facilitate referral ofclients to the secondary facilities for an optimal performance of the health sector inthe State. However, availability of Specialist Doctors (O&G) and Other SpecialistDoctors in the Facilities in the rural areas enhance the ability of these facilities toprovide CEmONC services.b) Nursing and Midwifery PersonnelThe Nursing and midwifery personnel comprised of RNM, RN, RM and RNA. InTable 3.8 and Figure 3.13a and 3.13b below, the supported facilities in the State hada total of 793 Nursing and Midwifery professionals, out of which the highest numberof 588 (74.1%) were registered Nurse/Midwives, and the least number of 7 (0.9%)were Registered Midwives. The balance comprised of 189 RN (23.8%) and 9 NurseAnesthetists (1.1%).The distribution of the Nursing and midwifery professionals by the types of facilitiesshows that 458 (57.8%) worked in the secondary facilities, while 335 (42.2%) workedin Primary Facilities. The distribution by residence reveals that 747 of the Nursingand midwifery professionals (94.2%) were available in the urban areas compared to46 (5.8%) that worked in the facilities in the rural areas.25

Table 3.8: Frequency distribution of Nursing and Midwifery Professionals bytypes of health care facilities and nature of residenceFacilitytype NM RN RM NA Total %CHC 16 3 1 1 21 2.6PHC 121 185 4 4 314 39.6GH 451 1 2 4 458 57.8Total 588 189 7 9 793 100.074.1 23.8 0.9 1.1 100.0CHC 0 0 0 0 0 0.0PHC 11 2 1 0 14 1.8GH 32 0 0 0 32 4.0Sub‐Total 43 2 1 0 46 5.8% rural 7.3 1.1 14.3 0.0 5.8CHC 16 3 1 1 21 2.6PHC 110 183 3 4 300 37.8GH 419 1 2 4 426 53.7Sub‐Total 545 187 6 9 747 94.2% urban 92.7 98.9 85.7 100.0 94.2Figure 3.13a: Frequency distribution of Nursing and Midwifery Professionalsby types of health care facilities26

Figure 3.13b: Frequency distribution of Nursing and Midwifery Professionalsby nature of residencei) Availability of Registered Nurses and MidwivesRegistered Nurses and Midwives (RNM) are popularly referred to doublequalifications. The visibility of registered Nurses and Midwives (RNM) in facilitiesensures safe births and averting maternal and newborn deaths and disabilities. RNMalso play a central role in providing FP and counseling, and in preventing HIVtransmission from mother to child. Investments in strengthening the RNM workforceskills with life saving competencies; and the adequate policies surrounding theirretention, deployment and distribution; can help to prevent some 80% of maternaldeaths. Hence, UNFPA is one of the donours that invests in midwifery skills toaccelerate progress towards MDGs 4 and 5. The number of RNM was requestedthrough the questionnaire and the responses from the supported facilities arepresented in Table 3.8 and Figures 3.13a and 3.13b.In distribution depict that 92.0% of the 588 RNM were available in the Secondaryfacilities, and only 8% were deployed to the primary facilities. Meanwhile, 545(92.7%) were deployed to the urban areas against 43 (7.3%) in the rural areas. TheRNM were not available some CHCs in the rural areas. The non-availability of RNMsin some of the Primary Facilities in the rural areas places constraints on the ability ofthese facilities to handle pregnancy related complications, which also imply thatthere should be a strong referral system for unskilled health workers to refer clientsto primary and secondary facilities, where Doctors and RNMs were available.ii) Registered NurseRegistered Nurses provide patient care, educate patients on their disease and howto live a healthy lifestyle, they monitor the patients’ illness and record and monitortheir responses to treatment and medication. Table 3.8 and Figures 3.13a and 3.13bpresent the data on the registered Nurses that were available in the supportedfacilities. The results reveal the almost all of the registered nurses (99.5%) weredeployed to the Primary Facilities. Only 1 RN (0.5%) worked in one of the secondaryfacility. This may imply that the least qualified skilled health workers were deployedto the Primary Facilities. None the less, the existing RNs should be strengthened27

with midwifery skills and life saving competencies to accelerate progress towardMDGs 4 and 5.iii) Registered MidwivesA registered midwife is a health care professional who provides primary care towomen during pregnancy, labour and birth, including conducting normal vaginaldeliveries and providing care to mothers and babies during the first 6 weekspostpartum. Midwives provide safe, personalized, research-based care. They attendbirths in hospital or home according to the woman's choice and professionalprotocols and are on-call and available to their clients 24 hours a day during thecourse of care. The study further examined the visibility of registered midwives in thehealth facilities. The distribution of registered Midwives available in the supportedfacilities is presented below in Table 3.8 and Figures 3.13a and 3.13b.The results in Table and Figures above show that 5 or 71.4% of the 7 RMs were inthe Primary Facilities; while remaing 2 (28.6%) were deployed to the secondaryfacilities. Almost all RMs at 6 (85.7%) were in urban areas comared to only 1(14.3%) in the rural areas. These results suggest that registered Midwives were veryscarce in most of the UNFPA supported helath facilities, especially at the PHCs.The attention of policy makers, planners and donours should drawn to the criticakrole that midwives play in facilities, and the urgent need to invest midwives andothers with midwifery skills to accelerate progress towards MDGs 4 and 5.iv) Registered Nurse AnesthetistA Nurse Anaesthetist (NA) specialises in the provision of anaesthesia care to apatient from pre-operation procedures through surgery and into recovery, ensuringthat the patient is as safe and comfortable. They administer anaesthesia to patientshaving surgery or other procedures and/or work alongside anaesthesiologists, whoare trained as physicians. The distribution of registered Nurse Anesthetist availablein the UNFPA supported facilities is presented below in Table 3.8 and Figures 3.13aand 3.13b. The results depict that all the 5 (55.5%) of registered Nurse Anesthetistsin the supported facilities were in the Primary Facilities, while 4 (44.5%) were in thesecondary facilities. However, all the NA worked in the urban areas. This suggestthat many of the supported facilities in the State did not have any registered NurseAnesthetists to support Physicians in performing surgeries, with negativeimplications for effective implementation of EmONC services. This implies that NurseAnaesthsist are very rare in the UNFPA supported facilities.Data was however not collected on visibility of other types of Nursing such asObstetrics Nurse who takes care of the mother before and during labour, and provideneonatal care to unhealthy newborn babies.3.2.1.2 Unskilled Health WorkersThe unskilled health workers are the community health workers (which includeCHOs, CHEWs and JCHEWs in Nigeria) and Ward Attendants. First, communityhealth workers, also called "Village Health Workers” (VHWs), or ‘lay health advisors’are members of a community who are chosen by community members to providebasic health and medical care to their community. In many developing countries,including Nigeria, there are critical shortages of professional health workers. Currentmedical and nursing schools cannot train enough workers to keep up with internal28

and external emigration, deaths from AIDS and other diseases, low workerproductivity, and population growth. CHWs are therefore given a limited amount oftraining to provide essential, safe, and highly effective primary health care servicesto the population. Programmes involving CHWs in China, Brazil and Iran havedemonstrated that utilizing such workers can help improve health outcomes for largepopulations in under-served regions. “Task shifting” of primary care functions fromprofessional health workers to CHWs is considered to be a means to improving thehealth of millions at reasonable cost. But, experience in Nigeria has also shown thatthis task shifting is a drag on efforts to accelerate progress towards MDGs 4 & 5.Secondly, ward attendant or assistant supports skilled health workers in the healthfacilities in providing basic care for patients. The job requires ability to lift patients,great people skills, a sense of humour and tolerance for cleanup and care of patientswho cannot fully care for themselves. Most nursing assistants, undergo trainingthrough on-the-job experience or short-term programmes offered by some schools,colleges and organizations like the Red Cross. Table 3.9 present data on the numberof these unskilled health workers that were available in the supported facilities.Figures 3.14a and 3.14b summarise the distribution by the types of facilities andresidence.Table 3.9: Frequency distribution of unskilled health workers by types of health carefacilities and nature of residenceResidenceFacilitytype HO CHE JCH WA Total %Rural/urban CHC 4 2 3 8 17 3.3PHC 31 35 18 186 270 52.7GH 5 2 1 217 225 43.9Total 40 39 22 411 512 100.07.8 7.6 4.3 80.3 100.0Rural CHC 0 0 0 0 0 0PHC 2 7 0 33 42 3.3GH 0 2 0 14 16 4.1Sub‐Total 2 9 0 47 58 7.4% rural 5 23.1 0.0 11.4 11.3Urban CHC 4 2 3 8 17 4.7PHC 29 28 18 153 228 37.3GH 5 0 1 203 209 50.5Sub‐Total 38 30 22 364 454 92.6% urban 95 76.9 100.0 88.6 88.729

Figure 3.14a: Frerquency Distribution of unskilled health workers by the typesof facilitiesFigure 3.14b: Percent Distribution of unskilled health workers by ResidenceAccording to the results in Table 3.12 and Figures 3.14a and 3.14b indicate thatmost (80.3%) of the 512 unskilled health workers were Ward Attendants. CHOs,CHEW and JCHEW accounted for 7.8%, 7.6% and 4.3% respectively. More than halfof unskilled health workers at 56% worked in the Primary type of facilities, while 44%worked in the secondary afcilities. Most (87.5%) of the 40 CHOs were in the primaryfacilities, while 12.5% were in the secondary facilities. Also, 95% of the CHOsworked in the urban areas compared to only 5% in thr rural areas.The distribution of the CHEWs indicate that 37 (94.9%) worked in the primaryfacilities while only 2 (5.1%) worked in the secondary facilities. Similarly, 30 (76.9%)were available in the urban areas as against 9 (23.1%) were in the rural areas. Forthe JCHEWs, 21 (95.4%) were available in the primary facilities, and only 1 (4.6%)was in the GH; but all of them worked in the urban areas. Similarly, more than half(52.8%) of the WA were in the secondary facilities and 47.2% were in the primary30

facilities. Mean while, 88.6% of the WA were in urban areas compared ton 21.8% inthe rural areas.3.2.1.3 Other Health Workers in the supported HCFsa) Pharmacists, Pharmacy Technicians and Pharmacy Assistants in thesupported facilitiesThe Drug and Pharmacies Regulatory Act stipulates that no person other than apharmacist or an intern or a registered pharmacy student acting under thesupervision of a pharmacist who is physically present, shall compound, dispense orsell any drug in a pharmacy. For this purpose, pharmacists are specialists in theknowledge of medications, and an important medical worker in the health facility whohelps physicians, dentists and veterinarians by dispensing appropriate medicationsto patients. However, pharmacy assistants or pharmacy aides work in pharmaciesstocking shelves, answering phones, completing administrative duties, and assistpharmacy technicians, while pharmacy technicians prepare medication, fillprescriptions and maintain medical records, deliver medication to patients, andmaintain medical supplies for each patient. In many facilities, the terms ‘pharmacyassistant’ and 'pharmacy technician' are used interchangeably, so that titles andresponsibilities may overlap. Table 3.10 below shows the distribution of Pharmacists,and Pharmacy Assistants in the supported facilities.Table 3.10: Frequency distribution of pharmaceutical health workers by types ofhealth care facilities and nature of residenceFacilitytype Ph PA Total %CHC 9 8 17 12.5PHC 19 31 50 36.8GH 39 30 69 50.7Total 67 69 136 10049.3 50.7 100.0 73.5CHC 0 0 0 0PHC 0 0 0 0GH 3 4 7 5.1Sub‐Total 3 4 7 5.1% rural 4.5 5.8 5.1CHC 9 8 17 12.5PHC 19 31 50 36.8GH 36 26 62 45.6Sub‐Total 64 65 129 94.9% urban 95.5 94.2 94.931

Figure 3.15a: Frequency distribution of pharmaceutical health workers by types ofhealth care facilities and nature of residenceFigure 3.15b: Percent distribution of pharmaceutical health workers by residenceThe data on the number of Pharmacists and Pharmacy Assistants indicate that therewere 136 of them in the supported facilities, and about half (50.7%) of thepharmaceutical health workers were available in the secondary facilities compared to49.3% worked in the Primary Facilities. The distribution by residence depict that94.9% were in urban facilities as against only 5.1% in the rural areas.The distribution of pharmaceutical workers by the types also shows that 50.7% werePharmacy Assistants, while 49.3% were Pharmacists. Almost all (94.9%) of the 136pharmaceutical workers were deployed to the urban facilities while 5.1% worked therural facilities. Similarly, the distribution of the types of pharmaceutical workers byresidence depict that 95.5% Pharmacists and 94.2% of Pharmacist Assistantsworked in the urban areas as against 4.5% and 5.8% respectively available in therural areas.32

The distribution of pharmaceutical workers by the types of facilities shows that 39(58.2%) of the 67 Pharmacists worked in the GHs, while 28 (41.8%) was working inthe Primary Facilities. Similarly, 30 (43.5%) of the 69 Pharmacy Assistants weredeployed to the GHs, while the balance of 39 (56.5%) were in Primary Facilities.These findings suggest that Pharmacists were available in the supported facilities,but they unevenly distributed between the rural and urban areas and betweenprimary and secondary facilities. Programme interventions should advocate the redistributionof these pharmaceutical workers in the supported facilities, in favour ofthe primary facilities and rural areas. The results indicate the need for training ofpharmacy assistants to helps physicians, dentists and veterinarians by dispensingappropriate medications to patients.. Hence, UNFPA programme intervention shouldadvocate for the training and re-training of especially the Pharmacy Assistants todispense drugs correctly.b) Medical Laboratory Technologists and Medical Laboratory Assistants inthe supported FacilitiesMedical laboratory technologist (MLT) and Medical laboratory assistants (MLA)prepare and process laboratory tests in a wide variety of areas; blood banking,chemistry, hematology, immunology, and microbiology, etc in any facility. The data intable 3.11 below reveal that there are few MLT and MLA. Figure 3.16a and 3.16bsummarise the data by types of facilities and residence, respectively.Table 3.11: Frequency distribution of laboratory health workers by types of healthcare facilities and nature of residenceResidenceFacilitytype MLT MLA Total %Rural/urban CHC 3 1 4 5.2PHC 17 19 36 46.8GH 24 13 37 48.1Total 44 33 77 100.057.1 42.9 100.0Rural CHC 0 0 0 0.0PHC 0 0 0 0.0GH 2 2 4 5.2Sub‐Total 2 2 4 5.2% rural 4.5 6.1 5.2Urban CHC 3 1 4 5.2PHC 17 19 36 46.8GH 22 11 33 42.9Sub‐Total 42 31 73 94.8% urban 95.5 93.9 94.833

Figure 3.16a: Frequency distribution of laboratory health workers by types of healthcare facilitiesFigure 3.16b: Percent distribution of laboratory health workers by residenceThe data on the number MLT and MLA in supported facilities revealed that therewere a total of 77 medical laboratory personnel in the facilities. More than half ofmedical laboratory personnel at 57.1% were MLT and the balance of 42.9% wereMLA. Also, more than half of the laboratory staff at 52% worked in the primaryfacilities, while 48% worked in secondary facilities. Further, only 5.2% of thelaboratory staff was available in rural facilities as against 94.8% that were in theurban facilities. Furthermore, there were more MLT at 95.5% and MLA at 93.9%worked in the urban areas as against 4.5% and 6.1% respectively who worked in therural facilities.In view of the fact that most the facilities in the State were located in the urban areaswhere almost all the MLT and MLA were deployed, these findings suggest that MLTand MLA were also very scarce in most of the rural health facilities in general thePrimary facilities.c) Health educators, social workers, labourers, watchmen and othersHealth educators work to encourage healthy lifestyles and wellness by educatingindividuals and communities about behaviors that can prevent diseases, injuries, and34

other health problems. Within health facilities, health educators work one-on-onewith patients and their families to educate them on their diagnosis and how that maychange or affect their lifestyle. In doing this, health educators explain the necessaryprocedures or surgeries as well as how patients will need to alter their lifestyles tomanage their illness or return to full health. They also direct patients to outsideresources, such as support groups, home health agencies, or social services. Often,health educators work closely with other health workers to create educationalprogrammes or materials, and in some cases, to train facility staff on how to betterinteract with patients.On the other hand, the primary role of social workers in the health facilities is toassess the needs (based on such criteria as your educational level, support fromfriends and family, your financial situation and living arrangements) and then to helpclients and the facilities to take care of those needs. The information collected bythe social worker can help inform the healthcare providers and clients about howbest to treat illnesses, manage diseases, how to best interact with clients, and evenhelp weave through the healthcare system and leverage local resources to manageday-to-day life. Hence, social workers offer a broad range of services in healthfacilities, including emotional support, referrals for community resources, counselingservices (perform one-on-one counseling with a variety of clients), advocate for aservices/patient, and work with community groups to develop resources that will aidmedical patients and other constituencies, including people with hard-to-diagnosesymptoms. The distribution of Health Educators, Social Workers, CompoundLabourers, Watchmen and Other workers in the supported facilities is shown Table3.12 below. The summaries of the data are shown in Figures 3.17a and 3.17b.Table 3.12: Frequency distribution of other health workers by types of health carefacilities and nature of residenceResidenceFacilitytype Wm Labour HE SW Others Total %Rural/urban CHC 12 2 0 1 4 19 6.6PHC 44 11 3 7 13 78 27.3GH 31 19 0 13 126 189 66.1Total 87 32 3 21 143 286 100.030.4 11.2 1.0 7.3 50 100Rural CHC 0 0 0 0 0 0 0.0PHC 5 4 0 0 1 10 3.5GH 4 4 0 1 0 9 3.1Sub‐Total 9 8 0 1 1 19 6.6% rural 10.3 25.0 0.0 4.8 0.7 6.6Urban CHC 12 2 0 1 4 19 6.6PHC 39 7 3 7 12 68 23.8GH 27 15 0 12 126 180 62.9Sub‐Total 78 24 3 20 142 267 93.4% urban 89.7 75.0 100.0 95.2 99.3 93.435

Figure 3.17a: Frequency distribution of other health workers by types of health carefacilities and nature of residenceFigure 3.17b: Percent distribution of other health workers by residenceThe data in Table 3.12 Figures 3.17a and 3.17b depict that 286 other staff wereavailable in the facilities, out which half were others, 30.4% were Watchmen, 7.3%were SWs and 1.0% were HE. Most (93.4%) of the other workers were in the urbanfacilities compared to 6.6% in rural areas.The results also show that out the 21 Social Workers, 13 (61.9%) worked in the GHs.The balance of 8 of the social workers (38.1%) was available in the Primary facilities.However, most of the social workers (95.2%) worked in the urban facilities as against1 (4.8%) in the rural areas. Further, out of 32 Compound Labourers, 19 (59.4%)worked in the in the GHs compared to 13 (40.6%) available in the primary types offacility to ensure compound sanitation. None of the compound labourers worked inthe PHCs with negative implication for environmental sanitation. There were only(25%) of the labourers worked in rural facilities while Three-quarter (75%) worked in36

the urban areas. Availability of compound labourers has implication forenvironmental sanitation of the facilities.Among the 87 Watchmen, 31 (35.6%) were available in the GHs while 266 (64.6%)were in primary types of facilities. Only 9 Watchmen (10.3%) worked in the ruralareas, as against 89.7% available in urban areas. Furthermore, out of 143 othertypes of workers, which included Drivers; 88.1% worked in secondary types of facilitywhile the balance of 17 (11.9%) were available in the primary facilities. Almost all(99.3%) of the other category of workers in the facilities were available in urbanfacilities. Only 0.7% worked in the rural areas. Availability of Drivers has implicationsfor functional means of transport. Hence, there is the need to validate findings on theothers type of health workers, which were largely Drivers with respect to the data onavailability of functional means of transport.The overall results on human resources depict that there were uneven distributionsof health workers between the rural and urban areas, as well as between the varioustypes of health facilities. There were generally low levels of human resources in mostof the supported facilities, and the situations in the PHCs were more critical. It isexpected that the Federal Government Programme that recently recruited about6,000 midwives and deployed them to 600 rural local governments areas and theproposed mandatory posting of house doctor to rural areas will help to alleviate thechallenges of the low human resources and capacities in public health facilities in thesupported state and to address the capacity gap in the primary healthcare sector ofthe State. The availability of medical personnel in the primary health sector of theState is critical to the successful delivery of UNFPA mandate in the RHR. UNFPAwill need to intensify advocacy efforts to strengthen the health sector and to recruitand train more health workers especially in the public primary and secondary healthcare facilities of the State, if the health system will be strengthened and enhanced.3.3 TYPES OF TRAINING RECEIVED BY HEALTH WORKERSCentral to UNFPA programme delivery is the capacity building of health workers.Factors such as the shortage of health workers and the need to scale up servicedelivery have critical impact on the IPs’ capacity to recruit and trained health careworkers to deliver quality health services. Therefore, the facility assessment includedquestions to track the types of training attended or received by health workers in thesupported facilities of the State. The number of health workers trained in thesupported facilities in the State by the types of training is shown in Tables 3.13.37

Table 3.13: Number of health workers trained by the types of trainingResidenceFacilitytypeNumber of staff by the types of training and facility typesDoctors DoctorsNMon on Doctors NM VVF NMELSS CLMS on PM ARH repairs CLMSNMFPTechRural/urban CHC 0 0 0 5 0 3 0 0 30 38NMIECNMPMTotalPHC 3 2 4 22 3 24 4 8 19 89GH 0 0 0 2 0 19 0 1 15 37Total 3 2 4 29 3 46 4 9 64 164% 1.8 1.2 2.4 17.7 1.8 28.0 2.4 5.5 39.0 100.0Rural CHC 0 0 0 0 0 0 0 0 0 0PHC 0 0 0 1 0 2 0 2 3 8GH 0 0 0 0 0 0 0 0 6 6S/Total 0 0 0 1 0 2 0 2 9 14% 0 0 0 3.4 0.0 4.3 0.0 22.2 14.1 8.5Urban CHC 0 0 0 5 0 3 0 0 30 38PHC 3 2 4 21 3 22 4 6 16 81GH 0 0 0 2 0 19 0 1 9 31S/Total 3 2 4 28 3 44 4 7 55 150%23.254.322.6100.00.04.93.78.523.249.418.991.5% 100 100 100 96.6 100.0 95.7 100.0 77.8 85.9 91.5Figure 3.18a: Number of health workers trained by the types of training and facilities38

Figure 3.18b: Percent distribution of health workers trained by residenceTotal of164 health workers have received some types of training according to thedata in Table 3.13. Out of this total figure, the higher number of 127 (77.7%) workedin the primary facilities while 37 (23.8%) were available in the Secondary facilities.Further 150 of the health workers that received different types of training (91.5%)worked in the urban facilities as against 14 (8.5%) worked in the rural facilities.The highest number of 64 RNM in the facilities (39.0%) has received training onProgramme Management, followed by another 46 RNM (28.0%) who receivedtraining on CLMS. The least number of 2 Doctors (1.2%) received training on CLMS.A few other Doctors were trained on ELSS, and programme management. Theseresults point to the fact that some concerted efforts have been in the State toimprove the capacities of the health workers on ELSS, CLMS, FP Technology, ARH,VVF repairs and IEC, especially in view the number of health workers that wereworking in the supported facilities and the soaring population of the State at the ratemore than 3%. The results also suggest that no health worker in the supportedfacilities of the State were trained on MLSS, LSS, Integrated SRH/HIV preventionservices, HIV counseling and HIV testing. The training of health workers on MLSS,LSS, and especially HIV counseling, HIV testing and Integrated SRH/HIV preventionservices will enhance the provision of HIV prevention services in the supportedhealth facilities.The results also show that apart from Doctors and RNM, no other categories ofhealth workers in the facilities were trained. Hence, programme intervention shouldsupport the training of other categories of health workers, especially the CHEW,Nurses and Midwives on LSS and MLSS. None the less, data on the number ofhealth workers trained by the types of training was collected disaggregated by sex,but data entry did not capture it by sex. There is therefore the need to collect andanalyse data on the number of health workers trained by sex.3.4 TYPES OF HEALTHCARE SERVICES PROVIDEDTable 3.14 shows the services provided by facility types and how frequently theservices were provided.39

Table 3.14: Percentage Distribution of the Types of Services by the Types of supportedFacilities and how frequently the services were providedTypes of services offered Types of Facilities Average DemandCHC PHC GH How often provided Freq3 19 6 28ANC 100 100 100 100 Daily 6Twice Weekly 4Three times weekly 3Weekly 13On demand 1Unstated 1Delivery care services 100 63.3 100 75 NAPNC services Twice weekly 2Weekly 7Monthly 16 weeks after delivery 1On demand 6Unstated 8100 94.7 100 96.4 NA NAChild welfare services 100 100 100 100 Four times weekly 6Three times weekly 6Twice weekly 3Daily 7Weekly 6FP services 100 100 100 100 Daily 19Weekly 3On demand 5Unstated 1HIV Counselling 100 57.9 100 71.4 Daily 11Weekly 3On demand 3Unstated 3HIV testing 66.7 42.2 100 55.1Immunisation 100 100 100 100 Daily 11Twice weekly 3Thrice weekly 4Four times weekly 5Weekly 5Syndromic management of STIs 33.3 21.1 60 32.1 NATreatment of minor ailments 100 100 100 100 NAObstetrics Fistula repairs 0 5.3 33.3 10.7 NAReferrals 100 94.7 66.7 89.3 NAHome visits 66.7 78.9 33.3 67.9 Twice weekly 1Weekly 6Twice monthly 1Monthly 2On demand 7Unstated 1Community outreach services 100 89.5 33.3 78.6 Daily 1Twice weekly 7Weekly 8Thrice monthly 1Twice monthly 2On demand 13.3.1 ANC, Delivery Care and PNC ServicesTable 3.14 and Figure 3.19 present the data on ANC, delivery care and PNCservices by the types of supported facilities in the State.40

Figure 3.19: Percentage of the Types of facilities that offered ANC, Deliverycare and PNC servicesTable 3.14 and Figure 3.19 show that on the average, 100% of the supportedfacilities in the State offered ANC services; 75% of the supported facilities provideddelivery care services; while 96.4% of them provided PNC services. These resultssuggest that there were gaps between attendance for ANC and those for PNC anddelivery care services. These results means that the was dichotomy between in theprovision of ANC, delivery care and PNC services by the types of supportedfacilities. The proportion of supported facilities that provided PNC services werelower than the percentages of facilities that provided delivery care and ANC services.This suggest that there were facilities that offered ANC and delivery care services,but did not offered PNC services; which depict a break in the continuum of maternalhealth care. It is also means that most PNC services were probably those associatedwith post-delivery complications, which could explain why higher percentages ofMCH and GHs offered PNC services.The results in Table 3.14 also reveal that ANC services were provided on weeklybasis in 13 facilities (41.4%). Similarly, PNC services were provided on demand in 6facilities (21.4%) and weekly in 7 supported facilities (25.2%). However, there were 8facilities (28.6%) that did not indicate when services provided. The results suggestthat maternal health appears as one of the primary focus of all supported healthfacilities in the State. The results on the provision of ANC, delivery care and PNCservices also offers great opportunities and potentials for the integration ofRH/FP/HIV services.3.4.2 Child Welfare and Immunization ServicesThe study shows that the provision of child welfare and immunization care servicesin the supported health facilities in the State were very high at 100% each (Table3.14 and Figure 3.20). The child welfare and immunization services captured arelargely Infant and Mother TT Immunizations.41

Figure 3.20: Percentage of the Types of Facilities that Provided Child Welfareand Immunisation ServicesThe frequency in the provision of Child welfare services by the supported facilities inthe State were mix - on daily basis reported 25%, weekly basis with 21.7%; fourtimes in a week (21.4% and three times a week at 21.4%. In the mean time, 64.5%)of the supported facilities in the State provided immunization care services on dailybasis in 11 (39.3%) or more than one-third of the facilities.3.4.3 Family Planning ServicesTable 3.14 and Figure 3.21 show that three-quarters (75%) of the selected facilitiesoffered family planning services.Figure 3.21: Proportion of the Types of Facilities That Offered FP servicesAll the supported facilities (100%) provided FP services, and this should besustained and explored as avenue for provision of integrated SRH/HIV preventionservices. Nineteen facilities (67.9%) provided FP services on daily basis. The resultsfurther show that all of the GHs, MCH, BBHSC, Dispensary, and Other types offacilities, 85.7% of PHCs and 77.8% of the CHCs offered FP services.3.4.4 STI and HIV ServicesThe respondents were asked if the supported facilities also offered SyndromicManagement of STIs, HIV Counseling and HIV Testing. The results in Table 3.14and Figure 3.22 showed that overall, 71.4%, 55.1% and 32.1% of all the supported42

health facilities offered Syndromic Management of STIs, HIV Counseling and HIVTesting services, respectively.Figure 3.22: STIs management, HIV counseling and HIV testingThe results depict that all the types of facilities provided HIV counseling, HIV Testingservices and STIs management. However, more types of these facilities providedHIV counseling than HIV testing, which is an indication that HIV Counseling wereconducted after some HIV Testing in line with the ethics and human rights of clients.3.4.5 Obstetric Fistula repairThe health facilities officials were asked to indicate if they, engaged in the repairs ofobstetric fistula; and the results are presented in Table 3.14 and Figure 3.23 above.Figure 3.23: Obstetric Fistula RepairsThe results in Table 3.14 and Figure 3.23 depict that only 10.7% on the averagerepaired Obstetric Fistula. This comprised of a primary and two secondary facilities.These results should serve entry point for HSS of all types of facilities to provideObstetric Fistula repairs.43

3.4.6 Treatment of Minor AilmentsThe data in Table 3.14 and Figure 3.24 indicate that all supported facilities,irrespective of type treated minor ailments. These very high proportions should besustained and strengthened.3.4.7 Referral ServicesThe provisions of referral services by the types of facilities were generally high at89.3% (Table 3.14 and Figure 3.24).Figure 3.24: Referral ServicesExpectedly, almost all primary facilities (95.4%) conducted referral services. Thisshould be sustained, while the remaining facilities are strengthened to providereferral services.3.4.8 Demand Creation ServicesThe demand creation activities are home visits and community outreaches, theresults of which were shown in Table 3.14 and Figure 3.25.Figure 3.25: Demand Creation Services44

Generally, 67.9% and 78.6% of the supported facilities conducted home visits andcommunity outreaches respectively to create demand for RH/FP/HIV preventionservices largely on demand (25%) and weekly basis at 21.4% for home visitsservices. It was provided on weekly basis (28.6%) and twice in a week (25%) forcommunity outreach services. Besides, the provision of demand creation activitieswere higher than among primary facilities at 80.9% for home visits and 95.4% forcommunity outreach than in secondary facilities at 33% each for Home visit andcommunity outreach. There is therefore the need to scale up demand creationactivities, especially by secondary facilities for clients to access available services aswell as to eliminate or at least reduce the first two delays (delay in seeking medicalassistance, and the delay in reaching the medical facilities).3.4.9 Other Services.Data collection during the facility assessment in the State did not capture any otherservices, which include Youth-focused RH services; including Counseling on ASRH.In summary, most of the services required for quality maternal health care deliverywere provided by the supported health facilities in the State including the PrimaryFacilities. However the quality of these services needs to be further investigated toensure quality services, especially those provided by the Primary Facilities in view ofthe low human resources in the facilities.3.5 PROVISION OF SERVICES IN THE LAST THREE MONTHS3.5.1 Attendance for ServicesTable 3.15 and Figure 3.26a and 3.26b below presents the data on total attendancefor services in the last three months (June – August 2009) by residence and type offacilities in the State.Table 3.15: Frequency distribution of attendance for healthcare services in the past 3 months (June-August 2009) by type of facility and nature of residence.Types of servicesResidenceFacilitytypeTotANCattendTotPNCTot NDeliverTotCSTotADTotABDTotNeonResTotNeonUnsTotdpt3TotmotherTT2 Total %Rural/urban CHC 1439 14 154 23 4 0 0 0 949 744 3327 8.3PHC 6620 108 608 51 1 2 12 1 6070 2906 16379 40.9GH 12982 1386 751 553 43 34 0 108 1955 2513 20325 50.8Total 21041 1508 1513 627 48 36 12 109 8974 6163 40031 100.0% 52.6 3.8 3.8 1.6 0.1 0.1 0.0 0.3 22.4 15.4 100Rural CHC 0 0 0 0 0 0 0 0 0 0 0 0.0PHC 969 0 70 0 0 0 0 0 333 368 1740 4.3GH 777 0 98 8 0 0 0 0 233 41 1157 2.9S/Total 1746 0 168 8 0 0 0 0 566 409 2897 7.2% Rural 8.3 0 11.1 1.3 0 0 0 0 6.3 6.6 7.2 0.0Urban CHC 1439 14 154 23 4 0 0 0 949 744 3327 8.3PHC 5651 108 538 51 1 2 12 1 5737 2538 14639 36.6GH 12205 1386 653 545 43 34 0 108 1722 2472 19168 47.9S/Total 19295 1508 1345 619 48 36 12 109 8408 5754 37134 92.8% Urban 91.7 100 88.9 98.7 100 100 100 100 93.7 93.4 92.845

Figure 3.26a: Frequency distribution of attendance for healthcare services in the past 3 months by typeof facility and nature of residence.Figure 3.26b: Frequency distribution of attendance for healthcare services in the past 3 months by typeof facility and nature of residence.A total of 40,031 clients attended the supported facilities in the last three months(June-August 2009) for different healthcare services. The highest proportion of52.6% of attendance was for ANC while Total Neonates Resuscitated accounted forleast attendance at 12 (0.01%). A little more than half of the number (50.8%) was insecondary facilities while 49.2% were primary facilities. Also, most of the attendees37,134 (92.8%) took place in urban facilities against 2,887 (7.2%) in the ruralfacilities. These results show were large gaps between attendance for ANC at21,041 (52.6%) and those for Delivery care services at 1,513 (3.9%) and PNCservices at 1,508 (3.9%). The difference in the figures of attendance for delivery careservices in the last three months as against those for PNC suggest that clientsdelivered outside facilities before visiting supported facilities for PNC services. Theseresults further confirm the 2008 NDHS results that a sizeable number of deliveries inthe Territory take place outside the health facilities. It also shows that PNC services46

was not a popularly sought for healthcare service by most citizens of the State. TheTable also shows that some of the health facilities provided 627 Caesarian sectionservices in the previous 3 months, which accounted for 1.6% of attendance forservices in the last three months. The low availability of this CS services are pointersto issues of policy issues and supplies, equipment and drugs. The number of youthsserved was not captured, which indicate very low availability of youth friendlyservices in the supported healthcare facilities in the State.3.5.2 Family Planning Services, Contraceptives and Stock Outs3.5.2.1 Availability of FP ServicesThe results on availability of FP services in Figure 3.27 reveal that all 28 supportedfacilities (100%) offered FP services in the last three months (June-August 2009).Figure 3.27: Percentage availability of FP Services by the Types of FacilityThese high levels of availability of FP services in supported facilities should besustained by programme interventions.3.5.2.2 Number of FP acceptorsData on FP acceptors was disaggregated by the number of FP new acceptors andthe number of FP revisits. Table 3.16 presents the data on the number of FPacceptors by types and according to residence and types of facilities. The datadepicts that the supported facilities recorded a total of 1471 new acceptors, out ofwhich 221 (15%) were from the rural areas compared to 1,250 (85%) from the urbanareas. Very few number of revisits at 97 (3.1%) out of the 3,173 revisits for FPservices reported by the facilities were from the rural areas against 3,076 (96.9%) inthe urban areas in the last three months. In view of the large population of the State,this number of FP acceptors may be very low. Programme interventions shouldtherefore advocate and support demand creation activities for FP services. It shouldstrengthen FP room to guarantee the rights of FP clients to choices andconfidentiality.47

Table 3.16: Frequency Distribution of FP clients in the last three months by thetypes of acceptors, residence and types of facilities.FP servicesResidence Facility typeNew acceptors RevisitsRural/urban CHC 43 178PHC 768 2234GH 660 761Total 1471 3173Rural CHC 0 0PHC 24 55GH 197 42Sub‐Total 221 97% rural 15.0 3.1Urban CHC 43 178PHC 744 2179GH 463 719Sub‐Total 1250 3076% urban 85.0 96.93.5.2.3 Stock out statusStock out is a situation where the demand or requirement for anycommodity cannot be fulfilled from the current (on hand or available)inventory; or simply a situation where stocks of commodities have run outor are not available. Figure 3.28 depicts the status of contraceptives stock outs bythe types of supported facilities in the State.Figure 3.28: Percentage availability of Contraceptives by Types of FacilityFigure 3.28 shows that overall; 89.3% of the supported facilities in the State hadcontraceptives, while the remaining 10.7% had contraceptive stock outs. Thecontraceptives stock outs were largely reported by primary facilities. These low48

proportions of stock outs in the primary facilities may portend threat to theachievement of ICPD agenda and MDG 5. Hence, there is the need for programmeinterventions to ensure that all facilities do not experience any stock outs.3.5.2.4 Type and number of contraceptives availableDuring the facility survey exercises, information was collected on the types andnumbers of contraceptives available for those facilities which had contraceptives.The data on these are shown in Table 3.17.Table 3.17: Distribution the types and numbers of contraceptives availableType of HCF Type of Contraceptive QuantitiesCHCPHCGHDepo ProveraNAIUCD 41Male Condom 135Female Condom 15Lofemenal 11Implano 1Jadelle 2Combined PillsInjectablesProgesterone only pills 50Lofemenal 113Female condom 129Male condom 708IUCD 130InjectablesDepo 8Ovrette 124Noristat 2IUCD 153Female condom 106Male condom 953Noristerat 94Combined Pills 71Progesterone 9Depo 118Jadelle 26Lofeminal 22Overrate 21It was observed that most types of the facilities reported availability of somequantities of different types of contraceptives. The distribution of Contraceptives byNANANA49

the types of facilities in Table 3.17 shows that minimum of four types ofContraceptives was available in every type of facilities. These are Combined Pills,Injectables, Male Condoms and Female Condoms. The results also shows that, thequantities of most the types of contraceptives available were accounted for byservice providers, which indicate good record keeping that should be sustainedthrough refresher training on CLMS, supportive supervision and technicalbackstopping mission. However, the quantities of a few contraceptives were notaccounted in some facilities, which also require strengthening through refreshertraining on CLMS, supportive supervision and technical backstopping mission.3.5.2.5 Number of FP complications referredThe numbers of FP complications referred by the supported facilities in the last threemonths are shown in Table 3.18.Table 3.18: Number of FP complications referred by residence and type of facilityFacility%Residence type FrequencyRural/urban CHC 0 0.0PHC 0 0.0GH 1 100Total 1 100% 100Rural CHC 0 0.0PHC 0 0.0GH 0 0.0Total 0 0.0% 0.0 0.0Urban CHC 0 0.0PHC 0 0.0GH 1 100Total 1 100% 100.0According to the results, one case of FP complications was reportedly referred in aSecondary facility in the urban area. This result suggests that prevalence of FPcomplications was low. However, interventions should sensitise service providers toidentify and document any FP complications referred for planning.3.5.2.6 Availability and adequacy of FP roomData was not collected on availability and adequacy of FP room to ensure comfortand confidentially of clients, including availability of model and equipment.3.6 INTEGRATED SRH/FP/HIV SERVICESIntegrating SRH/FP/STI/HIV prevention and treatment services is critical for UNFPAwork in ensuring universal access. Integration requires that health care workers canprovide an appropriate comprehensive package of services under one roof, and referclients to other services if required. Attempts to integrate SRH services with FP/HIVprevention services have encountered challenges at the programme and service50

level, including difficulties in allocating and coordinating responsibilities; ensuringeffective communication between staff in programmes; training staff with appropriateskills to meet a broader range of demands; and strengthening referral services. Thefollowing section present and discuss issues of integrated SRH/FP/HIV preventionservices.3.6.1 Provision of Integrated SRH/HIV ServicesIntegrated SRH/HIV prevention services were provided in 80.1% of the facilities onthe average (Figure 3.29).Figure 3.29: Percentage of Facilities Providing Integrated SRH/HIV Services bythe Types of FacilityAll the secondary facilities and 84.25 of the primary facilities provided integratedSRH/HIV prevention services.3.6.2 Types of Integrated SRH/FP/HIV ServicesThe different types of integrated SRH/HIV prevention services provided by thesupported facilities are shown in Table 3.19. The results depict that the facilitiesprovided varied types of integrated SRH/HIV prevention services. However, facilityspecificchallenges involved in the provision of these critical services should beidentified for appropriate strengthening measures - training, provision of equipmentand sensitization/policy dialogues.51

Table 3.19: Types of Integrated SRH, HIV&AIDS services provided by Type ofHCFsType of HCF Types of Integrated ServicesFreqHCT, PMTCT, FP, and STI treatment 1CHC FP and STI treatment 1HCT and PMTCT 1HCT, PMTCT, FP and STIs management 1HCT, PMTCT, ASRH, FP and STIs management 1HCT, FP and STIs management 1HCT and PMTCT 1HCT and FP 1HCT, PMTCT, FP and STI treatment 1HCT, FP and STI treatment 1HCT, ASRH, FP and STI treatment 1ASRH, FP and STI treatment 1HCT, FP and STI treatment 1PHC HCT, PMTCT, ASRH, FP and STI treatment 1Unstated 2PMTCT, FP and STI treatment 1HCT, PMTCT, FP and STI treatment 2GHHCT, PMTCT, ASRH and STI treatment 13.7 EMERGENCY OBSTETRIC AND NEW BORN CARE SERVICESEmphasis on making EmONC available to all women who develop complications iscentral to UNFPA’s efforts to reduce maternal mortality worldwide. This is becausethe major causes of maternal mortality, namely haemorrhage, sepsis, unsafeabortion, hypertensive disorders and obstructed labour, can be treated at well-staffedand well-equipped HCF.3.7.1 Basic Emergency Obstetric and New Born Care ServicesBEmONC provided in primary health care centres includes the capabilities for theAdministration of Parenteral Antibiotics, Administration of Uterotonic Drugs(Oxytocins, Engometrine, Misoprostol); Administration of anticonvulsants for pre-Eclampsia and Eclampsia (such as Magnessium Sulphate); Manual removal of thePlacenta; Perform removal of retained products following miscarriage or abortion(e.g Manual Vacuum Aspiration, Dilation and Curettage); Perform assisted vaginaldelivery, preferably with vacuum extractor, forceps delivery; and Newborn care. It isexpected that less than or equals to 15% of all births should take place inB/CEmONC facilities. Table 3.20 and Figure 3.30 present data on percentdistribution of the supported HCFs by the signal functions of BEmONC services.Also, Table 3.21 summarise the reasons why BEmONC services were not providedby the primary facilities.52

Table 3.20: Availability of Basic Emergency Obstetric and Newborn Care Services in the selected HCFsSignal functionsBEmONCTypes of facilitiesCHC PHC GH3 19 6AveAdmin of Parenteralantibiotics 33.3 52.6 100 62.1Administer Uterotonic drugs 66.7 73.7 100 75.9Administer anticonvulsants 33.3 42.1 88.3 50Manual removal of placenta 33.3 36.8 100 50Removal of retained products 33.3 21.1 100 39.3Perform assisted vaginaldelivery 33.3 10.5 100 32.1Resuscitation of Newborns Data was not collectedReasons for not providing theEmOCFreqPolicy isuues 5No indication 2No indication 2Management issues 1Policy issues 3Policy issues 4Supplies, equipment and drugs issues 2No indication 4Unstated 4Policy issues 5Supplies, equipment and drugs issues 1No indications 3Unstated 6Supplies, equipment and drugs issues 1Policy issues 4No indication 4Unstated 1Training issues 1Supplies, equipment and drugs issues 1Policy issues 5No indication 2Unstated 1Figure 3.30: Availability of Basic Emergency Obstetric and Newborn CareServices in the selected HCFs53

Table 3.21: Summary of reasons for not providing BEmOCReasonFrequencyTraining issues 1Supplies, equipment and drugs issues 5Policy issues 26Management issues 1No indication 17Unstated 12Of the seven signal functions of BEmONC services; provisions by the 28 supportedfacilities in the State were high for Administration of Uterotonic Drugs andAdministration of Parenteral Antibiotics at 75.9% and 62.1% respectively. Theprovision of Administration of anticonvulsants and Manual removal of the Placentawere average at 50% each. But the provision of removal of retained products andperformance of assisted vaginal delivery were low at 32.1% and 39.3% respectively.Data was not collected on Newborn care. Hence, the provisions of BEmONCservices were generally mix. The results in Table 3.21 show that policy issues werelargely responsible for the inability of facilities to provide BEmONC services. Otherreasons were training issues and Supplies, equipment and drug issues. Thesefindings suggest that programme interventions should advocate for the State todevelop and implement EOC policy, which hinge on training and supplies, equipmentand drugs to facilitate the provision of BEmONC services.3.7.2 Comprehensive Emergency Obstetric and New Born Care ServicesCEmONC typically delivered in GHs, MHCs and some CHCs includes all theBEmONC signal functions above, plus Caesarean Section, Safe Blood Transfusionand Care to the sick and low birth weight newborns, including resuscitation. Theguidelines jointly issued in 1997 by WHO, UNICEF, and UNFPA, recommended that:‣ Every 500,000 people should have four facilities offering BEONC and onefacility offering CEmONC.‣ To manage obstetric complications, which is the life-saving component ofmaternity care; a HCF must have at least two skilled attendants covering 24hours a day and seven days a week, assisted by trained support staff.‣ To manage complications requiring surgery, the facilities must have afunctional operating theatre, more support staff and must be able toadminister blood transfusions and anaesthesia.Information on the status of CEmONC in the State was obtained from the supportedHCFs and the results are discussed below. Table 3.22 and Figure 3.31 display thedata with respect to the provision of CEmONC services in the supported HCFs in theState. Table 3.23 on the other hand highlight the reasons why the secondaryfacilities did not provide CEmONC services.54

Table 3.22: Provision of CEmONC service in the supported HCFs in the StateCEmONCSupplies, equipment and drugs issues 1Policy issues 5No indication 1Perform Blood transfusions 33.3 10.5 88.3 28.6 Unstated 11Policy issues 5Supplies, equipment and drugs issues 1No indication 1Perform Caesarian Sections 33.3 10.6 88.3 28.6 Unstated 11Figure 3.31: Provision of CEmONC service in the supported HCFs in the StateTable 3.23: Summary of reasons for not providing CEmONC servicesReasonFrequencySupplies, equipment and drugs issues 2Policy issues 10No indication 2Unstated 22Table 3.242and Figure 3.32 depict that 28.6% each of the facilities performed BloodTransfusion and Caeserian Sections, respectively. These proportions were higherthan the minimum requirement stipulated by WHO. Further, the results in Table 3.23show that the greatest challenge to the provision of CEmONC services in the Statewas policy issues, which corroborate the findings on BEmONC services, andreinforce the need for programme intervention to advocate and support the State todevelop and implement a policy on EmOC services. However, the data is notsufficient to determine status of CEmONC in the supported facilities. The resultsmay suggest that many facilities effectively provided CEmONC services; but data onskilled manpower requirement, availability of a functional operating theatre, andsupport staff that are able to administer blood transfusions and anaesthesia are notavailable to justify conclusive statement.55

3.7.3 Total number of obstetric complications in the last three monthsData was collected on records of obstetric complications in the last three months,and the results are shown in Table 3.24.Table 3.24: Number of Obstetrics Complications.NumberResidenceFacilitytypeReferrals forpregnancyrelatedcomplicationsPersonstransfusedObstetricscomplicationsin the lastthree monthsRural/urban CHC 7 0 3PHC 10 45 35GH 8 1240 43Total 25 1285 81Rural CHC 0 0 0PHC 0 0 0GH 2 1 6Total 2 1 6% 8.0 0.1 7.4Urban CHC 7 0 3PHC 10 45 35GH 6 1239 37Total 23 1284 75% 92.0 99.9 92.6The results in Table 3.24 reveal that a total of 81 obstetric complications were seenin the last 3 months, out of which 75 (92.6%) were in the urban areas compared to6(7.4%) in the rural areas. More than half of the obstetric complications (57.3%)were seen in the secondary facilities compared to 38(42.7%) in the primary facilities.Only 25 Referrals for pregnancy related complications were seen in the last threemonths, among whom 23 (92.0%) were in the urban areas against 2 (8.0%) in ruralareas. Less than one-third (32%) of referrals for pregnancy related complicationwere seen in the secondary facilities compared to 17 (68%) seen in primary facilities.A large number of 1,285 persons were transfused in the last three months. Almost allof the transfusion took in urban areas with 1,284 (99.9%) against only 1 (0.1%) in theurban area. Meanwhile, 1,240 transfusions (96.5%) took place in the secondary andthe remaining balance of 45 (3.5%) were done in primary facilities. These resultsimply that there were variations in the number of complications seen in the last threemonths between the types of health facilities as well as between the rural and urbanfacilities.However, the data in Table 3.25 below indicate that Ante/post partum haemorrhage,pre-Eclampsia and Eclampsia, and obstructed labour were the most frequentlyreported types of Obstetric complications by the supported facilities. The other wasBreach presentation. The supported facilities in the State should therefore bestrengthened to tackle these types of obstetric complications. Similarly, programme56

intervention should be tailored towards awareness on the implications of obstructedlabour and Ante/post partum haemorrhage.Table 3.25: Types of obstetric complicationsS/N Types Frequency1 Ante/post partum haemorrhage 72 Obstructed labour 23 Breach presentation 14 Pre-eclampsia/Eclampsia 33.7.4 Other requirements for EmONC services3.7.4.1 Availability of Referral formsAvailability of referral forms enhances referral of clients with complications for qualityhealth services. Referral forms were available in most of the facilities (92.9%), andall the forms were used to refer clients for quality healthcare services; as shownFigure 3.32. However, 7.1% of the facilities did not have any referral forms.Figure 3.32: Percentage distribution of Facilities that utilised Referral Forms bythe Types of HCFsThese findings suggest that there were no gaps between availability and utilisation ofreferral form. However, the non-availability of referral forms in 7.1% of the supportedfacilities has negative implications for the health of clients with complications. Thereis the need for interventions to provide referral forms to facilities that do not have anyand ensure that the forms are used for referrals.The data in Table 3.26 show that the supported facilities made referrals to largelysecondary facilities (General and Cottage Hospitals) and tertiary institutions such asLASUTH. These results suggest that referrals were made to appropriate places forprompt, timely and quality healthcare services, and justify the need for programmeinterventions to strengthen secondary facilities.57

Table 3.26: Names of Health Facilities where referrals are made in the StateName of HCFFrequencyGH & Massi Children Hospital 1GH Igando & LASUTH 1LASUTH, LIMH Ikeja 2General Hospital, Mushin 1Massi Children Hosp & GH Isolo 1General Hospital Isolo 1GH I gando & LASUTH 1Massi Children Hospital 1LIMH & Onikan Health Centre 2General Hospital, Marian & LASUTH 1Cottage Hospital, Akoda 2Island Maternity &LASUTH 1General Hospital, Ghagada 2General Hospital 1GH Badagry 1GH Orile, Agege 1General Hospital, Igando 1General Hospital, Apapa 1GH & Island Maternity 1GH Mainland 13.7.4.2 Provision of Birth Preparedness Services by the Types of HCFsThe provision of birth preparedness services is a determinant in minimising one ofthe delays to access service delivery that inhibits improvements in maternal health.The data on birth preparedness services are shown in Table 3.27.Table 3.27: Provision of Birth Preparedness Services by the Types of HCFsType of HCFs Yes No Unstated TotalCHC 3 0 0 3PHC 14 1 4 19GH 3 2 1Total 20 3 5 28Average 71.4 10.7 17.9 100.0The results in Table 3.27 show that as many as 20 facilities (71.3%) provided birthpreparedness services to enhance the maternal health. Out of the balance, 3facilities (10.7%) did not provide birth preparedness services, while 5 facilities did notindicate status of birth preparedness services. Further, 3 secondary facilities (66.7%)and 17 primary facilities (77.3%) provided birth preparedness services. Hence,programme interventions should strengthen the remaining facilities to provide birthpreparedness services.58

3.7.4.3 Functional means of transport for emergenciesFunctional mean of transport eliminates one of delays accessing service delivery.Only the 11 supported facilities representing 44.3% had a functional means oftransport (Table 3.28).Table 3.28: Availability of Functional Means of TransportType of HCFs Number YesCHC 3 100PHC 19 94.7GH 6 100Total/Average 28 96.4The distribution of availability of functional means of transport by the types offacilities has shown that 27 (66.7%) of the 28 facilities had functional means oftransport while 1 facilities (4.6%) did not have any functional means of transport. Allthe secondary facilities and almost all the secondary facilities had functional meansof transport. Further, according to the results in Table 3.29 below, Motor Ambulance(85.2%), LASA Utility Bus (3.7%) and others (11.1%) were the types of functionalmeans of transport.Table 3.29: Type of, who provided and maintained the functional means oftransportS/N Characteristics Frequency %A Type of functional means of transport1 Motor Vehicle Ambulance 23 85.22 LASA utility bus 1 3.73 Others 3 11.1Total 27 100B Who provided functional mean of transport1 Government 25 92.62 Hospital 1 3.73 Individual 1 3.7Total 27 100C Who maintains means of transport1 Government 24 88.92 Hospital/Facility 1 3.73 Community 1 3.74 Individual 1 3.7Total 27 100Unstated 1Government provided 25 of the types of functional means of transport (92.6%), whileHospital and Individual provided a type of functional means of transport (3.7%),each. Similarly, Government maintained 24 of the types of functional means oftransport (88.9%). Hospital, Community and Individual maintain a type of functionalmeans of transport (3.7%) each. These findings suggest that Government waslargely responsible for the provision and maintenance of functional means oftransport in the facilities. However, the involvement of Facility and Individuals in theprovision; and Facility, Community and Individuals in the maintenance of functional59

means of transport in the facilities should be advocated by programme interventionsto compliment the efforts of Government in the provision of quality service delivery.3.7.4.4 Availability of maternity equipment in health facilityThe study examined the availability of basic maternity equipment in health facility,and the results are presented in Table 3.30.Table 3.30: Availability of maternity equipment in health facility by types ofbeds, residence and facility typesNumber of beds by typesResidence Facility type Total beds Maternity beds Delivery bedsRural/urban CHC 47 21 5PHC 205 131 38GH 468 197 20Total 720 349 63Rural CHC 0 0 0PHC 17 17 6GH 41 18 2Sub-total 58 35 8% rural 8.1 10.0 12.7Urban CHC 47 21 5PHC 188 114 32GH 427 179 18Sub-total 662 314 55% urban 91.9 90.0 87.3The data in Table 3.30 shows that all the types of facilities have dedicated maternityand delivery beds. The distribution of the beds according types of facilities revealsthat 65% of 720 total beds; 5.4% of 349 maternity beds and 31.7% of 63 deliverybeds were available in the secondary facilities. Further, the distribution of these bedsby residence show that 91.9% of the total beds were in the urban areas compared to58 (8.1%) in the rural areas; 90% of the 349 maternity beds were in urban areas asagainst 10% in the rural areas; and 87.3% of delivery beds were also in urban areascompared to 8 (12.7% in the rural areas. The results in Table 3.30 also show thatsome primary facilities did have any types of beds, which has negative implicationsfor EmONC services. These results imply disparity in the availability of all the typesof beds between the types of facilities and between the rural and urban areas, whichneeds to be addressed. The results of the assessment in terms of ration shows therewas a ratio of 26 total beds, 21 maternity beds and 2 delivery beds to a facility.Figure 3.33a and 3.33b summarise the distribution of the beds by the types offacilities and residence, respectively.60

Figure 3.33a: Number of the Types of Beds in the selected Facilities.Figure 3.33b: Percent distribution of Beds in the selected Facilities byresidence.Expectedly, the summaries show concentration of all types of beds in the secondaryfacilities (Figure 3.14a) as well as in urban areas (Figure 3.34b), with negativeimplications for EmONC services, especially the provision of delivery services inprimary facilities and in the rural areas.3.7.4.5 Availability of essential drugs and consumablesAccording to WHO 2002, essential medicines are those that satisfy the priority healthcare needs of the population. They are selected taking into cognisance the publichealth relevance, evidence on efficacy and safety, and comparative costeffectiveness.Essential medicines are intended to be available within the context offunctioning health systems at all times in adequate amounts, in the appropriatedosage forms, with assured quality and adequate information, and at a price theindividual and the community can afford. The implementation of the concept ofessential medicines is intended to be flexible and adaptable to many differentsituations; exactly which medicines are regarded as essential remains a nationalresponsibility. Other healthcare consumables and reagents include tapes, testing61

kits, cleaning products, hygiene monitoring systems, and record keeping materials(forms) that are use for different purposes. Some of these consumables aredisposables while other items are re-usable through sterilisation. The availability ofessential drugs enhances EmONC service delivery. However, data was not collectedon essentials drugs and consumables to serve as the benchmark for backstopping.3.7.4.6 Methods of SterilizationMethod of sterilisation also facilitates EmONC service delivery. Sterilisation in thiscontext refers to any process that effectively kills or eliminates transmissible agents(such as fungi, bacteria, viruses, spore forms, etc.) from a surface, equipment ormedication through application of heat (steaming and boiling), chemicals, irradiation(gas or ionizing), high pressure or filtration. Information on the common methods ofsterilisation in the supported HCFs in the State were Boiling at 78.6% andAutoclaving at 14.3% as shown in Figure 3.34.Figure 3.34: Percent Distribution of selected HCFs by Methods of SterilisationThe balance of 7.1% did not indicate their method of sterilisation. These resultssuggest that more than three-quarters of the supported HCFs in the State practicedBoiling, which may not kill all types of bacteria and virus. In view of the concerns inan era of HIV/AIDs scourge, especially due to complicities associated with boiling asa method of sterilisation; programme intervention should advocate and support allfacilities to use Autoclaving as a method of sterilisation.3.8 DATA COLLECTION FORMS, SUPERVISION AND COMMUNITYSUPPORT3.8.1 Availability, utilisation and transmission of RH/FP data formsOn the average, RH/FP data forms were available in 96.4% of the supportedfacilities, and all of the available forms were utilized for data collection and collation(Table 3.31). More than half of the collected and collated RH/FP data forms (60.7%)are submitted to the LGA M&E officer. The remaining balance submitted to differentMDAs in the State.62

Table 3.31: Availability of RH/FP data forms by the Types of HCFs and wheredata is sent toType of HCFs Number Yes Usage UnstatedCHC 3 100 100PHC 18 94.7 100 1GH 6 100 100Total/Average 28 96.4 100Where RH/FP data collected and collated are sent toLGA M&E 17 60.7LGA and Health Service Commission 2 7.1LGA and SMOH 2 7.1LGA AND SHOH 2 7.1Health Service Commission 2 7.1LGA and SMOE 1 3.6Health Educator 1 3.63.8.2 Other statistical data formsGenerally, just a few of the supported facilities had other statistical data forms(Figure 3.35).Figure 3.35: Availability of other statistical data by the Types of HCFSProgramme interventions should sensitise and strengthen facilities to obtain and useother statistical data forms.3.8.3 Types and quantities of IEC materials available -IEC materials were reported by the supported facilities, and the results are shown inTable 3.32.63

Table 3.32: Distribution of IEC materials available in the facilitiesType of facility Types of IEC materials Frequency QuantitiesHIV 1 Not givenCHCPosters 1 Not givenHIV 3 4ANC, FP and RBM posters 1 40Avain Flu prevention 1 1Immunisation 4 6Flip charts 1 Not givenLeaflets 1 1000Nutrition in pregnancy 1 1Booklets 1 20Hand bills 1 500PHCPosters 2 7STIs/FP 1 Not givenTypes of FP 1 4Posters 1 Not givenMDG achievers 1 3GHImmunisation 1 1The result show that some of the supported facilities in the State had different typesof IEC materials on display to create awareness on availability of RH/FP services,including ANC, Avian Flu, Nutrition, STIs/FP, Immunisation, RH/FP, HIV/AIDS,MDGs and RBM. There is however the need for programme intervention to provideculturally-sensitive IEC materials to the remaining facilities that did not have any orenough of the IEXC materials. However, the quantities of all IEC materials availablewere mix with some provided, but some did not provide.3.8.4 Supervision of facilities by LGAsLGA has the responsibility to supervise health facilities within its jurisdiction. Table3.33 present data on supervision of facilities by the authorities of the LGA.Table 3.33: Supervision of HCF by officials of the LGA departmentDescription of characteristics Number % SupervisedType of facilityCHC 3 33.3PHC 19 89.5GH 6 50Total/Average 28 71.4Last time of supervisory visit FrequencyThis week 2 7.1Last week 6 21.4Last two weeks 3 10.7Last month 7 25.0Last quarter 1 3.6Unstated 1 3.664

Many facilities (71.4%) reported that they were supervised by the LGA officials(Table 3.33). Half of the GH and most of the primary facilities (95.2%) reported thatthey were supervised by LGA officials. The results also showed that the last date ofsupervision by the LGA officials was last month for 25% of the supported facilitiesand ‘last week’ for another 21.4% of the facilities. Others reported different dates oflast visits by LGA officials. There is therefore the need to strengthen monthlysupervision of facilities by the LGA to ensure standard and quality provision ofhealthcare services.3.8.5 Village Health CommitteesVHCs provide support to facilitate and strengthen service delivery. Tables 3.34present data on availability, activities and meetings of functional VHCs.Table 3.34: Existence, Functionality and Meetings of VHCsCharacteristics Total No Yes exist FunctionalTypes of HCFsCHC 3 66.7 100PHC 19 89.5 94.1GH 6 33.3 100Total/ Average 29 75.0 95.2If the VHC is functional, list their activitiesFrequencyNIDs and referrals. 1 5.0Community mobilisation 3 15.0FP counselling and Referrals 1 5.0Vitamin A supplementation 3 15.0Eko free health mission 2 10.0Immunisation 3 15.0Incubators 1 5.0De-worming 1 5.0Outreach 3 15.0Monitoring 1 5.0LIDs 1 5.0Beddings 1 5.0NIDs 1 5.0H+ supplementation 1 5.0How often VHCs meetings were conductedWeekly 3 15.0Monthly 13 65.0Quarterly 3 15.0Unstated 2 10.0Total 20 100On the average, 75% of the supported facilities in the State had VHCs, out of which95.2% were functional VHCs. Almost all of the primary facilities 19 or 90.5% out ofwhich 94.1% were functional. Only one-third of secondary facilities reported havingVHCs, out of which all were functional.65

The most frequently occurring activities of the functional VHCs were communitymobilisation, provision of Vitamin A supplement, outreach, and Eko free healthmissions. Close to two-third of the VHCs (65%) conducted their meeting monthly todiscuss challenges and the way forward to strengthen health facilities. The balanceconducted meetings quarterly (15%), but 10% did not indicate how frequently theirmeetings were held.4. RECOMMENDATIONSBased on the findings of the assessments, recommendations are suggested underthe major sub-heading as follows:Background information and physical status of facilities Validate the findings of the assessment periodically to monitor progresstoward CPAP. Conduct further analysis to obtain facility-specific data for health systemstrengthening. Only 21.4% of the facilities that UNFPA is supporting were secondary, while78.6% were primary facilities. This distribution was in line with UNFPA’s ratioof the secondary facilities to primary facilities, which is 1 secondary facility tofour primary facilities (1:4). Strengthen 3.6% of the health facilities with dirty physical status and 4.0% ofmaternity wards/delivery rooms with dirty floors; to make them attractive toclients to access quality health services. Provide curtains to 32.1% of the maternity wards or rooms in the supportedfacilities that were without curtains to guarantee the rights of clients to privacyand confidentiality, and make them more attractive. Ensure availability of functional amenities in all the supported facilities;especially provide water in 32.1% of facilities without it, Toilets to 7% andBathroom to 7.4% with a view to enhance access and provision of qualityservices. Collect and analyse data on methods of waste disposal. Create awareness on the implications of the commonly reported healthproblems by the supported facilities. The most frequently occurring healthproblems were - early marriage, miscarriages/induced abortions, STIs,teenage pregnancy, HIV and VVF/RVF.Availability of health workers and capacity building received• Advocate redistribution of health workers between rural and urban areas onthe one hand and between secondary and primary facilities on the other hand.This is because urban areas and secondary facilities accounted for 92.6%and 54.7% of health workers respectively, while some primary facilities did nothave any health worker.• Train additional health workers on ELSS, LSS, MLSS, with emphasis on othercategories of health workers in the facilities such as RN, RM to improveservice delivery. Also train health workers on HIV Counseling, HIV Testingand Integrated SRH/HIV prevention services.•66

• Interventions should advocate availability of enough Pharmacists to dispensedrugs, and MLT to diagnose specimens, especially in rural facilities, forfacilities to function optimally and contribute their quota towards effectivemanagement of the HIV/AIDS scourge.• There were only 3 Health Educators, all of whom were working urban areas.Programme intervention should advocate availability of adequate numbers ofHealth Educators in rural and primary facilities to facilitate the achievement ofcommunity hygiene and health.• Very few health workers in the supported facilities have received differentforms of training in ELSS, LSS, MLSS, VVF/RVF, CLMS, FP Technology, STImanagement, ASRH, IEC, and Programme Management. And no staff of thefacilities has received any training in HIV counseling, HIV testing andIntegrated SRH/HIV prevention services. There is therefore the need forprogramme intervention to advocate and support training of health workers onHIV counseling, HIV testing and Integrated SRH/HIV prevention services. Italso advocates and support of additional numbers of health workers onELSS/LSS/MLSS, VVF/RVF, CLMS, FP Technology, and STI management.Provision of, and attendance for healthcare services The supported facilities in the State provided all the types healthcare service,except youth-focused services. There is therefore the need to strengthenfacilities to provide youth-focused care and services. The provision of obstetric repairs and STI management were low at 10.7%and 32.7% respectively. Programme interventions should advocate andstrengthen facilities to scale up the provision of obstetric repairs and STImanagement. Overall, there is the need for interventions to:‣ Ensure all facilities provide the types of services that they were meantto provide.‣ Bridge the gaps in the provision of ANC services on the one hand withthe provisions of PNC and Delivery care services on the other hand.‣ Also bridge the gaps the provision of HIV Counseling and HIV Testingincluding STI management. A total of 40,031 clients attended the supported facilities in the State in thelast three months for healthcare services. This figure is low in view of thepopulation of the State. Besides, more than half of attendance for thesehealthcare services in the last 3 months was largely for ANC with 21,041which accounted for 52.6%. In addition, there were significant gaps betweenattendance for ANC at 21,041, and PNC and delivery care services at 1,508and 1,513 respectively. Hence, there is the need to create demand forRH/FP/HIV services to increase access as well as to bridge the gap betweenattendance for ANC, PNC and delivery care services. Demand creation activities were average, which should scale up, especially insecondary facilities. Sustain the high level of referral services and system, and strengthen referralsfrom the secondary facilities to the Tertiary institutions. Ensure the provision of youth friendly RH services, ASRH and STImanagement. Ensure that facilities provide and keep records of EmONC such AssistedDelivery and Assisted Breech Deliveries.67

Family Planning services• FP services were available in all facilities. Hence, interventions should ensuresustenance of this availability of FP services in all facilities through continuousprovision commodities and strengthening of the FP rooms; with a view toenhance acceptance and utilization of FP services.• There were low patronages for FP services (new acceptors and revisits) inview of the scouring population of the State. Interventions should thereforestrengthen demand creation for FP services.• Collect and analyse data on status of FP rooms, including availability ofcommodities and equipment, and the provision of comfort and confidentialityto clients.• One-tenth of the facilities reported stock out of contraceptives. Therefore,interventions should eliminate contraceptive stock outs, by ensuring steadyavailability and accessibility of contraceptives.• All facilities accounted for the quantities of the various types of contraceptivesavailable in the facilities. This may indicates a functional and result-basedRHCS, which should be sustained through refresher training on CLMS.• Only one FP complications was reported by a secondary facility. Interventionsshould strengthen facilities to identify and document FP complications,including referrals.Integrated SRH/FP/HIV services• Close to one-fifth of the facilities did not provide integrated SRH/HIV services.Hence, programme intervention should scale up the provision of integratedSRH/HIV services, especially in the Primary Facilities through training,sensitization and dissemination of protocols for integrated SRH/HIV services.• Primary facilities provided different types of integrated SRH/HIV services. ThePrimary facilities should be strengthen to provide a minimum package ofintegrated SRH/FP/HIV services, including HCT, PMTCT and ASRH services.• Health workers should be sensitise on integrated SRH/HIV services.EmONC services The provision of BEmONC services were generally of low, medium and highranging between 32.1% and 35.3% for Assisted Vaginal Delivery andRemoval of retained products respectively to 75.9% and 62.1% for theadministration of Uterotonic Drugs and administration of ParenteralAntibiotics. However, the provision of CEmONC services was high at 28.6%each for Blood Transfusion and CS. None the less, the major reason for nonprovisionof BEmONC and CEmONC services by the facilities was policyissues. It is therefore important for programme interventions to advocate for,and support the State to develop and implement a policy on maternal,including EOC to scale up the provision of BEmONC and CEmONC services.Where such a policy exists, programme interventions should advocate itsimplementation. Collect and analyse data on the provision of New Born Care services. A number of obstetric complications were reported by the supported facilitieswith huge disparities between urban and rural areas and between primary andsecondary facilities. Hence, Programme intervention should strengthenfacilities to attend to such complications.68

A proportion of 7.1% of the facilities did not have any referral forms.Interventions should support such facilities to obtain and use referral forms.The major reason for the non-utilisation of referral forms was that they werenot provided. Ensure the provision of birth-preparedness care services by all the supportedfacilities due to the fact that 10.7% did not provide the services. Ensure that 5.6% of the facilities that did not have functional means oftransport at the moment, were provided functional means of transport. Theexisting functional means of transport in the 96.4% of the facilities should besustained. Also advocate public-private or public-community partnership in theprovision and maintenance of functional means of transport. Ensure availability and functionality of delivery beds, especially in the PrimaryFacilities in the rural areas that did not have these beds. Collect and analyse data on essential drugs, equipment and consumables tostrengthen EmONC services. Advoacte and support scale up in the use of autoclaving currently at 14.3% asa method of sterilization in view of HIV/AIDS and emerging diseases, and toeliminate the complicities in the use of boiling and disinfection as methods ofsterilization by health workers.Data collection, supervision and community management• Ensure availability and utilization of RH/FP data collection forms, since a few(5.6%) of the facilities had no RH/FP data form. Also encourage the high rateof utilization of available RH/FP data forms and support the implementation ofthe NHMIS forms.• Other statistical data collection forms were available in a few of the facilities.Interventions should encourage many facilities to obtain and use these otherstatistical data collection forms.• Sensitise health workers on the submission of collated RH/FP/HIV data formsto LGA M&E officers for timely collation and feedback.• IEC materials were reported to be available in some of the facilities. Hence,ensure availability of IEC materials in all the supported health facilities toenhance awareness about RH/FP/HIV services.• Ensure timely visits to facilities by LGAs• Sustain availability of functional VHCs in the 21 facilities (75%), out of the 20facilities (95.2%) were functional. Also, ensure availability and sustenance offunctional VHCs in the remaining supported facilities that did not have anyVHC, with a view to support demand creation and facility strengtheningefforts.69

5. REFERENCES70

6. APPENDIX 1Frequencies71