Many Nigerians encounter a range of service delivery and health system problems when trying to access health care. Such problems range from drug stock-outs to poor infection prevention practices to shortages of health staff, and can lead to unnecessary suffering by patients or in the worst cases, death. Yet rural communities, in particular, usually lack the means to challenge these failures, leading to distrust of health providers and low service utilisation rates.
In response, the UK aid and Norwegian government-funded Programme for Reviving Routine Immunization in Northern Nigeria and Maternal, Newborn and Child Health Initiative (PRRINN-MNCH) built the capacity of Facility Health Committees (FHCs) to enhance community voices on health issues and increase the responsiveness of health providers to community needs. The programme was implemented between 2009 and 2014.
Supply-side improvements can help to address service delivery failures. But if service utilisation rates are to improve, these changes need to be implemented alongside strategies that enhance the responsiveness of health providers to community needs. PRRINN-MNCH therefore looked at how it could introduce a stronger emphasis on voice and accountability within a broad-based health systems strengthening programme.
Baseline studies showed that there was already a surprisingly high level of health committee activity in rural communities in the programme’s four intervention states. Many of these had originated as a grassroots response to the challenging local health situation; others had been established in response to the activities of development agencies. It made sense to build on what already existed on the ground by strengthening the capacity of these structures. To this end, the committees were trained to consult with the community and represent community views on health issues; lobby and advocate for improvements in service delivery; and monitor facility performance and the supply and use of drugs.
By late 2013, 279 FHCs were operational at primary and secondary health care levels. The FHCs provided practical support to the health facilities by fundraising, maintaining the facility environment, ensuring that clients understood the pressures under which health staff were working, and helping to increase demand for services. Many of the FHCs could also list examples of how they had successfully challenged service delivery failures. For example, a FHC in Zango Local Government Area, Katsina State, successfully lobbied for the removal of a member of health facility staff who was consistently absent from work and who had refused to improve her attendance, despite repeated warnings from the committee. In Jigawa, a FHC supported by a local traditional leader, successfully challenged the misappropriation of drug funds by a member of facility staff. The health provider was reprimanded and forced to refund the money from his salary. In Funtua LGA in Katsina, a dossier of complaints about an abusive midwife was presented to the local government by the FHC, led by the Village Head. The health worker was transferred immediately and replaced by another midwife. These and many other examples demonstrated a new willingness on the part of the committees to challenge problems that were of concern to the local community, drawing on the support of Village Heads and other traditional leaders, as and when needed.
An endline survey and external review undertaken in the final months of PRRINN-MNCH found that communities with FHCs were more likely to be involved in community activities focused on improving Maternal Newborn and Child Health (MNCH), had a better understanding of what health services should deliver and of healthy MNCH behaviours, a better relationship with the local health facility, and a higher satisfaction with services. To this end, PRRINN-MNCH demonstrated the value added by FHCs.
The programme’s strategy of training core trainers from government in each of the programme states, meant that it left behind capacity that can be used to roll out support to FHCs across entire states in future. Seeing the positive effects of the health committees, the state government of Katsina endorsed the FHC training manuals produced by the programme by late 2013 and was intending to scale-up the work independently.
For more information contact Cathy Green at firstname.lastname@example.org
A more in-depth policy and technical brief:
Community interventions to improve access to maternal, newborn and child health services. PRRINN-MNCH