Score for Health Project

 quality and affordable primary healthcare services to local communities where it is most needed. Although the country has over twenty thousand (20,000) Primary healthcare centres (PHCs) scattered across its seven hundred and seventy-four (774) local government areas, many of the residents in local and rural communities still do not have access to basic healthcare. Poor infrastructure and inadequate provision of equipment, supplies and medicines have crippled service delivery in most of these centres. For some other centres inadequate human resource for health (HRH) has limited their capacity. While some centres have surplus resources and service lesser volume of clients, some other with larger clients’ flow have limited resources. This is due to the lack of real-time data by managers and policymakers to monitor resources supply and consumption, as well as human resource distribution across these centres and these, have negatively affected the effectiveness of resources allocation and planning by the national primary healthcare development agency and state primary healthcare boards. >span class="NormalTextRun SCXW142553554 BCX9">network is caused by the inability to track the resources available to primary care providers (HRH, medicines, supplies, equipment), and feedback from clients on the quality of care they received. As a consequence, there is little available data to understand how often primary care workers are available at the health facilities, how accurately they diagnose and treat patients, and the experience of patients that receive care. With more scarce resource allocation to health by the Nigerian government, service delivery may grow worse in PHCs if there is no system to know the pain points, identify the waste points and shortages so that there is the reallocation of resources including human resources to ensure that all centres provide quality basic care to the communities that they serve. 

To change the current narrative about tracking and measuring Primary healthcare performance improvement in Nigeria, our intervention, the Score4Health (S4H) project will utilise a three-pronged approach (research, innovation, collaboration) to transform the measurement of performance improvement in PHCs by collecting and utilising existing but unprocessed service delivery data to provide primary healthcare workers and health agencies with real-time data-driven insights about the performance of PHCs in service delivery. This will provide evidence to help primary healthcare managers and policymakers in identifying weak points in primary healthcare service delivery and developing novel approaches and strategies to resolve the challenges that surround such weaknesses. 

Research: we will conduct desk research to identify and understand the existing standard performance improvement metrics and the measurement guidelines by the World Health Organization (W.H.O), the Federal Ministry of Health in Nigeria, and the State governments of Oyo and Osun states where the project will be implemented. The identified indicators will be reviewed by stakeholders in a participatory workshop to understand the current gaps in the implementation of the guidelines and measurement of the indicator. Through this workshop, feedback will also be obtained from key stakeholders on the other important points in the service delivery process where important data is lost and needs to be digitized in order to have a holistic insight from the data that will be collected.  

Innovation: Paper remains a fixture in health systems in Low and Middle-Income countries. To change this narrative, our team at HACEY Health Initiative, in partnership with IPRD Solutions is currently implementing an intervention, the Impact Health application in two states across Nigeria which deploys and demonstrates the value of interoperable (FHIR-based) digital tools to improve the care delivered by healthcare workers. It comprises a mobile application and a web-based platform that enables community health workers (CHWs) to register pregnant women, generate and record progress against Care Plans, and compute program indicators for state stakeholders. In the last 7 months, the application has been deployed in over 100 PHCs and used by over 300 primary healthcare workers to record ANC care data of patients against care plans and provide basic insights on ANC care and commodity use in each facility through a digital web-based dashboard to state policymakers. 

Collaboration: to adequately identify the necessary data points during service delivery and digitize the data collection, our project will partner with health agencies in the proposed project states including the ministries of health and the State Primary Healthcare Boards. The project will also partner with the World Health Organization offices in the project that the WHO guidelines for PHC performance improvement measurements are correctly implemented during the project. We also partner with technology firms that have years of building low requirement, fit-to-use health technology for low and middle-income countries. To ensure that holistic data is collected and that the insights provided are useful across boars, we will engage both local and international development partners working in primary healthcare centres in the project states in the design and development process to ensure that the dashboard is reflective of the exact situations at the PHCs. These stakeholders will also form the PHC performance improvement advisory committee. They will review the data at intervals and provide the state with recommendations and strategies on how to improve the performance of the primary health facilities. 

Goal: the score for the health project aims to improve service delivery in primary healthcare centres by providing quality data to identify weaknesses in the primary healthcare service delivery system and provide appropriate strategies to resolve such weaknesses. 

Objectives: 

• To develop technology-based measurement tools to collect data from service delivery processes across primary healthcare centres in project states which will inform performance improvement measurement 

• To develop a digital PHC performance improvement dashboard for accessing the performance improvement across primary healthcare centres in project states in real-time 

• To inaugurate the PHC performance improvement advisory committee in project states that will utilize the data provided to develop new strategies for improving service delivery at primary healthcare centres. 

The primary healthcare service in Nigeria is designed to bring affordable and quality healthcare to the poorest people leaving in remote villages and rural communities. Learning from our previous experience in many of these communities, the majority of the dwellers are farmers and artisans. The more hard-to-reach communities have poor road networks which make physical access to such communities and referral of emergency cases out of the communities, a challenging task to accomplish. Many of the residents resort to self-care and herbal medicines due to the lack of medicines and necessary supplies at the health facilities closest to them. In other communities where there is seemingly better infrastructure, the number of primary care providers available is too small compared with the population volume that such a facility is expected to serve.  

Primary healthcare providers include nurses, midwives, community health officers (CHOs), community health extension workers (CHEWs), laboratory technicians and health assistants (HAs). From our experience in working with PHCs in the last 5 years, more than two-thirds of PHCs in Nigeria are short-staffed. While a nurse is supposed to head the PHC under the supervision of a medical officer of health who is a medical doctor working with PHCs at the local government level, many facilities are led by CHOs for insufficient distribution of nurses. Pregnancy deliveries are attended to by CHOs and HAs in some other facilities due to the lack of midwives. Inadequate Security, clean water, constant power supply and lack of access to financial institutions are examples of factors that have contributed to the draining of skilled health workers in local communities. Ultimately there is improper coordination of service delivery, and a shortage of highly skilled staff to attend to patients in many of the local communities served by the PHCs. To complicate the issue, unstable funding and supply of medicines and equipment by the government to the health centres further limit their capacity to offer quality services. The PHCs use paper-based health information and commodity monitoring system which is not only cumbersome but becomes more tedious due to the lack of sufficient human resources. As a result of these, data accuracy is low, and a lot of useful data that can influence resource allocation to promote the delivery of better services is lost at the facility level. Our intervention will reduce this human resource burden by helping primary care workers to send in data in real-time to health managers without having to fill multiple sheets. Our intervention also allows health managers to monitor human resources distribution and commodity availability in real-time so that resources can be further reallocated to optimise quality primary care service delivery at the health centres. The intervention will also ease the provision of feedback to health facilities from the managers based on the data submitted 

In the last 2 years, our team has been working with community gatekeepers and primary healthcare workers to improve maternal health service delivery at local health facilities. Our interventions are co-designed and co-implemented in a bottom-top participatory approach to ensure that the input and ideas of the beneficiaries are put in context during these processes. For example, the Impact health system was co-designed with primary healthcare workers through a series of workshops and focus group discussions. Through these meetings, our team was able to understand the data flow at primary healthcare centres and the different paper-based tools that are used to capture these data on a daily, weekly, and monthly basis. The workshops also helped us to learn about client behaviour, client journey, and typical client experience at a local health facility when they come to access treatment. All these inputs allowed us to create a faster and more efficient data collection and management process for maternal health service delivery. Currently, we work with a network of 300 healthcare workers across over 100 primary healthcare centres in more than 21 local government areas in both Oyo and Osun states where the Impact Health project is being implemented. 
 
Our team comprises researchers, public health professionals, and international development experts. With this dynamic mix of skills and competencies, we are able to provide primary healthcare workers with on-the-go technical support every month and through these support meetings, we are able to take feedback on the performance of the application, resolve technical challenges and conduct retraining of the healthcare workers where necessary. The feedbacks gathered from different facilities are processed and analyzed as insights for the agile development of the Impact Health Platform. 

Using the same approach, we have implemented other health interventions at the primary healthcare level in the project communities. Our project agbebi was implemented in Oyo state and the project used a participatory approach to co-design and co-deliver together with primary healthcare workers, different interventions to prevent malaria in pregnancy. 

concept of using participatory strategies to build sustainable health interventions 

Primary healthcare service in Nigeria has been suboptimal since its inception. Although it remains the closest source of care to the public, its underperformance has contributed to the witnessed public neglect of primary care and increasing workload for secondary and tertiary health facilities. In Nigeria, PHCs cannot function optimally because they lack medicines, consumables and supplies, technical equipment and proper structural infrastructure. Many of these facilities do not have the required man power to provide high quality skilled services and coupled with this, they use paper-based health information system that requires a lot of human power to be effective. This challenge has contributed to the poor management of the health information system and the poor quality of health data captured by this system. The absence of reliable and accurate data in real time makes it rather difficult to allocate the few available resources and plan effectively at the management levels of the primary healthcare system. Although Nigeria has a vast network of primary healthcare facilities, these barriers reduce their effectiveness and the quality of services delivery 

To improve the capacity of primary care facilities, there is a need to urgently provide a fast, reliable, and effective means of managing data flow from facilities to the manager and vice versa. Our intervention will solve this problem by leveraging technology to collect unconventional and proxy data along the service delivery process of primary care, analyze, and present such data in an easy-to-read format for health manager and policy makers at the state health agencies. This intervention will no only provide data to monitor service provision at the facility, it will strengthen the monitoring of commodity consumption, and provide evidence to identify the weak points of primary care provision in the health facilities. This data can then be used by policy makers to make strategic decisions about resources allocation including human, material, and financial resources  

In the last 24 months, we have been supporting the health information system in primary healthcare to provide reliable, accurate, and real-time information about maternal health service delivery in primary healthcare, through our Impact Health Project. Currently, mobile tech-powered solution is being used in over 100 primary healthcare facilities to provide information like, total number of newly registered pregnant women per month, total number of women that attend antenatal clinic weekly, percentage of women that attended up to 4 ANC clinics compared with 1st ANC clinic, as well as total number of women that are currently receiving chemoprevention against malaria in pregnancy among the registered pregnant women. This information is present in the Impact Health dashboard that is presentable to state policy makers and health managers. Through this project, we have improved ANC service delivery by providing over 10,000 doses of intermittent preventive therapy in pregnancy to pregnant women through the implementing PHCs. We also provide up to 30,000 units of malaria rapid diagnostic tests which has improved the identification of women have malaria but are asymptomatic and equipped the implementing facilities with internet-enabled smart phones to support the easy deployment of our solution. The Impact health dashboard helps health managers to distribute other commodities for antenatal care based on consumption rate in each facility. It also helps to track the use of commodities by marching monthly consumption with the total commodities delivered to each facility. 

While our current intervention has helped both states where it is being implemented to track the changes in maternal health service provision, and to decide on the facilities that need specific kinds of intervention to improve maternal healthcare service delivery, we believe that this grant will help us to expand the capacity of our intervention. Specifically, this grant will help us to expand the capacity of our technical and software resources to collect data on other services provided in the health facilities and to digitize the data collection along the entire client journey in the health facility during service provision. It will also help us to support health facilities with other resources that will facilitate the easy deployment of technology in such places.  

According to the PHCPI dashboard, Nigeria has little or no available data to measure the sufficiency of inputs offered to PHCs specifically facilities, health care professionals, and supplies. This makes it difficult to compare the output indicators with the inputs indicators, service delievry indicators, and outcome indicators as a measure of PHC performance.  

Our intervention will provide a system for PHCs to manage their inputs and provide accurate data in real-time. The data can be viewed by health managers and policy makers as evidence for on-going programmatic decision making. The web based dashboard will also allow for real-time comparison on input indicators with output and outcome indicators in each facility, thereby making it easier to spot the weak points in each facility and identify areas to prioritize during decision making. The system will achieve this using low requirement mobilbe technology that is able to function properly in remote and hard-to-reach communities. 

Using unstructured supplementary service data (USSD) and the WhatsApp platform, our intervention will also collect feedback from healthcare consumers in the local communities who use either low-feature phones or smartphones. Data from the feedback will be used to measure perceived access to barriers due to treatment cost, perceived access due to distance, and other indicators that will help to evaluate the quality of service delivery and performance of PHC from the patient's perception. 

The improved management of performance data and provision of evidence of PHC performance will help policymakers and health managers to understand patients' pain points contextually, which will facilitate the development of user-specific interventions to bring quality healthcare closer to communities. The evidence provided will also support the state health agencies to determine the kind of competencies that is required for PHCs to function optimally and effectively. Ultimately, the provision of data evidence and the uptake of such evidence in PHC management will increase the quality of services provided by the health facilities and the effectiveness of such facilities to bring more health to the communities that they serve.

1. Implementing PHCs across project states have Improved Inputs management by 2023. This will be achieved by the creation of an inputs entry and management module on the mobile application that will be used by Primary care providers to report and manage commodities available at the facility per time. The data for each facility will be visible to health managers and policymakers for easy tracking of inputs distribution and consumption. The improvements will be determined by an evaluation exercise and data will be collected through a survey to access the changes in the availability of commodities necessary for service delivery in each facility at the end of each project year and these data will be compared with the baseline and over the years to determine the level of improvement 

2. There is improved service delivery in implementing PHCs across project states by 2025. This will be achieved by the creation of the Facility PHC performance improvement dashboard. The dashboard will provide evidence of the quality of service delivery in each facility using the PHCPI indicators and will compare the input, service delivery, output, and outcome indicators. The evidence gathered from the dashboard will be used by the inaugurated PHC performance improvement committee in each state to develop new strategies and approaches to improve service delivery in weak facilities. The improvement will be evaluated through a survey to quantify the change in service delivery per year. Data for each year will be compared with the baseline to determine the level of improvement 

3. Community members have Improved access to quality healthcare services at PHCs across the project communities by 2027. Feedback from user experience and perceived quality of service delivery will be integrated with dashboard insights to inform improvement strategies that will be recommended by the PHC performance improvement committee. With implementation over the years, community-wide surveys will be conducted in the communities served by the health facilities to access the change in their perception of service delivery post implementation of the improvement strategies. 

1. Percent change in the availability of inputs for service delivery at implementing health facilities. This will be measured through quantitative data from the evaluation survey, to access the improvements in the supply of necessary inputs based by the government based on the insights provided by the PHC performance dashboard. This will be measured at the end of each project year and compared against the previous year and the baseline data to determine the level of change in percentage 

2. Percent change in the quality of services provided by implementing Health facilities. This will be measured yearly to evaluate the level of change that has occurred in service delivery based on the insight provided by the data from the PHC performance dashboard. The indicator will be measured yearly through an evaluation survey at the facilities at the end of two project years and the data will be compared against the previous year and baseline to determine the level of change in service delivery per year in percentage 

3. Percent of community members that report improved access to quality healthcare services. This will be measured in year one, year three, and year five by an evaluation survey. Quantitative data will be collected at baseline to determine community members' access to quality healthcare services. Data for each round of the survey will be compared to determine the changes in the proportion of community members that report access to quality healthcare service at PHCs and this will be expressed as a percentage  

Problem: There is an insufficiency of quality data to identify service delivery weaknesses in the Primary healthcare system, which stands as a barrier to understanding how primary healthcare providers are available for services, diagnosis, and treatment of patients. There is also little or no data to understand patients’ measurement of the quality of care received at primary healthcare centres. 

Underlying cause: there is currently no functional process or system to accurately track resources availability at healthcare facilities (Human resources, medicines, supplies, and equipment), and patients’ measurement of the quality of care received at PHCs 

Consequence: Primary healthcare facilities provide poor or optimal healthcare services to the communities that they serve 

Path to Success (Activities):  

Learn: the project will Identify standardized measurement indicators and develop data collection templates with primary healthcare workers and community members who receive care from PHCs. The indicators will be measured by collecting existing data that is generated during the normal process of healthcare service delivery. A development workshop will be organized to achieve this and the workshop employ a participatory approach and will include staff of health agencies, primary care workers, and international and local development partners.  

Create: the project will expand the Impact Health System to develop a web-based Dashboard that will collect data using mobile interphase, aggregate the data collected along the service delivery process, analyze such data, and convert the data into a dashboard known as the digital Primary Healthcare Performance dashboard. The dashboard will change in real-time as data streams into it from the facility. The data will be collected using low-cost methods and instruments that fit into the primary healthcare service delivery process, which are shareable across existing health information systems across PHCs, and streamlined for primary healthcare workers to make data collection easy and blended with their routine duties. This is based on the assumption that connectivity is stable, connectivity requirements are moderate, and healthcare workers will utilize the data collection tools as planned consistently. 

Reiterate: the PHC performance dashboard will provide data-driven insights that will reveal the weaknesses of service delivery in PHCs, and form the basis of developing context-specific solutions that are low-cost and effective 

Immediate result: 

Primary healthcare facilities and MDAs have data to access their service delivery performance. 

Low-performing PHCs and services that are most poorly delivered are identified.  

Mid-term Outcome: new strategies to strengthen service delivery in low-performing facilities are developed and implemented by PHCs and Health MDAs with data evidence from the digital scorecard 

Long-term Outcome: Primary healthcare centres provide improved quality healthcare services to community members in their catchment areas 

Impact: Community members are healthy. 

Our intervention uses a combination of AI powered web-based applications, mobile applications, and mobile messaging platforms (SMS and WhatsApp) to collect unconventional and proxy data, sort and analyze the collected data, and interprete the results on the digital PHC performance dashbaord. Patients who are registered digitally with a specific health facility on the Impact Health system will be able to rate the quality of service delivery and access to health in that facility by answering series of questions through SMS or WHATSAPP platforms. The Impact Health application will feature an inventory management module that allows PHCs to account for and manage medicine, supplies, equipment, and human resources. The app will also have a module for collecting data along the service delivery process based on the service delivery, output, and outcome indicators from the PHCPI list of indicators. Data from the mobile application will be sent and stored on the cloud server from where it will be analyzed and fed into the digital dashboard to provide insights about the performance of the PHCs from where data is being collected. 

The Impact Health application is an FHIR (fast healthcare interoperability resources) - based system for the collection of clinical data. FHIR has been widely embraced for clinical data in the US and Europe and it's also being adopted in Africa and it was adopted for these reasons. Through this project, we will develop and deploy the same FHIR-based methodology for non-clinical data in  PHCs across Nigeria. Our expectation is that the same benefits and adoption being realized for clinical data will also be realized for non-clinical data such as inventory management, and service delivery data. In addition, we believe it will enable the machine-to-machine cross leverage of data across verticals that may include: campaign planning, supply chain management, training, campaign delivery (e.g. maternal, newborn, and child health workflows including diagnostics, nutrition, vaccination, family planning), information for workers payment systems, and monitoring and evaluation.

Nurses, Community health officers, Community Health extension workers, and Health records officers

Diversity: Our project team at HACEY is women-led and comprises at least 60% women. The team comprises members from different ethnic groups across the geopolitical zones in Nigeria including Yoruba, Urhobo, and Igbo. Our staff members have different religious orientations and have full freedom to practice their faith without discrimination.  

Equity: At HACEY, all staff members are entitled to a development allowance of $ 300 USD per year which is usually  for performance improvement 

Inclusion: our team includes people living with disabilities 

HACEY Health Initiative is a development organization that is running with the vision to create a healthy and sustainable society for all. We are on a mission to empower and support children, women and young people to lead healthy lives through capacity building, advocacy, research and education. We are achieving this through our mutilpronged approach that includes innovation, capacity building, advocacy, research and education (iCARE). We co-develop people-centred solutions using participatory and human –centred design approach to ensure that our solutions fit the context where the solution is needed as much as possible. We continually provide capacity building opportunities to women and girls in Nigeria to strengthen their agency and ability to lead the change that they deserve. Our research and development team comprise highly experienced and skilled public health and internationa development research experts who continually use scientific methods to investigate and provide evidence for our innovation and advocacy process. We continually learn from the work we do and the people we work with, and this evidence strengthens our grassroots and highly level advocacy acitivites 

Over the last 14 years, HACEY has worked with various international and local development partners some of which include; UNFPA, the UN Trust Fund to End Violence Against Women, Government of the United States of America, Australia Government, Path USA, Empower UK, Amplify UK, Nigerian government, Access Bank Plc and other private sector partners to implement health, nutrition, education, economic empowerment and human right programs focused on improving the life outcomes of women, girls and young people in Nigeria.  Our managerial staff comprises of the program managers, communication manager and program officers and they report to the executive staff. Our executive and managerial staff have received training at Institute of Development Studies (IDS), University of Leeds, Columbia University, Johns Hopkins University and renowned institutions across Nigeria, they have experience implementing projects funded by Gates Foundation, USAID, DFID, private sector organisations and other local and international donors. They have also worked with government in shaping policies and implementing and managing high impact programs on nutrition, girl's education, women empowerment, financial inclusion, sexual health, women’s right, sexual violence, technology for social good.  We have core skills in; 

• Community mobilisation. 

• Human centered design. 

• Integrating health and economic empowerment programs. 

• Designing and implementing Vocational, Media and Technology programs in low-income communities. 

• Monitoring, Evaluation, Reporting and Learning. 

• Designing scaling and sustainability systems for health and productivity interventions. 

HACEY is non-profit and our funding majorly comes from donations and grants from different funders. We do not directly make a profit by selling a product or service. However, we have been able to achieve financial sustainability by establishing a consulting firm that provides development and program management services in different sectors including health, agriculture, corporate sustainability, and the environment. A percentage of the profits made by the consulting firm is paid to HACEY as royalty which enables us to financially sustain our interventions when grant funding reduces or funders exit  

In the last five years, we have received funding from organizations including but not limited to United Nations Trust Fund to End Violence against Women, Amplify Change UK, GBC Health New York, and IPRD Solutions. We have also worked with a lot of private sector organizations to mobilize resources toward solving international development challenges in Nigeria