Strengthening Community Accountability Mechanisms for Quality Primary Healthcare – A spotlight on Niger State

By Oluoma Omeje (Lead Writer)

According to the 2021 Multiple Indicator Cluster Survey (MICS) report, the primary health care indices of Niger State have shown improvements when compared to the findings of the 2016 MICS. Under-five mortality rate has decreased from 149 per every 1,000 live births to 61 per every 1,000 live births. Likewise, the diphtheria, tetanus and pertussis vaccine (DPT3) coverage (the global indicator for RI performance) and percentage of births assisted by a skilled professional has improved from 20% and 34% to 39% and 38%, respectively.

While this indicates that Niger State is moving in the right direction, more effort needs to be made to achieve the Sustainable Development Goal (SDG 3) of ensuring healthy lives and promoting well-being for all, at all ages. The community is very critical to achieving this therefore, community accountability mechanisms that empower communities and hold people accountable for the delivery of quality healthcare services cannot be over emphasised.

Community accountability mechanisms for quality primary health care

Community accountability for quality healthcare refers to the continuous and meaningful engagement of communities, with public institutions to ensure accountability in delivering health services. An example of the application of community accountability for quality healthcare is the use of a Community Score Card (CSC) to improve quality of health services. This approach fosters collaboration among various stakeholders, including community members and health providers, to identify tailored solutions to enhance the quality of health services. It facilitates shared responsibility and mutual accountability in health service delivery.

Recognising the many ways community accountability can drive quality health service delivery, Nigeria Health Watch, in collaboration with the Niger State Primary Health Care Development Agency (now known as the Ministry of Primary Health) organised a Primary Health Care (PHC) policy dialogue themed “Strengthening Community Accountability Mechanisms for Quality Primary Healthcare — A spotlight on Niger State”. The aim was to improve the delivery of primary healthcare services in Niger State by providing a platform to listen to the voices of community members, healthcare providers and stakeholders as they share their experience when accessing or providing care.

In her opening remarks, Dr Kemisola Agbaoye, Director of Programmes at Nigeria Health Watch said, “There is a lot of value in bringing these policy dialogues and conversations closer to the communities, in ensuring that community perspectives are considered and incorporated into policy and decision-making for health”. She emphasised the need to amplify community voices and strengthen community accountability mechanisms, and its potential impact on improving quality health service delivery.

No one understands the health requirements of community members better than the community itself, therefore, engaging them during the planning, designing, delivery and monitoring of PHC services creates an opportunity for mutual responsibility and accountability that can result in community health improvement.

In his keynote speech, Dr Ibrahim Dangana, Executive Director, Niger State Primary Health Care Development Agency (NSPHCDA) represented by the Director of Health Planning, Research and Statistics (DHPRS), Dr Junaidu Inuwa, stated that “the NSPHCDA recognises that effective healthcare delivery does not occur in isolation. It is a collaborative effort that involves every member of society”. According to Dr Inuwa, when communities are empowered and mobilised, they transform into active agents of change, advocating for quality services, engaging in health campaigns, and promoting healthy lifestyles. He added that the state ensures they incorporate their viewpoints into the different programme designs and implementation. “In doing this, we improve health outcomes and foster a sense of ownership and pride in the health care services we provide”.

Increasing community demand for quality PHC services

During the first panel discussion, participants deliberated on the policies and programmes designed to strengthen PHC services and fulfil the health needs of rural communities. The discussion primarily centered around recognising gaps in these programmes and putting forth suggestions for improvement. The panellists were representatives from the Basic Health Care Provision Fund (BHCPF), the Ward Development Council (WDC), health facility and a community reporter.

Hajiya Aisha Musa Ahmed, Coordinator, BHCPF NSPHCDA Gateway, discussed the state’s effort in ensuring adequate access to the basic minimum package of health services through the BHCPF. “We use the WDCs. They are the voice of the community. When we want to achieve anything that concerns health, we must involve the community, the stakeholders at the grass root. The WDCs that we engage are playing very vitals roles and taking ownership of the programme in their communities”. She emphasised the importance of working in synergy with the primary health facilities and the communities during programme conceptualisation and implementation.

Hadiza Ahmed, the Officer-in-Charge of Kpakungu PHC, Chanchaga local government emphasised the role of the Community Health Influencers, Promoters Services (CHIPS) agents in encouraging and supporting community members to seek healthcare at the PHC facilities and outreaches. She highlighted the need for timely and adequate remuneration for the CHIPS agents to ensure continued health promotion at the communities.

Mallam Hassan, Secretary, Ward Health Development Committee discussed the role of the committee in improving the health of the community, acting as the gatekeeper between the community and the government. He emphasised the need for the NSPHCDA to ensure they continue to engage the WDC frequently to get their unique perspective for health programme design, implementation and evaluation. He also called for an improved feedback mechanism between the NSPHCDA and the WDC.

Rabiu Abubakar, the community reporter, discussed how geographical location limits access to quality healthcare, especially for pregnant women. He called on the NSPHCDA to ensure functionality of all PHCs to ensure improved healthcare access for community members in hard-to-reach areas.

Strengthening community accountability mechanisms for quality maternal health care

The second panel session discussed the state of maternal healthcare accountability mechanisms in the community. The panellists — stakeholders from the government, health development sector and the community, deliberated on the benefits of setting up and maintaining functional community maternal, perinatal and child death surveillance response (MPCDSR) committees. A consortium that included Nigeria Health Watch, with support from MSD for Mothers conducted a Community-Informed Maternal Death Review in Niger State in 2018. The findings highlighted the need to strengthen surveillance and an implementing effective reporting systems to capture data on maternal deaths in communities.

Dr Aminu Magaji, Chairman, State MPCDSR Committee, Niger State said “MPCDSR provides a platform to train healthcare workers on the new way of trying to account for women who die while giving birth. It helps to highlight what really caused the death of the woman, especially the contributory factors (like delay in accessing healthcare etc) because direct causes of maternal deaths are known worldwide like sepsis, prolonged bleeding and so on, but the contributory factors limit results from attempts at reducing maternal deaths”. He highlighted the fact that most of the contributory factors occur at the community level.

In June 2022, the Federal Government launched the revised National MPCDSR guideline which provides an opportunity to ensure proper accountability and response to maternal, perinatal and child deaths in rural communities.

Madam Mary Bawa, a woman leader, highlighted the need for adequate buy-in of the community, if community accountability for maternal deaths will be actualised. “Communities are easy to mobilise, except we do not mobilise them… and when community structures and resources are available and utilised, ownership is established”. She also emphasised the need for the inclusion of diverse women groups in the committees.

Mr Matthew Oladele, Director of Initiative for Social Development in Africa (iSODAF) said, “Communites should be mobilised to know the magnitude of the health indices, why it is like that and how it can be prevented, when it (maternal, perinatal or child death) happens what should we do and who should we report to or call”. He added that the efficiency of the community MPCDSR committees will depend on the inclusion of women groups in different communities and adequate community sensitisation especially on maternal, perinatal and child deaths.

According to Dr Inuwa, the revised National MPCDSR guideline has been adopted in Niger State because it fits the state’s context. He added that for the NSPHCDA to conduct the state training of trainers and cascade the training at the sub-national level, they need support from the National Primary Health Care Development Agency (NPHCDA) through IMPACT and other development partners in the state. Recognising the need for sustainability, the state is exploring diverse sustainable funding sources, from the national and state levels, as well as development partners with a similar objective. The Director stated that sustainable funding from internal and/or external sources will be achieved in the next quarter and the implementation of the community MPCDSR committees will be set up. “Whatever we do at the SPHCDA, we always put sustainability into context, so we are discussing with other existing programmes on how we can sustain this,” he said.

Community accountability for quality primary health care: The way forward

A communique summarising all the actionable recommendations from the panel sessions was presented following the conclusion of the discussion.

1. Adequate community engagement: The Ministry of Primary Health Care needs to work in synergy with facilities and communities. This will ensure an improved feedback mechanism between the Ministry and the WDC.
2. Adequate inclusion of women groups in the community MPCDSR committees: To amplify women’s voices, the community MPCDSR committee should take into consideration the different women groups in the different communities.
3. Sustainable financing for community MPCDSR: Given the opportunity of evolving into a Ministry in this new administration, the Ministry of Primary Health Care committed to allocate a dedicated budget line for community MPCDSR, to ensure its long-term sustainability. It will also leverage NiCARE and BHCPF community outreach activities to strengthen financing for community MPCDSR.
4. Set up community MPCDSR committees with political leadership: The Ministry of Primary Health Care will ensure the conduct of MPCDSR training at different levels in the state and set up functional MPCDSR committees by the next quarter. Additionally, the leadership of the State MPCDSR committee should be a ‘political leader on health’, because political will drives impact.
5. Timely remuneration for CHIPS agents: The Ministry of Primary Health Care should ensure adequate and timely remuneration for the CHIPS.