Reproductive, maternal, newborn, child and adolescent health + nutrition (RMNCAH+N) is a major health priority in Nigeria

Over the last two decades, Nigeria has made progress in reducing maternal and child morbidity and mortality. However, with illnesses in women and children accounting for almost two-thirds of the total disease burden in Nigeria, reproductive, maternal, newborn, child and adolescent health (RMNCAH) remains a major health priority. The RMNCAH and nutrition (RMNCAH+N) investment case (2017 to 2030), a subcomponent of the National Strategic Health Sector Development Plan II, demonstrates the Government of Nigeria’s commitment to strengthening health services and service uptake in newborns, infants, children, adolescents and women. Improved governance and accountability are identified as important prerequisites for achievement of the goals of the investment case. 

RMNCAH scorecard introduced in 2013 in Nigeria

RMNCAH scorecards are management tools used by countries across Africa to strengthen accountability, action, advocacy and transparency, in order to improve RMNCAH. Nigeria’s Federal Ministry of Health with support from ALMA and other partners introduced the RMNCAH scorecard tool initially at federal level in 2013. At that time, lack of access to routine data from the subnational level limited successful implementation of the tool.

Decentralised to state and local government level in 2017

Following the roll out of DHIS2, the scorecard was re-introduced in 2017 with a shift to anchoring its use at the state and local level, in alignment with Nigeria’s federal governance system. The rollout of the RMNCAH scorecard began with a pilot in Ebonyi and Kogi states in 2017, followed by further expansion to the 5 states of Niger, Kebbi, Bauchi, Oyo and Adamawa in 2018 and then to all the states. The RMNCAH+N scorecard which was also expanded to include an increased focus on nutrition, is now deployed in all 36 states and the Federal Capital Territory. Rollout of the scorecard has been driven by expressed interest by states and partner support. The Federal Ministry of Health plays a coordination and stewardship role, encouraging the tool’s effective use at state level, and partners, particularly UNICEF, support activation and continued implementation at decentralised level.

Findings from a recent assessment of the use of the scorecard done in 10 states (Adamawa, Bauchi, Ebonyi, Kaduna, Kano, Kebbi, Niger, Oyo, Osun and Rivers) illustrates successful uptake of the scorecard and provide examples of how the tool has contributed to RMNCAH programme advancements.

State-level scorecards customised to their context and priorities

The scorecard implementation process is similar across states, although its functioning is adapted to each state’s context. Indicators tracked by the scorecard, and their performance thresholds, are selected by each state based on its priorities and other contextual factors. For the 10 states assessed, the number of indicators actively tracked per state ranged from 14 to 22. All states track indicators covering the RMNCAH spectrum of care and one state (Kebbi) includes non-health sector indicators.

In general, the Departments of Planning Research and Statistics of the State Ministries of Health and officers from the State Primary Health Care Development Agency are responsible for quarterly scorecard update, production and sharing. State programme officers coordinate the dissemination and review of the scorecard. Scorecard discussions are integrated into routine RMNCAH and wider health management processes at state, local government area (LGA) and health facility levels, with varying levels of scale across states. Additionally, in several states the scorecard is reviewed beyond the health sector. For example:

• in Kano state, the scorecard is reviewed during biannual multisectoral meetings.
• in Adamawa, Kebbi and Oyo states, the scorecards are shared during ward development committee meetings as a mechanism to involve communities in the accountability process.
• in Kebbi state, the scorecard is shared during political visits with local government areas and state legislatures and local government area chairmen, as part of integrated support supervision activities.

The scorecards are also discussed when other strategic opportunities arise such as with visiting donors and partners in Oyo and Niger states, and for annual operational planning in Adamawa, Bauchi, Kaduna, Oyo and River states.

In addition to active review in the various forums, the scorecard is also printed and displayed at State Ministry of Health buildings in some states including Bauchi, Kebbi and Oyo. This widens stakeholder engagement, transparency and accountability.

Wide ranging action associated with scorecard use

The use of the scorecard at both state and LGA levels, in all states has triggered a wide range of actions and changes which have resulted in improvements in RMNCAH programmes and strengthened health systems. Examples of areas of success associated with the use of the scorecard are described below.

Strengthened evidence-based decision making and data quality improvement

The scorecard approach is recognized as a best practice in optimising data use for decision making across administrative levels and stakeholder groups in all states. This success is in part due to the tools simplified format and functioning as described by the following quotes:

The preparation of the scorecard [is] easier because we don’t have to download anything; we just log in [to the Scorecard Web Platform] and the scorecard is there for use.

Decision maker, Kebbi state

Though some of us do not understand the interpretation of the information on the scorecard, the colour codes [green, yellow and red] using the illustration of the traffic light help us to know areas we are doing well, those that require improvement and areas that we have failed.

Ward development committee member, Adamawa state

Through its continuous review and interrogation of indicator performance, the scorecard has also led to improvements in data quality. Examples of data quality improvements associated with scorecard use include: 

• In Kogi local government area (Kebbi state), use of the scorecard highlighted underreporting of vitamin A supplementation as an issue and action to resolve this led to an increase in reporting from 24% to 52% within three quarters.
• In Bauchi State, reporting on postnatal care (PNC) services increased as a result of the scorecard use leading to a change of reported postnatal care coverage from 27% to 86% within two quarters.
• In Bauchi State, scorecard discussions highlighted a problem of misreporting of assisted deliveries in 14 of 20 local government areas. Action to resolve this problem led to an immediate reduction in misreporting in 7 local government areas.
• In Kano state, the scorecard use is credited for strengthening monthly data quality checks and improving reporting on antenatal care visits, immunisation and skilled birth attendance.

Advocacy and resource mobilisation (from local authorities and communities) for priority gaps

The scorecard facilitates the identification of performance bottlenecks and as such has been used to advocate for financial and non-financial resources from local and state authorities and from communities. Examples of successful advocacy and resource mobilisation include:

• The head of Ibarapa local government area (Oyo state), when shown poor performance of several indicators, approved the release of 2,000,000 naira (approximately US$4,500) to purchase drugs and other essential materials.
• In Niger state, the scorecard was successfully used for advocating to political leaders at the local government area level to increase resources for RMNCAH.
• In Ogun state, the scorecard was used to successfully advocate for more skilled birth attendants, leading to the state employing 60 midwives and 40 doctors to serve underperforming areas.
• In Kebbi state, the scorecard was used to highlight low coverage of immunisation and utilisation of antenatal care to state decision-makers and local government area chairmen. This led to immediate release 6,000,000 naira (approximately US$13,300) to implement primary health care activities in 21 affected local government areas.
• In Ibadan North local government area (Oyo state), the ward development committee mobilised the community to contribute funds to buy supplies to renovate a maternity block and facility compound found to be in poor condition.

Partner engagement to support priority gaps and monitor progress

The scorecards systematic, evidence-based approach to monitoring performance and identifying areas of need has been important for discussions with partners to support underperforming areas; including requesting existing partners to adjust their portfolios and illustrating priority needs to new partners. The scorecard is also used to track indicators of interest or other relevance to partners.

Because of this scorecard, partners are seeing that we have many issues, they come and help us, like Breakthrough Action Nigeria, IHP, they are doing a lot. They are giving our health workers skills and they are training them, and they are giving equipment for them especially for labour and delivery.

Health worker, Niger state

• In Kebbi state, the scorecard was used to illustrate priority needs and obtain support for areas within maternal and child health to partners such as ISP (the service arm delivery of USAID), the Health Women Management programme and philanthropists.
• In several states, the scorecards are used by special initiatives and partners including the MamaYe initiative and NGOs for the implementation of new strategies and programmes.
• The UNICEF-led Accelerated Action for Impact initiative has used the scorecard extensively to identify interventions that work and to monitor the initiatives achievements.

Conclusion

The above examples of successful use of the RMNCAH+N scorecard tool give a glimpse into improvements in service delivery and indicator performance, associated with the tool. These improvements have been mediated by a range of scorecard-triggered changes such as increased human resource availability and capacity, increased availability of supplies needed for quality healthcare, better patient experience and increased demand for services.

Partner and government support for the use of the scorecard has greatly enabled the successes of the tool. The ability to use the tool to effectively engage communities has further galvanised these successes. Stakeholders at national and subnational levels have recently identified areas for further strengthening and expanded use of the scorecard in order to enable its continued contribution to progress towards Nigeria’s RMNCAH+N goals.