Hello listeners and welcome to the connecting citizens to science podcast.

I'm Dr.

Kim Ozano and together with a selection of co-hosts from around the world, we discuss

the ways in which people and communities connect with research and science.

We hear from patients and survivors, health workers, policy makers, scientists,

and implementing research organizations about the methods and approaches that

they apply to co-produced knowledge to address current global health challenges.

Thank you for listening and onto this week's episode.

Hello listeners, and welcome to the connecting citizens to science podcast.

This month series is all about improving the quality of antinatal and postnatal

care in Kenya, Nigeria, and Tanzania.

In this episode, we are going to be focusing on Nigeria.

Why Nigeria?

Well, Nigeria has one of the highest rates of maternal and

neonatal deaths in the world.

We know from episode one antinatal care and postnatal care can prevent,

identify and manage conditions that cause maternal and neonatal deaths.

However, a Nigeria based survey in 2018 revealed that only 43% of women had a

delivery with a skilled birth attendant.

What's interesting about this figure is that there are more

women attending antinatal care and postnatal care than ever before.

With up to 85% in one state yet when it comes to delivery, that percentage

is nearly halfed we will be discussing these differences throughout the episode.

And why antinatal care is a logical entry point for integration of services for that

continuum of care and integrating health services such as HIV, TB, and malaria.

But before we begin, let's welcome our co-host Lucy Nyaga welcome.

How are you today?

Thank you very much, Kim.

I'm well, thank you.

I hope you're well, too.

And I'm really happy to be here today, uh, together with our guests to speak really

about Nigeria and, uh, the topic of today.

Good day to our listeners, wherever they're listening

to us from across the globe.

And as you have heard, my name is Lucy Nyaga I am the country director Liverpool

School of Tropical Medicine in Kenya.

My background is medical anthropology and public health.

I have 20 years experience in implementing health programs, uh,

mostly in Eastern Africa with a special focus on maternal and newborn health.

In the course of my career, I've worked with a range of organizations

and stakeholders ranging from government ministries and departments

from academic institutions.

Research institutions, UN agencies, national and international and government

organizations, civil societies.

I've also had the privilege to work with really healthcare workers

at health facilities in the topic of maternal and newborn health.

And I'm really excited today to listen to, you know, the Nigeria bit and hear

how they are improving health of mothers and children and working to build the

capacity of healthcare workers in Nigeria.

Two states that will be focusing on today.

So it's really good to be here.

And, uh, I'm looking forward to this episode.

Thank you, Kim.

Thank you very much.

It's great to have you with us for this whole series as

well, we're all women today.

So let me introduce the other two wonderful women we will be speaking to.

We have Nafisatu Musa Isah who is a deputy director of family and community health

in Kauna state, within Nigeria and Dr.

Bunmi Ayinde who is director of public health in Oyo state, Ministry of

Health and both of our guests will be talking about quality improvement of

integrated HIV, TB, and malaria services in antinatal care and postnatal care.

So let's hear from our guests.

Nafisat Musa Isah tell us a bit about yourself.

hi Kim.

Um, my name is, uh, Nafisat Musa Isah.

I work with Kaduna State Primary Health Board , Deputy director, um, department

of family and community health services in charge of, uh, maternal and child

health division, uh, in Kaduna state uh, we have over 9 million people.

And up to 2.2 million women of childbearing age, we have up to 23 local

government area, uh, 255 wards up to 1,500 functional primary healthcare centers.

We have also 30 secondary facilities with five tertiary facilities I will

also have over 500 registered, private as well as faith based facilities.

Uh, as a deputy director in charge of maternal and childhood division, I oversee

the maternal and child health services across all, uh, primary healthcare

centers in the state in which quality improvement intervention is part of it.

Did you say 9 million people?

Yeah.

,We also have, it is very important for us to know that we have up to

2.5 million women of childbearing age

. That's incredible.

And, and you know, this particular intervention is basically concerned

with women of childbearing age, as well as children from zero to five years.

So when we are thinking about connecting with those 2.5 million

women, um, how do you normally work with communities in your role?

Always considering the need of the people and the community in terms of access

and availability of health facilities, and other social amenities that exist

within the people and the community.

We also considered existing opportunities, which can be used to mobilize people

and community to solve their problems such as type of food, crops, uh, that

is grown in the area, which we can use it to improve the nutritional

status of women and children.

We also consider the religion and the cultural norms of the people and

the community and each will determine what will be accepted by the people.

For example, uh, you know, in Muslim community, we don't accept, um, pork

meat and we know nutritionally it's a very good source of protein, but it,

that is not accepted in Muslim community.

And also another example is that in the Northern part of the country, we

don't really accept male to conduct deliveries, so it's those that those

are part of the cultures that we need to understand so that when are connecting

with people, we should be able to know what they are considering as important.

And we also need to consider the status or health seeking behaviors of

the people and the community, which could be either positive or negative.

Thanks.

Nafisat so you have to consider the culture, uh, people's behaviors.

So you must have to, mechanism, because things change over space or time and

situation as we've seen with COVID.

What functionality do you have to make sure that you're up to

date with community's needs?

Yeah, yeah, yeah.

For did we have a functional community structure, where, when we are connecting

with, um, with our communities, we need to, uh, call follow those, those

structures, uh, so that the community can be carried along in whatever

you are doing in the community.

Um, like in Kaduna, in each of the wards we have a ward development

committee, uh, that are oversee the entire, uh, activity of the ward in

regards to health related issues.

And, uh, within also do what we have community engagement focal persons,

that overseeing a, a lower structure of the community are members.

Those are the community volunteers that are the ones that have direct contact

with the people in the community and the function of those, community volunteers

is to constantly create demand in terms of maternal and child health

and as well, make referrals to closest the primary healthcare center where

they can be able to access services.

And if there are, if there is any information that we want to, um, pass to

the community that is from the facility.

Uh, the ward development committee add a link between the facility

as well as the community.

So we pass the information to the ward development committee and the information

will also be passed the community and if there are issues with the health facility,

Or any health related issues that, uh, the community wants the healthcare coworkers

or the government to, to know, and to be able to make, to, to have intervention,

the ward development committee members, uh, passes to the facility, uh, to the

local government as well as duty state so that, um, uh, intervention will

happen, uh, in that particular community.

So this is how the community operates, and this is how we link with the community.

And this is how the community links with the government.

That's fantastic.

And these community, uh, engagement or focal persons, do they tend to

stay in the role quite a long time or do you see that role changing?

When we are appointing, uh, any role in the community, we ensure that we always

select people that are staying within the community so that there won't be

much stress, there won't be much cost and they are willing to work because they

are working for their community members.

So the community engagement focused persons are selected, uh, people

within the ward that they are residing and they are doing their

intervention within that ward.

And they are part of the community.

That's great.

I understand the new program we're gonna hear about more,

uh, about that in a moment.

I know it's a lot about capacity strengthening.

Are these community health volunteers part of that process?

No.

Um, it's one of the gap that we have identified in this particular project.

There is one important component that we have missed in this intervention.

And we feel that that component is a very, is a very, very important

component where if we include that there will be more better impact,

um, on, this particular project.

We know that we must work with the community.

So even outside, um, the intervention, we were able to bring those community

members on board to be able to let them understand that this is what is happening.

At the end of the day, they will be the ones to give us feedback whether the

community are satisfied or not satisfied in regard to this particular intervention.

So we have, uh, included the community members, despite that the program has

not captured that, but we have tried as much as possible since we know

that we cannot work without community.

So we have to bring the community on board.

Wonderful.

Thank you very much.

So that's, Kaduna state, let's hear from Dr.

Bunmi about, uh, Oyo state.

Is that correct?

And how are you welcome to the podcast and tell us about yourself and where you work.

I am Dr.

Olubunmi Akinboye I'm a public health practitioner and I'm presently the

director of public health in Oyo state.

I have worked with Oyo state for about 15 years.

Presently.

I spent over 12 years as the HIV state coordinator in Oyo state, and I

coordinated malaria and TB, along with maternal and child health services.

All these activities included antenatal care for pregnant women and also

survival cancer screening for women of a reproductive age across the state.

My master's in public health was actually concerning maternal and

child health I provide evidence based people centered and sustained

healthcare service delivery to strengthen Oyo your state healthcare systems.

I lead cross functional teams to consistently meet with key states

and program indicators and program deliverables to ensure efficient,

affordable, accountable, and equitable way with full community participation.

When we provide our services in the states, we ensure that we carry

along the communities, the healthcare providers to ensure sustainability.

And we also look at health system strength on that global fund project.

I, I was also the health system strengthening coordinator in the states.

I've also led the implementation of this present project in collaboration

with Liverpool school of tropical.

And it was funded by global fund.

Also the services we actually provided across the state where we have 33

local government areas and we have 57 secondary healthcare facilities.

We have a lot of private facilities also, and we have over 700 primary healthcare

centers presently in the states.

Thanks Dr.

Bumi.

Um, so you've said that community participation is something that

you do, uh, in all of your work.

What does that look like in practice?

So we've heard about some, uh, committees in Kaduna.

Is there something similar in Oyo states?

We have ward development committees where you have meetings regularly on monthly

basis across these different communities.

And also when you are planning for a health program, key stakeholders

in the community are also part of your planning process.

For example, under this project, we have a QI team in the facility.

Where community members, that is faith based organizations like

Christian leaders, religious leaders, community leaders are also part

of quality improvement committee.

And this helps us with buy in of this program.

And it also helps increase the trust and these community leaders could also

advocate to other key stakeholders in the community to ensure that services are

being utilized, cultures, they invite new health cultures, and it also helps them

to build their health in the community and also strengthen their health and

their way of, um, thinking also changes to invite new, um, programs that are brought

to them that could actually improve the health of the community as we move along.

When you're engaging communities in different ways and gatekeepers

and leaders, we, uh, have to think about certain things so

that people can participate.

What are some of the considerations that you need to think about when

trying to get communities and people involved in the work you do?

For us in oil states, we look at so many issues.

The first and most important thing is ethical issues that binds the

relationship between we and the community.

We look at issues that come in play issues with trust issues and the ability

for the community to actually be able to participate and use appropriate technology

to imbibe what we are actually trying to implement at the different facilities.

Community participation is a form of feedback to the government to

know what exactly this facilities want, what they like, what is their

interest, what is their priority and what those governments need to do

to actually help and support them.

And we also look at issues of participatory culture.

We want them to participate.

We want the program to be a sustainable one.

We want the process of, um, sharing ideas and learning from each other.

You know, we don't always want it to be just feeding them in.

We want them to learn from us and we also want to learn from them, especially their

culture, their political inclination.

When we look at their political inclination, let me give an example.

If there are two communities in an area, and there is rivalry between

the communities and you want to put in a health facility and you put the

facility in one of the communities, the other side of the community will

not accept to use that facility.

So whatever health program you are bringing in will

not be utilized maximally.

So you want to know the culture, the political theory.

You want to carry them along in planning.

You want to also seek their consent.

Seeking their concept before we do any program is also very important because

we want to engage them with them.

And in engaging with them, we give them time to understand what we are bringing

in so that they could ask questions.

And in the process of asking questions, they believe in us, they're able to

trust in us and this bring transparency and trust, and it also impacts on

their needs and the action that we want them actually to take into cognisance

,it is also important to interact with the communities and health

workers before we actually start.

We need to see what the gatekeepers we need to talk to and at the end of

the day would realize that even these community members may advocate to other

community members, they can actually create support groups to help us build

the program and to help us ensure the success of what we are doing.

And at the end of the day, they would actually have improved health within the

community and they can actually change their way and outlook and outlook to

service delivery within the community.

So those are the things we look at as a state when we want to engage

with our different communities

Dr.Bunmi ,this is very, very impressive.

Um, a decision maker like yourself and a policy maker.

We don't always hear of these positions of, of power being

so participatory and inclusive.

Is, is that normal within the state within Nigeria or is that something that you

are passionate about and are trying to change from an organizational perspective?

It's two way for all programs.

I actually managed you need community participation.

Okay.

Like I've worked in HIV for over 12 years, and for you to be able to ensure people

living with HIV, buy into what you do, you pick them up from the planning stage.

We do the work plan together.

We do different services together.

You actually decide on where services would be.

Presently, we are talking about dispensing, um, drug

dispensers at the facility.

We are actually doing key informants interview with them to see their buy-in

and how it will affect their utilization when we are looking at issues of stigma.

So these are things that we normally do.

Like when we're talking about support group, we wanted to provide

support group within the community.

They didn't like it because people within the community would actually realize

that, oh, this is someone living with HIV.

And they may be stigmatized in as much as we are still trying to reduce

the stigma within the community.

But for them, we prefer the health facility support group.

So we discuss all the time.

And most of our meetings, like we have a TB, HIV and malaria working

group where we have community members, um, people from the different

communities, religious leaders, And they give them their own perspective.

And the truth about it is it's all these community leaders that

actually pay advocacy for us to ensure that these programs are

implemented at the community level.

So those are things we do routinely, and those are things that actually

help us to get into the community for maternal and child health.

We even work with the traditional, birth attendants to ensure that

the facility can reach out to these people, to do HIV tests.

syphilis screening and also we encourage the traditional birth attendants to

send their pregnant women for ultrasound scan it's interpreted and when there are

challenges, there are actually linked to the primary healthcare centers where

the work with healthcare providers.

We actually had a mapping of traditional bat attendance in the states, and

we are able to provide the mapping documents and with the traditional

birth attendants to ensure that we work together, we actually want to try to face

off the system over a period of time.

And in with this, we actually started sending their children to community

midwifery school through the local governments across the states and

the midwifery school is actually funded by the local government.

So we are hope they are expected to go back to that local government

work and it's under bond.

So they're going to work in those communities to ensure that

those systems are strengthened.

And in that kind of process, we had advocacy meetings with them.

They accepted the process.

We started sending their children to school and they're actually looking at

it that those children would actually be better healthcare providers in

their different communities instead of actually doing their, so they will just

be there and the children will take over their services as they grow older.

Those are things that we are trying to look at, and it helps us to

be able to engage closely with communities to ensure the success

of different activities and programs

So now I'll then, uh, move over to the project.

I think we've had quite a bit in terms of yourselves and also in terms of connecting

the work that you do with the community.

So I will now specifically move on to the global funded, project specific questions.

Uh, I'll start with, uh, Dr.

Bunmi to just give us an overview by telling us about the situation of

antinatal care and postnatal care in your facilities prior to the introduction

of this, global funded program and, uh, what the situation is now based on your

experience and involvement in the program.

The program of quality improvement with the integration of HIV, TB, and malaria

into antinatal care and postnatal care services started in Oyo state in year

2020, and when it started in state, we had an entry process which included

advocacy to key stakeholders, key gatekeepers at the primary healthcare

level, at the secondary healthcare level and at the ministry level, this was then

followed by selection of 60 healthcare facilities, which included secondary

healthcare, primary healthcare service centers and also private facilities.

This were selected across the local government of the state.

And this facilities had healthcare providers who were actually trained

on antinatal care, postnatal care, and quality improvement and over the

time, each of them were to set up the quality improvement team across their

different facility, using standard audits.

The standard audits were to evaluate the impact of their services,

really not impact, but to evaluate improvement in service delivery.

There were facilitators that were trained, who are from this state and

they presently exist in the state.

And these facilitators are able to expand services to train other

people, to ensure that these services would actually be able to continue.

We have review meetings quarterly.

Not regular, but we also, the facilities also have multi qu quality improvement

meetings because they've all had their quality improvement team in place, which

ex consist of about six to 10 people.

And we have heads of different units across the hospital and

also community members at part of that quality improvement team.

When the services started in OYO state, we actually had challenges with

antinatal care, syphilis screening was very low at the facility level.

Most facilities, we are not conducting postnatal care for their women.

After delivery, those women go home.

We actually have challenges with delivery.

Women attend antenatal care or do not deliver in the facility.

That's also a challenge.

Waiting time was long and equipment, we are not adequate

in the different facilities to ensure efficiency of services.

Malaria testing, antinatal care was actually low.

And then intermittent preventive therapy for the prevention of malaria was also

there, but it was also low and most women would not even complete it because

the register for antinatal care leads and they would just be able to get one

or two doses of the malaria prevention.

But over time, we realized that there was change in quality of care and

there were improvements over time.

I used data comparing it from January to June, 2020, that's the first two

quarters of the year, comparing it with the data of January to June for year 2022.

For postnatal clinic at that time, We had only about 9,000

women doing postnatal care.

Presently we have 42,000 women actually attending two postnatal

care services within six weeks.

For HIV testing in antinatal clinic.

Then we were testing about 90% of our women.

We had 51,000 then and presently we have over 57,000 women being tested,

which is about 97 to 98% of the women being tested, which is actually higher

than the UN aids, 95 targets, which we are hoping to achieve in 2025.

So with this, we would see that quality of care has improved standard

of service delivery has improved.

Postnatal care has actually been put in place and its institutionalized.

And before six weeks they have two visits and most importantly, respectful

antinatal care has been put in place by improving the waiting area.

I know you are both in two different locations, Nafisat picture pin for us, a

picture of, um, how it was before, the introduction of the program and how it

is now over to Nafisat for Kaduna state

The impact we are seeing since the inception of this intervention is that

now we have, uh, 15 master trainers on quality improvement and we also

have 29 on antenatal and postnatal integration which we feel they have

capacity to cascade this training to healthcare workers within the state.

We have also seen that in some of the secondary facilities where having cesarean

section women are now counselled and they know the reason and the implication

of the, their future pregnancies and we also have now equipments available

in the implementing facilities where it is, um, the health workers

in providing the quality services.

Based on our indicators, we have seen women coming for antenatal with their

babies within seventy two hours of birth have increased from 29 in

2020 to 82% in 2022, where there is remarkable increment in that regard.

We have also seen there is increase in the object of postpartum family planning,

from 11% in 2020 to 28% in 2022.

So these are the remarkable in increase, based on our indicators from our

administrative data in Kaduna state.

I think it's clear that, uh, we can see the changes that have happened

across the last two years with the figures to support that kind of change.

H ow does that relate to The community, basically, because, the healthcare

worker who the program takes care of, but then we see more people coming in.

Some of the major, um, reason is that, the healthcare workers now have the

capacity, improve capacity to be able to provide quality services during

antenatal as well as during postnatal.

And also there's also room for integration of services, initially we don't screen

women for, uh, malaria during booking, but with this intervention, and with

the capacity of healthcare workers, now they know that they are supposed to

screen women for malaria as well as other diseases such as Syphilis and orders and

that has really improved our indice s and also with the capacity of healthcare

workers now, we have seen that initially they don't have much skills and they don't

even pay much attention in monitoring of pregnant women during labor.

We're able to see that the women are now satisfied because exit interview

has been conducted after this particular intervention and we have seen that based

on the result of the exit interview, women are now getting satisfied with what the

healthcare workers are providing to them.

Once there is satisfaction, they will come to the facility and they can as

well influence others to also come to the facility to access services.

Wow.

That's impressive.

What I hear, you know, from Nafisat and from, uh, Dr.

Bumi is that the training of the healthcare workers knowledge, led to

their change in their attitude and then the other aspect, I think, is that,

uh, very, um, integrated community participation, that structured system,

uh, such that then, uh, the community itself, you know, sees, uh, that change.

The training has brought a change, uh, maybe because of the confidence of the

healthcare worker, when they have, uh, had the skills and therefore everything

snowballs and, uh, goes back to really what the program wants to do, have an

impact on the mothers and the child.

And it sounds really Rossy and nice, but I do think I'm sure there's

always, you know, room for improving and room for making more impact.

Cause we are not, you know, we can say our indicators are up there.

Uh, what more can this program do you know, in this context to have

even greater impact than what, uh, what you've just mentioned now?

I think I have mentioned some of the challenges as one number,

one major challenge that we have identified is that we have omitted,

um, involving or inclusion of the community from the initial state.

But we are able to mitigate that and know that yes, going forward, that if we

would be able to involve the community, they have a greater over making the

impact to have more achievement.

Also there was a little challenge in regard to formation Of care teams you

know, we have to include the community.

So that has became a challenge because we are not able to, uh, involve

the community at the initial state.

Since we know we must work with the community, so we had to

bring the community on board.

So there was a little.

In in for us to be able to set up those quality improvement teams,

because we have to bring the community on board so that they can

be able to also be part of the team.

There is also a challenge of having not having adequate supportive

supervision, uh, whereby you know, to train the healthcare workers,

you don't just leave them like that.

You need to be following them to be seen what they are.

To be mentoring in some, at some in.

To be also coaching at some instances.

So there was that, um, gap where we feel that we need to, uh, make it possible

for us to be having quarterly supportive supervision so that we'll be mentoring

and see how our healthcare care workers are linking themselves with the, with

the women and also linking themselves with the community to ensure that

they are given the best to the women.

To further increase the impact of this program?

Yes.

We've trained facilitators in the states who can actually help

in expansion across facilities.

We also need to put in place a mentorship program.

If there is a mentorship program, it helps for sustainability and it

helps the program to move on forward.

Then with the community engagement.

We need to create more awareness on the importance of antinatal service delivery

and we need to ensure male involvement in our antenatal care services, because they

are the ones that can take decision within the community and within their families.

Then if we have a program in which facilities can learn from each other,

like where facilities can learn from each other, they put in best practices

and they interact with each other and learn that kind of program would

actually put in competition into the facility system and help to improve

the system and the programming and give more impact to the program apart.

Expanding services there's always room for expansion of services,

but those things can actually help.

And for us in EO state, presently, we are actually looking at how can

quality improvement services be involved in all health programs.

This would actually help in improving all our indicators.

And we can also look at building a mechanism for cross facility consultation,

sharing of experience, and this would help improve service delivery.

And then we should remember that antenatal care is the entry

into the continuum of care.

Building capacity of healthcare workers alone would not be

able to sustain this process.

Okay.

Thank you very much.

We are working very limited number programs are really limited and they're

working in a limited number of facilities.

They cannot cover all, but what NAAT said and by extension also, Dr.

Bui indicated, you know, what, what the lessons we are learning

from implementing these.

They're not just staying within those facilities that we are working on

they're going, uh, into guidelines into the, you know, the health

information systems of the states.

So I think this is really encouraging for sustainability.

Really because we know programs only run for a specific time and they

will be through, within no time.

So I, I, if I got it right, I hear a lot of, uh, integrating the program

interventions, but also taking them to higher level into the guidelines and

the health systems, uh, like including indicators in state systems as

a way to ensure that there's that sustainability so great but I'll

stop there and and over back to Kim.

Thanks very much.

So we have a lot of listeners that are, uh, maybe new to working in this field

or, or early career, uh, possibly as well.

So, Dr.

Bunmi, what advice do you have for them?

Those working in research and working with communities needs to actually

understand the complexities of the research work and of the communities

and understanding the complexity of the problem within the community.

With this, they would be able to have better decision making and these

facilities would actually be able to accept their services better.

That is one of the issues that we need to communicate in ways that

communitywill actually understand.

Then when we want to use examples, we use examples with pictures that

are for the community to understand.

We also need to embrace open access.

The community should have open access to us.

We have a lot of researchers that listen to this podcast and scientists, and they

want to understand what they need to do to connect with communities better.

What advice would you give to them?

For us to be able to connect with, uh, with the communities, uh, and the people

we need to understand the need of our people, the community, and, um, where we

work and plan towards provider services that is accessible, affordable and

available using client centered approach because we are always concerned in

provider services that is needed by the client based on what she has presented.

We also need to employ multiple options and strategies on how

to better connect with people.

So as to understand what they need.

Finally, researchers needs to know where we are and what do we need to be done

to improve the status of health service delivery in our communities most, most,

especially with focus to improving the health of women and children,

meaning that we need to measure the level and the impact of implementation

in various communities, be able to know the gaps of implementation and

be able to know the area of interest so that we can work towards the

interest of the people so that they can have what they're expected to have.

So that at the end of the day, we can improve the health indices of the people

within that community, and try as much as possible to eliminate harmful traditional

practices within the community.

Thank.

Thanks very much.

Um, some wonderful insights there and, and thank you for sharing those.

So I think that's a perfect place to wrap up today's episode.

So a big thank you to our guests for really painting a picture for us about

this wonderful program and, and how you connect with communities and such a

structured and a thought through manner.

Thank you to our co-host Lucy for bringing her own insights

to this discussion as well.

And as always, thank you to our listeners.

These voices are really important.

The voices of decision makers of patients of the public, of our

co-host are really important.

So do like share and subscribe, and that's how you can support

this initiative to move forward.

Thank you and goodbye for this episode.

Goodbye.

Thank you, Kim.