January 2014

1. Subsidy Re-investment and Empowerment Programme (SURE-P) Maternal and Child Health (MCH) ProgrammeOverview of Conditional Cash Transfer Pilot Programme January 2014

2. Overview of the SURE-P Maternal and Child Health (MCH) Programme • The SURE-P objective is to mitigate the impact of the fuel subsidy reduction on vulnerable populations in Nigeria by initiating a robust social safety net programme to improve their lives • The MCH component aspires to contribute to the reduction of maternal, and newborn morbidity and mortality and increase maternal access to health services through two forms of intervention: • Supply side: providing primary health care (PHC) facilities with health workers, infrastructure upgrades, and commodities to enable sufficient and quality service delivery. • Demand side: providing conditional cash transfers (CCTs) to pregnant women in communities across the nation to encourage them to go through the full continuum of maternal, neonatal, and child health (MNCH) services. • The programme builds off the Midwives Service Scheme (MSS) of the National Primary Health Care Development Agency (NPHCDA), a parastatal of the Federal Ministry of Health.

3. % lost per step No. of women1 Antenatal visit 1 Antenatal visit 4 ~4% of women who attend one ANC visit go through the full continuum of care 64% 70% 62% Skilled attendant at birth Postnatal care Family Planning In Nigeria, very few pregnant women go through the full continuum of care Continuum of care 480,000 186,000 56,000 n/a 20,000 1 2009 figures SOURCE: MSS baseline report

4. The SURE-P MCH programme will build on the impact of MSS through supply and demand-side interventions along the continuum of care Recruitment Deploy-ment Training Payment Conditions Ident-ification Antenatal visit 1 Antenatal visit 4 Skilled attendant at birth Postnatal care Family Planning Supply Inputs Demand Inputs Continuum of care Human Resources for Health Conditional Cash Transfer • Midwives and CHWs recruited from school or unemploy-ment database, VHWs from commu-nities • Midwives and CHWs deployed after enrolment, VHWs deployed after training • All cadres receive a one-week training • Women who meet conditions are paid a set incentive value • Women are encour-aged to meet programme conditions (i.e. to access MCH services at PHCs) • Pregnant women in the community identified by VHW, CHW, or midwife SOURCE: PIU team

5. Hospital CHEWs CHEWs CHEWs VHWs VHWs CHEWs VHWs VHWs In the SURE-P cluster system, health workers are deployed to reach deeper into target communities with the help of ward development committees • WDCs play important roles in this system: • Ensure women are aware of the programme and receive its benefits • Monitor implementation within community • WDCs and health workers active in communities to refer women to PHCs • Hospitals key for providing services for complicated pregnancies and births WDC Client Client Midwives Midwives PHC PHC referral PHC PHC referral Client Client Midwives Midwives WDC SOURCE: MCH PIU

6. SURE-P MCH Demand Interventions (CCT) The overall goal of the CCT component of the SURE-P MCH Programme is to increase demand for basic MNCH services among pregnant women in the communities supported by this programme. Specifically, the programme objectives are to: • Reduce maternal and infant mortality by encouraging pregnant women to go through the full continuum of MNCH services, from their first ANC visit through to postnatal care for the newborn • Increase pregnant women’s welfare by providing them with cash support to reduce the impact of economic barriers to access to health services (e.g. transport to the PHC). SOURCE: MCH PIU

7. 1) N 1000 Amount (NGN) Registration + 1st ANC Disbursement Tranches ANC 2, 3 and 4 2) N 4000 Skilled attendant at birth Postnatal care + Immunization Family Planning Advice The SURE-P MCH Conditional Cash Transfer Programme is designed to encourage women to complete the continuum of care for MNCH services Continuum of care CCT Co-Responsibilities 1000 • There are four co-responsibilities in the CCT programme, spread sequentially over the continuum of care. • Beneficiaries are entitled up to N5000 cash support if they meet all 4 co-responsibilities, received in 2 disbursements. • Cash support to beneficiaries is pro-rated based on verification of co-responsibilities met. • Any CCT beneficiary referred to a SURE-P General Hospital at any point in the continuum of care receives free care, with all costs covered by the CCT programme. 1000 2000 1000 • As at the end of 2013, approximately 14,500 women had enrolled for the CCT Pilot Programme in 8 states and Federal Capital Territory (FCT).

8. mHealth and mobile money opportunities in CCT Mobile technology at different levels can improve our efficiency and patient care: SURE-P actions to expand CCT mHealth potential • Health workers can register patients and enter health records on tablet devices. In health facilities • Partneringwith Pathfinder International to make CommCare applications available for health workersand CHEWs. • Decision-making applications can tailor information to the beneficiary’s history. • CHEWs can use tablets to view and update beneficiary records on their visits, improving data completeness. In the community • Applications recording patient contact details can be used to send women appointmentreminders (to improve service uptake and retention) and health advice • Currently using ANC days and cash transfer days to provide supplementary mass health advice. • Hoping to leverage on Pathfinder collaboration to provide individual adviceand reminders. For beneficiaries • In development to be provided as part of Pathfinder collaboration. • Women can receive cash support by transfers to mobile wallets. Cash transfers

9. Plans for cash support using mobile money At present, the CCT Pilot Programme is distributing physical cash to beneficiaries • Cashier distribution is not sustainable for the programme, though it is perceived as more transparent by beneficiaries. • Mobile money transfers have lower overhead costs and fewer security issues than physical distribution of cash. • Challenges for mobile money: • Low financial inclusion and mobile penetration. • Relative unpopularityand low trust among women (>90% women in SURE-P pre-pilot opted for cashier disbursement). • Any mobile cash disbursement method must take this into account: • Use community-level structures (e.g. mobile agents) for women to access their funds. • Advocacy to build trust among beneficiaries. SOURCE: MCH PIU

10. mCCT: mHealthcollaboration with Pathfinder International Nigeria Pathfinder has developed CommCare applications for use in SURE-P CCT facilities • Pathfinder International Nigeria has been piloting a mHealth intervention, providing CHEWs with mobile phones equipped with a decision-making application. • SURE-P MCH is partnering with Pathfinder to make mHealth applications available in a selection of CCT facilities. • The decision-making application can be used in facilities and communities by health workers and CHEWs/VHWs. • Pathfinder are also developing a mobile payment application for use in the SURE-P CCT. • Linked beneficiarydatacan be drawn from HMIS records and CCT databases to create a unified CCT dashboard. • The collaboration is currently a pilot in Federal Capital Territory (FCT),which may be expanded to other SURE-P clusters later in 2014. SOURCE: MCH PIU; Pathfinder International

11. SURE-P MCH collaboration with CliniPAK Mobile Health Project SURE-P is joining a pilot NPHCDA collaboration with Qualcomm funded project • Provides Android tablet-based application to midwives in NPHCDA clinics. • The application is used for assessment, management and referral of pregnant women. • Application generates reports automatically, including: • ANC & Pregnancy Outcomes • Mortality & Morbidity • Immunizations • Referrals • Monthly Records of Growth Monitoring, Family Planning, ANC and Pregnancy Outcomes in District & LGA • NHIS & Area Council Monthly Summary Forms • Other stakeholders include: • Vecna Cares Charitable Trust [CliniPAK software] • Etisalat [subsidised/free data plans] • Evidence For Action [program M&E and reporting] • InStrat Global Health Solutions [project management] • The collaboration at pre-pilot stagein Federal Capital Territory (FCT),with the main pilot scheduled in three states for November 2014. SOURCE: MCH PIU; Pathfinder International

12. Thank You For Listening!