DFID CNTR: A. SLGP Consultants Report Number 817 (Original Number 368)

Transcription

1 DFID CNTR: A SLGP Consultants Report Number 817 (Original Number 368) Institutional Support to the Jigawa State Ministry of Health Issue Based Project: Water Supplies in Health Facilities by Muslim Idris vember 2006 Table of Contents 1.0 SUMMARY INTRODUCTION THE PROCESS ASSESSMENT OF THE ASSIGNMENT Outcome Logical Framework Institutional Strengthening Training and Tools Synergy with PATHS WATER ANALYSIS Water Demand and Supply Power Supply BUDGET Variance in 2006 Budget MANAGEMENT STRATEGY Water System Operators Hospital Management Committee Ministry of Health Budget Preparation And Implementation RECOMMENDATIONS List of Annexes Annex 1 Annex 2 Annex 3 Annex 4 Annex 5 Annex 6 Annex 7 Terms of Reference Agreed Logframe Action Plan Strengths and Weaknesses Summary of Facility Conditions Maintenance (Roles and Responsibilities) National and Jigawa State Water Supply And Sanitation Policies SLGP Consultants Report Number 817 1

2 List of Tables Table 1: Health Facilities in Jigawa State...4 Table 2: Water Demand Analysis...12 Table 3: Overhead Cash Ceilings Table 4: Overhead Disbursement...15 Table 5: Variance Assessment...16 Table 6: Total Disbursement to SMOH for Table 7: Cash Ceilings List of Abbreviations and Acronyms DFID - Department for International Development DRF - Drug Revolving Fund EU - European Union HC - Honourable Commissioner HMC - Health Management Committee HoS - Head of Service HSDP - Health Sector Development Project (World Bank) IBP - Issue Based Programme IGR - Internally Generated Revenue JUWASS - Jigawa State Urban Water Supply and Sanitation (DFID) MDG - Millennium Development Goals MoU - Memorandum of Understanding O & M - Operation and Maintenance PATHS - Partnership in Transforming Health System (DFID) PHC - Primary Health Care PS - Permanent Secretary SLGP - State and Local Government Programme (DFID) SMOBEP - State Ministry of Budget and Economic Planning SMOH - State Ministry of Health SMOLG - State Ministry of Local Government and Chieftaincy Affairs SMWR - State Ministry of Water Resources SRIP - Support to Reforming Institutions Programme (EU) SWB - State Water Board WSSSRP - Water Sector Supply and Sanitation Reform Programme (EU) Acknowledgement The consultant acknowledges support from the SLGP Programme Manager, Mr. Mark Walker, Auwalu Hamza, SLGP Programme Officer, and all the staff within the DFID-SLGP Office. Particular thanks also go to Dr Said Ahmed and Mr. Vincent of the DFID-PATHS programme in Jigawa State. The consultant also acknowledges the support and dedication of the State Ministry of Health, particularly the Honourable Commissioner, Permanent Secretary, Directors, Deputy Directors and all staff of the SMOH and its 22 health facilities. The consultant also recognises the support and assistance of the Permanent Secretary and all staff of the Budget and Economic Planning Ministry, the Honourable Commissioner Ministry of Water Resources and his staff as well as all lead consultants working with PATHS, SLGP, SMOH and SMWR. The participation and contribution from the State Water Board and communities in Jigawa State has also been welcome and productive. SLGP Consultants Report Number 817 2

3 1.0 SUMMARY The Jigawa State Ministry of Health (SMOH) manages twenty two health facilities including hospitals, clinics, cottage hospitals and primary health centres. The State and Local Government Programme (SLGP) has worked with SMOH to ensure the provision of safe clean water for staff, patients and patient s relatives at ten of these facilities, at Babura, Bulangu, Dutse, Gumel, Gwaram, Kazaure, Kaffin Hausa, Kiyawa, Mallam Madori and Roni. In accordance with the findings of the institutional design phase (July 2005), an institutions specialist was engaged for 143 days to support SMOH in water supply system operation and maintenance. Engineering works were completed, including the drilling of boreholes, installation of pumps, construction and rehabilitation of tanks. The emphasis of this institutional support assignment was to ensure the adoption of processes and procedures that would ensure the ongoing operation, maintenance and repairs necessary for sustainability in the water supplies. The objectives included: a) to develop suitable managerial tools that will strengthen the management of the water infrastructure; b) to ensure that a mechanism is in place for training of staff in operation and maintenance; and c) to continue the partnership with other DFID projects, including PATHS. In accordance with the Terms of Reference, and in order to achieve the objectives, the consultant visited sites, consulted with stakeholders, collected and analysed data, provided on site operation and maintenance support, provided direct training to operators, and ensured the development of institutional linkages between stakeholder agencies. This report therefore presents the outputs of the assignment, centring on an assessment of strengths and weaknesses, an assessment of the Logical Framework, training and tools, water demand analysis, budgetary assessment, institutional linkages and recommendations concerning a long term management strategy and monitoring processes As a result of this assignment, operators have been identified and trained in all ten facilities, health management committees have been empowered to manage operation, maintenance and repairs, log books have been institutionalised to support monitoring of water systems and generators, facility based budgets have provided an input to the 2007 budget, a Round Table on Health has been established and SMOH has instituted a management forum. All facilities are operating, maintaining and repairing their water supply systems. Wider lessons have been learnt by SMOH, who wish to scale up across all 22 health facilities in Jigawa State. Other Ministries, Departments and Agencies wish to learn from the lessons on contracting, due process, and operation and maintenance. SLGP Consultants Report Number 817 3

4 In the long run, SMOH and the facilities still need to improve institutional links (for example, with the State Water Board), ensure the continuation of the Round Table on Health, improve internally generated revenue, and ensure effective monitoring and evaluation. 2.0 INTRODUCTION In March 2001, Jigawa State established the Bureau for State and Local Government Reform. The Bureau is charged with responsibility for pushing forward governance reform in the state and is chaired by the Deputy Governor. The work of the Bureau is currently supported by the State and Local Government Programme (SLGP). SLGP is a UK-DFID financed programme that aims to support the effective pro-poor state and Local government in Nigeria. The purpose of the programme is to enhance the capacity and effectiveness of state and local government to formulate policy, manage resources and support service delivery in the interests of the poor people. The Jigawa Ministry of Health (SMOH) operates 22 health facilities including general hospitals, cottage hospitals and primary health centres as shown in Table 1. SLGP supported an Issue Based Project (IBP) with SMOH to provide water supply systems to ten facilities. The IBP is working with the State Ministry of Health to ensure that the staff and patients at these facilities have sustainable reliable access to safe water. The IBP was designed to enhance the capacity and effectiveness of SMOH to deliver services in the interests of poor people particularly the provision off safe clean water. Table 1: Health Facilities in Jigawa State General Hospitals Cottage Hospitals Primary Health Centres Dutse Gumel Hadejia Kazaure Babura Ringim Jahun Birnin Kudua Kaffin Hausa Bulangu Gwaram Birniwa Gwaram Basirka Sagu Kiyawa Mallam Madouri Garki Taura Roni Galambi Yankwashi Under the IBP programme, upgrading of water facilities has been completed at all ten facilities. The work included the drilling and rehabilitation of tube wells and boreholes, provision of new pumps, repairs and provision of new tanks, minor reticulation to standpipes and provision of new standpipes. The institutional support assignment was designed to ensure that: The infrastructure is put in place and running successfully There is capacity building for effective management of the infrastructure Budgetary allocations for effective operation and maintenance are made and implemented Water supply demand analysis and policy formulation is put in place Synergy with other initiatives such as PATHS is maintained and strengthened Monitoring and evaluation is put in place SLGP Consultants Report Number 817 4

5 Long term measures for effective management are developed and recommended There are ongoing programmes under SMOH, particularly those supported by PATHS, to upgrade selected hospital buildings, including the internal water facilities and sanitation, and additional work in the rehabilitation of laboratories, theatres and maternity wards. The outcomes of this institutional support assignment have clear relevance to this work in terms of ongoing operation and maintenance post rehabilitation. The Terms of Reference to the assignment are provided in Annex 1 and this report covers the activities of the Institutional Specialist in the period 15 th May to 30 th vember THE PROCESS A process approach was adopted in achieving the Terms of Reference. In particular, this included: Development of a close working relationship with SLGP, SMOH, PATHS and the Project Engineer Development of an Action Plan for achieving objectives Careful examination and discussion of the Logical Framework Documenting, evaluating and analysis of data collected Frequent visits to sites to confirm the present position, determine next steps, and to train the operators in the operation and maintenance of the systems Capacitating the Hospital Management Team, operators and communities on existing conditions, operation and maintenance requirements and the way forward Providing technical support Developing institutional links between stakeholders, including the State Ministry of Water Resources and the Jigawa State Water Board, and the Ministry of Budget and Economic Planning, Ministry of Local Government, as well as communities and community leaders Developing a Memorandum of Understanding between stakeholders for effective operation and maintenance of facilities Monthly progress reporting Data collected included the following: Agreed Logical Framework SLGP report Development of Effective Management of Health Infrastructure in Jigawa State PATHS reports including Institutional Analysis ; Safe Motherhood ; Drug Revolving Fund ; Health Management Information System ; Stewardship Minutes of the Round Table meetings Minutes of Health Management Committee meetings Strategic plan for the Health Sector in Jigawa State with PATHS and CAP collaboration. Water demand analysis and policy issues of the centres Budget, actual allocations and variance assessment for the facilities Detailed borehole drilling reports and engineering drawings Logbook records on the operation and maintenance of water supply systems and generators SLGP Consultants Report Number 817 5

6 4.0 ASSESSMENT OF THE ASSIGNMENT 4.1 Outcome The key outcomes as a result of this assignment are: Water supply systems in all ten facilities are functional, and they are being operated, maintained and repaired. Staff, patients and patients relatives have access to safe clean water. Operators and some key management staff have been trained in effective operation and maintenance, sanitation and budget preparation (with support from PATHS). Monitoring has been institutionalised with the provision of logbooks that record essential data on generator operation, borehole operation and water consumption. The Hospital Management Committees (HMC) in the respective facilities are effectively functioning with collaboration with communities Technical problems relating to electrical and plumbing works have been addressed, partly by ensuring an effective link with the State Water Board. Sanitation in the facilities has been improved. The 2007 budget for the State Ministry of Health has been prepared, using facility based submissions from each facility. Budget lines for the operation and maintenance of generators and water supply systems have been maintained and enhanced. The principle of change has been introduced to all other facilities managed by SMOH in Jigawa State, and SMOH is interested and committed to rolling out lessons learnt in contracting, due process, operation and maintenance. The Round Table on Health has been restored with an expanded membership comprising SMOH, Ministry of Budget and Economic Planning, PATHS, SLGP, SRIP, WSSSRP, State Water Board, and the Ministry of Local Government. Permanent Secretary, SMOH chairs the meetings. Four productive meetings have been held since May 2006, with minutes produced and circulated by SMOH. The State Ministry of Health has adopted the due process mechanisms including tendering and contracting for other capital projects being implemented, including those financed by the World Bank HSDP II project. 4.2 Logical Framework A separate Logical Framework was prepared for the IBP to guide design and implementation. The Logical Framework takes account of both engineering and institutional objectives, and is given in Annex 2. Key elements include: Infrastructure in place and running successfully Capacity building for effective infrastructure management Budgetary allocation for operation and maintenance Water supply and demand analysis, and policy formulation Synergy with PATHS Monitoring and evaluation Long term measures for effective facility management SLGP Consultants Report Number 817 6

7 At the initiation of the institutional support assignment, engineering and infrastructure works were near completion, but little had been achieved in the area of institutional change for effective operation and maintenance. An assessment of strengths and weaknesses was therefore made as a basis for developing an action plan for development. Annex 3 provides this Action Plan, whilst Annex 4 presents a summary of strengths and weaknesses, and Annex 5 indicates the condition of each facility at the end of the assignment. Key elements within the agreed log frame have been successfully achieved, and all outputs attained, with the exception of budget implementation. There has been a lack of political will or a supporting policy environment to ensure budget implementation, leading to an ineffective delivery of services to and from health facilities. To this end, a policy towards effective budget implementation with strong political support is needed to achieve budget discipline. This needs to be achieved with the support of all stakeholders (especially the Traditional Institutions, Legislators and the Donor Partners). 4.3 Institutional Strengthening The institutional requirement for operation and maintenance is focused on the operators, Hospital Management Committees (HMC), communities, and SMOH management. In order to strengthen institutional linkages, roles and responsibilities have been drawn up from the community level through the HMC to the SMOH to ensure that the facilities put in place are well manned and sustained. Roles and responsibilities are given in Annex 6. The Hospital Management Committees for each facility comprises about ten members, including the heads of departments within the facility, community representatives, the Hospital Secretary, and chaired by the Doctor or Officer in Charge of the facility. The committee meets monthly unless there is an urgent need for a meeting. Minutes are prepared and copied to SMOH. The institutional support assignment was able to strengthen linkages between stakeholders in the HMCs, including the signing of a Memorandum of Understanding with the Jigawa State Water Board in respect of Gumel General Hospital. The institutional support assignment was also able to capacitate the HMCs to meet regularly, minute its meetings, and forward minutes to relevant stakeholders. Cognisance was taken of an impending institutional change being supported by PATHS this is the formation of a larger institutional structure comprising a number (commonly three) of local governments to provide for effective management of health facilities. Staff shortages will be addressed through this forum, referred to as a Gunduma, which brings together the responsibilities of the State Ministries of Health and Local Government. As well as the operation of water supplies, sanitation issues were addressed. Sanitation Officers from SMOH participated in meetings on water projects for effective coordination and collaboration with Development Partners. A mock review meeting was held in Ringim on 24 th August 2006 to share ideas on issues relating to policy, and experiences on current works under the Ministry of Water Resources and its parastatals, UNICEF, DFID-JUWASS, DFID-SLGP (IBP) and WATERAID. The following Case Studies illustrate the impact of institutional strengthening at various facilities. SLGP Consultants Report Number 817 7

8 1. Roni Primary Health Centre The Roni facility is located adjacent to community settlements and has no fencing. The borehole, storage tank and one standpipe are close to the community, out of sight of the health centre. As there is no fence, community members have taken advantage of the availability of water, but have not paid attention to looking after the standpipe, and have not participated in the smooth running of the water system. Roni Primary Health Centre was incurring all costs of operation, maintenance, and frequent repairs as a result of misuse of the system. Facility management, community leaders and the District Head of Roni came together to agree on roles and responsibilities, and to agree on how they could collaborate to run and sustain the system effectively. The community is now participating in operation and maintenance, and the system is running smoothly. 2. Dutse General Hospital Despite being the State Capital, Dutse General Hospital never had a water supply system until the IBP over a period of ten years, the hospital had depended on buying in water from water sellers in the town, adding a burden to already stretched overhead budgets. The IBP was able to provide a borehole, pumps and water tanks. However, with the provision of water, numerous other bottlenecks came to light. Generator sets were in poor condition or of inappropriate size, fuel was scarce, and there was a very high water demand. Despite the bottlenecks, the Hospital Management Committee recognised the importance of the water scheme, and moved to operate, maintain and repair the system. In October 2006, poor power supply led to the burning out of the submersible pump. Replacement was the only option, and within two weeks, the Management Committee purchased a submersible pump and carried out borehole repairs worth over N 70, They have proven their ability to manage the system, and have now also connected piped water to the laboratory, theatre and maternity wards. They have also adopted a drive to improve internally generated revenue. SLGP Consultants Report Number 817 8

9 3. Bulangu and Kaffin Hausa Cottage Hospitals These facilities had been enjoying the water supply for almost three months when suddenly the bore holes developed a problem. On assessment, it was noted that the pumps had, like that of Dutse, burnt out and required replacement power supply was the likely cause. Facility management recognised the importance of the water supply, and staff, patients and relatives were all demanding water. Facility management procured new pumps in each case, and collaborated with the State Water Board for their installation. Both facilities now intend exploring revenue generation through water sales to provide an income to support operation, maintenance and repairs. A permanent institutional link with the State Water Board is being put in place. SMOH, recognising the issue over power supply, has incorporated rational generator provision for health facilities under the World Bank Health Sector Development Project II. 4. Gumel General Hospital The IBP intervention rehabilitated tanks and established an independent tank purely for hospital use. All other water supply equipment (including the borehole) at the site is owned and operated by the State Water Board, and the old tank is linked to the town water supply as well as the hospital. Gumel General Hospital and the State Water Board came together to define a Memorandum of Understanding on the co-ownership and management of the infrastructure the hospital would provide diesel and a generator to power the borehole, whilst the Water Board would participate in maintenance and repairs, and provide technical advice. Water Board operated stop taps on the pipelines would only be adjusted in consultation with the hospital. A major water beneficiary in the form of the nearby school joined the partnership as a contributor for maintenance and repair costs. The Hospital Management Committee is also in the process of finalising a water selling project the plan is to install a series of taps at the main gate, allocate a member of staff to operate the taps and receive income, and to sell water to water sellers. Private individuals collecting small amounts of water for personal use would be able to do so free the hospital will only target those who are on-selling water in the nearby communities. The service and maintenance of the generating sets, water structures and others infrastructure in the facilities has improved, making the facility environment cleaner and more conducive to health care. Communication links with other stakeholders especially the SMOH with the facilities were weak as there was no proper record keeping, no linkages through electronic medium and no effective administrative procedure to enhance good operation and maintenance. Communication links have been improved as a result of the assignment. SLGP Consultants Report Number 817 9

10 Manuals on roles and responsibilities provided to the facilities did not carry the communities along and had been improved through the review of the roles and responsibilities to ensure that the communities participate and management is strengthened to understand the manual for effective service delivery. Over head returns to the SMOH were lacking from the facilities, this had been addressed as return copies are now sent to the Ministry. The Sanitary Officers through training and sensitisation have improved the facility environment through proper disposal of waste by ensuring that proper disposal method is applied in the facilities. This has led to the construction of V.I.P Latrines, incinerators and pits in facilities. 4.4 Training and Tools Prior to the IBP, operators only had experience with generators. Their knowledge of water facility operation and maintenance was minimal. All operators were therefore given on the job training during the construction, installation, plumbing and electrical works. The operators can now carry out simple day to day checks, operation and repairs on the water supply systems. A plumbing and electrical tool kit was provided to each facility. The following provides an overview of training provided and mechanisms instituted to ensure effective operation and maintenance. Operators identified and named (as per Annex 7), on-the-job training provided along with toolkits. Logbook format created, tested, improved, printed and provided to all facilities/operators, and operators trained in its completion and utility. Budget Process Workshop supported by PATHS held for Secretaries and Accountants of all health facilities in the basic budget process, and the preparation of budgets which take account of operation and maintenance requirements. Agreement made between the State Water Board and health facilities had been reached to ensure sustenance of the water supply in the facilities through on the job retraining, Round Table meetings and Memorandums of Understanding. Zonal Water Board Officers will be appointed to each health facility to provide technical advice and training support. 4.5 Synergy with PATHS DFID-PATHS in its effort to improve health service delivery has carried out various reforms, including rehabilitation works (laboratory, theatre and maternity wards) in sixteen facilities nine have been completed and handed over. PATHS have also provided extensive support to improving the administrative and financial process of SMOH and its facilities as summarised in the following paragraphs. SLGP Consultants Report Number

11 Strategic Plan for the Health Sector in Jigawa State: The strategic plan identifies key policies and institutional reforms for the health sector. Overall objectives include 1) Creation of the right enabling environment for health sector reform; 2) Improve the delivery of health services; 3) Develop resource mobilisation and planning for equitable services; 4) Develop a sector-wide approach to health and health care; and 5) Logical framework. Facility improvement, including provision and rehabilitation of water supply is included in the strategic plan, but operation and maintenance does not feature prominently. Integrated and Decentralised Health System: Agreement has now been reached to implement the Gunduma structure that will harmonise the staff of the Local Government Areas with SMOH for effective management, and to remove bottlenecks in the smooth running of the facilities. This will address the problem of staff deficiencies and improve the institutional strengthening of the two Ministries. Staff reorientation will be required to meet the new challenges, whilst it is unclear how dual responsibilities and leadership within two Ministries will operate. Training, capacity development and support to strengthening relationships will be required for the Hospital Management Committees (which play a vital role in facility operation and maintenance) to relate to the Guduma structure. Running costs for the first six months of the Gundumas have not included lines on operation and maintenance. Board members may also need technical/ engineering advice and guidance. Strengthening Supervision and Mentoring Skills: A series of checklists have been proposed to support accountability in equipment management. The operation, maintenance and control of drugs, buildings and other infrastructure are included, and the checklists can support the operation and maintenance of water supply infrastructure and associate equipment such as the generators. Budget Process: A PATHS consultancy reviewed the budget process in SMOH. The report identifies budgetary proposals, approvals, disbursements, returns and internally generated revenues of the SMOH and its respective centres. Poor coordination and accountability to the Ministry by the Health Facilities is noted. In many cases, they do not report to the Ministry on expenditure or revenue generated however, PATHS have provided training and reporting is improving. Also the basis for over head sharing were politically based rather than determined on the facility or the number of beds. The report recommended a formula for overhead sharing to the centres, and the need for analysis and feedback. PATHS have developed the capacity of the SMOH Budget Team by providing training and computers, and report formats for revenue and expenditure. 5.0 WATER ANALYSIS 5.1 Water Demand and Supply The National Policy on Water Supply and Sanitation clearly provides for the distribution of water to different categories of population: Urban Areas: litres per person per day Semi Urban/Small Towns: litres per person per day Rural Areas: litres per person per day This includes all loses, industrial, domestic and commercial uses for every individual. If these principles are applied to the health facilities and on bases of the population of the health facilities, the average water demand by facility is shown in Table 2. SLGP Consultants Report Number

12 Table 2: Water Demand Analysis Facility Consumers per day (A) Consumption per person per day (l) (B) Total water demand per day (l) (C) Add 30% losses (D= C + 30%) Borehole yield per day of 6hrs pumping (l) Water surplus /deficit per day (F=E-D) (E) BABURA ,780 16,614 33,600 16,986 BULANGU ,708 36,000 29,292 DUTSE ,925 36,000 (83,925) GUMEL , ,000 10,800 GWARAM ,826 36,000 15,174 KAZAURE ,620 2,400 (98,220) K/HAUSA ,800 30,275 KIYAWA ,600 9,090 M/MADORI ,400 27,330 RONI , Thus, in eight facilities, there is a surplus to demand. In two facilities, a deficit remains. The deficit in water demand in Dutse and Kazaure clearly shows that water commercialisation would be a problem as there is no surplus to commercialise. The facilities with surplus could commercialise if the political will and support is given especially when the State is still receiving 50 Naira by month per house hold with the pipe borne system. In Kiyawa as a case study, water supply is free as the political representative supplies the fuel, carries out the service and in some places provides replacement pumps when they are burnt. It should be noted that most of the systems are been run by the government and because there is no effective policy for Operation and Maintenance or commercialisation, water supply systems are inadequately operated, maintained or repaired. Overall, within the 22 facilities managed by SMOH, all have been designed for a pipe borne system, but only 12 have running water for a reasonable number of hours per day 10 of which have been supported by the IBP. The water shortage results in poorly or non-functioning flush toilets, poor sanitation and significant health implications. The source of the piped water systems is either a borehole within the compound of the facility or from the SWB supply. Both systems are badly affected by the irregular power supply that is provided by NEPA and where the generators are functioning, there is insufficient fuel to run it successfully. The problems are at times compounded by main supply pipes that are old and blocked. The DFID-SLGP/SMOH has initiated the improvement of the water supply in ten of the 22 facilities. The contracts proved effective and easy to manage and have been successful SMOH intends replicating positive lessons learnt in contracting and due process. SLGP Consultants Report Number

13 However, in the interim, the remaining 12 health facilities have to rely on one or more hand pumps for water. Most of the hand pumps were found in reasonable working condition, but although they provide a good backup service they are inadequate to provide the main supply of water. 5.2 Power Supply All health facilities are connected to the national electricity grid that is managed by the National Electricity Power Authority (NEPA). The provision of power however is very often interrupted and the voltage is fluctuating. The fluctuating voltage contributes to the breakdown of electrical equipment especially within the water supply system which permanently requires 24 volts. On average the health facilities receive between three and eight hours of power per day. Since there is no real pattern in the supply times it is impossible to adjust a work schedule around the supply hours. As a result generator supply has to be used to supplement NEPA and it has been a standing rule in the facilities to put on the generating sets in the evenings for between three and five hours. In recent years, some of the health facilities have been provided with new generators and the status of the generators is in general satisfactory with the exception of few. The fuel consumption of the large generators and other running costs is high, and not related to available budgets. In some cases, oversized generators have been provided to facilities. Other sources like solar power are not in use in the health facilities not even on an experimental basis. 6.0 BUDGET The Budget Department and the Office of the Head of Service that disburses the overhead were visited and data collected to assess variances between overheads and expenditure returns. The approved budget for the year 2006 for the SMOH and its facilities as well as the evidences of overhead collection and returns were also analysed. The key issue is that the disbursements of the overheads do not meet the requirement of some of the health facilities, and there are no guiding principles for the allocations. Equally the overhead is not disbursed regularly it is an intermittent allocation irrespective of the approved budget, with no specific reference to operation and maintenance, even though there are such line items in the approved budget. The report Support to Strengthen the Budget Process of Jigawa State Ministry of Health by PATHS clearly gave recommendations for implementation starting the year 2007 to effect effective and sustainable budget implementation, including the budget process, overhead allocation, expenditure returns and applications. The process of institutional support under this assignment worked alongside these recommendations: Evidence of overhead collections and returns from the Office of Head of Service were noted and forwarded to respective organisations including SMOH, along with an assessment of any variances. Budgetary discussions and proposals for effective operation and maintenance in each facility was incorporated in the 2007 proposed budget for the SMOH. SLGP Consultants Report Number

14 An additional N20million was provided over the current year (2006) to cater for operation and maintenance, inflation and running costs of the generating sets in the facilities. The year 2006 had N130million while 2007 has been allocated with N150million for recurrent expenditure. The Managers and Accountants of facilities as well as the key staff involved in budget preparation in the SMOH were given training in a workshop on budgetary processes which lasted two days in Dutse, supported by PATHS. Internally Generated Revenue (IGR) in the facilities was poor before the assignment. However, with improved awareness to the management of the facilities, IGR has increased in some, assisting them to operate and maintain their systems. Dutse, Gumel and Babura General Hospitals were able to buy pumps and starters and all have carried out some minor electrical and plumbing works. Several facilities have a Revolving Drug Fund (DRF) under PATHS support and these are working and successful. This approach has assisted in the application of the principle of change towards the sustainability of infrastructure within the health system in Jigawa State. Communities in the ten selected facilities have generally agreed with contributing towards the effective running of the water supply system and the facility itself through negotiation with the HMC and community leaders. 6.1 Variance in 2006 Budget An analysis was conducted for 2006 budget implementation against the approved budget. Approved overhead cash ceilings for 2006 are shown in Table 3, whilst Table 4 shows actual overhead disbursement, and Table 5 assesses variance health schools budgets are generally not shown. It is noted that of the N130million approved as overhead, only N49million (about 30 per cent) was meant for the facilities. Some N78million was headed for the SMOH, and N3million for the health schools. Columns 2 and 3 in Table 4 show the allocation of the overheads as recorded in the PATHS report (which is the actual approved for 2006) and Column 4 shows the actual disbursed by the Office of the Head of Service, with a variance of about N350, per month. Table 4 shows that the 22 facilities were supposed to have been given N33million as of October 2006, but only received N23.1million leaving a deficit of N9.9million. Even if the remaining two months of vember and December are paid, the deficit for the last three unpaid months of February, July and September will remain outstanding. Table 3: Overhead Cash Ceilings 2006 Facility Cash Ceilings (Naira) SMOH Headquarters 78,000,000 General Hospitals 24,000,000 Cottage Hospitals (Including Special Hospitals) 13,000,000 Primary Health Centres 12,000,000 School of Health Technology 3,000,000 Total 130,000,000 SLGP Consultants Report Number

15 Table 4: FACILITY Slgp Overhead Disbursement MONTHLY ALLOCATION (PATHS) MONTHLY BUDGET ALLOCATION FROM HoS APPROVED ESTIMATE FOR 2006 ACTUAL PAID BY OCTOBER 2006 FROM THE OFFICE OF THE HoS (7 Months) SMOH 250, , ,400,000 1,400,000 Sub- total 250, , ,400,000 1,400,000 General Hospitals BABURA 250, , ,400,000 1,400,000 B/KUDU 200, , ,400,000 1,400,000 DUTSE 300, , ,000,000 1,750,000 GUMEL 250, , ,400,000 1,400,000 HADEJIA 300, , ,000,000 1,750,000 JAHUN 200, , ,400,000 1,400,000 KAZAURE 250, , ,400,000 1,400,000 RINGIM 250, , ,400,000 1,400,000 Sub-total 2,000, ,700, ,400,000 11,500,000 Cottage Hospitals BIRNIWA 100, , ,200, ,000 BULANGU 100, , ,200, ,000 GWARAM 100, , ,200, ,000 K/HAUSA 100, , ,200, ,000 Sub-total 400, , ,800,000 2,800,000 Primary Health Centres BASIRKA 100, , ,200, ,000 GALAMBI 100, , ,200, ,000 GWARAM 100, , ,200, ,000 GARKI 100, , ,200, ,000 KIYAWA 100, , ,200, ,000 M/MADORI 100, , ,200, ,000 MAIGATARI 100, , ,200, ,000 RONI 100, , ,200, ,000 SAGU 100, , ,200, ,000 TAURA 100, , ,200, ,000 Sub-total 1,000, ,000, ,000,000 7,000,000 TOTAL 3,650, ,300, ,600,000 22,700,000 The SMOH also receives N200, as overhead monthly. The SMOH also receives a standing order for the sum of N8million initially, but only receives N4million on a monthly basis. If the SMOH had been paid the N8million monthly, they would have collected the sum of N96million which is far above their allocation of N78million. As at October, N40million had been received by SMOH as a standing order, and they will receive another N8million within the next two months making a total of N48million. If the N200,000 overhead is added for the seven months N1.4million will have been collected making a total of N49.4million received by the Ministry short by N28.6million from the initial allocation of N78million. SLGP Consultants Report Number

16 SMOH also collected N10million as a take off grant for the Gunduma project (verified by the Director Administration and Finance) and is expecting the release of another N52million for further developments. In all, the total amount collected by the SMOH in this years approved budget is summarised in Table 6. Table 5: Variance Assessment FACILITY APPROVED ESTIMATE FOR 2006 ACTUAL PAID BY OCTOBER 2006 ACTUAL EXPECTED TO BE PAID BY OCTOBER 2006 DEFICIT BY OCTOBER 2006 PROPOSAL FOR 2007 SMOH 2.4M 1.4M 2.0M 0.6M Sub- total 2.4M 1.4M 2.0M 0.6M General Hospitals BABURA 2.4M 1.4M 2.0M 0.6M B/KUDU 2.4M 1.4M 2.0M 0.6M DUTSE 3.0M 1.75M 2.5M 0.75M GUMEL 2.4M 1.4M 2.0M 0.6M HADEJIA 3.0M 1.75M 2.5M 0.75M JAHUN 2.4M 1.4M 2.0M 0.6M KAZAURE 2.4M 1.4M 2.0M 0.6M RINGIM 2.4M 1.4M 2.0M 0.6M Sub- total 20.4M 11.9M 17.0M 5.1M 24.0M Cottage Hospitals BIRNIWA 1.2M 0.7M 1.0M 0.3M BULANGU 1.2M 0.7M 1.0M 0.3M GWARAM 1.2M 0.7M 1.0M 0.3M K/HAUSA 1.2M 0.7M 1.0M 0.3M Sub-total 4.8M 2.8M 4.0M 1.2M 12M Primary Health Centres BASIRKA 1.2M 0.7M 1.0M 0.3M GALAMBI 1.2M 0.7M 1.0M 0.3M GWARAM 1.2M 0.7M 1.0M 0.3M GARKI 1.2M 0.7M 1.0M 0.3M KIYAWA 1.2M 0.7M 1.0M 0.3M M/MADORI 1.2M 0.7M 1.0M 0.3M MAIGATARI 1.2M 0.7M 1.0M 0.3M RONI 1.2M 0.7M 1.0M 0.3M SAGU 1.2M 0.7M 1.0M 0.3M TAURA 1.2M 0.7M 1.0M 0.3M Sub-total 12.0M 7.0M 10.0M 3.0M 12M TOTAL 39.6M 23.1M 33.0M 9.9M SLGP Consultants Report Number

17 Table 6: Total Disbursement to SMOH for 2006 Line Item Disbursement a) Approved Over Head for the SMOH and Facilities 130 million b) Actual Overhead Releases for 7 months to SMOH and Facilities 23.1 million c) Standing Order Releases to SMOH for 10 Months 40 million d) Release for Gunduma to SMOH 10 million e) Total Releases to October million f) Additional Releases Expected by December million g) Total Overhead Expected Releases by December million h) Short fall in the budget (a-g) 42.3 million Despite the rather confused nature and shortfall in budget implementation, the cash ceilings proposed for the SMOH and its twenty two facilities for 2007 (Table 7) have been increased by N20million, to a total of N150million. It is not possible to assess the likeliness of budget implementation. Table 7: Cash Ceilings 2007 Facility Cash Ceiling SMOH Headquarters 98,400,000 General Hospitals 24,000,000 Cottage Hospitals 12,000,000 Primary Health Centres 12,000,000 School of Nursing 1,800,000 School of Health Technology 1,800,000 Total Cash Ceiling Overheads 150,000,000 NEPA, NITEL and WATER bills for SMOH are, by routine, sent to the Treasury Department by the three organisations, as these bills are been paid collectively on a monthly basis by the State Government through the Treasury Department. On an average bases, the monthly bill paid are: 1. NEPA /POWER HOLDINGS N 4 million as a standing order 2. NITEL and NIPOST N 3 million as a standing order 3. WATER (SWB) N 770, 000 (but not a standing order) The budget processes and preparation guidelines appear effective and transparent, but clearly, implementation is poor and confusing. In general, the State Government dose not disburse funds as approved and when disbursed they are insufficient and irregular. SLGP Consultants Report Number

18 7.0 MANAGEMENT STRATEGY The strategy proposed for long term management for the effective operation and maintenance of health facilities is centrally based on the Logical Framework, highlighted strengths and weaknesses, and based on improvements made during the institutional support assignment. To this end, the following are recommended to strengthen the institutional set up within the Ministry and health facilities on a short (S), medium (M) and long (L) term basis: 7.1 Water System Operators PATHS financed a two day training programme (planned in conjunction with SLGP and SMOH) for operators using resource persons from SWB. However, operators require further and continued training, supported by the State Water Board, including a very clear and simple job description encompassing their specific roles and responsibilities (S) Operators need to continue to use the logbook, and to be held accountable for completing the logbook and reporting to the Hospital Management Committee (S, M, and L) Operators should be seen as integral to hospital management, operation and maintenance, and should be included, as other staff, in programmes financed by other projects or development partners (M and L) 7.2 Hospital Management Committee The HMC needs to continue to improve community relations by enlightening and co-opting community leaders in the forum, enabling them to give feedback on service quality and empowering them to contribute to operation and maintenance (S, M and L) The HMC needs to improve its feedback and linkage with SMOH, including the submission of minutes of meetings, financial returns etc (S) The HMC needs to further improve IGR by developing economically sound means of earning income from water sales, and recycling these revenues to support operation, maintenance and repairs (M and L) 7.3 Ministry of Health SMOH should monitor the facilities and provide financial support to the existing Monitoring Team to enable them to transparently cross check every month based on facility action plans (S, M and L) Further water supply development in any other facilities should be conducted in collaboration with SMWR and SWB in order to ensure sustainability and effectiveness (M and L) SMOH needs to institute an effective policy on asset and asset management the checklists developed in partnership with PATHS would be a useful component of this (S) SMOH should continue to chair and provide secretarial services for the Round Table on Health, bringing together SLGP, PATHS, HSDP II, SRIP, WSSSRP and stakeholder Ministries in Jigawa State Government (S, M and L) SLGP Consultants Report Number

19 7.4 Budget Preparation And Implementation Continue with bottom up approach to budget preparation ensuring the participation of each health facility, and including operation and maintenance (S) Provide support to ensuring budget implementation through the House of Assembly, traditional institutions, the media, and with donor partner support (M) Support the Public Accounts Committee to ensure due process in budget implementation (M) 8.0 RECOMMENDATIONS There is an urgent need for an effective supervision and monitoring team in the SMOH to carry out routine supervision of health facilities, including the maintenance of water facilities in each centre, and how the Hospital Management Committees are fulfilling their obligations. The SMOH planning department needs to assess the three reports of PATHS highlighted above and critically study, understand and apply the recommendations for Budget It will also assist the Ministry to improve its financial position through improved revenue generation and appropriate accountability. This will assist in the operation and maintenance of the facilities. The health facilities do not have any major source of income apart from the Drug Revolving Fund (DRF) and Internally Generating Revenue (IGR). The DRF is a revolving programme and based on the principle of sustainability. The IGR is not sustainable at present as the revenue generated is negligible especially in areas where the facilities are small. For the facilities to be sustained, the need to review the overhead allocation policy and improve IGR will be paramount. It is recommended that the operation manual supplied to hospital management be reviewed to include a community representative, with roles and responsibilities clearly spelt out. In addition, the Gunduma set up should also clearly identify the roles and responsibilities of each stakeholder. The law backing the commercialisation of water is enshrined in the Decree 101 as well as the National and State Policies on Water Supply and Sanitation of 2000, and the policy implementation of 2006 on operation and maintenance. These policies and decrees can be applicable to any water supply sector either as a government agency or the private sector to ensure income based on the economic income of the people in the area. The Ministry of Water Resources should regulate the rates to meet the operation and maintenance cost. SLGP Consultants Report Number

20 Water sales in some of the facilities are clearly not feasible due to high demand, provision of almost free water from the State Water Board, facilities proximity to the communities and insufficient water to meet hospital requirements, especially in Dutse, Kiyawa, Gwaram and Kazaure. However, places like Gumel, M/Madori, Roni, Babura, Bulangu, and Kaffin Hausa can effectively commercialise and generate some revenue to supplement the operation and maintenance of the water infrastructure. The overhauling or replacement and repair of generating sets in some facilities especially Dutse, Gumel, Babura, Mallam Madori and Kaffin Hausa is urgently needed to ease the operation of the water supply system. There is the need to improve communication linkages especially in facilities that lack easy assess to and from the SMOH in terms of radio, telephone/mobile phones, internet facility etc. especially in Kaffin Hausa, Bulangu, Babura, Gwaram, Roni, Mallam Madori and Kiyawa. Stakeholders need to collaborate further to advocate for sound budget implementation the Round Table on Health (which now includes the new EU funded SRIP and WSSSRP programmes) could be an effective forum, but any means should be explored to support transparent budget implementation. Memorandums of Understanding have proved effective at clarifying roles and responsibilities. Further awareness raising among Hospital Management Committees, communities and the State Water Board should be a priority. Rehabilitation and upgrading works to the water supply infrastructures in the remaining and proposed twelve facilities should be put in place through joint assessment, discussions and provision by the SMOH, SMOWR and Development Partners ensuring contracting and due process as implemented under the ten IBP sites. SLGP Consultants Report Number

21 Annex 1 Terms Of Reference For An IBP Institutional Change & Infrastructure Management Specialist Introduction The State and Local Government Programme (SLGP) is a UK-DFID financed programme that supports effective pro-poor State and Local Government in DFID s four partner-states in Nigeria (Lagos, Jigawa, Kano and Enugu). The purpose of the programme is to enhance the capacity and effectiveness of state and local government to formulate policy, manage resources and support improved service delivery in the interest of poor people. (For more information, see The Jigawa State Ministry of Health (SMOH) is the owner of extensive health facilities including hospitals, clinics and offices. The health facilities include the hospital buildings, quarters, electrical generators, and water infrastructure and equipment. Under the SLGP IBP programme, upgrading of water facilities is ongoing at ten health facilities. The work includes the drilling and rehabilitation of tubewells, provision of new pumps, repairs and provision of new tanks, and some reticulation to standpipes. The purpose of the programme is to improve the capacity and effectiveness of SMOH and health facilities to provide enhanced water supplies to ten health facilities. The outputs of the programme are broadly to: Rehabilitate the water infrastructure. Create a capacity in the health facilities to manage the water facilities. Create a capacity for the SMOH to oversee the asset management and prepare adequate budgetary allocation to O&M costs. Develop performance targets. Create a provision for any surplus water to be provided to the community. Work to date has focused primarily on the rehabilitation of the water facilities, assessment and allocation of budgets for O&M, and some training of operators. The rehabilitation activities have been based primarily on the water facilities but include cabling and controls for the electricity. The SLGP programme is providing water to stand pipes in the hospital yard. It has not included any piped water facility within the hospital buildings. There are ongoing programmes under the SMOH, with support from PATHS, to upgrade selected hospital buildings, including limited internal water facilities and sanitation. The PATHS programme is proposing to undertake some activities relating to the procedures for building maintenance in the context of the overall strengthening of the facility management system. This is intended to foster ownership, efficiency, effectiveness of service delivery, and overall public accountability of services provided by the facilities. SLGP Consultants Report Number