Nigeria: Nationwide Forecast and Funding Gap Analysis; Maternal, Newborn, and Child Health Commodities.

Publication date: 2013

Nigeria: Nationwide Forecast and Funding Gap Analysis Maternal, Newborn, and Child Health Commodities FEBRUARY 2013 This publication was produced for review by the U.S. Agency for International Development. It was prepared by the USAID | DELIVER PROJECT, Task Order 4. Nigeria: Nationwide Forecast and Funding Gap Analysis Maternal, Newborn, and Child Health Commodities The authors' views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government. USAID | DELIVER PROJECT, Task Order 4 The USAID | DELIVER PROJECT, Task Order 4, is funded by the U.S. Agency for International Development (USAID) under contract number GPO-I-00-06-00007-00, order number AID-OAA-TO-10- 00064, beginning September 30, 2010. Task Order 4 is implemented by John Snow, Inc., in collaboration with PATH; Crown Agents Consultancy, Inc.; Eastern and Southern African Management Institute; FHI 360; Futures Institute for Development, LLC; LLamasoft, Inc.; The Manoff Group, Inc.; Pharmaceutical Healthcare Distributers (PHD); PRISMA; and VillageReach. The project improves essential health commodity supply chains by strengthening logistics management information systems, streamlining distribution systems, identifying financial resources for procurement and supply chain operation, and enhancing forecasting and procurement planning. The project encourages policymakers and donors to support logistics as a critical factor in the overall success of their health care mandates. Recommended Citation Takang, Eric, Brian Serumaga, Chuks Okoh, and Elizabeth Obaje. 2012. Nigeria: Nationwide Forecast and Funding Gap Analysis; Maternal, Newborn, and Child Health Commodities. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 4. Abstract In July and August 2012, the Federal Ministry of Health (FMOH) of Nigeria, with technical assistance from the USAID | DELIVER PROJECT, Task Order 4, conducted a forecast of and funding gap analysis for commodities for maternal, newborn and child health (MNCH) in Nigeria for one year. The forecast and funding gap analysis would be used to inform the FMOH strategy for achieving Millennium Development Goals 4 and 5 by 2015 by focusing on integrated maternal and child services at public health facilities. This report includes the findings of the forecast, as well as the funding gap analysis, which can be used for advocacy with key stakeholders to increase the level of funding and, eventually, the availability of commodities for MNCH conditions in Nigeria. Cover photo: This photograph taken in Bauchi State of Nigeria shows a mother holding an infant, along with the child's completed vaccination card. JSI. 2010. USAID | DELIVER PROJECT John Snow, Inc. 1616 Fort Myer Drive, 16th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: askdeliver@jsi.com Internet: deliver.jsi.com Contents Acronyms. v Acknowledgments . vii Executive Summary . ix Background . 1 Overview of Health Care Delivery System . 1 Maternal, Newborn, and Child Health Situation in Nigeria . 2 Scope of the Quantification . 7 Methodology . 11 Quantification Approach . 11 Results . 19 Overall Estimates . 19 Maternal Health Estimates . 21 Child Health Estimates . 22 Newborn Estimates . 24 Funding Gap Analysis . 25 Discussion . 29 Projections of Increased Coverage . 29 References and Resources . 33 Appendix A: Quantification Workshop 1 Participants List . 35 Appendix B: Quantification Workshop 2 Participants List . 39 Appendix C: Estimated Annual Cost of MNCH Commodity Requirements and Funding Gap . 41 Appendix D: Maternal Health Commodity List for Nigeria MNCH Program . 43 Appendix E: Child Health Commodity List for the Nigeria MNCH Program . 51 Appendix F: Neonatal Health Commodity List for the Nigeria MNCH Program . 55 Figures Figure 1. Nigerian States by Population . 1 Figure 2: Maternal, Newborn, and Child Health Commodity Supply Chain . 5 Figure 3. Steps in Quantification . 11 Figure 4: Forecasted Annual National Requirement of All Commodities for the MNCH Program in Nigeria . 19 Figure 5: Forecasted Annual National Requirement for UN Commission 13 Core Lifesaving MNCH Commodities . 20 iii Figure 6: Forecasted Annual Cost (in millions of U.S$) of Commodities for Maternal Health (women 15–49 years) . 21 Figure 7: Estimated Annual Requirement for Maternal Health Commodities by Health Condition . 21 Figure 8: Forecasted Annual Cost (in millions of U.S.$) of Commodities for Child Health (1–59 months) by Commodity Category . 22 Figure 9: Estimated Annual Requirement (in millions of U.S.$) for Child Health Commodities by Health Condition . 22 Figure 10: Estimated Annual Requirements (in millions of U.S.$) for Child Health Commodities for Major Health Conditions . 23 Figure 11: Forecasted Annual Cost (in millions of U.S.$) of Commodities for Newborns by Commodity Category. 24 Figure 12: Estimated Annual Requirement (in millions of U.S.$) for Newborn Health Commodities by Health Condition . 25 Figure 13: Estimated Cost and Current Funding Commitments for Maternal Health Commodities . 26 Figure 14: Estimated Cost and Current Funding Commitments for Child Health Commodities . 26 Figure 15: Estimated Cost and Current Funding Commitments for Newborn Health Commodities . 27 Figure 16: Cumulative Neonatal Lives Saved by Provision of Health Commodities to Meet IMNCH Strategy Targets . 30 Figure 17: Cumulative Number of Child Lives Saved by Provision of Health Commodities to Meet IMNCH Strategy Targets . 30 Figure 18: Cumulative Number of Maternal Lives Saved by Provision of Commodities to Meet IMNCH Strategy Targets . 31 Tables Table 1: Scope of Commodities Quantified for Women of Reproductive Age (15–49 years) . 7 Table 2: Scope of Commodities Quantified for Newborns . 8 Table 3: Scope of Commodities Quantified for Children . 9 Table 4: Thirteen Core MNCH Commodities (UN commodities commission) . 14 Table 5: Description of Target Maternal Population for the MNCH Quantification . 15 Table 6: Description of Target Child Population for the MNCH Quantification . 16 Table 7: Estimated Annual Requirement of Nutritional Commodities for Nigeria . 24 iv Acronyms ANC antenatal care CHAI Clinton Health Access Initiative FGON Federal Government of Nigeria FMOH Federal Ministry of Health GDP gross domestic product GON Government of Nigeria HMB Hospital Management Board IPT isoniazid preventive therapy (TB) LGA local government area MCH maternal and child health MDGs Millennium Development Goals MMR measles, mumps, rubella (incidence) MSS Midwives Service Scheme NHA National Health Accounts NPHCDA National Primary Health Care Development Agency PFSCM Partnership for Supply Chain Management PHC primary health care or primary health centers PMTCT prevention of mother-to-child transmission SAM severe acute malnutrition SMOH State Ministry of Health STI sexually transmitted infection SURE–P MCH Subsidy Reinvestment and Empowerment Program for Maternal and Child Health THE Total Health Expenditure UN United Nations UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID U.S. Agency for International Development VVF vesico-vaginal fistula WHO World Health Organization v vi Acknowledgments The authors wish to acknowledge the support of the Federal Ministry of Health of Nigeria. Special commendations go to the Minister of State for Health, Dr. Mohammad Ali Pate, and his team of technical advisors, for their support in carrying out this activity. We are also grateful to the Clinton Health Access Initiative (CHAI), United Nations Children’s Fund (UNICEF), United Nations Population Fund (UNFPA), and Partnership for Supply Chain Management (PFSCM) for their time and effort in providing us with some of the data used for this quantification exercise. In addition, we would like to thank all the state level ministry of health representatives who attended and actively participated in the quantification and validation workshops, which were a cornerstone to the completion of this work. Finally, we wish to express sincere gratitude to everyone that contributed to the development and review of this report, starting with the USAID|DELIVER PROJECT Country Director, Peter Hauslohner; Deputy Country Director, John Durgavich; and Associate Director of Public Health, Elizabeth Igharo, as well as other staff of the USAID|DELIVER PROJECT in Nigeria. vii viii Executive Summary The Federal Ministry of Health (FMOH) of Nigeria and partners have made considerable efforts to combat maternal, newborn, and child health illnesses. Despite this, the burden of these conditions in Nigeria remains high. Results from the latest Demographic and Health Survey (Measure DHS 2008) of 2008 showed that Nigeria is still a long way from meeting the Millennium Development Goal (MDG) goals 4 and 5, which relate to reducing the burden in child and maternal deaths by 2015, respectively. In this survey, the infant mortality rate (per 1,000 live births) was estimated at 75 and the percentage of births attended by skilled health personnel was 38.9 percent. Immunization rates remain low, especially among rural populations. To accelerate progress toward meeting the MDG goals, the FMOH and partners have developed a number of strategic interventions, especially at primary health care level. These interventions aim at increasing basic antenatal, newborn, and child care for the most vulnerable populations, with the goal of saving approximately one million lives by 2015. The key to these interventions is to provide medicines and health commodities. In July and August 2012, the office of the honorable Federal Minister of State for Health, with technical assistance from the USAID | DELIVER PROJECT, Task Order 4, conducted a forecast and funding gap analysis of commodities for maternal, newborn, and child health (MNCH) in Nigeria for one year. Using morbidity information from various sources, the USAID | DELIVER PROJECT carried out a morbidity-based forecast. This report includes the findings from the forecast, as well as the funding gap analysis that can be used for advocacy with key stakeholders to increase the level of funding and eventual availability of commodities for MNCH conditions in Nigeria. The project quantified the main commodities needed for a comprehensive MNCH program in Nigeria, by commodity groups. These groups were nutrition, antimalarials, essential medicines, HIV and AIDS medicines and supplies, vaccines, family planning commodities, and general health consumables (e.g., syringes, giving sets, mama kits, etc.). In total, the project estimated the funding requirements for 135 medicines and 67 general health supplies. The quantification team used purchase prices that states and program representatives reported. If local prices were not available, we used the International Drug Price Indicator Guide (MSH and WHO 2011) median prices. The USAID | DELIVER PROJECT estimated an annual funding requirement of approximately U.S.$859,496,1261. Using information from the state-level ministry of health (MOH) officials, the FMOH, and partners, we estimated that $361,719,211, of this is currently funded, leaving a funding gap of approximately $497,776,915. In Nigeria, this is an annual expenditure of approximately $5.00 per person. Using the Lives Saved tool in the Spectrum set of models, we estimated that providing these medicines and commodities to a level of coverage sufficient to reach the 2015 MDG targets would result in a significant reduction in maternal, newborn, and child deaths by 2015. For example, the team estimated the potential reduction for child deaths only if the MDG targets were met by 1 In this document, all dollar amounts are U.S. dollars. ix 2015 could be up to 750,000 lives. Ensuring that the necessary commodities are available in public health facilities for the trained service providers will definitely contribute to saving the lives of mothers, newborns, and children, and to meeting the Government of Nigeria’s ambitious, “Saving One Million Lives Initiative.” Going forward, the USAID | DELIVER PROJECT recommends that the results of this forecast and funding gap analysis should be used by the FMOH and partners to source for funding. Concurrently, a supply plan that takes into account existing stock levels, as well as commodities that may already be on order needs to be developed in order to inform the procurement of these commodities. Finally, a national forum for all stakeholders (including state-level representatives) needs to be created to meet regularly and chart a way forward toward creating MNCH commodity security for Nigeria. x Background Overview of Health Care Delivery System The Federal Republic of Nigeria is the seventh most populous country in the world. The national population census from 2006 estimated that the country will have a population of about 171,468,040, by 2012; maintaining its position as the most populous African country. Also according to United Nations (UN) estimates, 50.2 percent of the population is located in rural areas and 49.8 percent in urban areas (United Nations 2012). The population density is 167.5 people per square kilometer. Figure 1 shows the distribution of population, by state. Figure 1. Nigerian States by Population Nigeria has three tiers of government: the federal government (the supreme administrative unit of the country), state governments (the administrative unit in charge of each state), and local governments that have jurisdiction over specific areas within a state. Health care provision in Nigeria is a concurrent responsibility of these three tiers. The federal, state, and local governments have broad responsibilities for tertiary, secondary, and primary health care, respectively. The concurrent nature of these obligations sometimes leads to an overlap and/or neglects to provide the necessary inputs. Source: Nigeria 2006 Census 1 Level 1, or the primary level, includes all the primary health centers (PHC), dispensaries, health posts, and community-based providers. Typically, local government authorities manage level 1. The medical staff at level I include nurses and community health extension workers. The health workers at this level are trained to manage uncomplicated cases; they focus on clinical symptoms to identify diseases before initiating the appropriate treatment. They are also trained to provide pre-referral treatments before referring cases of severe ailments to the next level. Level II is the second administrative level; facilities managed at this level may include health centers, comprehensive health centers, cottage hospitals, general hospitals; and some private hospitals, as well as all state secondary hospitals, which are the states’ responsibility. Some of these facilities may or may not have diagnostic laboratories. The responsibility for health programs is shared by the State Ministry of Health (SMOH) and the Hospital Management Board (HMB). The State Commissioner of Health, who heads the SMOH, is responsible to the State Executive Council and is assisted by the Permanent Secretary in the SMOH. Their responsibilities include planning and co- coordinating the state health systems; operating and maintaining secondary hospitals and some primary health facilities; implementing public health programs; training nurses, midwives, and auxiliary staff; and assisting the local government areas (LGAs) with managing and operating some primary health facilities. Each state has at least one health training institution. Level III, or the tertiary level, includes teaching hospitals, specialist hospitals, and federal medical centers. This level represents the highest level of care in the country; clinicians and medical staff are trained to make highly specialized diagnoses and to handle complicated cases. The federal government, through the FMOH, provides policy guidance and technical assistance to the 36 states and the Capital Territory (Abuja), and they coordinate the state efforts toward the goals set by the national health policy. The FMOH also monitors and evaluates the implementation of the national health policy. Additionally, the FMOH has direct operational responsibility for training medical doctors; operating teaching, psychiatric, and orthopedic hospitals; monitoring and controlling contagious and communicable diseases; and ensuring adequate availability of vaccines and essential drugs. Formal linkage between the FMOH and the SMOHs is through the National Council of Health, which the Federal Minister of Health chairs; it comprises all state commissioners of health. This council meets once a quarter to discuss national health concerns. In 2005, the FMOH estimated a total of 23,640, health facilities in Nigeria, of which 85.5 percent are primary health care facilities, 14 percent secondary, and 0.2 percent tertiary. The private sector owns 38 percent of these facilities. Maternal, Newborn, and Child Health Situation in Nigeria At the current annual population growth rate of 3.2 percent, the population is expected to double by 2030. The rapid population growth rate can be attributed to the high total fertility rate of 5.7, a large percentage of women in the reproductive age group, and a low contraceptive prevalence rate of 15 percent. Life expectancy at birth for women and men is estimated at 47.1 years and 46 years, respectively. Nigeria has a high burden of MNCH conditions. Every year, in Nigeria, an estimated one million children die from preventable diseases. Every day in Nigeria, approximately 700 babies die (around 30 every hour). This is the highest number of newborn deaths in Africa and the second highest in the world. With the current estimated maternal mortality ratio of 545 per 100, 000 live births (Measure DHS 2008), Nigeria still has one of the highest maternal mortality rates in the world. According to 2008 2 DHS, about four maternal deaths occur in Nigeria per hour, 90 per day, and 2,800 per month, for a total of 34,000 deaths annually, with wide regional and local variations. For pregnant women, aged 15–49 years, 57.7 percent received antenatal care from skilled providers, while skilled attendance at birth remains low at 39 percent. The 2008 DHS puts delivery in health facilities at 35 percent, while home deliveries were rated at 62.1 percent. It is also estimated that for every maternal death, at least 30 women suffer short- to long-term disabilities, such as vesico-vaginal fistula (VVF). Each year, some 50,000– 100,000, women in Nigeria sustain obstetric fistulae. Annually, it is estimated that more than 600,000, induced abortions take place in Nigeria. Abortions are often done under unsafe conditions, with an estimated 40 percent performed in privately owned health facilities. The consequences for the poor state of pregnant women in Nigeria are numerous and affect maternal as well as child mortality. The under-five mortality ratio in Nigeria is 201 per 1000 live births meaning that one in five Nigerian children never reach the age of 5. Infant deaths, which account for half of child mortality have increased from what they were in 1990. With a 13 percent immunization rate for children between 12–23 months, Nigeria is the African country with the lowest vaccination rate. Substantial presence of acute respiratory infections and diarrhea also contribute to the elevated mortality rates for children. Malaria is a leading cause of death of children under five years in Nigeria. Indeed it affects all ages, however its burden of mortality and disability is felt more acutely in children ages 0 to 4 years. The neonatal mortality rate in Nigeria is 40 deaths per 1,000 pregnancies. It is highest amongst teenage mothers and mothers aged 40–49 years (50 and 55 percent, respectively). Pregnancies that occur at less than 15-month interval have the highest neonatal mortality rate (76 deaths per 1,000 pregnancies). Birth asphyxia or intra-partum–related neonatal deaths remain a major cause of newborn deaths and disabilities in Nigeria—more than 25 percent for all causes. For each asphyxia- related newborn death, many more babies are left with permanent disabilities. Low birth weight and preterm babies are another group of babies who die daily. Infections, including neonatal tetanus, diarrhea, and pneumonia, account for about 34 percent; although contributions from each of these vary by region. MNCH Situation in Nigeria • 1 million child deaths per year due to preventable illnesses. • Only two out of five mothers receive intermittent preventive treatment for malaria. • On average, children under five years suffer 3 to 4 episodes of diarrhea each year. FMOH Interventions in MNCH During the past year, the FMOH has instituted a number of interventions to improve the MNCH situation in Nigeria. The signature intervention is the Government of Nigeria’s (GON) maternal and child health (MCH) program, which is under the subsidy reinvestment program: SURE – P. The program has been renamed SURE–P MCH. The SURE–P objective is to mitigate the impact of the oil subsidy reduction on vulnerable populations in Nigeria by initiating a robust social safety net program to improve their lives. The goal of the MCH component is to contribute to the reduction of maternal and newborn morbidity and mortality and to put Nigeria on track to achieve the MDGs 4 and 5. 3 Given its previous experience with the Midwives Service Scheme (MSS), the MCH project is likely to launch before other SURE–P programs, which may serve as an implementation model for the other programs. The program will run for four years, from 2012–2015. Using a conditional cash transfer program, the program builds on the MSS and will focus on increasing maternal access to health services during pregnancy and at birth. The MSS, backed by an MDG that mobilizes midwives, includes those newly qualified from the Nigerian Schools of Midwifery; unemployed midwives; and retired, but able, midwives. They will undertake one year of community service to health facilities in rural communities. The one-year service commitment would be mandatory for the newly graduated basic midwives, preparatory to being fully licensed to practice midwifery in Nigeria. The project will help increase skilled attendance at birth, which will facilitate a reduction in maternal, newborn, and child mortality and morbidity. Given the high level of fragmentation in the governance of the Nigerian health system, a crucial initiative for the MSS program was for state and local governments to sign a memorandum of understanding with the federal government agency responsible for primary health care (PHC) in Nigeria—the National Primary Health Care Development Agency (NPHCDA)—which is also the implementing agency for MSS. The state governments are expected to match with naira (N)20,000– N30,000 monthly remuneration that the federal government, through the NPHCDA, will pay the midwives. In addition to the monthly stipend, the federal government provided basic health insurance coverage for all the midwives; provided midwifery kits for each of the participating PHC facilities and for each midwife; and supplied a personal health record booklet, basic maternal and child health equipment, rugs, registers, and monitoring tools. The number of facilities in each of the six geopolitical zones of Nigeria was selected based on their maternal mortality burden. Nigeria was divided into three zones, based on the measles, mumps, rubella incidence (MMR): very high MMR (North-East [NE] and North West [NW]); high MMR (North Central [NC] and South South [SS]); and moderate MMR (South East [SE] and South West [SW]). The NE and NW have six clusters per state, SS and NC have four clusters per state, and SW and SE have three clusters per state. In Nigeria, the project currently serves an estimated aggregate of 15 million people (Abimbola et al. 2012). The outcome of the MSS after one year was an uneven improvement in maternal, newborn, and child health indices in Nigeria’s six geopolitical zones. Major challenges included retention, availability and training of midwives, and varying levels of commitment from state and local governments across the country. Despite the availability of skilled birth attendants at MSS facilities, in some parts of the country, women still deliver at home. Supply Chain System for Drugs and Health Commodities Despite a considerable investment in the health sector over the years, available evidence suggests that health services throughout Nigeria are delivered through a weak health care system (see figure 2). The latter is characterized by inequitable distribution of resources, decaying infrastructure, poor management of human resources for health, negative attitude of health care providers, weak referral systems; poor coverage, with high impact cost-effective interventions, unavailability of essential drugs and other health commodities, lack of integration, and poor supportive supervision. Consequently, the health care system cannot provide basic, cost-effective services for preventing and managing common health problems, especially at the LGA and ward levels. The Essential Drugs 4 Program, including the first national essential drug list in the country, was developed in 1988, after the 1987 Bamako Initiative, which aimed at strengthening PHC by ensuring sustainable quality drug supply systems. In Nigeria, this was reinvigorated in all LGAs in 1998, under the Petroleum Trust Fund. These initiatives are now ineffective because the commitment to establish systemic procurement systems for health commodities was weak. This resulted in a loss of confidence and decreased use of public sector health facilities because of the drug stockouts. Figure 2: Maternal, Newborn, and Child Health Commodity Supply Chain One consequence of a lack of trust in public health facilities is the proliferation of patent medicine vendors and drug hawkers who compound the problem of irrational drug use. The market is filled with substandard and fake drugs. In recent years, however, confidence has been growing for the 5 drug regulatory framework, which is operated by the National Agency for Food and Drug Administration and Control (NAFDAC). A significant, concerted effort is required to address the weak and fragmented logistics and supply chain system for drugs and health commodities in the country. Health Care Financing The National Health Accounts (NHA) for Nigeria during 2003–2005 estimate that the Total Health Expenditure (THE) in Nigeria has grown from N661.662 billion in 2003 to N976.69 billion in 2005. While the THE has grown in absolute terms by nearly one-third during this period; the THE, as a share of the gross domestic product (GDP) has actually declined, from 12.25 percent in 2003 to 8.56 percent in 2005. The federal government health expenditure was estimated to have grown threefold, from N47.02 billion in 2003 to N130.76 billion in 2005; while the estimated expenditures for the same period, by states, grew from N48 billion to N78.8 billion. The LGAs nearly doubled, from N28.63 billion to N44.64 billion. This trend is supported by figures from the Central Bank of Nigeria, which reveals that the proportion of the federal government’s total expenditure on the social sector between 2001 and 2005 ranged between 12–19 percent. Other sources confirmed that the absolute expenditure on health during 2001–2005 has increased by more than 150 percent. Households out-of-pocket expenses remain, by far, the largest source of health expenditure in Nigeria (about 69 percent) and, in absolute terms, increased from N489.79 billion in 2003 to N656.55 billion in 2005. The estimated health expenditure of private firms grew from N20.32 billion in 2003 to N29.67billion in 2005. The contributions from the development partners to the health sector in Nigeria are estimated to have increased from N48.02 billion in 2003 to N78.78 billion in 2005. There are, however, notable differences in the share of out-of-pocket expenditures across the states; some states in the northern zones estimated their household share as high as 86 percent. This underscores the huge economic burden of health care expenditure on households, especially the poorer households. Health Care Financing in Nigeria • Total Health Expenditure (THE) as a share of gross domestic product actually declined from 12.25 percent in 2003 to 8.56 percent in 2005. • Household out-of-pocket expenses remain, by far, the largest source of health spending in Nigeria (about 69 percent). • In terms of contribution from different levels of the government, the National Health Accounts 2003–2005 estimates that the federal government contributes more than one-tenth of the total sum (12.1 percent); state governments, about 7.6 percent; and local government areas, about 4.5 percent. 6 Scope of the Quantification To implement the GON MNCH program, the USAID | DELIVER PROJECT aimed to estimate an annual requirement of commodities for MNCH interventions. The timeframe for the quantification was, therefore, set for August 2012–July 2013. The results represent a 12-month national forecast of demand for MNCH commodities in Nigeria. In defining the scope of the quantification, lists of the standard interventions for women of child bearing age (15–49 years), newborns (0–28 days), and children (1–59 months) were compiled based on information from relevant, reputable literature. These interventions and commodity groups are summarized in Table 1, Table 2, and Table 3. Table 1: Scope of Commodities Quantified for Women of Reproductive Age (15–49 years) These lists were compiled based on a list of essential, evidence-based interventions to reduce morbidity and mortality in women of reproductive age, newborns, and children less than five years old (PMNCH 2011). Category Interventions Commodities Pre-pregnancy family planning Contraceptives management of sexually transmitted infections antibiotics (penicillin, macrolides, cephalosporins) screening for HIV and PMTCT antiretrovirals, HIV test kits Pregnancy (antenatal care) intermittent preventive treatment for malaria sulphadoxine-pyrimethamine, long- lasting insecticide-treated bed nets (LLINs) screening and prevention iron and folic acid, tetanus immunization pre-eclampsia and eclampsia magnesium sulphate, hydralazine, nifedipine, methyldopa, calcium pre-term rupture of membranes and complications antibiotics, corticosteroids, uterotonics (misoprostol, oxytocin) Childbirth normal delivery prophylactic antibiotics, uterotonics, IV fluids, mama kits caesarean section prophylactic antibiotics, IV fluids, analgesics, anesthetics, oxygen hemorrhage uterotonics, IV fluids Postnatal care postpartum sepsis antibiotics (ampicillin, gentamicin, metronidazole, etc.) 7 Table 2: Scope of Commodities Quantified for Newborns These interventions were prioritized using the following criteria: • Interventions that were expected to have a significant impact on maternal, newborn, and child survival; addressing the main causes of maternal, newborn, and child mortality, as articulated in health surveys from these population groups in Nigeria (e.g., Measure DHS 2008, UNICEF 2010). • Interventions that were suitable for implementation in low- and middle-income countries. • Interventions delivered primarily through the health sector, from the community to the highest referral level of public health service provision, excluding delivery of care through one-off or periodical campaigns. Category Interventions Commodities Immediate essential newborn care hygienic cord and skin care antiseptic solutions (e.g., chlorhexidine), dressings newborn immunizations bacillus Calmette-Guérin, polio, treatment for hepatitis B virus resuscitation ambulatory bag, bag mask Infection management presumptive antibiotic therapy for at risk newborns antibiotics neonatal sepsis antibiotics, IV fluids meningitis antibiotics, IV fluids, corticosteroids malaria artemisinin-based combination therapy, LLINs, quinine, rapid diagnostic kits diarrhea IV fluids, zinc, oral rehydration salts pneumonia antibiotics, IV fluids prevention of mother-to-child transmission (PMTCT) for at-risk newborns ARVs, co-trimoxazole Interventions for small and ill babies premature baby care corticosteroids, antibiotics, kangaroo slings, naso-gastric tubes birth asphyxia surfactants, oxygen jaundice IV fluids, exchange transfusion kit, antibiotics 8 Table 3: Scope of Commodities Quantified for Children Category Interventions Commodities Vaccinations tuberculosis tuberculosis vaccine, bacillus Calmette- Guérin syringes, diptheria, pertussis, tetanus, hemophillus influenza, hepatitis B pentavalent vaccine, reconstitution syringes, safety boxes measles measles vaccine, syringes polio oral polio vaccine meningitis meningococcal vaccine, syringes Prevention and management of childhood illnesses meningitis antibiotics, IV fluids, corticosteroids malaria artemisinin-based combination therapy, long-lasting insecticide-treated bed net, quinine, rapid diagnostic tests diarrhea IV fluids, zinc, oral rehydration salts pneumonia antibiotics, IV fluids Management of severe and acute malnutrition nutritional support ReSoMal, F75 therapeutic diet, folic acid, therapeutic spread, vitamin A Others helminthiasis mebendazole, albendazole non-specific fevers anti-pyretic medications 9 10 Methodology Quantification Approach Figure 3 summarizes the quantification approach that we adopted for this exercise. Because the quantification was not going to be used immediately for procurement, we omitted the supply planning step. Figure 3. Steps in Quantification 11 The methodology used for this quantification incorporated background document reviews, workshop discussion groups, as well as key informant interviews. The lack of timely and reliable consumption information at the national level meant that we were unable to carry out a consumption-based estimate of MNCH commodity dispensing. In Nigeria, consumption data on MNCH commodities is not reported at the national level. We could have used proxy consumption data from service statistics, but they were not available at the national level. Obtaining data on consumption would, therefore, have required us to visit at least 200 facilities in order to have a meaningful sample; given our time and budget constraints, it was impossible to do this. The quantification team, therefore, carried out a one-year (August 2012–July 2013) morbidity-based estimate by determining the incidence of the main MNCH conditions common in Nigeria. This method requires information about the frequency of common health problems, treatment guidelines, regimens, and number of people to be treated. Quantification Workshop The USAID | DELIVER PROJECT convened two quantification workshops to generate assumptions and validate results for this quantification. At the first workshop (July 23–24, 2012), state MOH representatives and other stakeholders were tasked with creating a list of major MNCH conditions, and also commodities used, in their states, as well providing information on how MNCH services are funded. We compared this information to the international best practice guidelines and, by consensus, with all participants, created a standard list of conditions and commodities. The quantification team then proposed some assumptions for the forecast that we refined, based on feedback from the participants. We used this information to estimate the commodity needs for the national MNCH program, as well as to estimate a funding gap for Nigeria. We then met the participants for a second workshop (August 24, 2012) to review the assumptions and validate the results of the quantification. Creation of a Model List of MNCH Commodities A national list of commodities for the MNCH program in Nigeria was not available before this quantification, but the USAID | DELIVER PROJECT created this list: First, we invited relevant health officials from the states (e.g., directors of primary care services and directors of pharmaceutical services) and partners working on MNCH issues in Nigeria to a two-day quantification workshop in Abuja. (See appendix A for a list of attendees and their designations.) At this workshop, the quantification team presented a sample list of conditions and treatment protocols to all the participants. The participants were divided into working groups, based on Nigeria’s six geopolitical zones; each group was asked to— • review the sample list provided • populate one master list with the major MNCH conditions prevalent in their states, then add their incidence, how they are treated, and the source of funding. The groups were reconvened in a plenary session; each group/region presented its results to the main plenary. At each presentation, the plenary adjusted the list based on feedback from other participants; one master list was generated at the end of the sessions. 12 Where there was no agreement between the states/regions, we used international best practice guidelines from the World Health Organization (WHO) as the default. After the lists were generated, we used Quantimed software to quantify the commodity requirement. We presented the results to a second workshop, attended by state level and partner participants, in August 2012. (See appendix B for a list of attendees and their designations). Participants were given a second chance to review the list of commodities, based on the results, and to make final adjustments. Key Informant Interviews The quantification team held a number of individual meetings with stakeholders at the central level to discuss the plans for the quantification exercise; and to gather data on morbidity, patterns of consumption, and commodity funding. In addition, stakeholders were asked to discuss relevant issues or challenges they encountered, when trying to ensure adequate supplies of MNCH commodities in both the public and private sectors. The team met with the CHAI, UNICEF, SURE–P MCH, NPHCDA, FMOH, and UNFPA. Data Collection and Document Review A key part of our process was the review of national policy and technical documents; we familiarized ourselves with the recommended treatment guidelines and previous activities that could impact the quantification. In addition, we reviewed policy documents to assess information on other major policy decisions that may affect the MNCH program; several documents are listed below: • Standard treatment guidelines for Nigeria (FMOH 2008) • National strategic health sector development plan 2010–2015 (FMOH 2010) • Nigerian 2006 Census Figures (available at http://www.nigeriamasterweb.com/Nigeria06CensusFigs.html) (accessed on 01-23-2013) • National Demographic and Health Survey (Measure DHS 2008) • Multiple Indicator Cluster Survey (Nigeria) (UNICEF 2010) • Saving newborn lives in Nigeria: Newborn health in the context of the Integrated Maternal, Newborn and Child Health Strategy (FMOH 2011) • Standards for Maternal and Neonatal Care (WHO 2007). Organizing and Analyzing Data In carrying out the forecast, the team used the Quantimed software, developed by Management Sciences for Health (MSH). Quantimed facilitates the process of determining the quantities of medicines and related supplies that are required for any health program. For each condition, we used incidence rates to determine the total number of patients who will require treatment for one year. We then entered information on all medicines and related supplies; and added the total requirement and costs by the maternal, newborn, and child categories. Whenever possible, we used local prices for commodities procured locally in Nigeria. Otherwise, prices were taken from the latest International Drug Price Indicator Guide (MSH and WHO 2011). We also estimated commodity requirements for the core 13 MNCH commodities stipulated by the UN commodities commission as vital to every MNCH program (see table 4). 13 Table 4: Thirteen Core MNCH Commodities (UN commodities commission) The UN commission underscored that, although this list of commodities is not sufficient to run a comprehensive MNCH program, these items must always be available for MNCH conditions because they are key lifesaving commodities. The quantification team collected information from partners, states, and the Federal Government of Nigeria (FGON) about the current level of funding of commodities for the MNCH program. We totaled this information to determine the current level of expenditure (commitment) for these commodities. We estimated a funding gap as the difference between the results of the forecast and the current level of funding commitment. The quantification team used Spectrum 4.0 software, developed by The Futures Institute, to model the effect of increasing funding for MNCH commodities on key MNCH indicators. Spectrum is a system of policy models that help analyze, plan, and advocate for improved programming. It can be used to project the impact of increasing the provision of services on key health and social outcomes, at the national level. We used the Lives Saved tool in Spectrum to model the impact of increasing the provision of health commodities to levels indicated in the national Integrated Maternal Newborn and Child Health Strategy targets, by 2015. We compared the cumulative number of maternal, newborn, and child lives saved by increasing funding for commodities to meet these targets between 2012 and 2015 to the goal of continuing the current level of funding (i.e., no increase in funding for commodities) for the same period. Core commodities oxytocin misoprostol magnesium sulphate injectable antibiotics antenatal corticosteroids chlorhexidine resuscitation devices amoxicillin oral rehydration salts Zinc female condoms contraceptive implants emergency contraception Assumptions Quantification is an estimation of the drugs that will be required over a specific period. The results of any quantification are highly dependent on the accuracy of the data available and the key assumptions made when organizing and analyzing the data to arrive at an estimate. If data are not available, or if the available data are not accurate, complete, or reliable, the accuracy of the quantification results will be affected. These limitations do not mean that quantification cannot be performed with less-than-perfect data. It is crucial that there is a clear understanding of the available 14 data and assumptions by all users of the quantification results. More important, it is vital that the implications are understood—financial and otherwise—when these assumptions, data, and results are used. The USAID | DELIVER PROJECT invited the SMOH representatives for a two-day prequantification workshop in Abuja, Nigeria. To generate broad consensus and understanding of the assumptions for this quantification, the workshop participants were divided into six groups, based on the geopolitical regions of Nigeria. Each group discussed a set of prepared assumption questions that were generated using the available data. Each group reviewed the available data and used that data to develop a consensus on broad assumptions, which included the methodologies for determining incidence rates for major MNCH conditions; and defining population groups, targets for different patient groups, and number of episodes in the different population groups. Following are the key assumptions that were used for the national quantification of MNCH commodities. Service Population The quantification team determined the service population based on recent population census results. We backed this up with relevant information from national surveys, such as the Measure DHS 2008. The population projections for August 2012–July 2013 were based on the 2006 Nigeria Census and the annual natural increase of 3.2 percent (Nigeria 2006 Census), which has held constant since 2006. From this, we determined that our target population would include approximately 35 million women of childbearing age (15–49 years), just over seven million newborns (0–28 days), and just under 35 million children less than 5 years of age (1–59 months). See table 5Table 5 and table 6 for more details. Table 5: Description of Target Maternal Population for the MNCH Quantification Descriptor Variable Factor (%) 2012 Total population 171,468,040 Projected annual population growth 3.20 5,486,977 Female population 48.12 82,510,421 Women of childbearing age 21 35,493,884 Proportion of pregnant women of the total population 5 8,573,402 Proportion of pregnancies likely to result in live births 85 7,287,392 Maternal mortality (/100,000) 545/100,000 (not %) Percentage of pregnant women likely to attend antenatal clinic in public health facilities 45 3,858,031 Percentage of pregnant women who delivered in health facilities 35 3,000,691 Percentage of pregnant women likely to deliver at home 62 5,324,083 Percentage of women that may require assisted delivery by skilled staff (out of those who receive antenatal care (ANC) in public health facilities) 20 771,606 Percentage of women that may present with pregnancy- 21 1,530,352 15 related complication (out of pregnancies that result in live births) Percentage of pregnant women that receive isoniazid preventive therapy (IPT) at ANC 8.70 745,886 Total percentage rate 5.7 Contraceptive prevalence rate 15 5,324,083 Percentage of women of child bearing age may present with fistula 1 85,734 Percentage of pregnant women on PMTCT program 2 171,468 Table 6: Description of Target Child Population for the MNCH Quantification Descriptor Variable Factor (%) 2012 Children population under 5 years (1–59 months) 20.4 34,979,480 Proportion of children of age 0–12 months 4 6,858,722 Neonatal mortality 0.4 34,294 Proportion of children under five that may present with anemia 28.6 10,004,131 Proportion of children under five that may present with malaria fever 36.4 12,732,531 Proportion of under-five fever cases that uses public health facilities 32 11,193,434 Prevalence of severe acute malnutrition (SAM) 7 2,448,564 Incidence of SAM over for children over one year 1.5 524,692 Health facilities providing immunization 40 13,991,792 Malaria 2006–2010*, under-fives sleeping under long-lasting insecticide-treated bed nets 29 10,144,049 Estimated Requirements for Existing Program Commodities Several of the target MNCH commodities are already part of the national health programs in Nigeria, or they are provided through partners like UNICEF and UNFPA. The USAID | DELIVER PROJECT, therefore, approached these partners and programs for information on their commodity estimates, if available; as well as any planned changes in coverage for the period of this quantification. From this information, we extracted projections for the relevant MNCH commodities. Where forecasts were available from programs or partners, we compared and reconciled our forecasts with existing forecasts. Malaria quantification variables were adopted from the national malaria quantification of 2010–2012, which JSI completed on behalf of the National Malaria Control Program (NMCP) (Teclemariam and Mwencha 2010). The SCMS project provided the HIV and AIDS estimates. UNICEF–Nigeria provided the nutrition and vaccine estimates. Family planning commodity figures were extracted from estimates provided by the national family planning program. 16 Estimation of Percentage of Mothers and Newborns Receiving Post- Natal Care Data from the Measure DHS 2008 shows that the majority of mothers in Nigeria give birth at home (62 percent). We used data from existing reports to estimate the percentage of newborns and mothers receiving post-natal care in Nigeria. A report from the FMOH, published in 2011, revealed that 38 percent of home births had skilled post-natal care within 48 hours (FMOH 2011). We also found from the same source that 35 percent of deliveries occur in health facilities. We assumed that all deliveries occurring in health facilities would receive postnatal care. We therefore, estimated the percentage of newborns and mothers receiving postnatal care: Postnatal care = 35% who deliver in a health facility + 38% of the home births Treatment Protocols To obtain an accurate estimate of national needs for MNCH commodities, it is important to have specific treatment protocols for the dosage, frequency of administration, and duration of treatment. To estimate a standard list of medicines and supplies in the entire country, we assumed that treatment in primary PHCs and hospitals follows the standard treatment guidelines for Nigeria. If no guideline exists, treatment will follow the international best practice guidelines. Where we found a discrepancy in treatment protocols between states, we followed the international best practice guidelines from WHO. We also assumed that admissions (in-hospital stay) for severe infections would last approximately one week (seven days). For adults who receive intravenous (IV) medications during this period, two giving sets would be required. For children and neonates, two giving sets and one nasogastric tube for feeding would be required. Estimation of Funding Gap We contacted the FMOH officials, SMOH, and partners for funding commitments for the MNCH commodity groups that were relevant to this forecast. For nutrition expenditures, we contacted the UNICEF–Nigeria office for details about their current estimates and projected expenditures for the next 12 months. We obtained projected figures for PMTCT coverage and estimated expenditure from the SCMS–Nigeria office. We also referred to a 2010 national quantification of malaria commodity requirements. The quantification projected commodity needs for five years, from 2010 to 2015. We extracted the projected requirement for 2012. For family planning commodities, we referred to the latest quantification of contraceptive requirements and funding commitments completed by the USAID | DELIVER PROJECT in 2010. Using information from the National Strategic Health Plan for Nigeria 2010–2015 (FMOH 2010), we estimated the percentage of expenditures for out-of-pocket and private health care. For each commodity group, we added these quantities to determine the current level of funding available for commodities. We determined the funding gap by subtracting this number from the cost of the national commodity estimate in this quantification. 17 18 Results The results of the forecasted requirement and financing needs, based on the assumptions made at the stakeholders’ workshops, are shown in the following tables and figures. The estimates are shown by target population, commodity category, and health condition. Overall Estimates Figure 4 shows the annual national requirement for MNCH commodities for Nigeria. We estimated a total requirement of $859,496,126. Of this requirement, 68 percent was for children less than 5 years of age. Figure 4: Forecasted Annual National Requirement of All Commodities for the MNCH Program in Nigeria Maternal $183,344,290 21% Child health, $586,087,755 68% Neonates $90,064,082 10% total requirement $859,496,126 19 Figure 5 shows the overall cost for the 13 core MNCH commodities recommended by the UN commodities commission. (See Table 4 for a list of these commodities). Of the total requirement, 19 percent would be for women of childbearing age. Of this, $26,507,588, would be required for essential medicines; $7,172,734, for family planning commodities; and $14,950,922, for supplies. Just over half the total requirements would be for children less than 5 years old. Of this, $94,219,008, would be required for essential medicines, while $38,541,202 would be required for supplies. For neonates, $63,212,674, would be required for essential medicines; while $10,002,491, would be required for supplies. Figure 5: Forecasted Annual National Requirement for UN Commission 13 Core Lifesaving MNCH Commodities Maternal $48,631,243 19% Child health $132,760,211 52% Neonates $73,215,164 29% total requirement $254,606,618 20 Maternal Health Estimates Figure 6: Forecasted Annual Cost (in millions of U.S$) of Commodities for Maternal Health (women 15–49 years) $42.0 $43.1 $8.0 $13.4 $76.8 $0 $10 $20 $30 $40 $50 $60 $70 $80 $90 M ill io ns Figure 66 and Figure 7 show the forecasted commodity requirement, by commodity group and by health condition. The largest requirement was for commodities for a normal delivery at $58,623,542, with mama kits accounting for $51,011,743, of this, per annum. Medicines for PMTCT were the next highest cost, at $31,193,294, per annum. Other significant costs were commodities for sepsis and abortion ($19,627,014) and malaria ($14,647,958). See appendix D for a detailed list of maternal commodities and the cost of the annual requirement. Figure 7: Estimated Annual Requirement for Maternal Health Commodities by Health Condition $0 $10 $20 $30 $40 $50 $60 $70 M ill io ns supplies medicines 21 Child Health Estimates Figure 8: Forecasted Annual Cost (in millions of U.S.$) of Commodities for Child Health (1–59 months) by Commodity Category $203.68 $80.10 $100.06 $38.54 $197.78 Figure 8Figure , figure 9, and figure 10 show the annual estimated cost by commodity group and by health condition. Out of the total cost of requirements for essential medicines, medicines and supplies for diarrhea alone accounted for $95,035,239, which was almost half of the annual requirement. A detailed list of child commodities and cost of the annual requirement is available in appendix E. Figure 9: Estimated Annual Requirement (in millions of U.S.$) for Child Health Commodities by Health Condition $0.51 $1.36 $22.26 $1.64 $1.03 $4.04 $7.94 $11.11 $2.39 $1 $5 $0 $5 $10 $15 $20 $25 M ill io ns supplies medicines 22 Figure 10: Estimated Annual Requirements (in millions of U.S.$) for Child Health Commodities for Major Health Conditions Table 7 shows the estimated cost of commodities for nutritional support for the MNCH program in Nigeria. This forecast was heavily supported by information provided by UNICEF–Nigeria. Given an estimated prevalence of severe acute malnutrition of 7 percent and a therapeutic feeding target number of admissions of 3,505,404, we estimated that, in the next year, Nigeria will need to procure nutrition supplies at a total cost of $197,784,399. The estimate takes into account the nutrition supplies currently in stock in-country and in the pipeline, including 10 percent for wastage and leakage. The most costly commodity was therapeutic spread, mainly because there is no local source. It would have to be procured from international suppliers. $197.78 $100.06 $83.57 $70.21 $80.10 $11.46 $1.27 $1.95 $0 $50 $100 $150 $200 $250 nutritional support malaria diarrhoea nutritional anaemiaImmunization M ill io ns supplies medicines 23 Table 7: Estimated Annual Requirement of Nutritional Commodities for Nigeria Nutrition supplies Unit cost Quantity required Estimated cost of supplies International freight costs* Total cost of supplies ReSoMal, 42g sachet/1L/CAR-100 $26 771 $19,755 $1,056 $20,811 F75 Therapeutic diet, sachet 102.5g/CAR-120 $58 9640 $558,156 $15,977 $574,133 Folic acid 5mg tabs/PAC-1000 $4 386 $1,664 $6 $1,670 Therapeutic spread, sachet 92g/CAR-150 $54 3496056 $188,787,078 $6,213,977 $195,001,055 Retinol 100,000IU soft gel.caps/PAC-500 $7 7712 $55,218 $496 $55,714 Retinol 200,000IU soft gel.caps/PAC-500 $9 7712 $70,719 $347 $71,066 Mebendazole 500 mg tabs/PAC-100 $3 38559 $104,498 $806 $105,304 Amoxici.pdr/oral sus 125mg/5ml/BOT-100ml $0 3470346 $1,596,359 $100,828 $1,697,187 Estimated total cost (Usd) $191,440,263 $6,344,137 $197,784,399 (Source: UNICEF 2010 ) Newborn Estimates Figure 11 and figure 12 show the annual requirement of commodities for newborns by commodity category and by health condition. The USAID | DELIVER PROJECT estimated a total cost of requirement of $71,512,444, for essential medicines and $11,597,118, for supplies. The bulk of this was for neonatal sepsis at $10,943,268, followed closely by medicines for PMTCT ($6,954,519) and diarrhea ($ 4,832,066). Figure 11: Forecasted Annual Cost (in millions of U.S.$) of Commodities for Newborns by Commodity Category $71.51 $6.95 $11.60 24 Figure 12: Estimated Annual Requirement (in millions of U.S.$) for Newborn Health Commodities by Health Condition $9.54 $2.65 $1 $6.95 $1.06 $1.42 $2.19 $0.61 $- $2 $4 $6 $8 $10 $12 M ill io ns supplies medicines A detailed list of all newborn commodities and cost of the annual requirement is available in appendix F. Funding Gap Analysis The quantification team found an annual requirement of $859,496,126, for commodities and supplies for Nigeria’s MNCH program. According to the Nigeria health sector strategic development plan, 12.1 percent of this requirement is funded by FGON, 7.6 percent by the state governments through drug revolving funds and other sources, and 4.5 percent by local government authorities. Using information provided by the state MOH representatives, FGON, and development partners, we were able to estimate a current level of funding commitment toward the purchase of these commodities of approximately $361,719,211. The remaining annual funding gap was approximately $497,776,915. See appendix C for a detailed breakdown of current levels of funding. The team found the biggest gap in funding for maternal commodities—approximately $49,901,419. Out of the total annual requirement for maternal supplies of $76,816,539, we found a current level of funding commitment of only $18,589,602. Most of this was estimated to be currently provided by the states and the local government authorities, through their federal grants. For family planning commodities, the team found an annual requirement of $8,011,136. However, information from FGON, UNFPA, DFID, and CIDA showed a current level of commitment of $11,350,000, for the next fiscal period. This meant that there was an excess of $3,338,864, for family planning commodities, which will probably be carried into the next fiscal period. Figure 13, figure 14, and figure 15 illustrate the current level of funding commitments and the estimated annual requirement for newborn, child, and maternal health commodities. 25 Figure 13: Estimated Cost and Current Funding Commitments for Maternal Health Commodities Essential medicines HIV/AIDS (inc. PMTCT) Family planning Malaria Supplies $41,990,979 $43,113,636 $8,011,136 $13,412,000 $18,589,602 Current Funding Commitments Estimated Cost of commodities For maternal health commodities, we estimated an annual requirement of $174,599,420, and current funding commitments of $49,901,419, leaving a gap of about $124,698,000. Figure 14: Estimated Cost and Current Funding Commitments for Child Health Commodities $76,816,539 $10,161,817 $6,800,000 $11,350,000 $3,000,000 Essential medicines Vaccines Malaria Supplies Nutrition Sub-total $203,684,314 $80,097,864 $65,979,976 $38,541,202 $197,784,399 $586,087,755 $49,291,604 $58,391,251 $24,000,000 $9,326,971 $150,000,000 $291,009,826 Current funding commitments Estimated cost of commodities 26 For child health commodities, we estimated an annual requirement of $620,167,755, and current funding commitments of $291,009,826, leaving a gap of $329,157,929. For newborn health commodities, the team estimated an annual requirement of $90,064,082, and current funding commitments of $20,807,966, leaving a gap of about $69,256,116. Figure 15: Estimated Cost and Current Funding Commitments for Newborn Health Commodities Essential medicines HIV/AIDS (PMTCT) Supplies Sub-total $71,512,444 $6,954,519 $11,597,118 $90,064,082 $17,306,012 $695,452 $2,806,503 $20,807,966 Current Funding Commitments Estimated cost of commodities 27 28 Discussion This forecast does not include guidance on the logistical support that needs to be in place to ensure these supplies reach the mothers, newborns, and children in need after they have been procured, or the program management costs. The quantification team estimated an annual commodity requirement of $859,496,126, which is an annual spend of approximately $5.00 for each Nigerian. Our results show that significant reductions in newborn mortality can be achieved by making comparatively small, but highly effective, investments in maternal health interventions. We found that to provide the total annual requirement of maternal commodities would require approximately $133 million in additional funding, while neonatal commodities would require $295 million. By increasing provision and coverage of timely antenatal care, especially to rural communities, it is possible to offset a substantial percentage of newborn mortality and morbidity for full-term pregnancies. Projections of Increased Coverage Our projections show that by significantly increasing commodity availability only for Nigeria’s MNCH program, it is possible to save approximately 1,800,000, lives by 2015. We used the Lives Saved tool in Spectrum to model the impact of increasing the provision of health commodities to levels indicated in the national Integrated Maternal Newborn and Child Health Strategy targets by 2015. We compared the cumulative number of maternal, newborn, and child lives saved by increasing funding for commodities to meet these targets between 2012 and 2015 to continuing with the status quo of funding (i.e., no increase in funding for commodities) for the same period. 16, Figure 17, and 18 show the results of the estimated projections of lives saved for newborns, children less than 5 years old, and mothers, respectively. We estimated that by 2015, about 274,856, women of reproductive age would be saved by increasing commodity availability compared to continuing with the current level of funding. Similarly, we estimated that by 2015 about 475,072, newborns and about 1,139,810, children less than five years old would be saved by increasing the availability of commodities alone. 29 Figure 16: Cumulative Neonatal Lives Saved by Provision of Health Commodities to Meet IMNCH Strategy Targets 184,457 370,542 556,290 678,674 27,669 70,403 133,510 203,602 2012 2013 2014 2015 Funding to MDG coverage targets Base projection _ no coverage change Figure 17: Cumulative Number of Child Lives Saved by Provision of Health Commodities to Meet IMNCH Strategy Targets 445,715 885,144 1,317,288 1,910,068 89,143 283,246 540,088 770,252 2012 2013 2014 2015 Funding to MDG coverage targets Base projection _ no coverage change 1,139,810 lives saved 475,072 Lives saved by 2015 30 Figure 18: Cumulative Number of Maternal Lives Saved by Provision of Commodities to Meet IMNCH Strategy Targets 217,065 266,990 333,737 383,798 71,631 82,376 94,733 108,942 2012 2013 2014 2015 Funding to MDG coverage targets Base projection _ no coverage change 274,856 lives saved Further work is required to determine the timing and methods of procurement for these commodities each year. Therefore, it is necessary to develop a procurement plan that considers the existing stock levels and commodities that may already be on order through the states or partners. To ensure a constant availability of all MNCH medicines and supplies in Nigeria, this plan should match the procurement and timing of commodities with the fluctuating levels of demand. In other words, it is important to develop a supply plan. Furthermore, the quantification team recommends that the FMOH and its partners use the results of this forecast to source for funding. The creation of an MNCH commodity security group that brings together key stakeholders to review the status of MNCH commodities in the country would go a long way toward achieving this goal. The success of the similar reproductive health commodity security group in finding sufficient resources for contraceptives for 2012 should offer encouragement to all MNCH stakeholders that this strategy could pay dividends in Nigeria. Also, given the high level of fragmentation in the governance of the Nigerian health system, it is important to involve states in this coalition. It is through this forum that innovative ways of procurement— such as framework contracting and pooled procurement, which have the potential to significantly the return per dollar spent—should be discussed with all stakeholders. Finally, approximately 95 percent of the commodity requirement for nutritional support would be spent on therapeutic spread annually. From our estimates, this accounted for just over $195 million. This high cost is mainly due to a lack of local sources for this commodity. It is imperative that the FGON and partners agree to accelerate efforts to produce therapeutic spread locally. This would offset a significant proportion of the nutritional commodity cost. 31 32 References and Resources Abdulraheem, I. S. 2012. “Primary health services in Nigeria: critical issues and strategies for enhancing the use by the rural communities.” Journal of Public Health and Epidemiology, 4(1): 5–13. Abimbola, S., U. Okoli, O. Olubajo, M. J. Abdullahi, and M. A. Pate. 2012. The Midwives Service Scheme in Nigeria. PLoS Med 9(5): e1001211. doi:10.1371/journal.pmed.1001211 Adeyemo, D. O. 2005. “Local Government and Health Care Delivery in Nigeria: A Case Study.” J. Hum. Ecol., 18(2): 149–160. Black, Robert, Simon Cousens, Hope Johnson, and Harry Campbell. 2010. “Global, regional and national causes of child mortality in 2008: a systematic analysis.”Lancet, 673: 110-12. Federal Ministry of Health (FMOH). 2008. Standard treatment guidelines for Nigeria. Abuja, Nigeria: FMOH. Federal Ministry of Health (FMOH). 2010. National strategic health development plan 2010–2015. Abuja, Nigeria: FMOH. Federal Ministry of Health (FMOH). 2011. 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Geneva, Switzerland: PMNCH. 33 Teclemariam, Lea, and Marasi Mwencha. 2010. Nigeria: National Malaria Control Program. Quantification of Anti- Malarial Medicines and Rapid Diagnostic Tests. Arlington, Va.: Capacity Building Services/Supply Chain Management Assistance Project. UNICEF. 2010. Multiple Indicator Cluster Survey (Nigeria). New York: UNICEF. United Nations. 2012. World Statistics Pocketbook 2011. New York, NY: United Nations. USAID | DELIVER PROJECT, Task Order 1. 2008. Quantification of Health Commodities: A Guide to Forecasting and Supply Planning for Procurement. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 1. World Health Organization (WHO). 2007. Standards for Maternal and Neonatal Care. Geneva: WHO. You, D., T. Wardlaw, P. Salama, and G. Jones. 2010. “Levels and trends in under-5 mortality, 1990–2008.” Lancet, 375: 100–103. 34 Appendix A: Quantification Workshop 1 Participants List PARTICIPATION LIST AL MNCH QUANTIFICATION ASSUMPTION BUILDING WORKSHOP TOP RANK HOTELS GALAXY, UTAKO, ABUJA NATION 23RD – 24TH JULY, 2012 S/ N NAMES DESIGNATION ORGANIZATION M/ F PHONE E-MAIL 1 Aminu Danmalam DPHC SMOH, Jigawa M 08032870914 aminudj@yahoo.com 2 Baba Gano Abiso DPHC SMOH, Borno M 08036136597 babagamabiso@yahoo.com 3 Baba Lamido DPHC SMOH, Bauchi M 08034371955 babalamido01@yahoo.com 4 Brian Serumaga Technical Advisor JSI M bserumaga@jsi.com 5 Chuks Okoh Log. Advisor USAID | DELIVER PROJECT M 08033482845 chuks_okoh@ng.jsi.com 6 Dr. Abba Paga DPS & Pharm. (PHCMB) SMOH, Yobe M 08034942012 abbapaga@yahoo.com 7 Dr. Abubakar Joshua Jifa DPHC SMOH, Gombe M 08039481970 joshdifa41@gmail.com 8 Dr. Akin Oyebade DPHC (Rep.) SMOH, Ogun M 08035389241 akinoyebade@yahoo.com 9 Dr. Akinsete O.O DPHC /DC SMOH, Ondo M 08034716192 yinkaakinsete@yahoo.com 10 Dr. C. J. Okoye DPHC /DC SMOH, Ondo M 08030864802 cjokoye@yahoo.com 11 Dr. C. N. Oluoha DPHC SMOH, Abia M 08037430167 coluoha2@yahoo.com 12 Dr. C.S. Amuebewomo DPHC SMOH, Edo M 08023346778 dramiebenomocs@yahoo.com 13 Dr. Ejiro Ogheneaga DPHC /DC (Rep.) SMOH, Delta M 08036680784 drejiroaga@yahoo.com 14 Dr. Elias Pede DPHC SMOH, Plateau M 08032253662 pedeelias@yahoo.com 15 Dr. Hauwa Larai Goni DPHC SPHCMB, Yobe M 08034764623 hlgoni@yahoo.co.uk 16 Dr. Igweagu C.P. DPHC/DC SMOH, Enugu M 08034075753 cpigweagu@yahoo.com 17 Dr. Ileke Joshua DPHC SMOH/SPHDA, Ekiti M 08062267648 joeileke2004@yahoo.com 18 Dr. J. Adze DPHC (Rep.) SMOH, Kaduna M 08037871472 joeladze@yahoo.com 19 Dr. John Duing HRH Advisor USAID M 07057995224 jduing@usaid.gov 20 Dr. John Ihebereme DPH/PHC SMOH, Imo M 08033385998 johnihebereme@yahoo.com 21 Dr. Lawal A. Rabeh DPHC SMOH, Kastina M 07033849404 drdandakyal@yahoo.com 35 22 Dr. Moh’d A. Ndagi DPHC SPHCDA, Niger M 08038909553 ndagimoh2006@yahoo.com 23 Dr. Ngozi Njepuome Independent Consultant Regia Resources Int. Ltd. F 08056010204 ngonjep@yahoo.com 24 Dr. O. Oyelaken DPHC SMOH, Oyo F 08053721414 toyelaken@yahoo.co.uk 25 Dr. Oguntoye Michael S. DPHC SMOH, Kwara M 08038403481 ogunski2001ng@yahoo.com 26 Dr. Oyinbo Manuel Newborn Health Advisor Save the Children M 07032947262 m.oyinbo@scuknigeria.org, omooyinbo@yahoo.com 27 DR. S.O. Ihinmikaye Ag. DPHC SMOH, Kogi M 08163564191 samtoyinn2006@yahoo.com 28 Dr. Z. Y.Umar DPHC SMOH, Nasarawa M 08037867793 zakariumar@gmail.com 29 Elizabeth Obaje Snr. Log. Advisor USAID | DELIVER PROJECT F 08033286917 elizabeth_obaje@ng.jsi.com 30 Emi Anakhuekha Program. Associate UNFPA M 08073893001 anakhuekha@unfpa.org 31 Eric Takang Regional Mgr. JSI M etakang@jsi.com 32 Ismail Abdulraham Log. Advisor USAID | DELIVER PROJECT M 08034535197 ismail_abdulraham@ng.jsi.com 33 James Haruna Log. Advisor USAID | DELIVER PROJECT M 08036130715 james_haruna@ng.jsi.com 34 Jerry Okoh Program Associate USAID | DELIVER PROJECT M 08035992273 jokoh@ng.pfscm.org 35 Lucy B. Enakirerhi DPHC /DC SMOH, Cross-River F 08036000622 divineri1@yahoo.com 36 Mario R. Sheriff FP State Coord. SMOH, Sokoto F 08067846830 merorabiu@yahoo.com 37 Maxwell Samson DPHC SMOH, Rivers M 08033366273 samsonmaxwell@gmail.com 38 Michael Egharevba Snr. Quant. Advisor USAID | DELIVER PROJECT M 08035973933 megharevba@ng.pfscm.org 39 Mr. Abah Alfred DPHC /DC (Rep.) SMOH, Ebonyi M 08032570090 allyabah@yahoo.com 40 Mr. Agba Angen DPHC (Rep.) SMOH, Benue M 08032479413 innogbaabgoo@yahoo.com 41 Mr. Oyelade Busola DPHC (Rep.) SMOH, Ogun F 08037229135 busabbey@yahoo.com 42 Mrs. M.O. Adetoro DPS (Rep.) SMOH, Oyo F 08136787112 mopsybw@yahoo.com 43 Mrs. Oladipo Ojo H.O DPHC (Rep.) SMOH, Lagos F 08023598161 dalatwins04@yahoo.com 44 Pastor Dan Michael DPS Office SMOH, Cross-River M 08023899838 pastordanlgm@yahoo.com 45 Pastor Vincent Bassey DPHC (Rep.) SMOH, Akwa-Ibom M 08023400768 vicebassy@yahoo.com 46 Pharm. (Dr.) Haruna Aliyu DPS SMOH, Niger M 08035905308 harunaaliyu01@gmail.com 47 Pharm. (Mrs.) A.A. Ojo DPS SMOH, Osun M 08034009610 ojoadepeju@yahoo.com 48 Pharm. (Mrs.) F.M.B. Salihu DPS SMOH, Kogi F 07035454565 fmbshayiodun@yahoo.com 36 37 49 Pharm. (Mrs.) Olileye A.A DPS (Rep.) SMOH, Lagos F 08023133291 nikadepharma@yahoo.com 50 Pharm. A.S. Gachi DPS SPHCDA, Kastina M 08036304655 gachipharm1174@yahoo.com 51 Pharm. Aje O.O AD (Pharm) FCT M 08066823001 oituje@yahoo.com 52 Pharm. Alao, Adebanjo J. DPFS SMOH, Kwara M 08033565742 adebanjoalao@yahoo.com 53 Pharm. Anne Amanze DPS SMOH, Imo F 08033324482 anamanze@yahoo.com 54 Pharm. C. O. Madubuike DPS SMOH, Abia M 08037798249 mon_norme@yahoo.com 55 Pharm. Chika Aneke DPS SMOH, Enugu F 08035260438 pharmchika@yahoo.com 56 Pharm. Doshu D. Nock DDPS SMOH, Kaduna M 08037012509 doshunock@gmail.com 57 Pharm. Edet Eniang DPS SMOH, Akwa-Ibom M 08035922110 eddieenian@yahoo.com 58 Pharm. G.E.Okonofoa DPS SMOH, Edo M 08097000657 dpsmph4all@yahoo.com 59 Pharm. H.M. Wakili DPS SMOH, Nasarawa M 08036019163 hawakili@yahoo.com 60 Pharm. M.I. Jalo DPS SMOH, Gombe M 0806048208 jalokun@yahoo.com 61 Pharm. Ojukwu O.N. Chief Pharmacist SMOH, Anambra M 08033324482 odemus2001@yahoo.co.uk 62 Pharm. Osunlaja Sule O. DDPS SMOH, Ogun M 08033447713 suleoyebanji@gmail.com 63 Pharm. Simeon I. Ityo DPS SMOH, Benue M 08064194919 ityosimeon@gmail.com 64 Pharm. Stephen Jasim DPS SMOH, Borno M 08035626010 jsn-stephen@yahoo.com 65 Pharm. Tongak Piwuna DPHC SMOH, Plateau M 08065540227 tongak.piwuna@yahoo.com 66 Pharm. Tukur Sanyinna DDPS SMOH, Sokoto M 08035051865 hannat10@yahoo.com 67 Pharm. Victor Chukwu DPS SMOH, Ebonyi M 08054183681 alcordpharm@yahoo.co.uk 68 Yusuf A. Musa DPHC SMOH, Jigawa M 08065722710 alhajiyusuf58@yahoo.com 38 Appendix B: Quantification Workshop 2 Participants List ATTENDANCE SHEET ACTIVITY: 2nd MNCH QUANTIFICATION WORKSHOP VENUE: TOP RANK HOTELS GALAXAY, UTAKO, ABUJA DATE: 24TH AUGUST, 2012 S/N NAMES DESIGNATION ORGANIZATION M/F PHONE E-MAIL 1 Adewara Juliana Consultant PATHS 2 F 0803858535(8)9 bukkyadewaea@gmail.com 2 Ajiboye Agnes Bolanle SFP Coordinator SMoH, Kwara F 08033617543 agnesajiboye@gmail.com 3 Aliyu Idris Asst. DPHC SMoH, Zamfara M 08139421141 idrisaliyu@yahoo.com 4 Auwai S. Noma Rep. DPHCDA Bauchi M 08028504568 Nisser.au@usa.net 5 Baba Gano Abiso DPHC SMOH, Borno M 08036136597 babagamabiso@yahoo.com 6 Brian Serumaga Technical Advisor JSI M bserumaga@jsi.com 7 Chuks Okoh Log. Advisor USAID | DELIVER PROJECT M 08033482845 chuks_okoh@ng.jsi.com 8 Dr. Akuro Okujagi DPH SMoH, Rivers M 08033101176 drakuro@yahoo.com 9 Dr. Alo I. S. Nutrition Specialist UNICEF M 080354351739 ialo@unicef.org 10 Dr. C. J. Okoye Chief Pharmacist SMOH, Anambra M 08030864802 cjokoye@yahoo.com 11 Dr. Igweagu C.P. DPHC/DC SMOH, Enugu M 08034075753 cpigweagu@yahoo.com 12 Dr. M. N. Mahmoud DPHC SMoH, Kano M 08037022026 mnmahmoud@yahoo.com 13 Dr. M.S. Labaran Exe, PHC SMoH, Sokoto M 08035072940 mslabaran2003@yahoo.com 14 Dr. Moh’d A. Ndagi DPHC SPHCDA, Niger M 08038909553 ndagimoh2006@yahoo.com 15 Dr. Ngozi Njepuome Independent Consultant for JSI Regia Resources Int. Ltd. F 08056010204 ngonjep@yahoo.com 16 Dr. Oguntoye Michael S. DPHC SMOH, Kwara M 08038403481 ogunski2001ng@yahoo.com 17 Dr. Oyinbo Manuel Newborn Health Advisor Save the Children M 07032947262 m.oyinbo@scuknigeria.org, omooyinbo@yahoo.com 18 Dr. Z. Y.Umar DPHC SMOH, Nasarawa M 08037867793 zakariumar@gmail.com 19 Ebue, G. J. DPS SMOH, Akwa-Ibom M 39 20 Elizabeth Igharo AD, Public Health USAID | DELIVER PROJECT F 08037348885 elizabeth_igharo@ng.jsi.com 21 Elizabeth Obaje Snr. Log. Advisor USAID | DELIVER PROJECT F 08033286917 elizabeth_obaje@ng.jsi.com 22 Emmanuel Sokpo Tech Admin – Health System PRRINN-MNCH M 08033177096 kmorenikeji@usaid.gov 23 Hannath F. Dung RHC SMoH, Plateau F 08036165837 hanyfrank@yahoo.com 24 Jerry Okoh Program Associate USAID | DELIVER PROJECT M 08035992273 jokoh@ng.pfscm.org 25 John_Durgavich DCOP USAID | DELIVER PROJECT M 08066180645 john_durgavich@jsi.com 26 Martala Bello DDPS SMoH, Sokoto M 08035327293 mbsilame@yahoo.co.uk 27 Marte A. DDPHS SMOH, Borno M 08030477009 marte_abubakar@yahoo.com 28 Mr. Abah Alfred DPHC /DC (Rep.) SMOH, Ebonyi M 08032570090 allyabah@yahoo.com 29 Mr. Oyelade Busola DPHC (Rep.) SMOH, Ogun F 08037229135 busabbey@yahoo.com 30 Musonda Kasonde Supply and Log. Specialist UNICEF F 07064189284 mkasonde@unicef.org 31 Okunmadewa Oluyemisi DFP Coordinator SMoH, Oyo F 08033244137 yokunmadewa@yahoo.com 32 Patricia E. Odeh FP Logistician SMOH, Delta F 33 Pharm Ali Adamu DPS SMoH, Kano M 08034321663 aliadamual@yahoo.com 34 Pharm J.O.Alade DPS SMoH, Ekiti M 08035057537 tundealadedanta@yahoo.com 35 Pharm. (Dr.) Haruna Aliyu DPS SMOH, Niger M 08035905308 harunaaliyu01@gmail.com 36 Pharm. (Mrs.) A.A. Ojo DPS SMOH, Osun M 08034009610 ojoadepeju@yahoo.com 37 Pharm. (Mrs.) F.M.B. Salihu DPS SMOH, Kogi F 07035454565 fmbshayiodun@yahoo.com 38 Pharm. Isah Moh’d Gusau DPS SMoH, Zamfara M 08065733795 gus_isah@yahoo.com 39 Rebecca Tarfa PP Coordinator SMoH, Adamawa F 08036431235 tarfabecky@yahoo.com 40 Risikat Bolanle Lawal Director, Pharmacy SMoH, Kwara F 08033576942 rblawal@yahoo.com 41 Vimal Kuma SLC PATHS 2 M 08039710072 v.kuma@paths2.org 40 Appendix C: Estimated Annual Cost of MNCH Commodity Requirements and Funding Gap Product Category Estimated Cost Ccommodities Current Funding Commitments Funding Gap Maternal Health Essential medicines $ 41,990,979 $ 10,161,817 $ 31,829,162 HIV/AIDS (inc. PMTCT) $ 34,368,766 $ 6,800,000 $ 27,568,766 Family planning $ 8,011,136 $ 11,350,000 (3,338,864) Malaria $ 13,412,000 $ 3,000,000 $ 10,412,000 Supplies $ 76,816,539 $ 18,589,602 $ 58,226,936 Sub-total $ 174,599,420 $ 49,901,419 $ 124,698,000 Child Health (1–59 months) Essential medicines $ 203,684,314 $ 49,291,604 $ 154,392,710 Vaccines $ 80,097,864 $ 58,391,251 $ 21,706,613 Malaria $ 100,059,976 $ 24,000,000 $ 76,059,976 Supplies $ 38,541,202 $ 9,326,971 $ 29,214,231 Nutrition $ 197,784,399 $ 150,000,000 $ 47,784,399 Sub-total $ 620,167,755 $ 291,009,826 $ 329,157,929 Newborns (0–1 months) Essential medicines $ 71,512,444 $ 17,306,012 $ 54,206,433 HIV/AIDS (PMTCT) $ 6,954,519 $ 695,452 $ 6,259,067 Supplies $ 11,597,118 $ 2,806,503 $ 8,790,615 Sub-total $ 90,064,082 $ 20,807,966 $ 69,256,116 $ 884,831,256 $ 361,719,211 $ 523,112,045 41 42 Appendix D: Maternal Health Commodity List for Nigeria MNCH Program Maternal Health Product Unit s Quantity Required Unit Price Extended Price ($) Subtotal ($) Total Cost ($) Anaemia medicines folic acid 5MG/tab TABLET (PO) tab 861,930,020 0.0023 2,165,127 4,745,430 ferrous salt 200MG/tab TABLET (PO) tab 861,930,020 0.0023 2,165,127 iron dextran 50MG/amp AMPOULE (INJ) amp 1,648,500 0.2306 415,176 supplies Blood Bags pcs 667,250 0.102 74,331 283,108 Giving Set IV pcs 70,650 0.09375 7,234 Giving Set Blood pcs 667,250 0.2342 170,671 Canula IV 18g pcs 70,650 0.3126 24,120 Syringe + Needle 5ml pcs 82,425 0.075 6,752 5,028,538 eclampsia medicines magnesium sulfate 500MG/vial VIAL (INJ) vial 1,802,360 0.0983 193,499 1,878,382 methyldopa 250MG/tab TABLET (PO) tab 32,437,770 0.0303 1,073,438 hydralazine 20MG/amp AMPOULE (INJ) amp 182,905 1.98749995 397,024 dextrose in water 50MG/ml SOLUTION (IV) ml 16,092,500 0.0009 15,818 calcium gluconate 100MG/amp AMPOULE (INJ) amp 80,463 2.25999999 198,603 supplies Giving Set IV pcs 64,370 0.09375 6,591 2,471,158 Antishock garment 2,416,099 Canula IV 20g pcs 64,370 0.3126 21,976 Syringe + Needle 5ml pcs 323,420 0.075 26,492 4,349,540 hemorrhage medicines oxytocin 10IU/amp amp 1,609,250 0.1495 262,753 1,111,886 43 AMPOULE (INJ) metronidazole 200MG/tab TABLET (PO) tab 9,655,500 0.0052 54,835 dextrose-normal saline 50MG+9MG/ml SOLUTION (IV) ml 96,555,004 0.0009 94,908 dextrose in water 50MG/ml SOLUTION (IV) ml 80,462,502 0.0009 79,090 Misoprostol 200MCG/tab TAB-CAP (PO) tab 724,163 0.78430003 620,300 supplies Chlorhexidine Surgical Scrub ml 4,023,125 0.00140325 6,166 673,401 Blood Bags pcs 193,110 0.102 21,512 Foley's Catheter 18g pcs 64,370 0.625 43,939 Examination Gloves pairs 1,931,100 0.0625 131,816 Face Masks pcs 965,550 0.00626 6,601 Giving Set IV pcs 643,700 0.09375 65,908 Giving Set Blood pcs 193,110 0.2342 49,394 Canula IV 20g pcs 643,700 0.3126 219,764 Suture chromic Catgut 1 pcs 128,740 0.25 35,151 Syringes + Needle 10ml pcs 321,850 0.1125 39,545 Urine Bag bags 32,185 0.025 879 Sanitary Pads pcs 1,931,100 0.025 52,726 1,785,287 Hyperemesis medicines dextrose in water 50MG/ml SOLUTION (IV) ml 117,750,006 0.0009 115,741 3,693,679 promethazine hcl 25MG/tab TABLET (PO) tab 33,558,751 0.0044 161,266 cyclizine 50MG/tab tab 1,766,250 0.122 235,340 promethazine 12.5MG/ml AMPOULE (INJ) ml 13,423,500 0.21699999 3,181,332 supplies Giving Set IV pcs 235,500 0.09375 24,113 881,522 Canula IV 18g pcs 235,500 0.3126 80,401 44 Syringe + Needle 2ml pcs 13,423,500 0.053 777,007 4,575,200 normal delivery medicines nifedipine 10MG/tab TABLET (PO) tab 2,747,500 0.0129 38,709 4,054,083 oxytocin 10IU/amp AMPOULE (INJ) amp 2,512,000 0.1495 410,152 metronidazole 200MG/tab TABLET (PO) tab 94,200,001 0.0052 534,980 sodium chloride 9MG/ml SOLUTION (IV) ml 1,256,000,037 0.001 1,371,744 sulfamethoxazole - trimethoprim 400MG+80MG/tab TABLET (PO) tab 75,360,004 0.0109 897,121 dexamethasone 4MG/amp AMPOULE (INJ) amp 2,001,750 0.0945 206,598 betamethasone 4MG/amp AMPOULE (INJ) amp 294,375 1.85000002 594,780 supplies Chlorhexidine Surgical Scrub ml 7,850,000 0.00140325 12,031 54,569,458 Cotton Wool Roll 392,500 0.1446 61,986 Examination Gloves pairs 4,710,000 0.0625 321,503 Giving Set IV pcs 6,280,000 0.09375 643,005 Canula IV 20g pcs 6,280,000 0.3126 2,144,036 Syringe + Needle 5ml pcs 1,962,500 0.075 160,751 Mama Kit pcs 6,672,500 7 51,011,743 Partograph pcs 6,280,000 0.03126 214,404 58,623,542 PMTCT medicines sulfamethoxazole- trimethoprim 800MG+160MG/tab TABLET (PO) tab 2,826,000 0.0225 69,445 31,193,294 3TC-AZT 150MG+300MG/tab TABLET (PO) tab 2,552,443 0.43250001 1,205,662 45 AZT 300MG/tab TABLET (PO) tab 14,506,800 0.20966667 3,321,885 3TC-AZT-EFV 150MG+300MG+600MG/tab TAB-CAP (PO) tab 12,011,630 0.37755555 4,952,977 3TC-AZT-ABC 150MG+300MG+300MG/tab TAB-CAP (PO) tab 290,136 0.46483332 147,293 Nevirapine 200MG/tab TABLET (PO) tab 94,200 0.357 36,728 Lopinavir-Ritonavir 200MG+50MG/tab TABLET (PO) tab 7,195,373 0.31499999 2,475,411 EFV-FTC-TDF 600MG+200MG+300MG/tab TAB-CAP (PO) tab 23,210,880 0.69733334 17,677,285 3TC-TDF 300MG+300MG/tab TAB-CAP (PO) tab 1,880,081 0.48500001 995,868 EFV 600MG/tab TABLET (PO) tab 1,880,081 0.15133333 310,738 31,193,294 Routine tests and immunizations medicines vaccine, tetanus toxoid 10ML/vial VIAL (INJ) vial 1,570,000 1.74000001 2,983,544 2,983,544 supplies Test, Syphilis VDRL Carbon Antigen TEST 7,850,000 0.30000001 2,572,021 6,176,750 Syringe + Needle 2ml pcs 15,700,000 0.053 908,781 Test, Hepatitis BSAg TEST 392,500 1.175 503,687 Pregnancy Test TEST 3,140,000 0.1192 408,780 Test, Hepatitis C, HCVScan (TM)Rapid test TEST 392,500 4.16049988 1,783,482 9,160,294 Sepsis and abortion medicines oxytocin 10IU/amp AMPOULE (INJ) amp 1,962,500 0.1495 320,431 16,008,147 ceftriaxone 1G/vial VIAL (INJ) vial 10,000,900 0.76319999 8,336,062 gentamicin sulfate 40MG/amp AMPOULE (INJ) amp 5,171,580 0.40401 2,281,912 46 47 metronidazole 200MG/tab TABLET (PO) tab 30,615,000 0.0052 173,869 dextrose in water 50MG/ml SOLUTION (IV) ml 1,020,499,992 0.0009 1,003,088 Misoprostol 200MCG/tab TAB-CAP (PO) tab 883,125 0.78430003 756,463 ampicillin-cloxacillin 250MG+250MG/caps CAP (PO) caps 40,820,000 0.063 2,808,646 metronidazole 5MG/ml VIAL (INJ) ml 61,230,000 0.0049 327,675 supplies Chlorhexidine Surgical Scrub ml 7,850,000 0.00140325 12,031 3,618,867 Foley's Catheter 18g pcs 628,000 0.625 428,670 Cotton Wool Roll 628,000 0.1446 99,177 Examination Gloves pairs 3,768,000 0.0625 257,202 Face Masks pcs 3,061,500 0.00626 20,931 Giving Set IV pcs 1,648,500 0.09375 168,789 Canula IV 20g pcs 1,020,500 0.3126 348,406 Syringes + Needle 10ml pcs 392,500 0.1125 48,225 Syringe + Needle 5ml pcs 3,768,000 0.075 308,642 Syringe + Needle 2ml pcs 2,355,000 0.053 136,317 Urine Bag bags 628,000 0.025 17,147 Chlorine based Cpd powder for soln 0.1% ml 12,560,000 0.00833333 114,312 Water for injection 10ml pcs 4,553,000 0.01875 93,236 Surgical Gloves size 8 pair 2,355,000 0.24379999 627,059 Sanitary Pads pcs 8,262,125 0.025 225,588 Izal ml 37,679,999 0.01732917 713,136 19,627,014 STDs medicines azithromycin 500MG/tab TABLET (PO) tab 2,331,450 0.62190002 1,583,544 2,694,190 penicillin, benzathine benzyl vial 223,725 0.242 59,131 48 2.4MU/vial POWDER (INJ) Cefixime 400MG/tab TAB- CAP (PO) tab 1,942,875 0.47409999 1,006,001 erythromycin 500MG/tab TABLET (PO) tab 659,400 0.0632 45,514 supplies Syringe + Needle 5ml pcs 626,430 0.075 51,312 51,312 2,745,502 surgical interventions medicines Amoxicillin 250MG/cap CAP (PO) cap 6,123,000 0.01716 114,753 7,911,380 oxytocin 10IU/amp AMPOULE (INJ) amp 785,000 0.1495 128,172 7,796,627 gentamicin sulfate 40MG/amp AMPOULE (INJ) amp 2,355,000 0.40401 1,039,122 metronidazole 200MG/tab TABLET (PO) tab 8,242,500 0.0052 46,811 dextrose in water 50MG/ml SOLUTION (IV) ml 863,500,002 0.0009 848,767 metronidazole 5MG/ml VIAL (INJ) ml 47,100,000 0.0049 252,058 halothane 10ML/each LIQUID (INH) each 113,825 3.10529995 386,033 amoxicilline 500MG/vial VIAL (INJ) vial 2,884,875 1.48500004 4,678,827 ketamine 50MG/vial VIAL (INJ) vial 1,259,925 0.0867 119,302 atropine sulfate 1000MCG/ml AMPOULE (INJ) ml 261,876 0.1 28,601 diclofenac 25MG/amp AMPOULE (INJ) amp 879,200 0.0708 67,984 pentazocine 30MG/amp AMPOULE (INJ) amp 219,800 0.1469 35,264 tramadol hydrochloride 100MG/amp AMPOULE (INJ) amp 1,538,600 0.0986 165,686 supplies Chlorhexidine Surgical Scrub ml 10,990,000 0.00140325 16,843 2,751,172 49 PVP Iodine ml 15,072,000 0.0069 113,580 Adhesive Plaster pcs 843,875 0.0125 11,521 Blood Bags pcs 62,800 0.102 6,996 Foley's Catheter 18g pcs 694,725 0.625 474,216 Face Masks pcs 1,648,500 0.00626 11,271 Gauze pcs 1,746,625 0.133 253,708 Giving Set IV pcs 843,875 0.09375 86,404 Giving Set Blood pcs 62,800 0.2342 16,063 Canula IV 20g pcs 1,000,875 0.3126 341,706 Surgical Blades Size 20 pcs 549,500 0.0625 37,509 Suture Chromic Catgut 0 pcs 549,500 0.25 150,035 Suture chromic Catgut 1 pcs 549,500 0.25 150,035 Syringes + Needle 10ml pcs 843,875 0.1125 103,685 Syringe + Needle 5ml pcs 1,177,500 0.075 96,451 Urine Bag bags 549,500 0.025 15,003 Water for injection 10ml pcs 1,099,000 0.01875 22,505 Surgical Gloves size 8 pair 2,814,225 0.24379999 749,335 Methylene Blue ml 157,000 0.5 85,734 Extra chromic suture 3 pcs 31,400 0.25 8,573 18,459,179 Family planning Condom Female 812,089 1.24 1,099,179 8,749,386.88 Condom Male 21,979,643 0.03 672,144 Depo Provera 1,210,518 0.75 989,835 Exluton/Microlut 716,586 0.46 358,832 IUD 459,951 0.41 208,319 Microgynon* 947,550 0.38 388,180 Noristerat 1,815,777 1.48 2,926,867 Implanon 53,100 19.44 1,127,281 50 Jadelle 45,861 18.84 943,549 Cycle Beads 26,881 1.20 35,200 8,749,387 Malaria IPTp (SP) 7,850,000 0.42 3,600,829 LLIN 1,011,500 10 11,047,129 14,647,958 Appendix E: Child Health Commodity List for the Nigeria MNCH Program Child Health Product Units Quantity Required Unit Cost Extended Price ($) Total ($) conjunctivitis medicines gentamicin solution 3MG/ml OPHT DROP (OPHT) ml 8,573,402 0.042 362,655 chloramphenicol 5MG/ml OPHT DROP (OPHT) ml 8,573,402 0.018 150,892 513,547 Burns medicines paracetamol 500MG/tab TABLET (PO) tab 1,714,680 0.004 6,687 metronidazole 25MG/ml SYRUP (PO) ml 7,201,657 0.004 32,407 sodium lactate compound 1ML SOLUTION (IV) ml 68,587,213 0.001 68,587 amoxicilline 25MG/ml SUSPEN (PO) ml 25,205,800 0.006 141,152 silver sulfadiazine 10MG/G CREAM (TOP) G 10,288,082 0.023 239,712 ibuprofen 20MG/ml SUSPEN (PO) ml 17,146,803 0.003 56,927 545,474 supplies Nasogastric tube size 8 pcs 685,872 0.219 150,206 235,957 Canula 22g pcs 342,936 0.156 53,601 Giving set IV pcs 342,936 0.094 32,150 Diarrhoea medicines dextrose-sodium chloride 40MG+1.8MG/ml SOLUTION (IV) ml 2,864,508,953 0.002 4,296,763 83,574,911 Oral Rehydration Salts 500ML/sachets POWDER (PO) g 229,160,713 0.060 13,657,978 Zinc Sulfate 20MG/tab TAB-CAP (PO) tab 1,604,124,990 0.038 60,315,099 darrow's half strength-dextrose 25MG/ml SOLUTION (INJ) ml 2,864,508,953 0.002 5,305,071 supplies Canula 22g pcs 45,832,143 0.156 7,163,564 11,460,327 51 Giving set IV pcs 45,832,143 0.094 4,296,763 Fever medicines 22,264,233 paracetamol 24MG/ml SUSPEN (PO) ml 2,921,815,344 0.004 12,563,806 ibuprofen 20MG/ml SUSPEN (PO) ml 2,921,815,344 0.003 9,700,427 Helminthiasis medicines Product 1,642,595 mebendazole 20MG/ml SUSPEN (PO) ml 77,160,619 0.009 702,162 mebendazole 100MG/tab TABLET (PO) tab 15,432,124 0.004 69,445 albendazole 400MG/tab TABLET (PO) tab 26,234,609 0.027 703,088 Albendazole 200MG/5ml SUSPEN (PO) ml 5,829,913 0.029 167,902 Vaccines medicines vaccine, polio 20ML/vial VIAL (PO) vial 6,858,721 0.410 2,812,076 80,097,864 vaccine, bcg 100MCG/10ml POWDER (INJ) vial 17,146,804 1.056 18,105,309 vaccine, meningococcal 10ML/vial VIAL (INJ) vial 2,057,617 17.490 35,987,712 vaccine, diphtheria-pertussis-tetanus 10ML/vial VIAL (INJ) vial 10,288,082 0.860 8,847,751 vaccine, hepatitis b 10ML/vial VIAL (INJ) vial 10,288,082 0.660 6,790,134 vaccine, measles 10ML/vial VIAL (INJ) vial 3,429,361 0.470 1,611,800 vaccine, yellow fever 10ML/vial VIAL (INJ) vial 3,429,361 1.733 5,943,082 Measles medicines 1,033,381 paracetamol 24MG/ml SUSPEN (PO) ml 22,290,845 0.004 95,851 paracetamol 500MG/tab TABLET (PO) tab 2,229,085 0.004 8,693 amoxicilline 25MG/ml SUSPEN (PO) ml 23,405,387 0.006 131,070 amoxicilline 50MG/ml SUSPEN (PO) ml 23,405,387 0.007 175,540 vitamin a 60MG/tab TABLET (PO) tab 1,337,451 0.032 42,665 calamine 1ML/ml SOLUTION (TOP) ml 89,163,380 0.007 579,562 meningitis medicines 4,042,798 gentamicin sulfate 40MG/amp AMPOULE (INJ) amp 24,084,389 0.040 965,784 penicillin, procaine-benzyl penicillin vial 836,762 0.244 204,170 52 53 3MU+1MU/vial POWDER ceftriaxone 250MG/vial VIAL (INJ) vial 6,384,098 0.450 2,872,844 Nutritional anaemia medicines ferrous salt 20MG/ml SUSPEN (PO) ml 9,272,991,458 0.006 58,419,846 70,210,455 ferrous salt 200MG/tab TABLET (PO) tab 1,390,948,753 0.002 3,199,182 folic acid 5MG/tab TABLET (PO) tab 2,202,335,411 0.002 5,065,372 vitamin, multi 1MG/tab TABLET (PO) tab 104,321,154 0.004 396,420 vitamin, multi 1ML/ml SYRUP (PO) ml 521,605,770 0.006 3,129,635 supplies Canula 22g pcs 4,636,496 0.156 724,684 1,267,618 Giving set Blood pcs 4,636,496 0.117 542,934 palliative care medicines 7,936,570 paracetamol 24MG/ml SUSPEN (PO) ml 514,404,113 0.004 2,211,938 ibuprofen 20MG/ml SUSPEN (PO) ml 180,041,436 0.003 597,738 diclofenac 25MG/amp AMPOULE (INJ) amp 34,293,608 0.149 5,126,894 ARTI medicines paracetamol 24MG/ml SUSPEN (PO) ml 488,683,908 0.004 2,101,341 11,109,935 gentamicin sulfate 40MG/amp AMPOULE (INJ) amp 23,456,827 0.040 940,619 amoxicilline 25MG/ml SUSPEN (PO) ml 136,831,496 0.006 766,256 amoxicilline 50MG/ml SUSPEN (PO) ml 169,410,422 0.007 1,270,578 ceftriaxone 250MG/vial VIAL (INJ) vial 5,212,628 0.450 2,345,683 amoxicilline-clavulanic acid 25MG+6.2MG/ml SUSPEN (PO) ml 9,505,677 0.233 2,218,625 amoxicillin 50MG/ml VIAL (INJ) vial 13,058,254 0.112 1,466,834 supplies Nasogastric tube size 8 pcs 5,212,628 0.219 1,141,566 4,765,645 Syringe + Needle 2ml pcs 11,728,414 0.059 691,976 Syringe + Needle 5ml pcs 39,094,712 0.075 2,932,103 54 Appendix F: Neonatal Health Commodity List for the Nigeria MNCH Program Neonates Medicines Product Units Quantity Required Unit Cost Extended Price ($) Total Cost ($) Birth asphyxia medicines dexamethasone 5MG/amp AMPOULE (INJ) amp 1,311,731 0.082 107,300 supplies Syringe + Needle 2ml pcs 4,372,435 0.053 231,739 candidiasis nystatin 100000IU/ml SUSPEN (PO) ml 473,680 0.028 13,453 diarrhoea medicines darrow's half strength-dextrose 25MG/ml SOLUTION (INJ) ml 1,311,730,664 0.002 2,429,325 2,645,411 Oral Rehydration Salts 500ML/sachets POWDER (PO) sachets 874,487 0.060 52,119 sodium lactate compound solution 500ML SOLUTION (IV) ml 2,623,461 0.063 163,966 supplies Canula 24g pcs 4,372,435 0.313 1,366,823 2,186,655 Giving set IV pcs 4,372,435 0.188 819,832 conjunctivitis medicines chloramphenicol 5MG/ml OPHT DROP (OPHT) ml 1,795,613 0.193 346,553 508,159 gentamicin solution 3MG/ml OPHT DROP (OPHT) ml 5,386,840 0.030 161,605 Jaundice medicines amoxicilline-clavulanic acid 100MG+5MG/ml VIAL (INJ) ml 102,023,490 0.460 46,930,804 48,023,913 dextrose-sodium chloride 25MG+4.5MG/ml SOLUTION (IV) ml 728,739,211 0.002 1,093,109 supplies Blood bag pcs 2,186,218 1.020 2,229,942 4,928,609 Canula 24g pcs 4,372,435 0.313 1,366,823 Giving set Blood pcs 2,186,218 0.234 512,012 Giving set IV pcs 1,457,478 0.188 273,277 Syringe + Needle 5ml pcs 7,287,392 0.075 546,554 55 meningitis medicines ceftriaxone 250MG/vial VIAL (INJ) vial 464,207 0.450 208,893 316,300 dextrose-sodium chloride 25MG+4.5MG/ml SOLUTION (IV) ml 67,499,470 0.002 101,249 penicillin, g sodium 5MU POWDER (INJ) vial 14,921 0.272 4,053 gentamicin sulfate 10MG/amp AMPOULE (INJ) amp 53,289 0.040 2,105 supplies Canula 24g pcs 120,789 0.313 37,758 161,897 Giving set IV pcs 120,789 0.188 22,648 Nasogastric tube pcs 7,105 2.180 15,489 Syringe + Needle 2ml pcs 483,154 0.053 25,607 Syringe + Needle 5ml pcs 805,257 0.075 60,394 Pneumonia medicines amoxicilline-clavulanic acid 25MG+31MG/ml SUSPEN (PO) ml 32,902,576 0.023 746,888 1,099,416 ceftriaxone 250MG/vial VIAL (INJ) vial 783,395 0.450 352,528 supplies Syringe + Needle 5ml pcs 783,395 0.075 58,755 58,755 Tetanus medicines dextrose-sodium chloride 25MG+4.5MG/ml SOLUTION (IV) ml 76,517,618 0.002 114,776 286,666 diazepam 5MG/amp AMPOULE (INJ) amp 459,106 0.072 32,872 penicillin, g sodium 5MU POWDER (INJ) vial 107,125 0.272 29,095 phenobarbital 100MG/amp AMPOULE (INJ) amp 38,259 0.275 10,521 tetanus antitoxin 1500IU/amp AMPOULE (INJ) amp 102,023 0.974 99,401 supplies Canula 24g pcs 153,035 0.313 47,839 87,347 Giving set IV pcs 153,035 0.188 28,694 Syringe + Needle 2ml pcs 204,047 0.053 10,814 respiratory distress medicines dexamethasone 5MG/amp AMPOULE (INJ) amp 16,323,758 0.082 1,335,283 1,335,283 supplies Syringe + Needle 5ml pcs 8,161,879 0.075 612,141 612,141 neonatal sepsis medicines ceftriaxone 250MG/vial VIAL (INJ) vial 495,543 0.450 222,994 9,541,179 56 57 darrow's half strength-dextrose 25MG/ml SOLUTION (INJ) ml 371,657,018 0.002 688,309 dextrose-sodium chloride 25MG+4.5MG/ml SOLUTION (IV) ml 743,314,035 0.002 1,114,971 gentamicin sulfate 10MG/amp AMPOULE (INJ) amp 2,973,256 0.040 117,444 ampicillin-cloxacillin 125MG+125MG/5ml SOLUTION (PO) ml 9,910,854 0.746 7,397,462 59 For more information, please visit deliver.jsi.com. D USAID | DELIVER PROJECT John Snow, Inc. 1616 Fort Myer Drive, 16th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: askdeliver@jsi.com Internet: deliver.jsi.com

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