Report on multi-country study on external monetary incentive policies for community volunteers in Kano State, North Western zone, Nigeria

AFRICAN PROGRAMME FOR ONCHOCERCTASTS CONTROL (APOC) Report on Multi Country Study on External Monetary Incentive Policies for Community Volunteers in Kano State, North Western zone, Nigeria By Dr Elizabeth Elhassan (Principal Investigator) Country Representative Sightsavers International Kaduna, Nigeria Dr T. I. Oyeyi (Co Principal Investigator) Associate Professor Department of Microbiology Bayero University Kano, Nigeria Miss B. Oyeyi (Research Assistant) Department of Economics Bayero University Kano, Nigeria r.I Mr Y. Sani (Research Assistant) Field Offïcer Sightsavers International Kaduna, Nigeria August 2007 i I l \ \-_ \ i1 )tï 1 J $EP, ?fln: (.()(i,r q.I1.:-:- J 4 ,7 .7 ,.7 .8 I TABLE OF CONTENT Acronyms Summary. INTRODUCTION. l.l Rationale for the study. 1.2 OperationalDefinitions 1.3 ResearchQuestions. STUDY OBJECTIYES 2.1 Main Objectives ... 2.2 Specific Objectives 3 METHODOLOGY 3.1 StudyDesign.............., 3.2 Study Sites.................. 3.3 Research Team........... 2 9 tI 9 3.4 3.5 3.6 3.7 3.8 3.9 3.10 3.11 Data Collection Instruments.. Advocacy /Pre-fi eld Visits.... Source of Information........... Data Collection.......... 3.7.1 Instruments ............... 3.7.2 Data Collection Techniques.........., Data Processing and Analysis.... Quality Control Measure.... Organisational of Field V/ork......... Study Limitations 4. 5. 6. 7. 8. 9. DISCUSSIONS.......... SCHEDULE............... RESULT AI\[D DISCUSSIONS oBJECTrvES.......... CONCLUSIONS...... RECOMMEDATIONS.......... APPENDrCES................... REFERENCES.................. t2 l3 26 29 30 30 .............3 I .,.,......,..47 l0 ll 2 o ... ...... ... , . ...1 1 .....12 l0 t2 12 ...........12 ,...........12 ACROIYYMS APOC Asap CDD CDTI EPI HIV/AIDS ITN LGA MoH MoU NGO TJNICEF wHo UN vHw IYHS RII IMCI TBL HE EMIs FOMWAI\ WOFAI\ ICC PHC NPI DFID CHR SUDIC GHON SFH COPOP SWAAII SWATCH FHI GHAIN YOSPIS EU PATHS IDH NMA African Programme for Onchocerciasis Control As soon as possible Community Directed Distributors o f Ivermectin Community Directed Treatment with Ivermectin Expanded Programme for Immunisation Human Immunodefi ciency Virus/Acquired Immunodeficiency S yndrome Insecticide-Treated Net Local Government Area (in Nigeria) Ministry of Health Memorandum of Understanding Non-Govemm ental Organisation United Nations Children's Fund World Health Organisation United Nations Voluntary Health Worker Integrated Village Health Services Reproductive Health Integrated Management of Childhood Illness Tuberculosis and Leprosy Health Education Extemal Monitoring Incentives Federation of Moslem'Women Association in Ngeria 'Women Farmers' Advancement Network International Coordinating Committee Primary Health Centre National Polio Immunisation Department for International Development Community Health Research Sustainable Development Initiative Centre Grass Root Health Organisation of Nigeria Society for Family Health Council of Positive People Society for'Women and AIDS in Africa Support for Women and Teenage Children Family Health International Global HIV/AIDS Initiative Youth Society for Prevention of Infectious Diseases and Social Vices European Union Partnership for Transforming Health System Infectious Disease Hospital National Medical Association _e J Summary The health services in developing countries are often unable to cope with high demand for health care delivery, thus the increasing dependence on community involvement and the use of volunteers to help provide these services. The organisations involved in community-based programmes, determine the degree and type of community involvement. The volunteers of Onchocerciasis control (CDDs) are involved in census, distribution, record keeping and management of side effects. Many were motivated not by monetary incentives but by recognition, self-esteem and skills acquired. Eighÿ two percent (82%) of CDDs were involved in additional health and development actiüties in their communities. Some are reported to be involved in as many as six additional actiüties (Homeida et.al. 2002; Okeibunor et. al. 2004). The main activities they were involved in wer.e expanded programme on immunisation (EPI), community development projects, water and sanitation and agriculture. Over time, the use of community volunteers has been on the increase as well as extemal monetary incentives. The multi country study general objective set out to documenl the policies on external monetary incentives for community volunteers by different health programmes, the determinants of these policies and to what extent they overlap at the implementation level. Seven specifu objeaives of documenting any general policy at the national level (states/provinces) on extemal monetary incentives for community volunteers in the health, HIV/AIDS, agriculture and water sectors; policies of the different health programmes for community volunteers (type, monetary value and frequency) involvement of communities in setting these incentives and the rationale for the policies and the role of donors in influencing these policies. Other objectives were the curuent and potentiaUfuture overlap of these health prograrnmes in the different districtsllGAs; whether programmes have policies on using volunteers selected for other health programmes and how they deal with incentives in such cases; coordination/harmonisation of incentive policies and practices among different health programmes at national and state/provincial levels and compare extertnl monetary incentive policies in different countries (existence; range; and uniformiÿ of donors' and programmes' policies). The results showed that at the national level, 3 of 4 ministries (health, agriculhre and environment) use community volunteers. Two of 3 ministries; agriculture and environment had general policies on external monetary incentives. At the programme level, miniss of health did not have a general policy. We talked to 68 programme staff under 11 health issues. Of these, 45.6% had policies to provide external monetary incentives. Twenty two percent prescribed that incentives be given while another 22o prescribed that incentives should not be given. Cash and in - kind incentives were provided. Stipends (14.7%) accounted for the most followed by transport (7.4%). Other §pes were minimal. The major in-kind were also small and bicycles which were the most frequent type of incentive made np 5.9oÂ. At the state level, there was a general policy on external monetary incentives which prescribed that monetary incentives are given. At prograûrme level, 93.8% of progrimlmes had policies. Majority (81yc) prescribed that monetary incentives are given. The monetary incentives were cash, in - kind or both with cash accounting for most frequent spe. Transport made tp 78Yo, stipend (34%) and per diem (18.8olo) were the 4 major types of cash incentives. The major tlpes of in - kind incentives were non substantial items (71.9%). High monetary items such as bicycle, motor bicycle and radio were minimal and accounted for 15.5%o. Only 4l% of communities were involved in setting the incentives. Donors influence in setting the incentives was minimal. Nine donors (28%) influenced the policy of which a donor made it a funding condition (3%) and 8 (25%) convinced partners to pay incentives. The main role played by donors was an indirect role of providing funds for the incentives (81%). There was overlap of programmes in every LGA. The range of current overlap was ll - 19 with a mean of 13.8. The average current incentive overlap per LGA was $3,074.8 per LGNyear. This 5 fold the state annual minimum wage of $589.2. The implications for sustainability of health care delivery should donor funding cease are immense. Only 7 partners gave their future plans because of funding constraints. The range of future overlap of programmes \ryas 18 -24 with an average oî20. asing community volunteers of other programmes was common at national level. Twenÿ eight programmes (87.5%) had policies which prescribed doing so to avoid conflict and promote integration. The policies were formulated by all partners (donors, government, state and LGA). The rationale for the policy was to ensure cost- effectiveness, reduce attrition and promote integration. Fewer prograürmes (55.6%) had policies for dealing with sharing volunteers. The policies prescribed volunteers sharing programme incentives. The majority of incentives (56.3%) were higher and an equal number were either atpar or lower. At the state level, several prograûrmes used the volunteers of other programme. The majority of programmes (81.3%) had policies to use volunteers of other prograûrmes. The policies were formulated by partners (MoH, LGAs, Programme Mangers, NGOs, Donors, Associations of NGOs working on HIV/AIDS, Donor coordination forum at the State and ICC working group for Immunization). The policies prescribed using available human resource, integration, net working, negotiating or harmonising incentives and payment of organisational rate. The community leaders, volunteers and progrzülme staff were often not involved in setting these policies. The rationale for the policies was motivation, improving services, integration into PHC and promoting sustainability. The rationale for not having the policies was to promote self. At the national level, 29o of programmes discussed coordination/trarmonisation of incentives and 16.2%o harmonised incentives at the national level. At the state level, 43.8% ofprogrammes held discussions while 31.3% harmonised policies. The donor spread of extemal monetary incentives was widest in reproductive health/Safe motherhood. The 4 donors provided incentives in the range of $24.4 - I,603.7 while MoH gave its volunteers the second lowest incentive of $59.2. This was followed by HIVIAIDS where the 9 donors gave incentives in the range of $45.3 -I,291.2. Ministry of Health did not provide volunteers incentives. The 4 donors of immunisation offered 5 t incentives in the range of $60.4 - 461.4; Ministry of Health did not provide incentives while NPI gave $56.5. Tuberculosis and nufition had no donors but MoH offered volunteers $483.2 and $90.6 respectively. In conclusion, majority of partners implementing health programmes and the big donor funded programmes at the state level i.e. Immunisation, HIV/AIDS, Malaria, Reproductive Health, Nutrition and TB/Leprosy had policies. Among partners with polices, there was no uniformity in its application despite the parLners in the state being members of the Association of Kano NGOs and implementers. It is recommended that a Phase 2 study be carried out to ascertain the outcome of the Phase I study at the community level, determine if the policies are reflected in practice at the community level, extent of community involvement in setting policies, harmonisation, perception of volunteers and community members. Introduction Rationale for the study The health services in developing countries are often tmable to cope with high demand for health care delivery, thus the increasing dependence on community involvement and the use of volunteers to help provide these services. The organisations involved in community-based programmes, determine the degree and t5pe of communiÿ involvement. The communiÿ-directed fieatment with ivermectin (CDTI) is a stategy in which communities are responsible for managing and implementing their own programme, selection of community-directed distributors (CDDs) and deciding the type of incentives (monetary and non monetary) to provide to volunteers. CDTI promotes active community participation and decision-making as a means of improving access to the drug and promoting a sense of responsibility, ownership and sustainabiliÿ (Amazigo et. al. 2002). The CDDs are involved in census, distribution, record keeping and management of side effects. Many are motivated not by monetary incentives but by recognition, self-esteem and skills acquired. Eighÿ two percent (82%) of CDDs are involved in additional health and development activities in their communities. Some are reported to be involved in as many as six additional actiüties (Homeida et.al.2002; Okeibunor et. al. 2004). The main actiüties they were involved in were expanded programme on immunisation (EPD, community development projects, water and sanitation and agriculture. Integration of various community-based prograrrunes will proüde opportunities for improved health care delivery and enhance their effectiveness and sustainabiliÿ (Okeibunor et. at,2004). Other externally funded conftol prograrnmes such as EPI, Vitâmin A distribuüon and family planning proüde volunteers with monetary incentives. In EPI, the polio eradication programme uses the campaign strategy to improve vaccination coverage and thus the payment of incentives. CDDs involved in EPI were more motivated for EPI activities than for CDTI and other activities they were involved in. This creates problems for volunteers in communiÿ-based programmes where incentives are not provided (Amazigo et. al. 2002). Also, CDTI technical project reports from various countries have attributed CDD attrition to monetary incentives proüded by other programmes (Okeibunor et. al. 2004). Partrsrs are therefore being encouraged to discontinue provision of incentives. A case study of incentives in the Mali health system reported a dissonant situation in which each programme implemented its own incentive policy. There was a lack of coordination a 6 of policy and a considerable dependence on external funds in most of the 14 health programmes supported by various parûrers (MOH, NGOs and UNICEF) in the country (Remme 2005). According to the study, incentives could therefore affect volunteerism, effectiveness of community involvement, coverage and sustainability. Cameroon has an incentive policy in which volunteers involved in the distribution of Mectizan@ are paid by government. There is however, a dearth of information on incentive policies and practices in other countries. To understand the extent of the incentive problem in Nigeria, APOC and National Programme on Immunisation agreed to a joint research study. The idea was later extended to include other APOC countries, namely Cameroon, Ethiopia and Uganda. This multi country study sets out to document the policies of external monetary incentives for communiÿ volunteers by different health prograrnmes, the determinants of these policies and to what extent they overlap at the implementation level, in the first phase. Based on the outcome of Phase I study, a second phase study will be carried out to determine the practices and perceptions at the communiÿ level with respect to external monetary incentives. The outcome of these studies could inform policies and practices on incentives for community-based programmes. 1.2 Operational Definitions Community Health Volunteers: Members of the community who are engaged to perform or offer to perform services at their own free will with or without monetary or in kind incentives. Donors are institutions that voluntarily support funding and may or may not be involved in direct proüsion of services. External Monetary Incentives: rewards/remunerations given to volunteers on ad hoc or regular basis by health and other programs in the form of cash or in-kind (such as bicycles, motorcycles, radios, ITNs and others) to motivate effort and encourage volunteers to improve and sustain their performance in the communiÿ. Health Programme: projects or activities organised by MOH, NGOs and other institutions to proüde preventive, curative, promotive or rehabilitative health services to the communiÿ through communiÿ volunteers. They include health and health related serÿices proüded, supervised and regulated by the MOH of a given country. NationaVGeneral Incentives Policies: formal statements of policy developed by govemment that guides the decisions and actions pertaining to proüsion of incentives to community volunteers. Non-Government Organisations §GOs) are non-profit organisations that are involved in proüsion, promotion or supporting the proüsion of services to the community that are not part of government bureaucracy, political parties or business community. Programme Incentives Policies: formal statements (written and non-written) of policy developed and endorsed at health programs level (MOH, NGOs, other institutions) that guide the decisions and actions pertaining to provision of incentives to communiÿ volunteers. Programme Overlap: health prograrmnes are said to overlap when their intervention areas coincide geographically at district (LGA) level. By district, we mean the next administrative level after the sub-national one (i.e. Naüonal - Regional/Provincial - District). 7 1.3 Research questions What are the policies of different health programmes relating to external monetary incentives for communiÿ volunteers? What are the determinants of policies of different health prograrnmes relating to extemal monetary incentives for communiÿ volunteers? Where do the policies of different health progranrmes relating to extemal monetary incentives for community volunteers overlap at the implementation level? a a a 2. Study Objectives 2.1 Main Objective To document the policies on external monetary incentives for community volunteers by different health programmes, the determinants of these policies and to what extent they overlap at the implementation level. 2.2 Specific objectives To document any general policy at the national level (states/provinces) on external monetary incentives for community volunteers in the health, HIV/AIDS, agriculture and water sectors. To document the external monetary incentive policies of the different health programmes for community volunteers, including the type, monetary value and frequency of the incentive provided, as well as the involvement of communities in setting these incentives. To determine the rationale for the above policies and the role of donors in influencing these policies. To determine the current and potentiaVfuture overlap of these health programmes in the different districts/LGAs. To determine whether programmes have policies on using volunteers selected for other health programmes and how they deal with incentives in such cases. To document any coordination/trarmonisation of incentive policies and practices among different health programmes at national and state/provincial levels. To compare external monetary incentive policies in different countries (existence; range; and uniformity of donors' and programmes' policies). o a o o a 8 r] o 3. Methodology 3.1. Study Design This phase of the multi-country study concentrated on documenting the existing extemal monetary incentive policies for the different community-based prograflrmes using community volunteers in frve APOC-selected countries, namely; Cameroon, Ethiopia, Nigeria and Uganda. The employed a qualitative approach, using checklists and document reviews. 3.2 Study Sites The study started with the national level, after which one state from each of the six (6) geopolitical zones was selected. This report represents the findings in Site 2; one of six (6) study sites from Nigeria. Selection of site: Kano State being the state with the most overlapping progrilnmes at the national level in the north western geopolitical zone was selected as the study site. 3.3 Research Team The study site had a principal investigator (PI), one co-investigator and two research assistants. Preference was given to persons with research experience. The team members were trained in data collection techniques, familiarised with the objectives of this study and role plays were held. 3.4 Data collection instruments The checklist and the document review guide were pre-tested before its use for data collection. 3.5 Advocacy/Pre-Iield visits APOC formally informed the Ministry of Health (MOH) of Nigeria and requested its cooperation, as well as that of other relevant ministries and government agencies at national and state/provincial levels. The letter from Federal Ministry of Health was received after the study at the national level. The study commenced with consultations between the six (6) country research teams and relevant staff of ministries of Nigeria. The consultations were aimed at explaining the significance of the study to key stakeholders in the relevant ministries and soliciting their support. The samo procedure was repeated for the Kano State Ministry of Health. Also no letter to facilitate the process at the state level was received from Federal Minis§ of Health. 3.6 Sources of information This first phase of the study information was collected from the national and state levels. At the national level, responsible staff of Ministries of Health, Agriculture, Water, goverTrment agencies, national and intemational NGOs and donors were consulted about the existing policies, their rationale as well as interpretations of these policies. Some 9 I community-based prograûrmes did not have national offices and we had to get information about them at the state level. The Nigerian research teams visited the three ministries (Health, Agriculture and V/ater) to compile the list of all community - based prograrnmes at the national level. All the different NGOs both national and international involved or supporting these programmes was identified. The key staff in these different organisations was consulted to share their policies regarding the issues of external incentives to volunteers. All relevant programme documents were reviewed. 3.7.Data collection 3.T.l.Instruments Checklists I and 2: Two checklists were used to collect information related to the specific objectives of the study, at the national and state levels for availability and provision of policies. Checklist 3: A document reüew guide was used for the content analysis of the relevant documents, such as policy documents, MoIJs, technical reports, work plans, minutes of meetings and other materials. 3.7.2 Data collection technique National level: Data was first collected at the national level using Checklists 1 and 2, the investigators collected data from all relevant sources identified in a face-to-face interaction and examined supporting documents. After the collection, the states for the study were selected from each geopolitical zone based on overlap of community-based prograrnmes. State level: At state level, also using Checklists I and 2, we collected data from all relevant sources identified in a face-to-face interaction and examined supporting documents. 3.8 Data processing and analysis Following data collection, the data was cleaned and open-ended responses were coded. Data was entered using Epi Info and later exported to the SPSS programme for analysis. Logical checks and frequency nms were made on all variables to improve the accuracy and consistency of the data and identiÿ any outliers before data analysis. Frequency tables, descriptive statistics, graphs and charts were used to present the findings. Results obtained from the qualitative data were reported in prose. 3.9 I Quality control measures Quality confrol was ensured through the following:o 10 o Pre-testing of the insüuments a a O Research assistants with research experience were recruitrnent. Training the research assistants in data collection techniques. Editing of the completed checklists was done after each successive fieldwork to ensure that the accurate response has been properly recorded. The principal investigator, throughout the entire data collection period, supervised the research assistants. The research team kept field diaries to record study activities. a I a 3.10. Organisation of Fieldwork ln conducting the fieldwork, the following steps were undertaken: At National level, the Ministries of Health, Agriculture, Environment and Water Resources were visited for the list of health, water, environment and agricultural programmes using community volunteers. Checklist I was applied. At National level, the Ministries of Health, Agriculture and 'Water for the list of health, water and agricultural prograrlmes using community volunteers. Checklist 7 was applied Also government agencies were visited for a list of their programmes using community volunteers. Checklist 1 was not applied to these informants. Instruction for each visit: Administrative clearance was obtained at the national level from the Minister of Health. A list of programmes with community volunteers was obtained from the policy makers at the national level. Using the above list (1b) all health prograrnmes/agencies using community volunteers were visited and Checklist 2 was applied to each of these programmes. From each progrruilne, the list of its major partners in implementation: UN agencies, national and Intemational NGOs were obtained. From each prograrnme, the list of its major financial partners (donors) was obtained. Checklist 2 was applied (tnstrument 2) to the prograrnme managers in National NGOs, Intemational NGOs and UN agencies using community volunteers. 11 The Document review guide was applied (Instrument 3) to all policy-related documents obtained. 3.11. Study Limitations The state study areas were purposively chosen in order to capture the maximum number of progralnmes at the state. The results may therefore be skewed and not entirely representative. The choice of only one state per geopolitical zone in Nigeria meant that the study was not exhaustive and has excluded states with other community-based programmes of interest. There may be gaps in the steps to follow to determine which prografirmes use communiÿ volunteers, as the informants might not know all the programmes concerned (especially non-governmental). Although the focus of the study is on health programmes using communiÿ volunteers, documentation of which Agriculture, Enüronment and Water programmes using communiÿ volunteers was made. The biased decision to include these three sectors was based on publications on other development activities in which CDDs were involved (Okeibunor et al; 2004) and on the experience of the participants. Since it was not considered to be feasible to visit all government ministries and agencies that might use communiÿ volunteers, the decision was made to confine the study to health, with some insight into the Agriculture, Enüronment and Water sectors. Nevertheless, this bias and confinement were limitations in terms of comprehensiveness. 4. Schedule Activities Dates/I)eadline l. Pre-testing of instruments 28 July 2006 2. Finalising the protocol 29 Jaly2006 3. Submission of protocol (to APOC) 3l July 2006 4. Approval and signing of APW (Agreement for Performance of Work) 15 August 2006 5. Recruit team members 15 August 2006 6. Advocacy/Administrative clearance (national and sub-national level) August - November 2006 7. Release of funds (check with APOC) 10 September2006 8. Reproduce instruments 14 September2006 9. Training of team members §ational and State) October and November 2006 I 0. togistics (e. g. transport, appointments) August - October 2006 11. Data collection at national level 8 - 13 October 2006 12. Data collection at state/provincial level 6 - 10 November 2006 14. Data entry and cleaning 20 -23 November 2006 15. Data Analysis 23 -24 November 2006 16. Draft Report writing (summary tables) 23 -2&November2006 17. Submission to APOC of summary report 28 November 2006 18. Multi country Data Analysis V/orkshop 3 -6Jnly2007 T t2 19. Finalisation of site report 9 - 2l August 2007 20. Finalisation of the multi country report End August2007 21. Dissemination of results By December 2007 5. Results and Discussions Objective I To document any general policy at the national level (states/provinces) on external monetary incentives for community volunteers in the health, HIV/AIDS, agriculture, environment and water sectors. 5.1 National Level 5.1.1 Use of Community Volunteers and Existence of policy at National level Three ministries (Health, Agriculture and Environment) of the four ministries use community volunteers. Ministry of Water Resources does not use community volunteers (Table 1). Two of four ministries namely Ministries of Agriculture and Environment had general polices on extemal monetary incentives for community volunteers. Ministry of Health has no policy on extemal monetary incentives for community volunteers while Ministry of Water Resources does not use community volunteers. The use of community volunteers is common. Table 1: Use of Community Volunteers and Existence of policy at National level SÀ[o Sector Use of Community Volunteers Existence of General policies I Ministrv of Health Yes No 2. Ministry of Agriculture Yes Yes 3 Ministry of 'V/ater Resources No Not Applicable 4 Ministry of Environment Yes Yes In Ministry of Agriculture, only the directorate of Corporate Policy Programme and Budget of 3 deparünents had a policy (Table 1). The policy of the directorate prescribed the provision of incentives for technical support especially transport. In Ministry of Environment, one of two departrnents, Department of Environmental Health and Sanitation had a policy. The policy prescribed provision of transport and lunch to compensate for volunteers' time. a t 13 5.1.2 State level 5.1.2.1 Use of Community Volunteers and Existence of General policy on External Monetary Incentives to community volunteers. All thirty two programmes used community volunteers irrespective of the implementing partner (MoH, national NGOs or other agencies). The state has a general policy on external monetary incentives. The policy prescribed provision of external monetary incentives to community volunteers. This is at variance with the national level policy. Objective 2 To document the extemal monetary incentive policies of the different health programmes for community volunteers, including the type, monetary value and frequency of the incentive provided, as well as the involvement of communities in setting these incentives. 5.2.1 Existence of policy on External Monetary Incentives by health issues at national level Sixty - eight health programmes under 11 health issues were consulted at the national level. Nine programmes (13.2%) namely Onchocerciasis, ITNÀ{alari4 Immunisation, Schistosomiasis, Guinea Vy'orm Control, Nutrition, Reproductive Health, HIV/AIDS and EPVIDRS had policies on external monetary incentives. 5.2.2 Existence of policy on External Monetary Incentives by health issues at state level Fourteen health issues were identified in the study. Thirty two partners made up of Ministry of Health (MoH), International NGOs, national NGOs, UN Agencies and donors implemented the programmes using community volunteers. Thirty programmes (93.8%) had policies on EMI while 2 (6.3%) programmes did not have policies. The two prograûrmes, HIV/AIDS and reproductive health- MoH had no plans to formulate policies. Policy formulation The Governance of Red Cross formulated a policy on Disaster management in 1960 and this applies to all its programmes. MoH and partners formulated theirs on Reproductive Health and FOMWAN Executive Board on health education in 1986. The National Guinea V/orm Eradication programme followed with its policy in 1992. Grass Root Organisation (for VHV/), MoH (for Integrated health workers), WHO for IMCI and a t4 a MotVLGAs for Bamako Initiative formulated their policies in 1996. Other policies were formulated in 1998 by ICC (immunisation NP[), MoH (nutrition) and SWAAN(HIV/AIDS). [n2002, PATHS formulated its policy on Malaria and CHRI and Fortress formulated theirs on HIV/AIDS. This was followed by SWATCH's HIV/AIDS policy in 2003. Other HIV/AIDS policies by FHI and Ghain and MOH and partners' policy on IMCI were formulated in 2004. Minis§ of Health (Leprosy) and SUDIC (Reproductive Health) formulated their policies in 2006. Fig. 1: Existence of Programme Policies on External Monetary Incentives Of the 30 withpolicies 26 (81.3%) prescribed that external monetary incentives be given, 2 (6.3%) prescribed that it should not be given, one each (3.1%) prescribed to grve when necessary andgave other reasons respectively (Fig 1). The other reasons cited \Mere directives from national level. Fig l: Existence of Programme Policies on External Monetary lncentives 100 90 80 !,ô e7o E 3so oè50 =340 - o30 s 20 10 0 Existence of Prog Policy To Give Notto Give Give if Næessary Oher Existence and Types of Policies 15 5.2.1 Type and frequency of External Monetary Incentive provided by the different health programmes to community volunteers at state level Table 2a.: Types of Cash lncentives Gash Number % Transport 25 78.1 Stipend 11 34 Per diem 6 18.8 Sales revenue 1 3.1 Other 1 3.1 Table 2b: Types of ln - Kind lncentives ln Kind Number Bicycle 2 M/Cycle 2 Radio 3 ITN 2 Other 16 % 6.3 3.1 9.4 3.'l 71.9 Programmes gave different types of monetary incentives either cash, in - kind or both. Twenty nine programmes (91%) provided cash incentives. Transport generally provided monthly had a frequency of 78oÂ, stipend was less frequent (34%) and per diem was even less frequent than stipend (18%) and was provided either monthly or half yearly. Sales revenue was only provided monthly by Sixteen programmes offered incentives in - kind; many of which were minimal. Bicycles and m/cycles as in-kind incentives were provided once in the life of the programme by Immunisation, HIV/AIDS, Guinea worrn and RH programmes. Bicycles accounted for 6.30 of these, motorcycles 3.1oÂ, radio 6.3Y" and ITN 3.1%. Low cost items such Reproductive Health had a frequency of (3.1%). Despite stipend being less frequent than transport, it contributed the most ($4,671.9) to the cash incentives. Transport the most frequent contributed $2,957 .9 and per diem $2,511.3. as refreshments, lunch, condoms, kits and feeding made tp 71.9o of in - kind incentives (Fig. 2b). Motor bicyeles contribute S388.1, radio S28.84, bicycles $21.9 and ITN $7.7. 5.2.3 Monetary value of External Monetary Incentives provided by the different health programmes to community volunteers at state level. Onchocerciasis provided $90.6 per volunteerlyear cash incentives. This ranked 19'h and was less than that of other progralnmes (Table 3). Voluntary Health'Worker Ministry of Health used voluntary health workers in communities. All attempts to interview the officer in charge failed. Grass Root Health Organisation which supports volunteers provided cash and in kind incentives. Its cash incentive of $126.8 per volunteer/yé- ** ranked lTth in the state. 16 ,Immunisation Immunisation is implemented by Ministry of Health and 6 partners namely NPI, DFID, Red Cross, WHO, Compass Polio and Compass Polio IPD. V/orld Health Organisation paid $ 90.6 per volunteer/year and this ranked l9th. Compass Polio and Compass IDP paid $ 2718 and $181.2 per volunteer each. These ranked 9tn and 13th respectively. DFID was new in Kano State and was working out the modalities of its support. NPI paid $56.6 per volunteerlyear and ranked 27ft. Red Cross paid its rate irrespective of the source of funding. Volunteers were paid different rates. Ward volunteers were paid $461.3, team leaders $241.6 and mothers clubs were $60.4 per volunteerlyear. These ranked 5, 1l and 26ü respectively. Bamako Initiative is implemented by MoH.. It paid volunteers $45.3 in cash per volunteer/year and the incentive ranked a low 29tn. Integrated Vitlage Health service is implemented by MoH. Its cash incentive of $317.1 per volunteerlyear ranked 7th. Safe Motherhood is executed by MoH and Community Health and Research Initiative who provided $52.9 and $185.9 ier volunte erl year and was ranked 28th and l2û respectively. Reproductive Health is supported by MoH, SFH and SUDIC. Information could not be obtained from MoH. SFH provided 524.3 per volunteerl year.Its incentives ranked 33rd. SUDIC provided $1,603.7 per volunteerl year to community and senior community volunteers. This topped the list and ranked 1't. IMCI is implemented by MoH. It paid $135.9 per volunteer lyear as cash incentives. It was rankedl5th. HIV/AIDS HIV/AIDS is implemented by Ministry of Health and 8 partners namely COPOP, SWAAN, Fortress for Women, FHI, Ghain, YOSPIS, SWATCH and Grass Root Health Organization. All partners provided different incentives rates. COPOP, Ghain and SWefCg each paià cash incêntive of $90.6 per volunteer lyear and ranked 19th' SVÿAAN provided $27.2 per volunteer lyear and ranked 32nd. Fortress for Women paid volunteers $135.9 per volunteer lyear and peer educators $45.3 per volunteer /year. Its incentives ranked l5th and 29th respectively. FHI gave $317.1 per volunteer /year and ranked 7th. YOSPIS paid $I,291.2 per volunteerlyear and ranked 3rd while Grass Root paid $406.2 per volunteer/year and ranked 6th. The HIV/AIDS partners collectively provided a total incentive oî $2,494.7 per year. In - kind incentives was only $30.3 of this. Ministry of Health and PATHS implementers of lTN/lVlalaria Control paid volunteers different rates. Ministry of Health paid $a5.3 per volunteerlyear and ranked 29th while PATHS paid $271.8 per volunteer/year and ranked 9th. Guinea Worm Control's sole implementer is MoH. It paid a cash incentive of $45.3 per volunteelyear and an in - kind incentive of $21.1. Its toial monetary incentive of $66.4 ranked 25ü. MoH controls TBlleprosy and paid a cash incentive of $483 .2 per volunteer/year in cash and this ranked 4th. Health Education is implemented by MoH, SUDIC and FOMWAN. 17 SUDIC provided $181.2 per volunteerlyear as cash incentive and ranked 13th WOFAN did not provide information on its incentives. MoH integrated health education into other programmes and did not provide incentives for this alone. Ministry of Health's Nutrition programme paid $90.6 per volunte erlyear as cash incentives and ranked 19th. Table 3: Monetary value of External Monetary Incentives provided by the different Health programmes to Community Volunteers Health lssue lmplementing Partners TotalGash/ volunteer/year us$ Total ln kind/ volunteer/year US$ Total Monetary value (Gash + ln kind) us$ Ranking of incentives Onchocerciasis MoH 90.6 0 90.6 19 Partner 1 TB/Leprosy MoH 483.2 0 483.2 4 Partner 1 Malaria MoH 45.3 0 45.3 29 PATHS 271.8 0 271.8 I Partners 2 lmmunisation MoH 0 0 0 NA Red Cross 72.5,241.6, 60.4 388.9,0, 0 461.4,24',1.6, 60.4 5,11, 26 NPI 56.6 0 56.6 27 DFID 0 0 0 NA WHO 90.6 0 90.6 19 Compass Polio 271.8 0 271.8 I Compass Polio IPD 181.2 0 181.2 13 Partners 7 Guinea worm 45.3 21.',| 66.4 25 Partner 1 Nutrition MoH 90.6 0 90.6 19 Partner RH/ Safe Mother Hood 1 MoH 52.9 0 52.9 28 CHRI 181.2 4.7 185.9 12 Compass 92.0 0 92.0 18 suDtc (cv, SCV) 1,603.7, 1,603.7 0,0 1,603.7, 1,603.7 1 1 SFH 22.7 1.7 24.4 33 Partners 5 HIV/AIDS MoH 0 0 0 NA COPOP 90.6 0 90.6 19 SWAAN 27.2 0 27.2 32 Fortress for Women (PAC, 135.9,45.3 0,0 135.9,45.3 l8 Peer Educator) 15, 29 FHI 3',17.1 0 317.1 7 Ghain 90.6 0 90.6 19 YOSPIS 1,268.5 22.7 1,291.2 3 SWATCH 90.6 0 90.6 19 Grass Root Health Organisation 398.7 7.6 406.2 6 Partners I Bamako lnitiative MoH 45.3 0 45.3 29 Partner 1 IVHS MoH 317.1 0 317.1 7 Partner 1 rcMcr MOH 135.9 0 135.9 15 Partner 1 VHW Grass Root Orqanisation 126.8 0 126.8 17 Partner 1 H Education FOMWAN 181.2 0 181.2 13 Partner 1 5.2.4 Involvement of communities in setting external monetary incentives Only forty one percent of communities were involved in setting the incentives. They were involved through consultations with representatives of the communities. The 59.4Yo of communities were not involved in setting external monetary incentives because it was not donor policy (12.5%) and 37.5% cited other reasons. The reasons stated were no budgetary provision, financial constraint, partners deciding rates, avoidance of confusion and central decision. Objective 3 To determine the rationale for the above policies and the role of donors in influencing these policies. 5.3.1 Rationale for policies at national level Eleven prograrnmes identified facilitation of service delivery as the rationale for the policies while 8 gave motivation as the rationale for the policies. Eleven prograûrmes gave sustainability as the reason for not giving external monetary incentives. o 19 5.3.2 Rationale for policies at state level Several reasons were given overall as rationale for the policies. The most common were motivation, encourage and appreciate volunteers (78%), facilitate services (32%), compensate for volunteers time (43.8%) and ownership ((12.5%). The rationale for not giving was to ensure sustainability @%). 5.3.3 Role of Donors in influencing policies on external monetary incentives by health programmes at state level Flg 3: Rolc of Donors in lnfluencing lncentivês 35 o E30 E925oo 1zo EË15 oÈ10 .ô Er52 0 I No, of h..lth progrrmmaa lTotal number ot hcalth orootammes """ "§ """"' ^§ .." § d§' Rol. of Dono13 Of the 32 programmes with policies on external monetary incentives on use of volunteers, donors directly influenced 9 progranrmes (28%). Donors convinced partners that external monetary incentives were necessary to address certain concerns in 8 programmes (25%) namely [VHS, Safe Motherhood and Reproductive Health. It was made a funding condition for TB/Leprosy (3%).Donors did not influence the policy in Onchocerciasis and Guinea wonn control programmes (6.3%). Twenty six donors (812%) provided funds for incentives in Voluntary Health'Worker, Immunisation, Bamako Initiative, ITN/lVlalaria Control, MCI, Health Education and Nutrition. Red Cross, NPI, SV/ATCH, Grass Root, PATHS, SV/AAN, MoH, YOSPIS, COPOP, and Compass Polio were among others. Five donors (16.7%) as a result of external formulation of policies in head offices, local and state governments classified donor influence as other reasons. Table 4: Health Issues, External Monetary Incentives and Donor Influence at State Level Health lssue Total Monetary value (Gash + ln kind) us$ Donor lnfluence No role Convinced programmê managers Funding conditions Provide funds for incentives Other Onchocerciasis 90.6 TB/Leprosy 483.2 20 Malaria 317.1 lmmunisation 1,363.6 Guinea worm 66.4 Nutrition 90.6 Reproductive Health/Safe Mother Hood 3,562.5 HIV/AIDS 2,494.8 Bamako lnitiative 4s.3 lntegrated Village Health Services 317.1 tcMcr 135.9 Village Health Worker 126.8 Health Education 181.2 Objective 4 To determine the current and potentiaUfuture overlap of these health programmes in the different districts/LGAs. S.4.LCurrent overlap of health programmes in the LGAs Health prograûrmes overlapped in all LGAs. The current overlap of programmes was in the range of l1 to 19 with a mean of 13.8 (Table 5). Programmes with the highest overlap were Ministry of Health's immunization, Bamako Initiative, Integrated Village Health Services, Safe Motherhood, HIV/AIDS, Health Education and ITN/Ivlalaria Control. Other programmes were TBlleprosy, WHO, (Immunization,), Compass Polio (Immunization), Compass (Immunization), Red Cross Immunization, FOMV/AN and NPI (Immunization). The average current overlap was 13.8. The average current incentives overlap per LGA was $3,074.8 per LGA/year. This is 5 fold the state annual minimum wage of $589.2 and has implications for sustainability should donor funding cease. 2l S/No Loca! Governments Current Overlap Future Overlap Current lncentives Overlap $ Ajingi Bichi Gabasawa Gwarzo Bebeji Dala Gwale Garko Gaya Kura Warawa Kano Municipal Kabo Kibiya Tsanyawa Nasarawa Rogo TAIVada 15 16 13 16 16 17 17 15 16 16 14 19 13 13 14 17 12 12 20 2t 20 23 22 2t 20 23 20)) 22 23 2t 20 2t 20 17 t7 2,675.6 4,059.1 2,491.4 4,190.3 2,989.7 2,724.1 4,027.2 2,609.2 2,675.6 2,923.4 2,582.0 4,480.2 2,491.4 2,491.4 2,557.8 3,104.6 3,91 1.1 3,91 1.1 Table 5: Current and future/potential health programmes overlap and associated incentives overlap in Local Governments 1 2 3 4 5 6 7 I I 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Takai Sumaila G/Mallam Rano Makoda Kiru Bunkure Albasu Wudil Madobi Karaye FÿGado D/Kudu Kumbotso Gezawa Ungoggo Minjibir Dffofa Bagwai Shanono Kunchi 11 14 11 11 11 14 11 1',| ',7 '|1 13 13 15 16 11 14 13 12 12 12 11 18 18 t7 18 t7 t7 t7 18 20 t8 t7 l8 18 19 18 19 18 18 19 17 17 2,307.4 2,611.1 2,307.4 2,307.4 2,307.4 2,739.4 2,307.4 2,307.4 4,278.2 2,307.4 4,097.0 3,935.4 2,830.0 3,930.9 2,307.4 3,752.6 2,620.1 3,911.1 3,911.1 2,373.8 2,307.4 36 37 38 39 22 40 41 42 43 44 Danbatta Doguwa Fagge Tofa Tarauni Range Mean 11 16 15 15 11- 19 13.8 18 17 17 19 18 18 -24 20.o 16 4,373.4 2,307.4 2,947.8 4,278.2 2,733.2 $2,307 - s4,480.2 $3,074.8 Several agencies identified funding as a constraint to expansion e.g. YOSPIS has plans only to expand within its current LGAs. They were reluctant to state their plans. The future overlap of programmes was in the range of 18 to 24 (Table 5). IMCI, Immunisation (Compass), HIV/AIDS by Fortress for Women and Red Cross, Health Education implemented by FOMWAN, TWOFAN and Red Cross were the most frequent programmes. The average future overlap was 20. Objective 5 To determine whether programmes have policies on using volunteers selected for other health programmes and how they deal with incentives in such cases. 5.5.1 Existence of policies on using volunteers selected for other health programmes and how they deal with incentives in such cases at national level Twenty eight prograrnmes (87.5%) had policies to use volunteers selected for other prograrnmes. The policies prescribed that programmes should avoid clashes and integrate programmes. Onchocerciasis, Lymphatic Filariasis, national programme on immunisation, Schistosomiasis, Malaria, HIV/AIDS, Guinea worn, Reproductive Health, Trachoma and Vitamin A shared community volunteers. All partners involved in the programmes/projects were involved in setting the policy guidelines. Cost-effectiveness, reduction of attrition, integration and maximising resources were the rationale for the policy. Fifteen programmes (55.6%) had policies for dealing with the incentives. The policy prescribed volunteers sharing incentives. o 23 5.5.2 Existence of policies on using volunteers selected for other health programmes and how they deal with incentives in such cases at state level Twenty six programmes (81.3%) had policies to use volunteers selected for other prograûrmes. Three programmes (9%) each had no policies to use the volunteers of other prograrnmes and did not know if they had policies (Table 6). Table 6: Existence of policy on use of other health volunteers and how it is dealt with at the state level The policies prescribed that programmes could share available human resource in communities (if available). Others prescribed that programmes should integrate, net work, negotiate or harmonise with other organisations using community volunteers. However on provision of incentives, some prescribed payment of organisational rate, or a standard polio rate, or a standard rate for transportation and refreshments. Some also required that the volunteers be trained before use or used for referrals. Several prograûrmes used the volunteers of other programmes. The national programme on immunisation prograrnme used volunteers of other prograrnmes the most. It was closely followed by Reproductive Health /Safe Motherhood, MCI, malaria and HIV/AIDS. Other prograrnmes were Onchocerciasis, Guinea wonn, Nutrition/Vitamin A and health education. The policies were formulated mainly by partners (MoH, LGAs, Programme Mangers, NGOs, Donors), Associations of NGOs working on HIV/AIDS, Donor coordination forum at the State and ICC working group for Immunization. These partners belong to the Association of Kano NGOs and implementers. The Community leaders, volunteers and Programme staff were not often involved. The rationale for having the policies were expanding coverage, sustainability, integration into PHC, cost effectiveness, use available human resource, promote ownership and community participation, harmonise rates and motivation. Existence of policy on use Number Percentage Number with Policy for Dealing with EMI Percentage Yes 26 81.3 24 75.0 No 3 9.4 1 3.1 9.4 21.93 7 Don't know 24 Twenty four programmes (75%) had policies for dealing with EMIs for health volunteers of other programmes while one progr:ürme (3.1%) did not have policies. Seven prograûrmes (21.9%) did not know if they had a policy (Table 6). For those who had a policy to share volunteers, most said it prescribed that the organisations pay its rate or pay a standard rate. Of the 75% who had policies for dealing with external monetary incentives for health volunteers shared with other programmes, 81.2%o provided the incentives in cash while 18.8% were in other forms. 5.5.3 Description of proportion of incentives contributed by health programmes and type at national level Two prograûrmes (12.5%) had higher incentives than those of other programmes. Nine programmes (56.3%) provided lower incentives than other progrilmmes while 3 programmes' (18.8%) incentives were at par. 5.5.4 Description of proportion of incentives contributed by health programmes and type at state level Nine programmes (37.5%) immunisation-WHO, MHS-MoH, Reproductive Health/Safe Motherhood-CHR[, HIV/AIDS-MoH, SV/ATCH and YOSPIS, TB/Leprosy and Reproductive Health, Nutrition-MoH were higher than those of other programmes. Monetary incentives of 8 programmes (20.8%) Compass Polio, Compass IDP, MCI, NPI, Safe Motherhood-MoH, Reproductive Health-SFH, Guinea'Worm Control-MoH and PATHS-Malaria programmes were said to be at par with other programmes to avoid creating problems and rivalry among progralnmes. Four pro grammes (1 6.7 %) Onchocerciasis, ITNÀ4alaria Control-MoH, Health education -FOMWAN and immunisation:Red Cross paid lower incentives. Six programmes (25%) VHS-Grass Root Health Organisation, immunisation and Bamako Initiative, Reproductive health - SUDIC and FORTRESS for Women, said it provided a standardised rate based on work load and demands of a project. Table 7: Proportion of incentives contributed by health programmes and type Proportion of incentives contributed by health programmes Number of Programmes Percentage Type of Incentives Cash In -kind More others than 9 37.5 8 I Less than 4 16.7 3 I 25 others Equal to others 5 20.8 1 1 Others * Don't know 6 25.0 J 0 Objective 6 . To document any coordination/harmonisation of incentive policies and practices among different health programmes at national and state/provincial levels. 6.1 CoordinationÆIarmonisation of external monetary incentives by health programmes at national level Forty two programm es (62%) discussed harmonisation of incentive policy. Of these , 35yo harmonised the policies. 6.2 CoordinationÆIarmonisation of external monetary incentives by health programmes at state level Fourteen programmes (a3.8%) discussed the use of volunteers by other health programmes (Table 8). Fifteen programmes $6.9%) did not discuss harmonisation of extemal monetary incentives while 3 programmes (9.3%) did not know if this was discussed. Harmonisation was better at the state level. Table 8: Discussion and Coordination/Harmonisation of policy on external monetary incentives by Health Programmes at State level Discussed that harmonisation of incentive policy Number that Discussed Policy Percentage Number that Harmonised Policy Percentage Yes t4 43.8 10 31.2 No t5 46.9 8 25.0 Don't know 3 9.3 t4 43.8 Ten programmes (31.2%) harmonised the policy on external monetary incentives on use volunteers of other prograûrmes. Eight prograûrmes (25%) did not have a harmonised policy while 14 programmes (43.8%) did not know if the policy was harmonised Table 10). For those who harmonised their policy, 8 programmes (80%) did so through joint planning, one programme (10%) through joint incentive package and one programme (10%) was classified as other. 26 6.2 Practices Objective 7 o To compare external monetary incentive policies in different programmes/countries (existence; range; and uniformity of donors' and programmes' policies). 6.2.1. Comparison of external incentives policy by health issue at State level (existence; range; and uniformity of donors' and programmes' policies) All partners implementing the above prograflrmes had policies on external monetary incentives. HIV/AIDS, Immunisation, Reproductive Health, TB, Malaria and Nutrition are programmes that receive a lot of donor support. The policies were fairly uniform. Each of them prescribed the use of existing volunteers or share available resources among other things (Table 2). Other things prescribed by the policies for immunisation and reproductive health were as each pays volunteers its rate, pay standard Polio rate, harmonise transport allowance and or refreshment, negotiate with donors and standardise rates. 6.2.2 Donors' and programme range in policies per health issue that give external incentives The donor spread of external incentives was widest in reproductive health/Safe mother hood. The 4 donors provided incentives in the range of $24.4 - 1,603.7 while MoH gave its volunteers an incentive of $sg.z. This was followed by HIV/AIDS where the 9 donors gave incentives in the range of 527.2 - 1,291.2. Ministry of Health did not provide volunteers incentives. The 4 donors of immunisation offered incentives in the range of $eo.l - 461.4; Ministry of Health did not provide incentives while NPI gave $56.5. Tuberculosis and nutrition had no donors but MoH offered volunteers $483.2 and $90.6 respectively (Table 9). Table 9: Donor/Programme range per health issue that give external incentives and ranking in HIV/AIDSr Immunisation, Reproductive Health, TB and Nutrition Health lssue lmplementing Partners Total Cash/ volunteer/year US$ Tota! ln kind/ volunteer/year US$ TotalMonetary value (Cash + ln kind) US$ Ranking of incentives MoH 0 0 0 NA Red Cross 5,'1 1 , lmmunisation 27 60.4 0 60.4 26 NPI 56.6 0 56.6 27 WHO 90.6 0 90.6 19 Compass Polio 271.8 0 271.8 I Compass Polio IPD 181.2 0 181.2 13 Donor/Prog /range of incentives 412 60.4 - 271.4 0 - 388.9 60.4 - 461.4 TB/Leprosy MoH 483.2 0 483.2 4 Donor/Prog /range of incentives ol1 483.2 0 483.2 Malaria MoH 45.3 0 45.3 29 PATHS 271.8 0 271.8 I Donor/Prog /range of incentives 111 45.3 - 271.8 0 45.3 -271.9 Nutrition MoH 90.6 0 90.6 19 Donor/Prog /range of incentives ol1 90.6 0 90.6 Reproductive Health/safe Motherhood MoH 52.9 0 52.9 28 CHRI 181.2 4.7 185.9 12 Compass 92.0 0 92.0 18 suDrc (cv, scv) 1,603.7,1,603.7 0,0 1,603.7, 1,603.7 1 ,| SFH 22.7 1.7 24.4 33 Donor/Prog /range of incentives 4t1 22.7 - 1,603.7 1.7 - 4.7 24.4 - 1,603.7 HIV/AIDS MoH 0 0 0 NA COPOP 90.6 0 90.6 19 SWAAN 27.2 0 27.2 32 Fortress for Women (PAC, Peer educator) 135.9, 45.3 0, 0 135.9, 45.3 15, 29 FHI 317.1 0 317.1 7 Ghain 90.6 0 90.6 19 YOSPIS 1,268.5 22.7 '1,291.2 3 SWATCH 90.6 90.6 19 Grass Root Health Organisation 398.7 7.6 406.2 E, Donor/Prog /range of incentives 811 27.2 - 1,268.5 7.6 - 22.7 27.2-1,291.2 28 6.2.3 Donors' and programme uniformity in policies per health issue that give external incentives Majority of partners implementing Immunisation, H[V/AIDS, Malaria and Reproductive Health had policies. Among partners with polices, there was no uniformity'in its application. The ranking in Table 9 elucidates this. 7.I)iscussion The absence of a national policy on monetary incentives did not seem to affect the state's formulation of a general policy on community volunteers' incentives. Provision of cash incentives to volunteers of health prograûrmes and particularly by donor driven prograûrmes such as Reproductive Health/Safe Motherhood, HIV/AIDS, Immunisation and TB/Leprosy could create dependency, poor community participation, ownership and diminish sustainability. The rationale for incentives given as motivation, facilitation, compensation of volunteers and ownership may be short term. It was acceptable that many donors did not directly influence policies on EMI. However, the provision of funds for the incentives creates dependence and raises expectations of managers and volunteers. The current mean overlap of 13.8 health programmes/ LGA and a corresponding monetary overlap of $3,074.8 per LGA/year which is 6 fold the state annual minimum wage have immense implications for sustainability. More so the monetary overlaps could create a financial burden for govemment, NGOs, INGOs and donors as well as competition among volunteers for the best paid prograrnme. As a result, the partners may end up working against the programmes they have supported over the years. Despite several agencies reluctance to provide information on future overlap, a mean future overlap of 20 health programmes/LGA, raises concern. The use of volunteers of other programmes by 81.3% of programmes and availability of policies to deal with incentives by 75o programmes may alleviate some financial difficulties. However, the poor harmonisation of policies by most programmes and non uniformity in neither donors' nor prograûrmes does not urgur well for sustainability. Majority of partners implementing Immunisation, H[V/AIDS, Malaria and Reproductive Health had policies. Among partners with polices, there was no uniformity in its application 8. Conclusions Two of four ministries at the national level had prograrnmes using community volunteers. One of 3 departments in ministry of agriculture and 2 departrnents in ministry of environment had policies that prescribed the provision of extemal monetary incentives. 29 At the state level, all programmes used community incentives and there was a general policy to offer give monetary incentives. Programmes provided cash, in-kind or both types of monetary incentives. Ninety one percent of programmes provided cash incentives made up of transport, stipend, per diem and sales revenue in a decreasing order. However stipends contributed the most to this. In-kind incentives were fewer and of lower monetary value. The total monetary incentive ranking ,rmong major donor programmes in descending order was Reproductive Health/Safe Motherhood, HIV/AIDS, Immunisation and TB/Leprosy. The rationale for providing incentives was motivation, facilitation, compensation of volunteers and ownership. Twenty eight percent of donors directly influenced policies and 8l%o provided funds for the incentives. Health prograflrmes overlapped in all LGAs. The current overlap of programmes was in the range of ll to 19 with a mean of 13.8. The average current incentives overlap per LGA was S3,074.8 per LGA/year. Several agencies were reluctant to state their plans because of funding constraints e.g. YOSPIS has plans only to expand within its current LGAs. The future overlap of programmes was in the range of 18 to 24. The average future overlap was 20. Most programmes used of volunteers of other programmes (81 .3%) andTlYohadpolicies to deal with this. Some prograrnmes discussed coordination/trarmonisation (43.8%) of monetary inc entives and 3 I .2o harmonised polici es. Majority of partners implementing Immunisation, HIV/AIDS, Malaria and Reproductive Health had policies except HIV/AIDS - MoH. Among partners with polices, there was no uniformity in its application 9. Recommendations A Phase 2 study will be required to ascertain the outcome of the Phase 1 study at the community level. The following could be considered 1. Determining if policies on external monetary incentives are reflected in practice at the community level. . Involvement of communities in setting external monetary incentives . Harmonisation of extemal monetary incentive policy when using the same volunteers 2. Perceptions of volunteers r Relationship between incentives and volunteerism . Workload 3. Perceptions of community leaders and other key players 30 APPENDIX 1: SI]MMARY TABLE 1 OF RESULTS SITE NAME: Site 2 Indicators related to Specific study objectives SA\ VARIABLES Yes No Number o//o I Availability of general policy on external incentives 2 3 2 66.7 1.a. Availability of general policy on external incentives at MOH 0 2 0 0 t.b. Availability of general policy on external incentives at MO Agriculture I 2 I 50 1.c. Availability of general policy on external incentives at MO \ilater NA NA NA NA 1d. Availability of general policy on external incentives at MO Environment I 2 I 50 2 No. of health programmes using community volunteers 30 2 30 93.8 3 No. of health programmes that have policies to give external monetary incentives 30 2 30 93.8 4 No. of health programmes that give cash incentives 29 3 30 90.6 5 No. of health programmes that give in kind incentives (with monetary value) 16 16 50 50 6 No. of health programmes that give both cash and in kind incentives (with monetary value) t6 t6 50 50 7 No. of health programmes that have a policy to involve communities in setting external incentives 13 t9 13 40.6 8 No of health programme where donors influenced incentive policy 26 6 26 81.3 9 Number of districts/LGAs with overlapping health programmes 44 0 44 100 l0 Average number of overlapping health programmes per district/LGA NA NA 13.8 NA t1 Number of districts/LGAs with potential 44 0 44 31 overlapping health proqrammes t2 Average number of potential overlapping health programmes per district/LGA NA NA 20 NA 13 No. of health programmes with policy of using existing community volunteers 26 6 26 81.3 t4 No. of health programmes with joint external incentive policies 24 8 24 75 15 No of health programmes with policy on coordination/ harmonisation of external incentive policies 10 8 10 31.3 NA = Not Applicable APPENDIX 2: SUMMARY TABLE 2 - INCENTIVES PROVIDED BY PROGRAMMES 91 TOTAL IN KIND 16 APPENDIX 3: SUMMARY TABLE 3 - List of health programmes (including HIV/AIDS) using community volunteers, their implementing partners, fÏnancial donors and types of external monetary incentives provided SITE 2 NO. OF PROGRATI/IMES %INGENTIVES CASH 29 18.8PERDIEM 6 78 TRAVEL ALLOWANCE 25 11 34STIPEND 1 3.1SALES REVENUE 3.1OTHER CASH 1 29TOTAL CASH 50IN KIND 16 2 6.3BICYCLES 2 6.3MOTOCYCLES 9.4RADIO 3 3.1ITN 2 71.9OTHER tN KIND 16 32 Type of External Monetary Incentives Legend: l:Per Diem, 2:Travel Allowance, 3:Stipend, 4:Sales Revenue, 5:Other Type of Extemal Cash Incentive, 6: Bicycle, 7: Motorcycle, 8:Radio, 9:ITN, l0:Other External In-kind lncentives SECTOR: HEALTH, including HIY/AIDS NO. OF PROGRAMME NATIONAL NGO INTERNATIONAL NGO UN AGENCY FINANCIAL DONORS TYPE OF EXTERNAL INCENTIVE S/ NO. Implementing Partner TYPE of External Incentive (Enter from 1-10 which is applicable) National NGO Int. NGO UN Agency I Onchocerciasis CBM 7 7 3 2 TBL 3 3 1,2,10 3 Malaria 20 , 62 I , 3 1,2,10 4 Immunization FOMV/AN, 19,67,68 22,87, T]NICEF 1,2,10 5 NA NA NA NA NA NA 6 NA NA NA NA NA NA 7 Guinea wonn t4 I 3,6 8 Nutrition GRASSROOT NETWORK, AHIP, COMM[.]NÏTY COALITIONS 20 I , 7 2,10 9 Safe Motherhood, Reproductive Health FOMWAN, CHR[, 19,1,62,54, 76,20 7 89,23 I , 2 ,3, 8,94,5 I0 33 10 HTV/AIDS FOMWAN, SV/AAN, NIGERIA CTVL SOCIETY NETV/ORK ON NGOs, CENTRE FOR RESEARCH AND DOCUMENT ATION, COALMIONS OF NGOs l9 7 39, 80, 87 2,3,6,'.7,6,10 ll NA NA NA NA NA NA t2 NA NA NA NA NA NA 13 NA NA NA NA NA NA t4 IMCI, Voluntary Health Worker, Bamako Initiative, Integrated Village Health, Health Education FORTRESS FOR VTOMEN, SV/AN, FOMWAN, 1,7,30,69 4 39,30, SWEDISH RED CROSS, IFRC, BRITISH RED CROSS 1,2,3,10,5 APPENDIX 4: ST.]MMARY TABLE 4 SITE NAME: 2 List of Agriculture programmes using community volunteers SECTOR: AGRICULTURE s/ft Name of Programme I Diregtorate of Corporate Policy Programme 34 APPENDIX 5: SUMMARY TABLE 5 SITE NAME: 2 List of Environment programmes using community volunteers SECTOR: ENVIRONMENT S/N Name of Programme I Department for Environmental Health and Sanitation APPEI\DIX 6z LIST OF PERSOhINEL Al[D IMPLEMENTING AGENCIES INTERVIEWED DTIRING STUDY ON EXTERNAL MOI\"ETARY INCENTIYES TO COMMIIMTY VOLT]NTEERS IN KAI\IO STATE NORTH WEST REGION SÀto NAMES OF PERSONNEL DESIGNATION IMPLEMENTING AGENCY PROGRAMMES 1 HAJIA RAMATU SHEHU GARBA EXECUTTVE DIRECTOR SV/ATCH . HTV/AIDS . REPRODUCTIVE HEALTH 2 HUSSAINI GWADABE HOD FINANCE 3 MOH'D N. HAMZA ACCOUNT OFFICER 4 MAL. SHEHU ONCHO. COORD. MINISTRY OF HEALTH ONCHO. CONTROL 5 MUSA D. ABDULLAHI EXECUTTVE SECRETARY RED CROSS INT'L HIV/AIDS CHILD & MATERNAL ISSUES IMMUNISATION DISASTER MGT. 6 ISSA SIDIBE PROGRAMME MANAGER COMPASS POLIO I IMMUNISATION 7 DR. GARBA AHMED RUFAI PRINCIPAL TECH. OFFICER NPI I IMMUNISATION 8 HAJIA HAFSAT EXECUTTVE DIRECTOR SUSTAINABLE DEVELOPMENT SAFE MOTHERHOOD t 35 l BABA MUSA INITIATTVE CENTRE (SUDIC) I COMM. MOBILISATION9 MUSTAFA MOH'D RASHID PROJECT ASST. 10 MUSA ABDULLAHI SUFI SAFE MOTHERHOOD COORD. COMMUNITY RESEARCH INITIATTVE (CHRI) REPRODUCTIVE HEALTH SAFE MOTHERHOOD ll MUSA MAXWELL M &E OFFICER FORTRESS FOR WOMEN HIV/AIDS STIs MCH t2 DANJUMA ADAMU EXECUTTVE DIRECTOR COPOP HTV/AIDS 13 DR. MUSA M. BELLO PROGRAMME COORD. MINISTRY OF HEALTH INFECTIOUS DISEASES HOSPTTAL (DH) ! HIV/AIDS t4 DR. ABDULLAHI SULAIMAN STATE COORD. ,wHo I EPI IMCI VITAMIN A 15 HAIIA SARATU HARUNA NUTRITION COORD. MINISTRY OF HEALTH NUTRITION &GROWTH MONITORING 16 DR. MOH'D NASIRU MAHMUD PROGRAMME MANAGER MINISTRY OF HEALTH TB/LEPROSY CONTROL PROG. t7 DR. MUSA M BELLO DEPUTY SECRETARY NIGERIA MEDICAL ASSOCIATION . IMMI-INISATION . SCHOOL HEALTH ' REPRODUCTIVE HEALTH 18 DR. EMMANT]EL SOKPO STATE TEAM COORD. PATHS MALART,A DOTs 19 LARABA UMAR CIMCI COORD. MINISTRY HEALTH OF IMCI 20 SANUSI USMAN MANDAWARI COORDINATOR MOH BAMAKO IN]TIATTVE GUINEA }VORM ERADICATION 2l BOB LEVERINGTON DEPUTY HEAD REGIONAL COORD. DFID IMMUNISATION HtV/AIDS WATER SI'PPLY 22 DR. RAHMAT MOH'D ASST. REGIONAL COORD. 23 MALLAM PROGRAMME MIMSTRY OF GUINEA WORMI 36 -I n n n T SIIEHU COORD HEALTH 24 GARBA BEBEJI PROGRAMME COORD. MINISTRY HEALTH OF INTEGRATED VILLAGE HEALTH SERVICES 25 SADTYYA ADAMU SECRETARY GENERAL FOlvfV/AN HEALTH EDUCATION SOCIAL SERVICES 26 HAIIYA SALAMATU GARBA COORDINATOR WOFAN HEALTH EDUCATION 27 MRS. SAMBA A EXECUTTVE DIRECTOR GRASS ROOT HEALTH ORGANISATION .WF . HTV/AIDS . VffWs ' TBAs . REPRODUCTTVE HEALTH . FAMILY HEALTH r §trI.B MOTHERHOOD . COMM. MOBILISATION 28 ABDULRASAK ALKALI MGT. STAFF YOPSIS REPRODUCTIVE HEAITH FAMILY PLANNING HIV/AIDSI 29 SANI GAMBO NPI ASST MANAGER NPYMOH IMMUMSATION 30 NURA MOH'D SANI COUNCELLING &, TESTING OFFICER FHYGHAIN . HIV/AIDS . DOTS 31 NGOZI EZEIù,IA FHI ABUJA 32 MOH'D A\MAL IBRAHIM SEMOR PROGRAMME OFFICER 33 FATMA INTIIVA PROGRAMME DESK OFFICER COMPASS a REPRODUCTTVE HEALTH SAFE MOTHERHOOD 34 DR. NASIRU MOH'D LLALLAH PROGRAMME COORD. COMPASS I CHILD SURVTVAL 35 BAFFA MOHAMUD KADEMI PROGRAMME COORD. 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É o NÉ B() r{ teriE t{ Fl (, o v4 (J a)I ,l È 22 lz= oÉt Év È z (r, F È a at) z o É tr El è(, À ÈlJ è,() o z d o V è, (ô\f, (r, () Fl z È Flil - o rilrà =à &(J oÉÈ Irirt t'r Fl rI]Hr{ q) lr k E æ x É €)ÈÈ È I \o$ æ æ ê\ êl c\ 6 o\ o\ ît o\ oê| e\ ( îl æ æ €\ æ æ êI o\ o o o o o o o Ê oq oq oq oq oq oq oq oq oq aq oe oq oq oq o oq oq oq oq oq o oq oq oq oq oq o oq oq o oq oq oq oq o o oq oq o -.: o o o ô o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o o D4 v riÉD V z =E p(, EII rl Ê =È Êe â 2 td cg oâ () È p â) E v)Fotrà V È N frl (J o o zD É É z à fr o Â È o É oz oz tt) (J z v F Êz â =(J oâ rd()(, ,\ h F 7 É F { t-- References Amazigo IfV, Obono M, Dadzie KY et al. (2002) Monitoring community-directed treatrnent prograrnmes for sustainability: lessons from the African Programme for Onchocerciasis Control (APOC). Annals of Tropical Medicine and Parasitology 96 (Suppl. 1), s75-S92. Bhattacharyya K, Winch P, LeBan K & Tien M (2001) Community Health Worker Incentives and Disincentives: How They Affect Motivation, Retention, and Sustainabiliÿ. Published by the Basic Support for Institutionalizing Child Survival Project (BASICS II). Arlington, Virginia. Homeida M, Braide E, Elhassan E et al. (2002) APOC's strategy of community-directed treatrnent with ivermectin (CDTD and its potential for providing additional health services to the poorest populations. African Programme for Onchocerciasis Control. Annals of Tropical Medicine and Parasitology 96,93-104. Rernme M (kr press) Different incentive policies for community health workers: The case of Mali. t l. the From:lnsttlvt StudY Phâsê I tr YES 1§ Flnal RêPoil? lDHttrnb.r: Sigttt Sæals lnûerndimd l(adma, Ntgeda @ UNDPrWodd B.nldlÂ't{Ô SpGcial Programme tor Rcscarch and Training in Tro$cal DÈeescs (fDR) FII.IANCIAL REPORT Oil TECFFflCAL SEF§NCES AGREEilIE}IT G-UrTenq, hlancc thê Principal lnvcstigator (Form 782) S âx\ t TOTAL I Chief Financial Officer Name: Date: SignatuG: llame: Dats: uS3 Dollars Local GurrcncY Exchange re!- Cash b.hrpc d sfa.t dthê P€dod (bahnca Funds dutu€ 126.10 6,E47.30 863,444.80 126.10 6,847.9q 863,444.80 126.10 and CASH . BelrrlcoÊom report PrrsonnC (personnel rcmuftêrstiorl) Eqnipænt Pdicfiteo§ts (drugs, lËf itCisCion) trrvel (field wsf<) lntêm.tional trarcl (rcscarch statf) expcrts (air ticket + hotcl) PrasniÊês rcnovdton (pr.rrctase, maintenance) Tt ining (tuition' stiPênd) (please sPecify and iudify belo\"') w 640.m .nd 2. Funds (us$) rcceived since last nPort 3. ErPèndibrês in thecurrent pGriod(t s$) in the locel 6. USI crsh batance stth. end of Pc@l- 126.88 16,000.00 81.12 1,158.61 146,101.20 {8,1.6t 4S.84 E,{XlO.(x, €9.84 2,938. 5^,,501.æ r,526.86 797-22 1æ,580.O0 481.12 {5.E1E.00 43.35 2É-17 Ë,Ù1 .t5.t7 6,089.23 767 thc accotttttarc corrGa*and any andagrce the of ,f,e- finrêp-tnc€flÙve sludy E. CtD t 1d).m ir 678.7 6,788.00