The Health Systems 20/20 cooperative agreement, funded by the U.S. Agency for International

Development (USAID) for the period 2006-2011, helps USAID-supported countries address health system

barriers to the use of life-saving priority health services. Health Systems 20/20 works to strengthen health

systems through integrated approaches to improving financing, governance, and operations, and building

sustainable capacity of local institutions.

1. Assess the role of non-state actors in HIV/AIDS prevention and mitigation In Nigeria, similar to other low income countries, the role of non-state actors in HIV/AIDS prevention, treatment, care, support and control is expected to be substantial. Among others, these stakeholders include NGOs, CSOs and FBOs. It is important for policy to assess the role of non-state actors, how many resources are they mobilizing, from what sources, as well as for what purpose. Further, in which HIV/AIDS services are non-state actors' resources allocated and used. The study will also track the number of people that are benefiting from each of the NGO interventions and services, and estimation of the unit costs will also be conducted. Based on evidence generated from the survey, recommendation will be made to improve contribution of non-state actors in HIV/AIDS as well as to facilitate consultation and dialogue on improving policy and operational environment. A comprehensive report of the study will be produced and disseminated/presented for relevant stakeholders. • Method/Strategies: Survey of a sample of FBOs and NGOs working in HIV/AIDS and their facilities • Deliverables: Sample NGOs and FBOs Survey report; Presentation of survey findings and facilitation of discussion Budget: $300,000

2. Assessing the role of non-health sector government ministries and agencies and mainstreaming of HIV/AIDS HIV/AIDS is multisectoral by nature and in addition to the National AIDS Control Agency and the Federal Ministry of Health, other departments and government agencies are expected to mainstream and play their roles in HIV/AIDS prevention and control. Assessment of key relevant Ministries (including Defense, Education, Transport, Mining, Energy, Police, Prison, etc.) will be conducted and their roles in HIV/AIDS will be assessed. In this process, sectoral policies, strategic and annual work plans and budgets of selected Ministries and agencies as well as their performance and financial report will be assessed to understand the level of mainstreaming of

HIV/AIDS. • Method/Strategies: Survey of selected federal and state level non-health sector ministries; Review of government expenditure and audit reports • Deliverables: • Ministries and Agencies survey report; Presentation of survey reports and facilitation of discussion to strengthen mainstreaming of HIV/AIDS Budget: $60,000

3. Cost-effectiveness of ART Service Delivery in Nigeria As the resource implications of expanding anti-retroviral therapy (ART) are likely to be large, there is a need to explore its cost-effectiveness. Also, there is a need to tie the cost-effectiveness information on ART to different modes of delivery, i.e., through lower level health facilities vs. higher level facilities. This may inform the procedure or appropriateness of a plan to decentralize ART or other HIV-related curative/care services in the future. So far, there is no such information available from Nigeria, where such services remain highly centralized. Objective To assess the cost-effectiveness of ART service delivery across a sample of disparate delivery settings (secondary facility, and an expanded primary care facility) in Nigeria.

Methods Estimate the unit cost of HIV-related care from the 2009/10 fiscal year expenditure of three different health care facilities in Nigeria, across tertiary, secondary, and primary levels. The study will include both direct and overhead costs. The study will utilize service records for the cohorts of patients accessing ARV Treatment. Service costs will be included from the point of identification of an HIV+ individual as 'eligible' to the continuing period of treatment up to a potential of seven years on treatment (or other maximum number for the cohorts in the facilities). The health effect of incremental years of life gained (YLG) will be estimated for patients receiving ART compared with those not receiving such treatment. Cost-effectiveness for the average patient in each of facilities will be estimated as the dollars per

incremental YLG, and compared. For capturing the uncertainties inherent in the model, the study will apply appropriate techniques, ranging from Markov Modeling to Monte Carlo methods, as appropriate. Budget: $250,000

1. Public Expenditure Tracking Survey in Nigeria (3 states) Description: This activity is continuing from Year 3 of the Health Systems 20/20 Project. The Health Systems Assessment tool was successfully applied in Nigeria during FY 2008-9. Nigeria's assessment results indicated an acute weakness in resource tracking for health across state and LGA levels, with a lot of missing information on resource pass-through and utilization, as well as findings on inadequacy of resource availability at frontline service delivery points. Health Systems 20/20 proposes to conduct a Public Expenditure Tracking Survey (PETS) in three high- priority states, using the basic methodology developed by the World Bank over several years and since then used in various countries for health, education, and other social sectors. A prior PETS in Nigeria (World Bank, 2002) tracked extensive leakages in the allocation of health-related budgets, especially for salaries, in two states (Kogi and Lagos). The proposed HS 20/20 survey, aimed at a sample of health facilities in each of the three priority states, will track the link between health related resource flows and outcomes. The proposed activity will complement the activity to conduct a Public Expenditure Review in four PATHS-2 states in Nigeria (a DFID supported project). The states chosen by HS 20/20 for PETS will be separate and in addition to the four PATHS-2 states. Joint development of tools will reduce costs to USAID, while the joint product across seven states will produce a richer source of public expenditure related information for policymakers. The PETS is intended to address issues such as the following at the facility level: • Spending inconsistent with allocation (leakage?) • Inconsistency of records between different levels (leakage?) • Patterns of actual allocation of resources across districts and facilities (equity and efficiency?) • Delays in financial transfers or distribution of material • Ghost workers and absenteeism based on salary payments

• Collection of user fees inconsistent with projected demand (leakage?) Budget: $400,000

2. System Wide Effects of HIV/AIDS Programming - Opportunities for Vertical-Horizontal Integration/Improvement Description: HS 20/20 was requested by NACA to assist in a review of Nigeria's experience with GFATM grants over the past several years, focusing on the effects on the wider health system, and especially on the discovery of opportunities for enhanced vertical-horizontal integration. This request was matched by interest in the USG mission in Nigeria towards identifying similar opportunities for integration and improvement of PEPFAR-related activities with the wider health system in Nigeria. The System Wide Effects methodology - developed under the PHRPlus project - is well- suited to answer these questions. HS 20/20 proposes to apply the methodology, with a 'backward' looking focus to understand the experience with the GFATM grants; and a 'forward' looking focus to identify opportunities for better integration of both GFATM and PEPFAR programming with the wider health system. For both backward and forward-looking parts, HS 20/20 will focus on: • Effects upon the policy environment and opportunities therein • Effects upon the public-private mix and opportunities for greater PPM • Effects upon human resources, and how to mitigate them or achieve better integration • Effects upon pharmaceuticals and commodities, how to mitigate them or achieve better integration

HS 20/20 will implement SWEF in Nigeria with a quantitative facility survey (of health centers and clinics managers and with health workers) and a qualitative survey consisting of in-depth interviews with key informants who were policymakers, program heads and implementers from government offices (national and regional), health facilities, non-governmental organizations (NGO,) donors, the Nigeria Country Coordinating Mechanism (CCM), and key program experts. Budget: $225,000

3. Priority Interventions from the Nigeria HSA: Developing Decision-Support Software to Enhance the Use of the DHIS in Nigeria Description: This activity is continuing from Year 3 of the Project. The Health Systems Assessment tool was successfully applied

in Nigeria during FY 2008-9. A crucial piece of conducting a Health Systems Assessment is the ability to respond to urgent priorities identified. Nigeria's assessment results indicated an acute weakness in the quality, availability and utilization of HMIS data for facility management and performance. As part of a targeted intervention, HS 20/20 was requested to strengthen capacity of federal and state institutions to use HMIS data in order to improve planning and management, services and programs in three states with highest needs, and the federal level. Nigeria has begun implementing the open-source 'District Health Information System' (DHIS) in a phased manner, with included HIV/AIDS modules. The proposed activity will focus on building a suite of "Data aggregating / Data Analysis" tools which will take as inputs the HIV/AIDS data from the DHIS and produce decision-support evidence for higher level policymakers at the state and federal level (NACA). The work will include the following steps: 1) identifying policymaking users for the DHIS data on HIV/AIDS in the three states and federal level (NACA), 2) developing decision support software to facilitate the aggregation, analysis and utilization of facility level HIV/AIDS DHIS data by state & federal level managers 3) pilot testing and implementing the new software system in the three states and federal level (NACA), 4) conducting training and capacity building of state and federal level (NACA) users of the policymaking data based on DHIS, 5) preliminary impact analysis of the improved decision-support system for the DHIS. Budget: $350,000

4. Developing & Implementing a State Level HRIS in Nigeria in Three Priority States Description: Human resources for health are a critical component of any health system. Strengthening management of HRH allows countries to adequately deploy, manage and reward staff. Computerized human resource information systems are an essential tool for capturing HR data on personnel profiles, access to training, and information on past and current positions/deployments etc. When used properly, an HRIS is an excellent tool for HR planning and management. In Nigeria, HS 20/20 was requested to assist in HRIS development. his activity will complement state-level HRIS investments in capacity-building that the PATHS-2 project (a DFID supported initiative) is

implementing in its four focal states. The states chosen by HS 20/20 will be in addition to the four PATHS-2 states. The joint development of initial 'needs' assessment instruments and coordination of HRIS activities will reduce costs for USAID. In sum, HS 20/20 proposes to implement the HRIS in 3 priority states. The activity will have the following phases: • Phase 1. Assessment of existing HRIS and customization of HRIS solution to state needs (Month 1- Month 4). The HS 20/20 team will work with national and state level stakeholders to build consensus on the scope, sequencing, and design and customization of the HRIS. The team will analyze the current system, develop a preliminary sketch of the state level HRIS, map data flows, identify strengths and weaknesses and liaise with key stakeholders involved in HRIS management (state civil service, LGA, SMOH etc). The results of these state assessments will provide information to guide the customization of the HRIS. A requirements engineering process will be carried out in conjunction with an infrastructure assessment to inform an investment plan. An M&E plan will also be developed during this phase. • Phase 2. Pilot test, adapt and roll-out HRIS (Month 5 - Month 12). Phase 2 will involve piloting the system in selected states, addressing software issues, developing training curricula and guides, developing standard operating procedures and beginning roll-out of the HRIS • Phase 3. Provide ongoing support and extend roll-out to additional states (Month 12 -18) Phase 3 will involve establishing a support infrastructure, extending the HRIS to additional states, training state level managers on data use and M&E of activity implementation. • Phase 4. Document experience and lessons learned (Month 18-20) HS 20/20 Project will document the Nigeria state level experience with HRIS development, identify key lessons learned and disseminate the information in national and international forums. Budget: $375,000

5. Training of Trainers and Mentored Roll-out of Training on Financial Management for Health System Managers (Pilot) Description: For health managers at the state and LGA levels in Nigeria to have adequate training in stewarding the financial resources available to them for programmatic spending is of the highest priority. Health system managers with task- oriented training in this

respect will be better able to ensure on-budget delivery of services, better tracking of resource spending, and generally provide for more efficient and transparent public health systems. The HS 20/20 project was requested to assist in training 'trainers' (also mentors) who will provide one-on-one coaching and mentoring to a certain number of key health managers in some pilot LGAs and states. The trainers/mentor will be retired Nigerian civil servants or senior business managers who are respected as a manager and change agent. He/she will be further trained by the project to be an effective mentor. Trainers/mentors will address the unique needs of each staff member, empowering all staff to perform financial management optimally. The Mentors will be supported by project staff and other short term technical assistance from HS 20/20. Training curricula/materials will be based on existing materials widely used in sub-Saharan Africa, adapted to the Nigerian context. • Phase 1. Adapt existing health-related financial management curricula for Train-the-trainers - to the Nigerian context. • Phase 2. Training of a cohort of selected trainers/mentors in Abuja (one week training) • Phase 3. Orientation of health managers who will receive training in pilot LGAs and state-level health offices. • Phase 4. Roll-out of mentors/trainers to the pilot LGAs and state-level health offices; with monitoring from HS 20/20 for up to 8 months. Review of the experience with the LGAs and state-level health managers, focusing on improvements in financial management. Budget: $250,000