Impact team last mile distribution of contraceptives in nigeria (2019-2020)

1. December 2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020)

2. December 2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020)

4. Contributors: Joachim Chijide Amaka Anene Stephanie Joyce Miranda Buba Gyanggyang Aigbe Eromon Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) iii

5. Table of Contents Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) iv EXECUTIVE SUMMARY 1 ListofFigures v ACRONYMS viii 4.0. LESSONS LEARNEDAND GENERALRECOMMENDATIONS 90 3.4. BenueState 19 3.15. KatsinaState 72 3.11. YobeState 49 3.14. Cross RiverState 60 3.9. Ondo State 39 3.16. KanoState 77 3.14. Kaduna State 68 2.0. THEIMPACTTEAMSTRATEGY 4 3.1. Abia State 9 3.8. Ogun State 34 3.13. BornoState 55 1.0 BACKGROUND 2 3.6. GombeState 24 3.10. Lagos State 44 3.17. TarabaState 81 5.0. CONCLUSION 91 3.7. Imo State 29 3.0. IMPLEMENTATION 8 3.2. Adamawa State 14 3.15. JigawaState 63 3.12. SCALE-UPOFIMPACTTEAMMEETINGS 54 3.18. ZamfaraState 86 6.0. ANNEX 92

6. List of Figures Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) v Figure5b: DataPlacematforAbiaState:January-February2019 Figure7a: Aggregate Stockout Rate and Reporting Performance for Adamawa State: January 2019 toOctober2020 Figure7b: DataPlacematforAdamawaState:January-February2019 Figure7c: DataPlacematforAdamawaState:September-October2020 Figure11: SupportiveSupervisionandLast-mileDistributiontoHealthFacilitiesinBenueState Figure5c: DataPlacematforAbiaState:September-October2020 Figure2: Data Placemat Used to Inform IMPACT Team Performance Review Meeting inAbia State(May/June2020) Figure5a: AggregateStockoutandReportingRates:January2019 toOctober2020 Figure1: Flow of Information and Commodities through the Contraceptives Logistics ManagementSysteminNigeria Figure14: Supportive Supervision and Last-mile Distribution to Health Facilities in Gombe State Figure3: Data Placemat (LGA) Used to Inform IMPACT Team Performance Review Meeting inYobeState(May/June2020) Figure4: Focus StatesforImplementationofIMPACTTeamModel:January–December2020 Figure6: SupportiveSupervisionandLast-MileDistributiontoHealthFacilitiesinAbiaState Figure8: Supportive Supervision and Last-Mile Distribution to Health Facilities in Adamawa State Figure9: Adamawa State IMPACT team and LMD review meeting at the State Hospitals ManagementBoard Figure10a: Aggregate Stockout and Reporting Rate for Benue state: January 2019 to October 2020 Figure10b: DataPlacematforBenueState:January-February2019 Figure10c: DataPlacematforBenueState:September-October2020 Figure13a: Aggregate Stockout and Reporting Performance for Gombe State: January 2019 to October2020 Figure13b: DataPlacematforGombeState:January-February2019 Figure12: Consultant from NPSCMP providing guidance to MCH Coordinators on how to ﬁll out proof of delivery forms during distribution and supportive supervision visits in BenueState Figure13c: DataPlacematforGombeState:September–October2020 Figure 15: Loading consumable kits procured by UNFPA for distribution to health facilities in NafadaLGA, GombeState

7. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) vi Figure16b: DataPlacematforImoState:January-February2019 Figure16a: Aggregate Stockout and Reporting Performance for Imo State: January 2019 to October2020 Figure18b: DataPlacematforOgun State:January-February2019 Figure21a: ReportingPerformancefor Ondo State:January2019 toDecember2019 Figure16c: DataPlacematforImoState:September–October2020 Figure21b: DataPlacematforOndo State:January-February2019 Figure19: SupportiveSupervisionandLast-mileDistributiontoHealthFacilitiesinOgun State Figure21c: DataPlacematforOndo State:November-December2019 Figure18c: DataPlacematforOgun State:November-December2019 Figure17: SupportiveSupervisionandLast-MileDistributiontoHealthFacilitiesinImoState Figure18a: Aggregate Stockout and Reporting Performance for Ogun State: January 2019 to December2019 Figure20: Ogun State IMPACT team meeting with Director, Reproductive Health Division, FMOH atSMOH Ogun State Figure922: Ondo StateIMPACTTeamMeetingatSPHCDA,Akure Figure23: SupportiveSupervisionandLast-MileDistributiontoHealthFacilitiesinOndo State Figure24a: Aggregate Stockout and Reporting Performance for Lagos State: January 2019 to December2019 Figure28a: Aggregate Stockout and Reporting Performance for Borno State: January to October 2020 Figure24b: DataPlacematforLagosState:January-February2019 Figure31: Supportive Supervision and Last-Mile Distribution to Health Facilities in Jigawa State Figure26b: DataPlacematforYobeState:January-February2019 Figure27: SupportiveSupervisionandLast-MileDistributiontoHealthFacilitiesinYobeState Figure30c: DataPlacematforJigawaState:September-October2020 Figure29: Supportive supervision and Replenishment Visit at Facility in Maiduguri Municipal Council Figure30b: DataPlacematforJigawaState:January-February2020 Figure25: SupportiveSupervisionandLast-MileDistributiontoHealthFacilitiesinLagosState Figure26a: Aggregate Stockout and Reporting Performance for Yobe State: January 2019 to October2020 Figure28c: DataPlacematforBornoState:September-October2020 Figure28b: DataPlacematforBornoState:January-February2020 Figure24c: DataPlacematforLagosState:November-December2019 Figure30a: Aggregate Stockout and Reporting Performance for Jigawa State: January to October 2020 Figure26c: DataPlacematforYobeState:September-October2020

8. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) vii Figure34: DeliveryofFPCommoditiesTo LGABYTHEStateTeam Figure33c: DataPlacematforKatsinaState:September-October2020 Figure35a: Aggregate Stockout and Reporting Performance for Kano State: January to October 2020 Figure32a: Aggregate Stockout and Reporting Performance for Kaduna State: January to October2020 Figure35b: DataPlacematforKanoState:January-February2020 Figure36a: ReportingPerformanceforTarabaState:JanuarytoOctober2020 Figure36c: DataPlacematforTarabaState:September-October2020 Figure38b: DataPlacematforZamfaraState:January-February2020 Figure35c: DataPlacematforKanoState:September-October2020 Figure38c: DataPlacematforZamfaraState:July-August 2020 Figure33a: Aggregate Stockout and Reporting Performance for Katsina State: January to October 2020 Figure33b: DataPlacematforKatsinaState:January-February2020 Figure37: MCH Coordinator for Ibi LGA travelling by canoe to pick up FP commodities from theTarabaStatecontraceptivestore Figure32c: DataPlacematforKadunaState:September-October2020 Figure36b: DataPlacematforTarabaState:January-February2020 Figure38a: ReportingPerformancefor ZamfaraState:JanuarytoAugust 2020 Figure32b: DataPlacematforKadunaState:January-February2020

9. ACRONYMS Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) viii FCDO UnitedKingdom's Foreign,CommonwealthandDevelopmentOﬃce FMOH FederalMinistryofHealth HLMIS healthlogisticsmanagementinformationsystem LARC long-actingreversiblecontraceptives LGA LocalGovernmentArea CLMS ContraceptiveLogisticsManagementSystem FP familyplanning LMCU LogisticsManagementCoordinatingUnit RIRF RequisitionIssue andReportForm SDP servicedeliverypoint UNFPA UnitedNationsPopulationFund USAID U.S.AgencyforInternationalDevelopment NPSCMP NationalProductSupplyChainManagementProgram LMD last-miledistribution OJT on-the-jobtraining MCH maternalandchildhealth NHLMIS NigeriaHealthLogisticsManagementInformationSystem JSI John Snow,Inc.

10. In Nigeria, the United Nations Population Fund (UNFPA) and the United Kingdom's Foreign, Commonwealth and Development Office (FCDO) provided funding for last mile distribution of FPcommodities and performance improvement in seventeen (17) states between 2019 and 2020, usinganadaptationofJSI's IMPACTteammodel. Following the implementation of the IMPACT Team model, the list of health facilities on the NHLMIS has been updated to remove duplications, displacements and reflect addition of active sites offering FP services. As a result, the number of health facilities on the NHLMIS increased from 5187 to 6073 in fourteen states, reflecting a realistic representation of health facilities offering FP services in the supported states. Average reporting rates in the supported states improved from 77% to 88%, with reporting rates in ten states exceeding ninety percent in the last quarter of 2020. Stock availability in the health facilities also improved from 71% to 74%, with last mile distributions contributing to an increase in Couple Years of Protection (CYP) from 1,397,967 to 2,031,826 in the supported states. Improved commodities at the health facilities led to an estimated 3,414 maternal deaths averted and a total cost savings of US$ 68,007,736.11 withintheimplementationperiod. A critical challenge to program implementation was the limited number of MCH Coordinators who have been trained on CLMS as majority of the FP workforce at the LGA and facility level have an insufficient understanding of logistics data for making informed decisions. This training would improve data quality and inventory management across all levels of the supply chain in the state. In addition, routine supportive supervision by the state FP and LMCU units would strengthen the capacity of MCH Coordinators to perform their oversight functions and to transfer theirknowledgetoimprovecommoditysecurityathealthfacilities. Bi-monthly supply chain performance review meetings were conducted at the state level, using data placemats derived from the Nigeria Health Logistics Management Information System (NHLMIS). These meetings were also used to plan for last mile distribution of FP commodities which are delivered to the health facilities by the MCH Coordinators during supportive supervision visits. Due to restrictions on travel and public gatherings imposed as a consequence of the COVID-19 pandemic, virtual meetings using Zoom and WhatsApp groups were set up for each state where relevant stakeholders could meet to review the stock situation at multiple levels andplanfordistributions,whichwereconductedduringsupportivesupervisionvisits. EXECUTIVE SUMMARY Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 1

11. The NHLMIS allows key supply chain performance indicators to be tracked across five health programs, include the Family Planning program. These indicators include reporting rates, stockout rates and data quality. In addition to the logistics data entered into the NHLMIS, there is a function for indicating the quantity of each commodity required to top up health facilities to The Federal Ministry of Health (FMOH) in Nigeria and global development partners like the United Nations Population Fund (UNFPA), the United States Agency for International Development (USAID), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the United Kingdom's Foreign, Commonwealth and Development Office (FCDO) have made significant investments towards building the country's health logistics management information systems (HLMIS) to improve supply chain data visibility and use across priority health programs. For the Contraceptives Logistics Management System (CLMS), essential logistics data were generated at health facilities and transmitted to higher levels at regular intervals. These reports were used to inform decisions on re-supply, quantification, and procurement of contraceptive commodities. The CLMS in Nigeria has operated through a predominantly paper-based logistics management information system. According to this system, service providers are required to fill out Requisition, Issue and Report Forms (RIRFs), which they submitted to the Maternal and Child Health Coordinator (MCH) at their Local GovernmentArea (LGA) every 2 months. In turn, MCH Coordinators filled out quarterly (every 3 months) RIRFs for the LGAlevel and submitted them to the state's Family Planning Coordinator. Thrice a year (every 4 months), state RIRFs are submitted to the FMOH, where the data were used to determine quantities to be delivered to states storesduringnationaldistribution(Figure1). Figure 1: Flow of Information and Commodities through the Contraceptives Logistics ManagementSysteminNigeria 1.0 BACKGROUND Federal Ministry of Health State Ministry of Health/State Primary Healthcare Development Board Local Government Healthcare Development Board LGA RIRFs State RIRFs State RIRFs Commodities Commodities Regional warehouse (used by GHSC-PSM project funded byUSAID Commodities Central Contraceptive Warehouse Facility RIRFs Health Facilities Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 2

12. Last-MileDistribution ofFPCommodities maximum inventory order levels. These quantities can be exported to inform distribution planning.Table1shows theperformancebenchmarksmarkedforeachperformanceindicator Table1: BenchmarkLevelsforPerformanceIndicators Supply chain performance for each state can be viewed on a dashboard, which is accessible globally. However, data availability alone is not enough for supply chains to perform and get critical reproductive health (RH) commodities into clients' hands. In addition to building robust information systems, ensuring commodity security, and improving supply chain performance requires creation of a “data culture” by training and empowering staff to analyze and use data for decision-making. For the reporting cycle in July 2018, only 56% of health facilities offering FP services had successfully submitted their reports on the NHLMIS, and even then, the reporting rate for eleven states was below 35%. Supply chain managers continued to have limited access to timely and quality logistics data from health facilities, which impeded effective supply chain decision-making. In the past, FP commodities were delivered to health facilities by service providers following review and re-supply meetings, and in few states, through the direct data and information capture models of last-mile delivery (LMD). Recently, FMOH through the NPSCMP recommended an integrated last-mile distribution of commodities across health programs; but this is only being implemented in few states. Funding constraints continue to challenge models for last-mile distribution, and states are not able to distribute products on a routine basis, which results in periodic stockout situations at health facilities even though, sufficient stock may exist at higher levels. Ad-hoc or non-existent distribution mechanisms in these states have contributed to high stockout rates of FP commodities at service delivery points (SDPs) (30%, stockout, according to the 2018 UNFPAsupplies survey, and 48% according to the routine data NHLMIS from the July 2018 reporting cycle). The disconnect between the reporting and resupply systems has de- motivated health facility service providers to submit their RIRFs. For example, in Borno state, at least five LGAs have failed to submit reports to the NHLMIS platform since June 2019; and in Kogi State the reporting rate dropped from 94% in May-June 2018 to 49% in September-October 2020. While the FMOH and stakeholders work to implement a more sustainable system for integrated last-mile distribution of all public health commodities, an interim solution was needed toensureclientshaveuninterruptedaccesstothecontraceptivemethodstheyneed. Performance Benchmark Critical Alert Good Aggregate Stock Reporting Rate < 70% 70% - 90% >90% Flagged Reports >50% 20% - 50% 0 – 20% Stockout Rates >10% 5% - 10% 0-5% Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 3

13. At the end of each reporting period, the data entered into the NHLMIS for that period are analyzed and exported to generate data placemats (Figure 2, Figure 3). These data placemats contain simple, easy-to-understand information on the reporting rate, stockout rate, and stock status of FP commoditiesatthestate,LGA, andhealthfacilitylevels. The key members of the IMPACT team include representatives from the Family Health Department of FMOH, state Family Planning Coordinators, state LMCU Coordinators, and MCH Coordinators overseeing FP activities in each LGA in the states implementing the approach. Other members may include monitoring and evaluation (M&E) oﬃcers, logistics oﬃcers, and other stakeholders from State Ministry of Health (SMOH) or State Primary Health CareDevelopmentBoard. b. DataAnalysis and DevelopmentofData PlacematsforPerformanceReview The Information Mobilized for Performance Analysis and Continuous Transformation (IMPACT) team strategy is a people-centered approach to holistically strengthening the supply chain. The model is based on continuous performance review by a team of stakeholders from national, state, and LGA levels, with the shared goal of improving product availability and a collectiveresponsibilitytoidentifyandimplementsolutionstosupplychainproblems. 2.0. THEIMPACTTEAMSTRATEGY The IMPACT teams support service providers to meet reporting timelines every two months. At the LGAlevel, MCH Coordinators review the reports before they are entered into the NHLMIS or sent to the state LMCU.At the state LMCU, the reports undergo another review before entry into the NHLMIS. This provides a good opportunity to identify service providers who need capacity buildingso thattheycangeneratereportsthatcontaingoodquality,reliabledata. a. ReportCollection,Review,andTransmission TheIMPACTTeam IMPACTTeamActivities Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 4

14. Figure3: Data Placemat (LGA) Used to Inform IMPACT Team Performance Review Meeting in YobeState(May-June 2020) Figure 2: Data Placemat Used to Inform IMPACT Team Performance Review Meeting inAbia State(May-June2020) Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) ABIA FAMILY PLANNING SUPPLY CHAIN PERFORMANCE MAY-JUNE 2020 POTISKUM FAMILY PLANNING SUPPLY CHAIN PERFORMANCE MAY-JUNE 2020 5

15. During IMPACT team meetings, participants compare order quantities from health facilities with the quantity of usable stock available at the state store. Where commodities can fill out orders in full, team members decide to re-supply based on request; but where there are shortages at the state store, the team decides to ration commodities or place emergency orders. The IMPACT team also agrees on how to deliver commodities to health facilities during the IMPACT team meetings (see Box 1 ondistributionmodels). e. Distribution Planning c. Stock StatusAssessments FP coordinators conduct a physical count of the FP commodities at the state stores. These counts are used to generate the most up-to-date stock status information to be used at the supply chain performancereviewmeetings. d. Supply Chain PerformanceReviewMeetings IMPACTteams meet at the end of the reporting period and use a quality improvement approach to interpret data, prioritize problems, agree on solutions, and take actions to improve performance. The state teams make invaluable contributions based on their knowledge of local context, functional health facilities, and the capacity of the health workforce at lower levels. For instance, MCH Coordinators know which service providers are trained on long-acting reversible contraceptive methods (LARCs) and therefore, would be able to identify if a stockout of such products was due to possible increase in consumption at the health facility or reported in error. In other instances, MCH Coordinators are able to identify errors on the health facility list reflected on the NHLMIS. These errors affect reporting rates; so the IMPACT team collaborates with NPSCMPtoensuresuchdiscrepanciesarerectifiedpromptly. In 2019, face-to-face meetings—including capacity building as necessary—were conducted at bi-monthly intervals. These meetings provided opportunities to strengthen capacity for mentoring and supportive supervision, calculate stock status, and make decisions to improve commodityavailabilityandminimizewastageandexpiriesathealthfacilityandLGAlevels. In 2020, following the onset of the COVID -19 pandemic, restrictions were placed on travel and public gatherings, hindering in-person meetings. Instead, IMPACT team and LMD review meetings were held virtually, using the Zoom meetings where participants shared data placemats. Key resolutions and observations were communicated to lower levels using LMD coordination groups on WhatsApp. These virtual meetings expanded representation from key stakeholders, especially those from higher levels who frequently could not travel to the meetings because of conflictingschedules. Box 1. Several models have been used to deliver contraceptive commodities to health facilities in Nigeria. Review and re-supply meetings are routine meetings between service providers, MCH Coordinators, and State FP Coordinator. Participants review stock-keeping records and daily consumption records at these meetings and provide is provided for delivery to health facilities. The Direct Delivery and Information Capture model was piloted as an automated, vendor-managed inventory model in which a delivery team made routine visits to health facilities. The team checked physical inventory, stock keeping, and consumption records, provided replenishment, or retrieved excess quantities during the time of the visits. Integrated distribution of commodities is an example of the review and direct delivery model, in last-mile distributions are provided to health facilities based on LMD orders, following review of records. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 6 Last-Mile Distribution of Contraceptive Commodities in Nigeria

16. In 2019, the MagPi digital application was installed on the personal mobile smartphones of MCH Coordinators. The forms contained information on physical stock available at health facilities, storage conditions and availability of stock-keeping records. This application enabled the supervisors to log in their findings, which were visible at higher levels in real time, and to record the facility's GPS location support Service providers or authorities higher up the supply chain filledoutfeedbackforms,whichservedasthebasisforreimbursementforthevisits. In 2020, IMPACT amended the feedback forms to contain more information on the quantities of commodities delivered or retrieved from the health facilities, their batch numbers, and expiry dates. f. Supportive Supervision and Last-MileDistribution Supportive supervision visits are made to each health facility following each supply chain performance review meeting. Adding on a distribution, mentoring, and supportive supervision component to the IMPACT team's performance review enables supervisors to address challenges due to inconsistent distribution mechanisms and human resource capacity to manage health supplies at the last mile. The MCH Coordinators receive the necessary tools to document their findings duringthesupportivesupervisionvisits. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 7

17. With funding from UNFPA, John Snow, Inc. (JSI) implemented the IMPACT team approach in nine states in 2019: Abia, Adamawa, Benue, Gombe, Imo, Lagos, Ogun, Ondo, and Yobe. In 2020, UNFPA continued to provide funding for implementation of the IMPACT team model in six states: Abia, Adamawa, Benue, Gombe, Imo, and Yobe; and included Cross River State in August 2020. With LAFYIAproject, FCDO provided funding through UNFPAand expanded the IMPACT team model to include seven states (Borno, Jigawa, Kaduna, Kano, Katsina, Taraba, and Zamfara) (Figure 4). The sections that follow describe IMPACT implementation in 2019 and 2020,includingtheadditionalsevenstates. Figure4:Focus StatesforImplementationofIMPACTTeamModel:January–December2020 3.0. IMPLEMENTATION Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 8

18. ReportingPerformance Maternaldeath averted(2019-2020):80 Findings from each supportive supervision visit were documented using the Magpi digital application, which contained a checklist of the questions on storage conditions, observations on stock-keeping tools and practices, and commodity availability. Upon completion of the visit to each facility, the data were uploaded to a web-based server. This improved data visibility for stakeholders at higher levels and facilitated insight to track the progress of the supportive supervision visits. Where mobile smartphones were not available or there was no internet access, apaper-basedversionofthechecklistwas usedtodocumentfindings fromthevisit. CommodityAvailability In 2019, MCH Coordinators picked up commodities for delivery to health facilities at the end of each IMPACTteam meeting. Quantities were pre-determined based on requisitions on the RIRFs and available quantities at the state store. The MCH Coordinators took the commodities to each LGAanddeliveredthemtohealthfacilitiesduringsupportivesupervisionvisits. CYP(2019)distributed –21,711 Last-MileDistribution and Supportive Supervision In January/February 2019, the NHLMIS reflected that there were five hundred and fifty-seven (557) health facilities offering Family Planning services in Abia state. During this period, only slightly more than half of the health facilities submitted reports (51%). After two IMPACT team and LMD review meetings, reporting rates surged to 100%. This reporting rate has remained consistenttillthetimeofthispublication. Location:SouthEast,Nigeria 1 Population:3,727,347(2016) 3.1.Abia State CYP(2020)distributed –46,114 Totalcostsavings -US$ 1,717,991.36 NumberofLocalGovernmentAreas:Seventeen(17) PeriodofImplementation:January2019todate In 2019, the aggregate stockout rate reported by health facilities in Abia state was 51%. Consumables kit and cycle beads accounted for the highest proportion of stockout within this period. By May/June 2019, however, last-mile distributions had commenced and stockout rates reduced to 3%. Stockout rates have continued to fall within 10% for subsequent periods, indicating availability of contraceptive commodities in at least 90% of health facilities over the courseofimplementation(seeFigures5a,5b,5c). 1 NigeriaData PortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 9

19. In 2020, the global COVID-19 pandemic disrupted supply chain activities. Restrictions on public gatheratings made in-person IMPACTteam meetings impossible, and travel restrictions hindered intra-state travels, making supportive supervision visits diﬃcult. From March to April 2020, IMPACT teams held meetings using the Zoom virtual platform. Stakeholders from the national and state levels met after each reporting period to review supply chain performance and plan for last-mile distribution, and used WhatsApp groups to share data placemats for the LGA level and key resolutions from the meetings with MCH Coordinators. Following COVID prevention guidelines from the government and the World Health Organization (WHO), the MCH Coordinators travelled to the state store on appointed dates to pick up commodities for distribution to health facilities, and used the occasion of supportive supervision visits to deliver commodities to each health facility. Quantities delivered to each health facility were documented on proof of delivery forms, which were also used to track batch numbers and expiry dates, and to accountforcommoditiesretrieved(Figure6). Figure5a:AggregateStockout and ReportingRates: January 2019toOctober2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 10

20. Figure5c:Data PlacematforAbia State:September-October2020 Figure5b: Data PlacematforAbia State:January-February2019 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 11

21. The data placemats were used to identify health facilities that did not submit reports. In remote areas, MCH Coordinators were advised to employ the WhatsApp platform to receive reports, as had been done in Katsina State to improve their reporting rates. During supportive supervision visits to remote facilities, re-supply quantities were adjusted to include buffer stock, and service Figure6: Supportive Supervision and Last-Mile Distribution to Health Facilities in Abia State Due to the COVID-19 pandemic, in-person supply chain review meetings could not take place as planned in April 2020. This was a concern, as these meetings facilitate engagement with stakeholders at the state and LGA levels, especially for the MCH Coordinators, who are well- positioned to provide feedback on the reasons for low reporting rates or lack of commodities at health facilities. Additionally, MCH Coordinators conduct last-mile distribution during supportivesupervisionvisitsandthesemeetingsprovideagoodavenuefortheirfeedback. Challenges StrategiesImplementedtoAddress Challenges During seasonal rains, there is limited access to health facilities in some areas of the state, such as Arochukwu LGA. This lack of accessibility usually affects report submission and replenishment visits,leadingtopoorreportingandperiodsofstockout. Capacity-building sessions were introduced into the IMPACT team and LMD review meetings, resulting in a gradual improvement in data quality. From March 2020, however, data quality issues began to increase again. Since this period coincides with the emergence and control of COVID-19 in Nigeria, the decline in data quality may be attributed to reports prepared in a hurry, and to the interruption of the face-to-face meetings with MCH Coordinators, who could have reinforced good reporting practices. The in-person meetings resumed in November, after the September-October review period, providing an opportunity for dialogue and capacity building withMCH Coordinatorsandotherstakeholderspresentatthemeeting. Lack of capacity to fill out bimonthly reports is reflected in the proportion of reports flagged on the NHLMIS in each period. In 2019, the percentage of flagged reports fromAbia state fluctuated between 10% (Jan-Feb), which is considered to be good, to 24% (July-August). This indicated capacity gaps both in filling out the reports and in reviewing them before transmission to the nationallevel. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 12

22. providers were advised on procedures for placing emergency orders. To sustain high reporting rates during the COVID-19 pandemic, members of the LGAFPTask Force inAbia state collected reports from health facilities and submitted them to the MCH Coordinators for transmission to the NHLMIS. Recommendations The IMPACT team held virtual, rather than in-person, meetings with national and state stakeholders, and conducted data-driven supply chain review, prioritizing reporting rates, stock status, and commodity availability.The meetings were also used to review stock status at the state store and distribution planning. On a broader level, these discussions were facilitated on a WhatsApp group created for the state, and data placemats were shared for the LGA level following each reporting period. In addition to reviewing performance, the group provided updatesonlast-miledistributionandsupportivesupervision. Abia State has improved commodity availability through routine supportive supervision visits, which were used to deliver commodities and provide mentorship and on-the-job training. These routine visits resulted in improvements in data quality and reporting rates, which in turn supported commodity availability. However, sustaining these improvements will require regular performance review meetings and capacity-building, especially at the LGA level. Sustaining these meetings will enable MCH Coordinators to advance their oversight functions and transfer knowledgetoimprovecommoditysecurityathealthfacilities. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 13

23. CommodityAvailability NumberofLocalGovernmentAreas:Twenty-one(21) In Adamawa state, the NHLMIS reported that 329 health facilities offered FP services in January/February 2019. During this period, 63% of facility reports were transmitted to the NHLMIS.At the IMPACT team meeting, MCH Coordinators identified some mistakes on the health facility list—for example, duplicate facility names on the list, facilities listed under the wrong LGA, and facilities missing from the list (Box 2). By the following period, the IMPACT team reviewed an updated list of 381 functional health facilities, 76% of which had transmitted reports to the NHLMIS. In July-August 2019, further review of the health facility list ledtoanupdateontheNHLMIS toreflect521functionalhealthfacilities. Location:NorthEast,Nigeria Between January and August 2019, the aggregate stockout rate reported by health facilities in Adamawastateaveraged46%.An analysisof thereports indicatesthatSayanaPress, cyclebeads, and IUCDs accounted for the highest proportion of stockout within these periods. By May 2019, last-mile distributions had commenced, but the high stockout rates for these commodities 3.2. Adamawa State ReportingPerformance Totalcostsavings -US$7,807,672.33 PeriodofImplementation:January2019todate. CYP(2019)distributed–101,431 CYP(2020)distributed –206,810 Maternaldeath averted(2019-2020):393 2 Population:4,248,436(2016) The updated health facility lists are usually compiled by the IMPACT team (MCH Coordinators and LMCU Coordinators), and then the list is sent to NPSCMP to effect the changes. With time, the reporting rates and other indicators reflected on the NHLMIS began to reflect a more accurate pictureofthesituationatthestatelevel. 2 NigeriaDataPortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Box 2. IMPACT team meetings conducted continuous review of the health facility list to: · Identify duplicated, displaced, and non-functional health facilities for removal from the list, as well as new or omitted functional health facilities to add to the list · Guide report collection and tracking of reporting rates · Inform distribution planning and guide last-mile distribution Box 2. Facility List Review Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 14

24. InAdamawa,proceduresforsupportivesupervisionandLMD weresimilartootherstates: · In 2019, commodity quantities were determined based on requisitions on the RIRFs and available quantities at the state store. MCH Coordinators picked up the commodities at the end of each IMPACT team meeting, transported them to each LGA, and delivered them to their assigned health facilities during supportive supervision visits. They used the Magpi digital application to document findings, including observations on storage conditions, stock-keeping tools and practices, and commodity availability (Figure 8). Where mobile smartphones were not available or there was no internet access, the MCH Coordinators used a paper-based version of the checklist. Upon completion of the visit to each facility, the data were uploaded to a web-based server, which enabled visibility on facility performanceathigherlevels. persisted. Feedback from the supportive supervision and last-mile distribution visits showed that the stockout rates reflected on the NHLMIS stemmed from data quality issues—specifically, errors in entering commodities that facilities did not classify as being stocked out. By September- October 2019, after on-the-job mentoring during supportive supervision visits, stockout rates diminished to 17%. From then on, stockout rates continued to remain below 20%, indicating availabilityofcontraceptivecommoditiesinatleast80%ofhealthfacilities(Figures7a,7b,7c). · In 2020, the global COVID-19 pandemic disrupted supply chain activities made in-person IMPACT team meetings impossible, and hindered intra-state travel and by extension made supportive supervision visits difficult. From March-April 2020, IMPACT team meetings were held via Zoom. Stakeholders from the national and state levels met after each reporting period to review supply chain performance and plan for last-mile distribution; and shared data placemats for the LGA level and key resolutions from the meetings with MCH Coordinators using WhatsApp groups. The MCH Coordinators travelled to the state store on appointed dates to pick up commodities for distribution to health facilities. Transportation of FPcommodities and supportive supervision visits took placealongsidethepublichealthresponsetoCOVID-19 atthecommunitylevel. Supportive Supervision and Last-MileDistribution Figure7a: Aggregate Stockout Rate and Reporting Performance for Adamawa State: January 2019toOctober2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 15

25. Figure7b: Data PlacematforAdamawa State:January-February2019 Figure7c:Data PlacematforAdamawa State:September-October2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 16

26. · Holding virtual meetings usingWhatsApp with state and national stakeholders, beginning in May 2020, to review supply chain data, reporting rates, and commodity availability; Some facilities in Mubi North and Mubi South LGAS are poorly accessible due to security challenges. In some other LGAs, access to health facilities is restricted by flooding due to seasonal rains. This lack of accessibility usually affects report submission and replenishment visits,leadingtopoorreportingandperiodsofstockout. StrategiesImplementedtoAddress Challenges Figure8: Supportive Supervision and Last-Mile Distribution to Health Facilities in Adamawa State Challenges In general, the reports transmitted to the NHLMIS from Adamawa State have been of good quality. This is a reflection of the competencies at the state level, from where the reports are reviewed and entered. For the November-December review period in 2019, however, entries were made at the LGA level, of which 26% were flagged for data quality issues. This was an indication of gaps in the ability of MCH Coordinators to adequately review reports submitted by healthfacilitiesatthislevel. As in other states, IMPACT teams implemented these measures to improve data quality, strengthenLMD, andaddressrestrictionsensuingfromtheCOVID-19 pandemic: · Introducing capacity building into the IMPACT team and LMD review meetings to improve MCH Coordinators' review of the reports before submission to the state level for entryintotheNHLMIS. As inAbia State, in-person supply chain review meetings could not take place inApril 2020, due to the COVIC-19 virus, which impeded stakeholder engagement and affected LMD by MCH Coordinators. Also, in October 2020, the FP store was vandalized alongside other offices and structures at the State Primary Healthcare Development Board.This resulted in significant loss of FPcommodities,whichwerestoredinthepremises. · Using data placemats to identify facilities that did not submit reports, and advising MCH CoordinatorstouseWhatsApptoreceivereports. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 17

27. Recommendations Figure9: Adamawa State IMPACT team and LMD review meeting at the State HospitalsManagementBoard assess stock status and distribution planning at the state store; and provide updates on LMD andsupportivesupervision. Adamawa State has improved commodity availability through routine supportive supervision visits, providing opportunities for mentorship and on-the-job training. These routine visits resulted in improvements in data quality and reporting rates, which in turn supported commodity availability. However, sustaining these improvements will require regular performance review meetings and capacity-building, especially at the LGA level. Sustaining these meetings will enable MCH Coordinators to advance their oversight functions and transfer knowledge to improvecommoditysecurityathealthfacilities. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 18 Photo submitted by Aigbe Eromon, John Snow Inc.

28. 3.4. BenueState Location:NorthCentral,Nigeria 3 Population:5,741,815(2016) CommodityAvailability Maternaldeaths averted(2019-2020)–306 According to the NHLMIS, 375 health facilities oﬀered FP services in Benue State in January/February 2019. At this time, the reporting rate was 67%. In the following reporting periods, there was only a slight improvement in reporting rates, which averaged 69%. The poor reporting rate was attributed to errors on the health facility list, security challenges, and late reporting in some LGAs. By May-June 2020, the IMPACT team had reviewed the health facility list to include 419 functional health facilities, and had implemented more rigorous report collectionmechanisms,so thatthereportingrateincreasedto97%. PeriodofImplementation–January2019todate CYP(2019)distributed–93,738 Totalcostsavings- US$ 6,087,122.66 ReportingPerformance NumberofLocalGovernmentAreas:Twenty-three(23) CYP(2020)distributed –146,577 The aggregate stockout rate was 47% for the FP program in Benue State in January-February 2019. Feedback from the supportive supervision and last-mile distribution visits showed that the stockout rates reﬂected data quality issues, including data entry errors when facilities did not classify commodities as being stocked out. The IMPACT team incorporated capacity building during meetings to address capacity gaps at the LGAlevel, and addressed other data quality issues though on-the-job (OTJ) training during supportive supervision visits. This resulted in a steady decline in stockout rates in health facilities across the state. Between January and April 2020, there was a delay in national distribution, exacerbated by the COVID-19 pandemic, leading to low stock levels at the state store. By May 2020, stock replenishment had begun, but stock availabilityathealthfacilitiesremainedbelow70%(Figures10a,10b,10c). 3 NigeriaDataPortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 19

29. · In 2019, commodity quantities were determined based on requisitions on the RIRFs and available quantities at the state store. MCH Coordinators picked up the commodities at the end of each IMPACT team meeting, transported them to each LGA, and delivered them to their assigned health facilities during supportive supervision visits. They used the Magpi digital application to document ﬁndings, including observations on storage conditions, stock-keeping tools and practices, and commodity availability (Figure 10). Where mobile smartphones were not available or there was no internet access, the MCH Coordinators used a paper-based version of the checklist. Upon completion of the visit to each facility, the data were uploaded to a web-based server, which enabled visibility on facility performanceathigherlevels. · In 2020, the global COVID-19 pandemic disrupted supply chain activities made in-person IMPACT team meetings impossible, and hindered intra-state travel and by extension made supportive supervision visits diﬃcult. From March-April 2020, IMPACT team meetings were held via Zoom. Stakeholders from the national and state levels met after each reporting period to review supply chain performance and plan for last-mile distribution; and shared data placemats for the LGA level and key resolutions from the meetings with MCH Coordinators using WhatsApp groups. The MCH Coordinators travelled to the state store on appointed dates to pick up commodities for distribution to health facilities. Transportation of FPcommodities and supportive supervision visits took placealongsidethepublichealthresponsetoCOVID-19 atthecommunitylevel. Figure10a: Aggregate Stockout and Reporting Rate for Benue state: January 2019 to October2020 Supportive Supervision and Last-mileDistribution InBenueState,proceduresforsupportivesupervisionandLMD weresimilartootherstates: Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 20

30. Figure10b: Data PlacematforBenueState:January-February2019 Figure10c:Data PlacematforBenueState:September-October2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 21

31. Challenges Some are poorly accessible due to security challenges in some parts of Benue state, such asAgatu LGA. In some other LGAs, access to health facilities is restricted by flooding due to seasonal rains. This lack of accessibility usually affects report submission and replenishment visits, leadingtopoorreportingandperiodsofstockout. · Introducing capaicity building into the IMPACT team and LMD review meetings to improve MCH Coordinators' review of the reports before submission to the state level for entry into the NHLMIS. However, data quality problems persisted in Benue, suggesting a need for more focused capacity building sessions with providers. The state consultant from FMOH's National Product Supply Chain Program also provided guidance on using Proof ofDeliveryformstoaccountforcommoditiesissued(Figure18). In January/February 2019, the flagged reports (18%) for submitted RIRFs in Benue State was considered good, when compared to the national performance benchmarks. In subsequent periodshowever,dataqualityissues inthereportstranslatedtoanincreaseinflaggedreports. StrategiesImplementedtoAddress Challenges As in other states, IMPACT teams implemented these measures to improve data quality, strengthenLMD, andaddressrestrictionsensuingfromtheCOVID-19 pandemic: Figure11: Supportive Supervision and Last-mile Distribution to Health Facilities in BenueState · Using data placemats to identify facilities that did not submit reports, which would provide an accurate facility list to the FMOH, from which the NHLMS list could be updated. As in other states, in-person supply chain review meetings could not take place inApril 2020, due to the COVID-19 virus, which impeded stakeholder engagement and affected LMD by MCH Coordinators. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 22

32. Recommendations · Holding virtual meetings usingWhatsApp with state and national stakeholders, beginning in May 2020, to review supply chain data, reporting rates, and commodity availability; assess stock status and distribution planning at the state store; and provide updates on LMD andsupportivesupervision Figure12: Consultant from NPSCMP providing guidance to MCH Coordinators on how to ﬁll out proof of delivery forms during distribution and supportive supervision visitsinBenueState In addition to the capacity-building provided during IMPACT Team meetings, MCH Coordinators and service providers would beneﬁt from training on CLMS. This training will improve data quality and reporting performance, and will improve inventory management across all levels of the supply chain in the state. In addition, routine supportive supervision to the LGA level by the state LMCU would strengthen the capacity of MCH Coordinators to perform their oversight functions and to transfer their knowledge to improve commodity security at health facilities. · Advising MCH Coordinators to use WhatsApp to receive reports. During supportive supervision visits to remote areas, MCH Coordinators adjusted re-supply quantities and advisedprovidersonproceduresforemergencyorders. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 23 Photo submitted by Shaibu Adams Itopa, Benue State Consultant, NPSCMP via Benue State FP Coordination Group on WhatsApp

33. 3.6. GombeState 4 Population:3,256,962(2016) Location:NorthEast,Nigeria CYPdistributed (2019)–33,721 ReportingPerformance NumberofLocalGovernmentAreas:Eleven(11) There were 353 health facilities reported to be offering FPservices in Gombe State as of January- February 2019. The reporting rate for the period was 68%, a poor rate attributed to late reporting in some LGAs.With continuous review of supply chain performance and active report collection, reportingratesimprovedoversubsequentperiods. CommodityAvailability Supportive Supervision and Last-MileDistribution CYPdistributed (2020)–69,039 · In 2019, commodity quantities were determined based on requisitions on the RIRFs and available quantities at the state store. MCH Coordinators picked up the commodities at the end of each IMPACT team meeting, transported them to each LGA, and delivered them to their assigned health facilities during supportive supervision visits. They used the Magpi digital application to document findings, including observations on storage conditions, stock-keeping tools and practices, and commodity availability (Figure 14). Where mobile InGombeState,proceduresforsupportivesupervisionandLMD weresimilartootherstates: PeriodofImplementation–January2019todate Maternaldeath averted(2019-2020)–131 Totalcostsavings –US$2,602,886.73 In January-February 2019, over half of health facilities offering reproductive health services in Gombe State were stocked out of FP commodities. Following two cycles of supportive supervision and distribution visits, there was an improvement in commodity availability such that by November-December 2019, aggregate stockout rates had declined to less than 15%. The following year, stockout rate was 6% in January-February, but due to disruptions in supply chain activities over the following months, stockout rates increased significantly. Noristerat, Implanon and consumable kits contributed the highest proportion of stockouts in health facilities. With funding from UNFPA, the state procured consumable kits which were distributed to health facilitiesleveragingonsupportivesupervisionvisits(Figures13a,13b,13c). 4 NigeriaDataPortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 24

34. smartphones were not available or there was no internet access, the MCH Coordinators used a paper-based version of the checklist. Upon completion of the visit to each facility, the data were uploaded to a web-based server, which enabled visibility on facility performanceathigherlevels. · In 2020, the global COVID-19 pandemic disrupted supply chain activities made in-person IMPACT team meetings impossible, and hindered intra-state travel and by extension made supportive supervision visits diﬃcult. From March-April 2020, IMPACT team meetings were held via Zoom. Stakeholders from the national and state levels met after each reporting period to review supply chain performance and plan for last-mile distribution; and shared data placemats for the LGA level and key resolutions from the meetings with MCH Coordinators using WhatsApp groups. The MCH Coordinators travelled to the state store on appointed dates to pick up commodities for distribution to health facilities. Transportation of FPcommodities and supportive supervision visits took placealongsidethepublichealthresponsetoCOVID-19 atthecommunitylevel. Figure13a: Aggregate Stockout and Reporting Performance for Gombe State: January 2019toOctober2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 25

35. Figure13c:Data PlacematforGombeState:September–October2020 Figure13b: Data PlacematforGombeState:January-February2019 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 26

36. Figure14: Supportive Supervision and Last-mile Distribution to Health Facilities in GombeState Challenges There were significant issues with data quality in Gombe state. In March/April 2019, 24% of the submitted RIRFs were flagged for errors. These errors included mistakes in entering opening balances, mathematical errors, and entering data for commodities not managed at health facilities.According to reporting protocol, where a commodity is not in stock, a zero is entered for that product. If the commodity is not being managed at that health facility—as may be the case for long-term methods requiring administration by skilled workers—the entry for such a commodity is supposed to be left blank. These data quality issues translated to exaggerated stockout data that neededtobeaddressedduringIMPACTteammeetings. As in other states, in-person supply chain review meetings could not take place inApril 2020 due to the COVID-19 virus, which impeded stakeholder engagement and affected LMD by MCH Coordinators. StrategiesImplementedtoAddress Challenges · Holding virtual meetings usingWhatsApp with state and national stakeholders, beginning · Introducing capacity building into the IMPACT team and LMD review meetings to improve MCH Coordinators' review of the reports before submission to the state level for entryintotheNHLMIS. As in other states, IMPACT teams implemented these measures to improve data quality, strengthenLMD, andaddressrestrictionsensuingfromtheCOVID-19 pandemic: · Mentoring MCH Coordinators on how to input entries for commodities not managed at health facilities; and advising them to provide seed-stock to health facilities that had not been managing condoms and cycle beads. The MCH Coordinators provided guidance to service providers to enable them to report on these commodities properly, resulting in a decreaseintheaggregatestockoutrateforthestate(Figure15). Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 27

37. in May 2020, to review supply chain data, reporting rates, and commodity availability; assess stock status and distribution planning at the state store; and provide updates on LMD andsupportivesupervision. Recommendations In addition to the capacity-building provided during IMPACT Team meetings, MCH Coordinators and service providers would beneﬁt from training on CLMS. This training will improve data quality and reporting performance, and will improve inventory management across all levels of the supply chain in the state. In addition, routine supportive supervision to the LGA level by the state LMCU would strengthen the capacity of MCH Coordinators to perform their oversight functions and to transfer their knowledge to improve commodity security at health facilities. Figure15: Loading consumable kits procured by UNFPA for distribution to health facilitiesinNafada LGA,GombeState Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 28 Photo submitted by Nwese Apu, Maternal and Child Health Coordinator, Nafada LGA in Gombe State, via Gombe IMPACT Team on WhatsApp

38. Location:SouthEast,Nigeria 3.7. Imo State NumberofLocalGovernmentAreas:Twenty–Seven(27) PeriodofImplementation–January2019todate Totalcostsavings -US$7,505,538.89 ReportingPerformance There were 129 health facilities reported to be offering FP services in Imo state as of January- February 2019. The reporting rate for this period was 88%. The health facility list was revised to remove duplications and errors and then omitted facilities were added to the list. By July-August 2019, a total of 123 health facilities were submitting reports through the NHLMIS. Since then, reportingratesfortheFamilyPlanningprograminthestatehaveremainedabove95%. CYP(2020)distributed –166,636 Maternaldeath averted(2019-2020)-377 CommodityAvailability CYP(2019)distributed –129,677 5 Population:5,408,756(2016) Supportive Supervision and Last-MileDistribution In January-February 2019, 30% of health facilities offering reproductive health services in Imo state were stocked out of FP commodities. With the implementaiton of supportive supervision and distribuiton visits, commodity avaliablity improved significantly. By June, stockout rates had declined to 16%, and in following review periods, commodity availability averaged 92% in facilitiesreportingthroughtheNHLMIS (Figures16a,16b,16c). InImoState,proceduresforsupportivesupervisionandLMD weresimilartootherstates: · In 2019, commodity quantities were determined based on requisitions on the RIRFs and available quantities at the state store. MCH Coordinators picked up the commodities at the end of each IMPACT team meeting, transported them to each LGA, and delivered them to their assigned health facilities during supportive supervision visits. They used the Magpi digital application to document findings, including observations on storage conditions, stock-keeping tools and practices, and commodity availability (Figure 17). Where mobile smartphones were not available or there was no internet access, the MCH Coordinators used a paper-based version of the checklist. Upon completion of the visit to each facility, the data were uploaded to a web-based server, which enabled visibility on facility performanceathigherlevels. 5 NigeriaDataPortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 29

39. · In 2020, the global COVID-19 pandemic disrupted supply chain activities made in-person IMPACT team meetings impossible, and hindered intra-state travel and by extension made supportive supervision visits diﬃcult. From March-April 2020, IMPACT team meetings were held via Zoom. Stakeholders from the national and state levels met after each reporting period to review supply chain performance and plan for last-mile distribution; and shared data placemats for the LGA level and key resolutions from the meetings with MCH Coordinators using WhatsApp groups. The MCH Coordinators travelled to the state store on appointed dates to pick up commodities for distribution to health facilities. Transportation of FPcommodities and supportive supervision visits took placealongsidethepublichealthresponsetoCOVID-19 atthecommunitylevel. Figure16a: Aggregate Stockout and Reporting Performance forImo State: January 2019 toOctober2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 30

40. Figure16b: Data PlacematforImo State:January-February2019 Figure16c:Data PlacematforImo State:September–October2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 31

41. Figure17: Supportive Supervision and Last-MileDistribution toHealthFacilitiesinImo State Challenges Some of the MCH Coordinators had not been trained on CLMS and had insufficient capacity to understandlogisticsdatatomakeinformeddecisions. As in other states, in-person supply chain review meetings could not take place inApril 2020, due to the COVID-19 virus, which impeded stakeholder engagement and affected LMD by MCH Coordinators. StrategiesImplementedtoAddress Challenges · Introducing capacity building into the IMPACT team and LMD review meetings to improve MCH Coordinators' review of the reports before submission to the state level for entry into the NHLMIS. In addition to the capacity-building provided during IMPACT Team meetings, MCH Coordinators and service providers would benefit from training on CLMS. This training will improve data quality and reporting performance, and will improve inventory management across all levels of the supply · Holding virtual meetings using WhatsApp with state and national stakeholders, beginning in May 2020, to review supply chain data, reporting rates, and commodity availability; assess stock status and distribution planning at the state store; and provide updates on LMD and supportivesupervision. · Using data placemats to identify facilities that did not submit reports, and advising MCH CoordinatorstouseWhatsApptoreceivereports. Recommendations As in other states, IMPACT teams implemented these measures to improve data quality, strengthen LMD, andaddress restrictionsensuingfromtheCOVID-19 pandemic: Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 32

42. chain in the state. In addition, routine supportive supervision to the LGA level by the state LMCU would strengthen the capacity of MCH Coordinators to perform their oversight functions and to transfertheirknowledgetoimprovecommoditysecurityathealthfacilities. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 33

43. 3.8. Ogun State Location:SouthWest,Nigeria NumberofLocalGovernmentAreas:Twenty(20) 6 Population:5,217,716(2016) Maternaldeath averted(2019)-152 CommodityAvailability ReportingPerformance CYPdistributed (2019)–119,478 Totalcostsavings –US$3,026,350 In 2019, there were 429 health facilities transmitting reports to the NHLMIS. The reporting rate for this period was 88%. During IMPACT team meetings, assessments of supply chain performance informed the revision of the health facility list. Duplications and errors were corrected, and omitted health facilities were included on the list. By July 2019, 474 health facilities were reﬂected on the NHLMIS. Reporting rates also improved and remained above 90%. PeriodofImplementation–JanuarytoDecember2019 In January-February 2019, the stockout rates reported by 429 facilities was 23%. In the following periods, the number of health facilities that submitted reports increased to 441(March-April 2019) and 468 (May-June 2019). Stockout rates for these periods was also 23%. In September- October 2019, stockout rates increased to 30% as a result of additions to the health facility list on the NHLMIS. By December 2019, the stockout rate reported by 474 health facilities had declined to25%(Figures18a,18b,18c). 6 NigeriaDataPortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 34

44. Figure18a: Aggregate Stockout and Reporting Performance for Ogun State: January 2019toDecember2019 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 35

45. Figure18c:Data PlacematforOgun State:November-December2019 Figure18b: Data PlacematforOgun State:January-February2019 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 36

46. Supportive Supervision and Last-mileDistribution In the states, commodity quantities were determined based on requisitions on the RIRFs and available quantities at the state store. MCH Coordinators picked up the commodities at the end of each IMPACTteam meeting, transported them to each LGA, and delivered them to their assigned health facilities during supportive supervision visits. They used the Magpi digital application to document findings, including observations on storage conditions, stock-keeping tools and practices, and commodity availability (Figure 19).Where mobile smartphones were not available or there was no internet access, the MCH Coordinators used a paper-based version of the checklist. Upon completion of the visit to each facility, the data were uploaded to a web-based server,whichenabledvisibilityonfacilityperformanceathigherlevels. Figure19: Supportive Supervision and Last-mile Distribution to Health Facilities in Ogun State Challenges In some LGAs, access to health facilities is restricted by flooding due to seasonal rains. This lack of accessibility usually affects report submission and replenishment visits, leading to poor reportingandperiodsofstockout. There was consistent representation from FMOH and UNFPA at the IMPACT Team meetings in The LMCU spearheaded capacity-building sessions which were incorporated into the IMPACT team meetings to build skills on inventory management, calculating stock status and determining how much to re-supply/retrieve from health facilities. With MCH Coordinators, the LMCU reviewed mistakes on the submitted reports and provided guidance to prevent future mistakes. Thisadditionhelpedtoimprovecommoditysupplyandpreventexpiriesandwastageatfacilities. Some MCH Coordinators had not received CLMS training and did not understand logistics data sufficientlytomakeinformedre-supplydecisionsorreviewreportsfromhealthfacilities. StrategiesImplementedtoAddress Challenges Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 37

47. Ogun state, which increased stakeholders' commitment to coordinate and conduct last-mile distribution. The activity also increased overall improved understanding of the challenges aﬀecting commodity availability at health facilities that need to be addressed at national level (Figure20). Recommendations Since December 2019, Ogun state has adopted an alternative mechanism for last-mile distribution for FP commodities. Nevertheless, MCH Coordinators and service providers would beneﬁt from training on CLMS to improve data quality and reporting performance. Routine supportive supervision by the State LMCU to the LGA levels would also improve oversight and promotecommoditysecurityathealthfacilities. Figure20: Ogun State IMPACT team meeting with Director, Reproductive Health Division,FMOHatSMOHOgun State Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 38 Photo submitted by Miranda Buba Gyanggyang, JSI

48. Location:SouthWest,Nigeria CYPdistributed (2019)–39,350 NumberofLocalGovernmentAreas:Eighteen(18) PeriodofImplementation–JanuarytoDecember2019 Maternaldeath averted–50 Totalcostsavings –US$ 996,726 3.9. Ondo State ReportingPerformance 7 Population:4,671,695(2016) CommodityAvailability In January 2019, the NHLMIS reflected that there were 547 health facilities offering FP services in Ondo state. The reporting rate for this period was 93%. Following an assessment of supply chain performance, the health facility list was reviewed to 531 health facilities. With the deletion of inactive health facilities, duplications, and displacements, reporting rates improved to over 97%inthefollowingreviewperiods. In January-February 2019, five hundred and forty-seven (547) health facilities were reflected on the NHLMIS, with a stockout rate of 38%.The stockout rates reflected on the NHLMIS increased but this was not a true representation of stock availability at health facilities. A review of stock status at health facilities identified data quality issues that resulted in misleading information. On- the-job mentoring during supportive supervision visit enabled service providers to minimize errors in data entry and improve inventory management. This improved skill translated to transmission of more accurate data and improved commodity availability (Figures 21a, 21b, 21c). 7 NigeriaDataPortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 39

49. Figure21a:ReportingPerformanceforOndo State:January 2019toDecember2019 Supportive Supervision and Last-mileDistribution Commodity quantities were determined based on requisitions on the RIRFs and available quantities at the state store. MCH Coordinators picked up the commodities at the end of each IMPACT team meeting, transported them to each LGA, and delivered them to their assigned health facilities during supportive supervision visits (Figure 22). They used the Magpi digital application to document ﬁndings, including observations on storage conditions, stock-keeping tools and practices, and commodity availability.Where mobile smartphones were not available or there was no internet access, the MCH Coordinators used a paper-based version of the checklist. Upon completion of the visit to each facility, the data were uploaded to a web-based server, which enabledvisibilityonfacilityperformanceathigherlevels. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 40

50. Figure21b: Data PlacematforOndo State:January-February2019 Figure21c:Data PlacematforOndo State:November-December2019 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 41

51. The State FP Unit and LMCU were very hands-on during the IMPACT team meetings, which promoted commitment from MCH Coordinators. After a few sessions, the MCH Coordinators led the supply chain performance review for their LGAs, which built their capacity to use data for decision-making. LMCU participated actively in the capacity-building sessions, which were incorporated into the IMPACT team meetings to build skills on inventory management, calculating stock status, and determining how much to re-supply/retrieve from health facilities. With MCH Coordinators, the LMCU reviewed mistakes on the submitted reports and provided guidancetopreventfuturemistakes. There was consistent representation from FMOH and UNFPA at the IMPACT Team meetings in Ogun state, which increased stakeholders' commitment to coordinate and conduct last-mile distribution. The activity also increased overall improved understanding of the challenges affecting commodity availability at health facilities that need to be addressed at the national level. MCH Coordinators used supportive supervision visits to provide guidance on reporting commodities that were not managed at health facilities, and on correcting and preventing errors that had been observed in submitted reports. They also advised service providers to procure plastic containers for storing commodities safely—which would prevent exposure to rodents, dampenvironments,anddust,andthusmaintainthecommodities'shelflife. Challenges Figure22: Supportive Supervision and Last-Mile Distribution to Health Facilities in Ondo State In some health facilities, service providers lacked sufficient capacity to fill out RIRFs correctly. For instance, stockouts were reported for LARCs in health facilities that did not manage these commodities. Some MCH Coordinators reported observing poor storage conditions and lack of sufficient space to store FP commodities during supportive supervision visits in certain health facilities. StrategiesImplementedtoAddress Challenges Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 42

52. Recommendations Figure 23:Ondo StateIMPACTteammeetingatSPHCDA,Akure Since December 2019, Ondo State has adopted an alternative mechanism for last-mile distribution of FP commodities. Nevertheless, MCH Coordinators and service providers would beneﬁt from training on CLMS, which would improve data quality and reporting performance. Routine supportive supervision by the State LMCU to the LGA levels would also support oversightandpromotecommoditysecurityathealthfacilities. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 43 Photo submitted by Miranda Buba Gyanggyang, JSI

53. 3.10. Lagos State Location:SouthWest,Nigeria 8 Population:12,550,598(2016) NumberofLocalGovernmentAreas:Twenty(20) Maternaldeath averted(2019)-92 The first round of distributions conducted using the IMPACT team model commenced following the March/April review period. Following regular supervision visits, commodity availability started to improve. In addition to more regular re-supply, service providers received guidance to correct data entry errors on RIRFs. Subsequently, the reports transmitted to the NHLMIS became increasinglyreflectiveofthestocksituationathealthfacilities(Figures24a,24b,24c). Totalcostsavings - US$1,827,795.90 ReportingPerformance CommodityAvailability PeriodofImplementation–JanuarytoDecember2019 CYPdistributed (2019)–72,160 In January 2019, the NHLMIS reported 314 health facilities offering FP services in Lagos State. The reporting rate for this period was 91%. Following an assessment of supply chain performance, the health facility list was reviewed to exclude duplications and displacement, resulting in a revised list of 308 facilities. Reporting rates remained over 93% for every review periodin2019. 8 NigeriaDataPortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 44

54. Figure24a: Aggregate Stockout and Reporting Performance for Lagos State: January 2019toDecember2019 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 45

55. Figure24c:Data PlacematforLagos State:November-December2019 Figure24b: Data PlacematforLagos State:January-February2019 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 46

56. Recommendations StrategiesImplementedtoAddress Challenges Figure25: Supportive Supervision and Last-Mile Distribution to Health Facilities in Lagos State Some MCH Coordinators had not been trained on CLMS and had insufficient understanding of logistics data for making informed decisions. At some facilities, service providers lacked sufficient capacity to fill out RIRFs correctly. For instance, stockouts were reported for LARCs in healthfacilitiesthatwerenotmanagingthesecommodities. The LMCU spearheaded capacity-building sessions, which were incorporated into the IMPACT team meetings to build skills on inventory management, calculating stock status and determining how much to re-supply/retrieve from health facilities. With MCH Coordinators, the LMCU reviewedmistakesonthesubmittedreportsandprovidedguidancetopreventfutureoccurrence. MCH Coordinators used supportive supervision visits to provide guidance on reporting commodities that were not managed at health facilities, and on correcting and preventing errors thathadbeenobservedinsubmittedreports. Supportive Supervision and Last-mileDistribution Commodity quantities were determined based on requisitions on the RIRFs and available quantities at the state store. MCH Coordinators picked up the commodities at the end of each IMPACT team meeting, transported them to each LGA, and delivered them to their assigned health facilities during supportive supervision visits. They used the Magpi digital application to document findings, including observations on storage conditions, stock-keeping tools and practices, and commodity availability (Figure 25).Where mobile smartphones were not available or there was no internet access, the MCH Coordinators used a paper-based version of the checklist. Upon completion of the visit to each facility, the data were uploaded to a web-based server,whichenabledvisibilityonfacilityperformanceathigherlevels. Since December 2019, Lagos state has adopted an alternative mechanism for last-mile Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 47

57. distribution for FP commodities. Nevertheless, MCH Coordinators and service providers would beneﬁt from training on CLMS, which would improve data quality and reporting performance. Routine supportive supervision by the State LMCU to the LGA levels would also support oversightfunctionstopromotecommoditysecurityathealthfacilities. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 48

58. PeriodofImplementation–January2019toDecember2020 InYobeState,proceduresforsupportivesupervisionandLMD weresimilartootherstates: CommodityAvailability Despite regular supervision and last-mile distribution visits, there has been marginal improvement in stockout rates in Yobe State. Some of the stockout may have been reported in error, as some service providers are not trained on CLMS and cannot fill out RIRFs correctly (Figures26a,26b,26c). CYPdistributed (2020)–86,581 Maternaldeath averted(2019-2020)–164 3.11. YobeState NumberofLocalGovernmentAreas:Seventeen(17) 9 Population:3,294,137(2016) CYPdistributed (2019)–41,912 Totalcostsavings –US$3,254,697.59 ReportingPerformance In January 2019, the NHLMIS reflected that there were 188 health facilities offering FP services in Yobe State. The reporting rate for this period was 100%. In July-August, the health facility list was reviewed and updated to 211 service delivery points on the NHLMIS. In this period, reporting rates dropped; but frequent review of supply chain performance review facilitated identification and solving problems with report submission, leading to a gradual improvement in reportingratesfromhealthfacilities. Location:NorthEast,Nigeria Supportive Supervision and Last-MileDistribution · In 2019, commodity quantities were determined based on requisitions on the RIRFs and available quantities at the state store. MCH Coordinators picked up the commodities at the end of each IMPACT team meeting, transported them to each LGA, and delivered them to their assigned health facilities during supportive supervision visits. They used the Magpi digital application to document findings, including observations on storage conditions, stock-keeping tools and practices, and commodity availability (Figure 27). Where mobile smartphones were not available or there was no internet access, the MCH Coordinators used a paper-based version of the checklist. Upon completion of the visit to each facility, the data were uploaded to a web-based server, which enabled visibility on facility performanceathigherlevels. 9 NigeriaDataPortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 49

59. Figure26a: Aggregate Stockout and Reporting Performance for Yobe State: January 2019toOctober2020 · In 2020, the global COVID-19 pandemic disrupted supply chain activities made in-person IMPACT team meetings impossible, and hindered intra-state travel and by extension made supportive supervision visits diﬃcult. From March-April 2020, IMPACT team meetings were held via Zoom. Stakeholders from the national and state levels met after each reporting period to review supply chain performance and plan for last-mile distribution; and shared data placemats for the LGA level and key resolutions from the meetings with MCH Coordinators using WhatsApp groups. The MCH Coordinators travelled to the state store on appointed dates to pick up commodities for distribution to health facilities. Transportation of FPcommodities and supportive supervision visits took placealongsidethepublichealthresponsetoCOVID-19 atthecommunitylevel. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 50

60. Figure26c:Data PlacematforYobeState:September-October2020 Figure26b: Data PlacematforYobeState:January-February2019 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 51

61. Figure27: Supportive Supervision and Last-Mile Distribution to Health Facilities in YobeState Challenges Some MCH Coordinators had not been trained on CLMS and had insufficient understanding of logistics data for making informed decisions.. The IMPACT team meetings have been used to build skills on inventory management, calculating stock status, and determining how much to re- supply/retrieve from health facilites, but this targeted MCH Coordinators only. Although MCH Coordinators are expected to step the training down to service providers, this would require a morefocusedcapacitybuildinginterventionatthislevel. At some facilities, service providers lacked sufficient capacity to fill out RIRFs correctly. For instance, stockouts were reported for LARCs in health facilities that were not managing these commodities. Some facilities in Yobe State are poorly accessible due to security challenges, and in some other LGAs, access to health facilities is restricted by flooding due to seasonal rains. This lack of accessibility usually affects report submission and replenishment visits, leading to poor reportingandperiodsofstockout. As in other states, in-person supply chain review meetings could not take place inApril 2020, due to the COVID-19 virus, which impeded stakeholder engagement and affected LMD by MCH Coordinators. · Introducing capacity building into the IMPACT team and LMD review meetings to improve MCH Coordinators' capacity in inventory management. This improved commodityavailablityandhelpedtopreventexpiriesandwastagesathealthfacilities. StrategiesImplementedtoAddress Challenges As in other states, IMPACT teams implemented these measures to improve data quality, strengthenLMD, andaddressrestrictionsensuingfromtheCOVID-19 pandemic: Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 52

62. · Holding virtual meetings, attended by state and national stakeholders, using WhatsApp with state and national stakeholders, beginning in May 2020. Participants reviewed supply chain data, reporting rates, and commodity availability; assessed stock status and at the state store and distribution planning; and provided updates on LMD and supportive supervision. Recommendations · SharingdataplacematsfortheLGAlevelfollowingeachreportingperiod. In addition to the capacity-building provided during IMPACT Team meetings, MCH Coordinators and service providers would beneﬁt from training on CLMS. This training will improve data quality and reporting performance, and will improve inventory management across all levels of the supply chain in the state. Use of WhatsApp can increase access to health facility reports from hard-to-reach areas, as in Katsina State. In addition, routine supportive supervision to the LGA level by the state LMCU would strengthen the capacity of MCH Coordinators to perform their oversight functions and to transfer their knowledge to improve commodity security athealthfacilities. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 53

63. 3.12. SCALE-UPOFIMPACTTEAMMEETINGS With funding from FCDO, the implementation of the IMPACT team model was expanded to include seven states in 2020: Borno, Jigawa, Kaduna, Kano, Katsina, Taraba, and Zamfara. Lagos, Ogun and Ondo states discontinued the use of the IMPACTTeam model and implemented alternativedistributionmechanisms. In the first quarter of 2020, plans were made to conduct the first IMPACT team meeting in these states. However, during this period, the government responded to the detection of the first few cases of COVID-19 across the country, imposing public health restrictions and limiting travel and public gatherings. Since women's reproductive health needs remained a priority in the state, the IMPACT team used virtual platforms, rather than in-person meetings, to review supply chain performance. · Stakeholders from the national and state levels reviewed reporting rates, stockout rates, and stock status during Zoom meetings, using information developed ahead of the meetings and shared using data placemats. Facility orders derived from the NHLMIS were used to develop a distribution plan, which was compared with stock status at the state store. Using these data, the meeting participants agreed on a schedule for distribution to eachLGA. · A WhatsApp group was created for coordination of last-mile distribution. After each meeting at the state level, data placemats were shared to the WhatsApp group, enabling discussion of key issues in commodity availability at health facilities. The WhatsApp group was also used to provide guidance to MCH Coordinators, and to facilitate updates bythecoordinatorsontheprogress ofdistribution. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 54

64. Maternaldeath averted(2020)-11 CommodityAvailability Location:NorthEast,Nigeria NumberofLocalGovernmentAreas:Twenty-Seven(27) CYPdistributed (2020)–8,681 Totalcostsavings -US$ 219,887.70 The IMPACT team meetings were held using the Zoom virtual platform and follow- on discussions on supply chain issues were conducted with MCH Coordinators in a WhatsApp group. According to the NHLMIS, only 34 health in Borno State oﬀered FPservices in January 2020. In this period, only 41% of facility reports were transmitted to the NHLMIS. The state IMPACT team (FP, LMCU, and MCH Coordinators) reviewed the list of health facilities to remove duplications, correct displacements, and include omitted service delivery points. The revised list was sent to NPSMCP to update the site list on NHLMIS, but as of October 2020, the list had not been updated on the site. Thus, even though reports were submitted to the state, they are not availablefordecision-makingathigherlevels. 10 Population:5,860,183(2016) In January-February 2019, there was no stockout reported by any of the 34 facilities on the NHLMIS; but after that period, reports of stockouts increased. As the health facility list is not comprehensive, the stockout rates depicted below are not representatives of the actual stock situationforeachperiod(Figures28a,28b,28c) ReportingPerformance 3.13. BornoState PeriodofImplementation–JanuarytoDecember2020 Prior to the implementation of the IMPACT team model, FP commodities were picked up from the state store by MCH Coordinators when their facilities ran out of stock. These pick-ups were not regular due to funding constraints and therefore, there were frequent episodes in which facilitieswerestockedoutofcommodities. 10 NigeriaData PortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 55

65. Figure28a: Aggregate Stockout and Reporting Performance for Borno State: January to October2020 Supportive Supervision and Last-mileDistribution For the ﬁrst distribution, MCH Coordinators travelled from the LGAs to the state store to pick up commodities, which were pre-packed according to facility orders and in line with stock levels at the state store. The commodities were then delivered to 93 health facilities during supportive supervision visits (Figure 29). In subsequent distribution rounds, MCH Coordinators from 20 LGAs travelled from their LGAs to the state store to pick up commodities, while the state distribution team delivered commodities to seven LGAs. The delivery visits were also used as an opportunity to inspect storage conditions and provide MCH Coordinators with guidance on inventorymanagementpriortohealthfacilityvisits. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 56

66. Figure28c:Data PlacematforBornoState:September-October2020 Figure28b: Data PlacematforBornoState:January-February2020 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 57

67. Even after validation and updates were made to the Borno State health facility list on the NHLMIS platform, currently, only 51 out of 225 health facilities offering FPservices are reflected for the state. There are LGAs for which reports have not been uploaded on the NHLMIS for several consecutive periods, which impedes assessment of commodity availability and needs for health facilities in these locations. Furthermore, some facilities in Borno State are poorly accessible due to security challenges. This lack of accessiblity usually affects report submission andreplenishmentvisits,leadingtopoorreportingandperiodsofstockout. · Holding virtual meetings with state and national stakeholders, using WhatsApp, beginning in May 2020, to review supply chain data, reporting rates, and commodity availability; assess stock status at the state store and plan distribution; and provide updates onLMD andsupportivesupervision. · Using WhatsApp to share placemats at the share data at the LGA level following each reporting period, review performance, and provide updates on last-mile distribution and supportivesupervision. State FP and LMCU teams reviewed the health facility list to ensure that all facilities were represented on the NHLMIS platform and improve visibility into the stock situation at the last mile.Additionalmeasuresincluded: Challenges Starting in April 2020, the COVID-19 pandemic made it impossible to hold in-person supply chain review meetings—a major concern, since facilitate engagement with stakeholders at the state level, especially the MCH Coordinators. Additionally, MCH Coordinators were unable to provide supportive supervision and last-mile distribution, which created a missed opportunity to discuss challenges, best practices, or service updates at their assigned facilities. In Borno State, the virtual meetings that the IMPACT team conducted as a substitute for the in-person meetings were effective at the state level only. Data placemats were shared for discussion with MCH Coordinators in aWhatsApp group created for this purpose, but this was not an effective means of engagementattheLGAlevel. StrategiesImplementedtoAddress Challenges Lessons learned from other states show that input from the LGAlevel is critical to addressing the challenges that hinder timely reporting and affect data quality and commodity availability at health facilities. In Katsina and Jigawa states, the virtual platfroms were effective for working with LGA level input to develop solutions. However, in Borno State, in-person supply chain performance and LMD review meetings would provide better opportunities for in-depth engagementwithstakeholdersattheLGAlevels. Based on feedback from the state LMCU, and verified by poor reporting performance, there is a need for training on CLMS across all levels of the FP supply chain in the state. This will improve data quality and reporting performance, and will support effective inventory management across theselevels. Recommendations The facility list reflected on the NHLMIS need to be complete for the data to be able to inform re- supplyforallthehealthfacilitiesofferingFPservicesinthestate. Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 58

68. Figure29: Supportive Supervision and Replenishment visit at a Health facility in MaiduguriMunicipalCouncil Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 59 Photo submitted by Yammama Bukar via Borno Child Birth Spacing Group on WhatsApp

69. CommodityAvailability Totalcostsavings -US$ 3,360,955.96 11 Population:3,866,269(2016) NumberofLocalGovernmentAreas:Eighteen(18) PeriodofImplementation–SeptembertoDecember2020 CYPdistributed (2020)–132,688 Prior to the implementation of the IMPACT team model, FP commodities were delivered to health facilities from regional warehouses. This distribution was funded by USAID and conducted by GHSC-PSM project. When funding support ceased, there was a need to provide a distribution mechanism to prevent commodity stockouts at facilities. IMPACT team meetings were held using the Zoom virtual platform; and follow-on discussions on supply chain issues wereconductedwithMCH CoordinatorsinaWhatsAppgroup. Location:South-South,Nigeria Maternaldeaths averted(2020)-169 ReportingPerformance According to the NHLMIS, five hundred and ninety-three health facilities offered FP services in Cross River state as of September/October 2020. The reporting performance for this period was 97%, which is considered to be good according to the national performance benchmark. Even with the good performance however, there were health facilities that were not reflected on the NHLMIS during the reporting period. The national program, NPSCMP, provided authorization to enable the state team to update the facility list, which would allow reports to be captured from allthehealthfacilitiesofferingfamilyplanningservicesinthestate. 3.14. Cross RiverState In September – October 2020, the aggregate stock out rate of FPcommodities in Cross River state was 25%, with the highest stock out rates attributed to cycle beads, consumable kits, and male condoms. The stock out rates were attributed to low stock status of majority of the commodities due to a delay in national distribution the COVID-19 pandemic (Figure 30). By December, however, the state had received commodities from the central contraceptive warehouse and could commencedistributiontohealthfacilities. 11 NigeriaData PortalAvailableat:https://nigeria.opendataforafrica.org/ifpbxbd/state-population-2006 Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 60

70. The ﬁrst round of supervision and distribution visits to health facilities was scheduled to follow the IMPACT team meetings for the September-November review period. Following the receipt of commodities from the central contraceptive warehouse, the state team delivered commodities to each LGA, from where commodities were delivered to health facilities by MCH Coordinators duringsupportivesupervisionvisits. Challenges State FP and LMCU teams reviewed the health facility list to ensure that all facilities were represented on the NHLMIS platform and improve visibility of stocks at last-mile facilities. Othermeasuresincluded: Figure30:Data PlacematforCross RiverState:September-November2020 StrategiesImplementedtoAddress Challenges As in other states, in-person supply chain review meetings could not take place in November 2020, due to the COVID-19 virus, which impeded stakeholder engagements and travels. In addition, there was low stock at the state store, due to protests that resulted in loss of commodities and logistics tools. As such, the state had to wait for replenishment during national distributions beforecommencingdeliverytohealthfacilities. Supportive Supervision and Last-mileDistribution · Holding virtual meetings with state and national stakeholders, using WhatsApp, beginning in September 2020, to review supply chain data, reporting rates, and Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 61

71. commodity availability; assess stock status at the state store and plan distribution; and provideupdatesonLMD andsupportivesupervision. · Using WhatsApp to share placemats at the share data at the LGA level following each reporting period, review performance, and provide updates on last-mile distribution and supportivesupervision. In addition to the capacity-building provided during IMPACT Team meetings, MCH Coordinators and service providers would beneﬁt from training on CLMS. This training will improve data quality and reporting performance, and will improve inventory management across all levels of the supply chain in the state. We also recommend using the WhatsApp platform to improve access to facility reports from hard-to-reach areas. In addition, routine supportive supervision at the LGA level by the state LMCU would strengthen the capacity of MCH Coordinators to perform their oversight functions and to transfer their knowledge to improve commoditysecurityathealthfacilities. Recommendations Project Implementation Report: Last-Mile Distribution of Contraceptives in Nigeria through the IMPACT Team Model (January 2019 – October 2020) 62

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