This document summarizes a presentation about building sustainable accountability into strategic routine immunization (RI) planning in Nigeria. It discusses the development of an Accountability Framework for Routine Immunization in Nigeria (AFRIN) to improve goal-directed spending, performance monitoring, and consequences for missed targets. The framework maps the immunization system process and defines roles and responsibilities. It also discusses developing appropriate performance and output indicators, potential incentives and sanctions, the importance of monitoring, and new roles for communities and donors in accountability.

1. Building Sustainable Accountability
into Strategic RI Planning
PRESENTED BY DR NKEM ENE
FEBRUARY 15TH, 2013

2. Contributors
Nkem Ene – Preston Healthcare
Consulting LTD.
Chizoba Wonodi – IVAC
Hashim El-Mousaad – CDC
Muyi Aina – Solina Health
Daniel Ali – WHO
Anita Okemini – CHAI
Frank Mahoney – CDC
Boubacar Dieng – UNICEF
Adesina Adelakun - NPHCDA
Others include:
Chris Collins – CHAI
Garba Abdu – CHAI
PS Adamu – NPHCDA
Giwa Zikrullah – NGF
Stacie Uncle – CDC
Daniel Erchick – IVAC
Other NPHCDA staff

3. Background
The current reversal of RI coverage and the inability
to interrupt wild poliovirus transmission are of grave
concern to the nation and the international
community.
These setbacks have galvanized the government and
partners to seek a different approach; to transform
the way we do things to ensure plans translate into
actions and actions into results.

4. Background
In response, the Executive Director of NPHCDA, who
considers Accountability a “game-changer”, inaugurated a
10-person Task Team in January 2013, to develop an
Accountability Framework for Routine Immunization in
Nigeria (AFRIN).
An Accountability Framework would allow for goal directed
expenditure, result-based performance monitoring, re-
defined roles and responsibilities, synergistic alignment of
resources, transparent reporting and data management, as
well as mutual consensus on pre-determined consequences
for falling short of articulated targets.

5. Background
Accountability is about relationships – between the
government and its citizens, management and staff, health
workers and communities, community leaders and families,
parents and children.
Giving account of one’s stewardship of responsibilities and
power should not only be top-down direction, but bottom-
up as well.
However, an Accountability Framework is only sustainable in
the context of broader strategic planning and stakeholder
buy-in.

6. Accountability & Strategic Planning

7. Accountability Framework for RI
The AFRIN Task Team has produced a comprehensive
mapping of the immunization system processes taking
vaccines from the manufacturer to the mother and child.
The resultant accountability matrix illustrates cross-cutting
system components - planning, forecasting and
procurement, vaccines & logistics, cold chain management,
demand creation, service delivery, and data management -
viewed through the lens of who is responsible for
governance, human resources, and implementation at the
federal, state and LGA levels.

8. Accountability Framework for RI
This exercise revealed lines of responsibilities that
are often blurred, however, the framework
provides clarity on overlaps and identify
responsible parties where gaps exist. The task now
is to implement the framework and get all children
vaccinated.
Ideally, the intensive 4 week exercise should have
been undertaken after the Baseline Strategic Plan
had been developed.

9. Accountability Framework for RI
PROCESSES OUTPUTS OUTCOMES
GOVERNANCE
Planning
Forecasting
Financing
Procurement
HUMAN -RESOURCES
LOGISTICS
COLD CHAIN
DATA MGT
DEMAND -CREATION
100% of needed vaccines
procured
Effective & Adequate
Cold chain systems
Skilled and Sufficient
Health Workers
Data-driven problem
solving
Improved utilization of
RI services
Increased DPT3
Coverage
80% fully immunized
Children
Polio Eradication
IMPACT
Reduced Infant and
Under 5 Morbidity &
Mortality Rates

10. Objectives of the Framework
Define roles and responsibilities across the immunization
delivery system
Encourage shared responsibility among stakeholders for the
different system processes
Create a system to track performance, milestones and data
trends
Involve the political leaders for buy in at state and LGA levels
Raise awareness of all stakeholders on available vaccines in the
communities

12. Performance Indicators (PIs)
A performance indicator is a type of performance measurement and
are commonly used by an organization to evaluate its success or the
success of a particular activity in which it is engaged.
Sometimes success is defined in terms of making progress toward
strategic goals, but often success is simply the repeated
achievement of an operational goal (for example, zero errors)
Accordingly, choosing the right PIs is reliant upon having a good
understanding of what is important to the organization.
Carol Taylor Fitz-Gibbon (1990), "Performance indicators", BERA Dialogues (2), ISBN 978-1-85359-092-4
http://www.collegesontario.org/outcomes/key-performance-indicators/2011_kpi_results.pdf

13. RI Process Indicators – Forecasting & Procurement
Levels Domain Activities
Current Staff /
person responsible
To whom are
they
accountable?
Time Frame
Who is
responsible for
providing
finance?
Technical & Logistics
Development Partner
Performance Indicator
Possible incentives
/sanctions
Receive and share the forecasting
tool
Director NSCS ED - NPHCDA
By August
Annually
NA WHO, UNICEF, BMGF, GAVI, CHAI
Forecasting Tool Shared
(Y/N)
Vet the country vaccines and
devices forecast including GAVI
forecast
Chair - LWG
ED - NPHCDA,
Core Group
By September
Annually
NA WHO, UNICEF, BMGF, GAVI, CHAI
% of vaccines and devices
Cost estimates approved
from forecast
Fund CEbased on forecast plan Director of Finance
ED - NPHCDA,
Core Group
By November
Annually
NPHCDA WHO, UNICEF, BMGF, GAVI, CHAI
Number of Approved cost
estimates funded
Develop air and sea shipment
plans
Director NSCS ED - NPHCDA Quarterly NPHCDA WHO, UNICEF, BMGF, GAVI, CHAI
Number of shipment plans
developed
Implement air and sea shipment
plans
Director NSCS ED - NPHCDA Quarterly NPHCDA WHO, UNICEF, BMGF, GAVI, CHAI
% of shipment plans
implemented
Develop and implement
distribution plans for vaccines and
devices
Chair - LWG ED - NPHCDA Quarterly NPHCDA WHO, UNICEF, BMGF, GAVI, CHAI
% of quarterly distribution
plans implemented
Develop and implement
distribution plans for vaccines and
devices by LGA
SIO Dir PHC
By December
Annually
Dir PHC WHO, UNICEF, BMGF, GAVI, CHAI
% of quarterly distribution
plans implemented
Monitor / Supervise use of
vaccine and devices by LGA
SIO Dir PHC Semi-Annually Dir PHC WHO, UNICEF, BMGF, GAVI, CHAI
Number of supportive
supervision visits conducted
at LGA level
National Governance
State Governance

14. RI Process Indicators
Activity Units have been delineated and assigned.
In assigning responsibilities, the framework aims to be more
specific than general. For example division heads within the
NPHCDA (e.g., logistics/RI/SI) are to be held responsible for
specific governance activities rather than NPHCDA as a
whole.
Timelines were set to eliminate system delays.
The frequency and method of verification of compliance has
also been articulated.

15. RI Process Indicators
These are used internally to guide and monitor performance.
They can be built into Job Descriptions for workers, so that the
expectations are known.
They act as milestones in the achievement of the core indicators.
Core indicators can only be achieved if the milestones are met.

16. Output Indicators
LEVEL OPERATIONAL AREA INDICATORS BASELINE
METHOD OF
VERIFICATION
RESPONSIBILITY FREQUENCY
2013 2014 2015
HEALTH FACILITY PLANNING
% of HFs with updated REW
Microplan
Y/N Plan available Ward Focal
Person/In-Charge
Quarterly
HEALTH FACILITY COLD CHAIN MGT
% of HFs where Daily Temperature
logs are updated per protocol
TBD Temperature
Logs
Ward Focal
Person/In-Charge
Monthly
HEALTH FACILITY VACCINES & LOGISTICS
% of HFs with vaccine stock out at
least once
TBD Stock level Data Ward Focal
Person/In-Charge
Monthly
HEALTH FACILITY FORECASTING
% of Catchment Area Forecasting
data submitted to LGA timely per
protocol
TBD
Forecasting
reports
LIO Quarterly
HEALTH FACILITY SERVICE DELIVERY
Proportion of planned fixed
session conducted
TBD Monthly RI
Reports
Ward Focal
Person/In-Charge
Monthly
HEALTH FACILITY SERVICE DELIVERY
Proportion of planned outreach
session conducted
TBD Monthly RI
Reports
Ward Focal
Person/In-Charge
Monthly
HEALTH FACILITY SERVICE DELIVERY
Monthly planned Coverage
achieved for DPT3
TBD Coverage Data Ward Focal
Person/In-Charge
Monthly
HEALTH FACILITY SERVICE DELIVERY
% of LGAs with DPT3 coverage
below 80%
TBD Coverage Data Ward Focal
Person/In-Charge
Monthly
HEALTH FACILITY DEMAND CREATION
% of VDCs supported to carry out
DC activities
TBD Financial Reports Ward Focal
Person/In-Charge
Quarterly
HEALTH FACILITY DATA MANAGEMENT
% of monthly RI reports submitted
to LGA timely
TBD Reports Ward Focal
Person/In-Charge Quarterly
CORE INDICATORS FOR ROUTINE IMMUNIZATION ACCOUNTABILITY IN NIGERIA
TARGETS

17. Output Indicators – Donors &
Community
Community participation is one of the pillars of the National
Strategic Health Devt Plan.
They are the ultimate consumers of the services and
understand the target populations more than any one else
Traditionally limited to improving utilization, but can be
involved in new roles (planning, monitoring, logistics, etc)
Donors are active in the RI space in various capacities and
locations at different levels.
The need for mapping Donor activity has already been
identified.

18. Sanctions
Critical to any Accountability Framework
Not to be confused with existing management disciplinary
and promotion assessment procedures
Have been used successfully in both high and low resource
Public Health Systems around the world.
Financial Incentives are extremely effective in influencing
performance/compliance

19. Sanctions
These can be Positive/Negative or Formal or Informal.
Different levers (both internal and external) would be needed to
keep stakeholders accountable.
The Framework recommends influencing political office holders
through public opinions by publishing performance reviews and
empowering CSOs to be watch dogs.
In scattered settlements, a community feedback mechanism or
complaints response should be established to provide an avenue
for the community to evaluate and give general feedback to the
RI management

20. Sanctions
For RI, formal negative sanctions could be enforced from external
stakeholders with great effect at Agency level. Donors may have to
deliberate on whether they should without specific support if key
milestones are not achieved.
Re-enforcing sub-optimal performance with additional cash
assistance/support is counter-intuitive and may be counter-
productive.
Performance-based pay is effective, but long-term sustainability is
a concern. Good for introduction of new initiatives

21. Sanctions
Disincentives
The cost and practicality of enforcing
sanctions must be carefully
considered.
Negative
◦ Demotions
◦ Docked wages
◦ Name and Shame
◦ Witholding financial or other support
Incentives
Terms of Enforcement must be
adequately publicized and
consistently applied
Positive
◦ Promotions
◦ Bonuses
◦ Employee Awards
◦ Pre-selection for opportunities e.g
Training

22. Monitoring
Entities that closely monitor themselves are categorized as high self-
monitors and often behave in a manner that is highly responsive to
social cues and their situational context. They project images in an
attempt to impress others and receive positive feedback.
Conversely, low self-monitors do not participate, to the same degree, in
expressive control and do not share similar concern for situational
appropriateness. Low self-monitors tend to exhibit expressive controls
congruent with their own internal states; i.e. beliefs, attitudes, and
dispositions regardless of social circumstance.
Low self-monitors are often less observant of social context and
consider expressing a self-presentation dissimilar from their internal
states as a falsehood and undesirable.

23. Monitoring
There is a fundamental tradeoff faced by individuals, firms and
institutions that monitor corporate management's performance,
between objectivity and proximity in monitoring, which is central
to the corporate governance debate.
Proximity exists when monitors maintain close contact with
management and participate in important decisions on a real-
time basis.

24. Monitoring
Objectivity exists when monitors, such as analysts, credit rating
agencies, accounting firms, and outside funders, remain distant
from management and evaluate management's performance
without influence by management.
Macey, Jonathan R. and Boot, Arnoud W. A., "Monitoring,
Corporate Performance: The Role of Objectivity, Proximity and
Adaptability in Corporate Governance" (2004). Faculty
Scholarship Series. Paper 1420.

25. Monitoring
The role of the Monitor (or monitoring team) of the Accountability
framework is critical to the improvement of service quality and outputs.
The integrity of the Monitor must be protected. Effectiveness will be
limited without unwavering Internal and External Governance support
It is a full time, long term commitment that will require substantial
funding
The suitability of potential internal and/or external monitors needs to
be explored.

26. New roles and responsibilities
in RI Accountability
Community
Utilization of available
Services
Planning?
Monitoring?
Logistics?
Others?
Donors/Partners
Funding Support
Technical Support
Planning
Procurement
Monitoring?
Others?

27. Public reporting
Promotes a culture of regular feedback, Corrective Actions
and Documented improvement
Needs to be embraced by every level of RI Programming
starting with Health Facility Teams, LGs, SMOHs to Zonal
and National NPHCDA ranks.
It is a key component of the Strategic Planning process as it
provides the impetus for new programme development and
innovation.

28. Recap: Accountability & Strategic
Planning
Source: City of Saint John 2012
http://www.saintjohn.ca/en/home/mayor-andcouncil/accountabilityframework/default.aspx

29. Thank You
for listening!!