Advocacy Visits and Orientation of CDA and “Baale”-In-Council.
Following advocacy visits, the five CDA chairmen (Magodo, Orisa, Isheri, Olowora and Omole Phase 11) were receptive to the idea of encouraging members of their communities to play more active roles in the management of their community data. They were able to persuade some CDA members and other community elders who were apparently withdrawing from community activities to forget past grievances and participate actively in the development of the ward.
They spoke of “information” as one of the common grounds on which to unite efforts for the promotion of development in the ward.
During a meeting of elders convened by a “Baale”, some of them expressed their fear of getting involved in community activities because such activities were often closely linked with politics. Some of their comments included:
“I would like to serve but I don’t like politics”- a retired female Professor.
“I will not want my head to be used for breaking a coconut”- Executive with a national parastatal.
“I want to hide my head and enjoy my peace with my family” – senior personnel of an embassy.
“I tried before; it is not worth risking one’s life” – an engineer.
“You should be careful and not stick your neck out”- retired executive
“ I was active before, I don’t want to be messed up” – retired male
Professor.
“I tried to participate before but I have decided not to get involved again”
– medical practitioner.
Women were very well represented (more than 50%) during advocacy meetings.
They and the Baales of Magodo and Isheri were excited about having vital information on their communities generated and managed by members of their communities. The “Baale” of Magodo immediately promised to identify a computer literate youth to handle data generated from his community. The Baale of Olowora was not available during the period of advocacy visits because he was not resident in the community. However, the chairman of the CDA, the secretary and treasurer were very receptive.
Baseline data
(i) Knowledge, Attitude, Practices and Expectations on the Ward Health System (WHS)
The CDA and the traditional committees had no knowledge of the WHS because no one had informed them about it before. After explanations, all of them had positive attitudes towards it, and were eager to know more on how to operate it in the ward.
(ii) Health Records (Appendices 5 and 6)
None of the groups had knowledge of the PHC community-based records (green and yellow cards) or their relevance to vital information on communities. After explanations on the importance and usefulness of the records for planning health intervention programmes and community development activities, they showed
keen interest and supported the idea of the CDA procuring the cards.
Each of the groups was very keen on having information on their youths. Other information that they perceived necessary to have was on home-based records utilization, births, deaths, health and health related problems.
The government owned PHC clinic, (the referral Ward Health Centre) at Isheri kept no records on births as no delivery was taken there. The reasons mothers gave for not delivering there were insecurity because of a fallen portion of the fence and invasion by miscreants. Data on deliveries earlier claimed to be submitted by a TBA from Magodo were not readily available. The clinic had no record on deliveries or deaths in other facilities within the ward. Monthly records on morbidity were filled and sent to the LGDA but they were not analyzed to reflect morbidity trends.
Responsibilities of CDA and “Baale”-In-Council
Convinced of the need for their community members to be involved in data management, the CDAs took up responsibility for:
procurement of community based records. A revolving fund for this was established in Magodo and is on-going.
remuneration of Community Mobilizers. The CHP in Magodo were paid honoraria of two thousand Naira each per month). The other CDA did not start paying their mobilizers at the time of the study but they had agreed to emulate the Magodo CDA.
The “Baale-In-Council” took up responsibility for:
periodic monitoring of the implementation of growth monitoring (GMP) and immunization interventions.
monitoring of births and deaths done indirectly through the chairmen of Residents’ Associations.
Provision of a place to be used as a Health Post. This was not an immediate necessity in Isheri because the PHC clinic was located there, nor in Olowora because a new private-public partnership facility had just been located there.
Population Variations
Observation on population variations showed that the most appropriate times for mobilization were evenings on week days and early in the morning on Saturdays.
Movement of people out of the communities except Magodo was not easy to determine because of their numerous outlets. Magodo, however, had a strategic place where the outlets converged. Here, it was observed that movement out of the community in the mornings was high. Recordings on week days were highest as they included school children. An average of 2,653 moved out including 746 males, 181 females and 109 school children in vehicles, 396 males, 462 females and 302 school children on motorcycles, and 88 males, 43 females and 326 school children walking. Those moving in were very few (altogether 32). The least movement in or out was on Saturdays. The highest figure recorded on a Saturday was 95 and there was little difference between mid-month and the last Saturday.
Those who moved out on the last Saturday did so before 7.00 am when the time of restricted movement for environmental sanitation commenced.
Many residents moved out of the communities on week day mornings to outside places of work. However, the Isheri population increased as a result of movement of people into the only market in the ward. The market population had a peak period between 2.00 pm and 10.00 pm (an average of 454 in the market streets) when school children were out of school and workers were returning home. The market, a major stop for all available means of public transportation was busy daily until about 11.00 pm.
Community Mobilization
Mobilizing from house to house and through the town crier, though time consuming, was cheaper and complemented that done through a mobile vehicle.
Mobilizing through formal leaders of the Eguns of Magodo, Ibos of Isheri market where approximately 50% of the traders were Ibo and of the Hausa community was very helpful.
Procurement, Launching and Sale of Cards.
The response of the community members and leaders to invitations to the launching of the cards showed effective mobilization. Even though invitations were limited to specific representatives of groups in the communities, the Community Hall that normally takes approximately 250 people was full to capacity and some people had to stay outside the hall. Attendance included Magodo zonal representatives, the CDAs of Orisa, Isheri, and Olowora, student representatives from a secondary school and community members. There were altogether 312 adults, 64 under-five year olds and 25 students.
The eagerness of leaders and community members to purchase both types of community-based records was also high. One hundred and five (105) adults, approximately 50% of the 312 who attended purchased the cards and had their blood pressures recorded in the cards. Forty-eight (75.0%) of mothers of children less than 5 years old purchased the green cards. During their community programme, the medical students sold more cards because they needed to record morbidity findings and immunizations administered in them.
Sources of Information Before and After the Study
Information on the communities was not readily available in places where one would expect to find them at the onset of the study (Table 1).
By the end of the study period, the various communities were at different stages of data collection and information was fully or partially available.
Information Gathering
Even though all the communities were to start collection of demographic information at the same time, only Magodo was able to start early and collect adequate information. The street committees of Isheri and Olowora were not as functional as the zonal Residents’ Associations of Magodo and their CDAs were, at the time of the study still making efforts to resuscitate dormant ones.
The first attempt to collect data on residents’ population was through the Chairmen of Zones/Residents’ Associations or Street Committees who were to encourage residents to purchase the Personal Health Records (yellow cards) for
persons over 5 years old. Only 5 RA chairmen sold a few during zonal meetings or passed them to secretaries who also could sell only very few even though anyone who sold a card (at N20 Naira per card) earned ten Naira on it and returned ten Naira to the CDA. This was attributed to inadequate opportunities to sell them. Zonal meetings held only once a month and the chairmen/secretaries worked outside the communities.
TABLE 1: AVAILABILITY OF VITAL INFORMATION BEFORE AND AFTER STUDY IN WARD A, IKOSI-ISHERI LGDA, 2007
AVAILABILITY OF INFORMATION TYPE OF
INFORMATION
PLACES EXPECTED TO HAVE
INFORMATION
BEFORE AFTER
MAGODO ISHERI OLOWORA MAGODO ISHERI OLOWORA
TOTAL POPULATION
- CDA OFFICES - PHC CLINIC - PRIVATE HEALTH FACILITIES - LGDA
NA NA NA
NA NA NA
NA NA NA
A P P
No. OF HOUSES - CDA OFFICES
- LGDA NA NA NA A P P
No. of CHURCHES AND MOSQUES
- CDA OFFICES
- LGDA NA NA NA A A A
No. OF HOUSEHOLDS
- CDA OFFICES
- LGDA NA NA NA A P P
POPULATION BY AGE GROUP
- CDA OFFICES - PHC CLINIC - PRIVATE HEALTH FACILITIES - LGDA
NA NA NA A P P
No. OF SCHOOLS AND No. OF PUPILS BY TYPE OF SCHOOL
- CDA OFFICES, - SCHOOLS - PHC CLINIC
- LGDA NA NA NA P P P
BIRTHS and DEATHS
- PHC CLINIC - PRIVATE HEALTH FACILITIES - LGDA - CDA OFFICES
NA NA NA A A A
GROWTH MONITORING OUTCOME AND
IMMUNIZATIO N STATUS
- PHC CLINIC - PRIVATE HEALTH FACILITIES - HEALTH POST - LGDA - CDA OFFICES - VHW/TBA
NA NA NA NA NA
A NA NA NA NA NA
NA NA NA NA NA
NA A P P P
A NA P P NA NA
NA P p NA NA MORBIDITY
PATTERNS
HEALTH CARE PROVIDERS
NA NA NA A A A
STATUS OF CDA OFFICES NA NA NA A P P
YOUTHS
A = Available P = Partially available NA = Not available
By the end of the study period, the various communities were at different stages of data collection and information was fully or partially available (Table 1).
An attempt to sell them through youths in the zones was also initially unsuccessful but their attitudes changed and they became more active when they realized that some of the information to be collected was to their advantage. The possibilities of refresher courses for those seeking admission to tertiary institutions and employment opportunities convinced them of the usefulness of the exercise. Community Mobilizers eventually took over the house-to-house sale of both green and yellow cards but coverage still fell short of expectations after 3 months as they had not completed areas far from the Health Post. As a result, the total population of under fives and those over five years old could not be determined immediately through the number of cards sold. The sale of the cards remained a continuous process and information on the number sold complemented other sources of information. These included the Residents Population forms later filled by the Chairmen of Residents’ Associations and youths, full membership and attendance records of churches and mosques as well as schools’ registers.
Information on births and deaths were collected from TBA/VHW, churches, mosques and the private clinics/hospitals by community mobilizers assigned to each zone. In addition, Chairmen of Residents’ Associations collected data on
obtain information during zonal meetings or as reported by members of the zone between meetings. This was to ensure that babies delivered in facilities outside the community and deaths of residents outside the community were also recorded.
Isheri PHC clinic staff claimed to obtain (but did not record) data on deliveries from the exercise book of a TBA/VHW based in Magodo monthly. She only provided information on the number of babies delivered by her. Even though she was aware of other TBAs practicing in the community, she could not say exactly how many babies were delivered in Magodo community in the month previous to her interview. She was also not involved in the analysis or presentation of the data generated by her and had never given any feedback on them to the community.
Other TBAs did not forward their records to the PHC clinic or LGDA. The PHC facility did not have information on births and deaths in the communities.
Data Management
Following the training/counseling sessions with TBAs, maternity staff and private clinic/hospital staff on data management, there was improvement on the type of data available from the communities to the PHC clinic (e.g. on demography, births and deaths). Record keeping also improved as copies were kept at the facilities.
Dissemination/ Display of Health Data
At the onset of the study, health data were neither displayed in the VHW/TBA’s residence, Health Posts, the ward’s referral facility (the PHC clinic) nor at the CDA offices. By the fourth month of the study all the health facilities (government owned and private) and CDA offices had started displaying
information in graphic forms in strategic places. The Magodo CDA also formed a Health Sub-committee that provided the “Baale-In-Council” and community members with information on the population or vital health data on the community. The CDA of Orisha, Isheri, Olowora and Omole Phase 11 did not constitute their Health sub-committees at the time of the study.
TABLE 2: NUMBER OF HOUSES AND HOUSEHOLDS BY ZONE MAGODO COMMUNITY, WARD A, IKOSI-ISHERI LGDA, LAGOS STATE, 2007.
No. ZONE No. OF
HOUSES
No. OF HOUSEHOLDS
h/H
1 ADEBIYI 47 (4.40) 134 (6.39) 3
2 AFOSE 98 (9.18) 172 (8.21) 2
3 AGILITI 11 156 (14.62) 244 (11.64) 2
4 AYO 13 (1.22) 14 (0.67) 1
5 FOLARIN 35 (3.28) 117 (5.58) 3
6 GATEWAY 136* (12.75) 118 (5.63) 1
7 GBELEGBO 28 (2.62) 81 (3.86) 3
8 GRA ZONE A 123 (11.53) 127 (6.06) 1
9 MAGODO NORTH 20 (1.87) 102 (4.87) 5
10 ORE-OFE 20 (1.87) 36 (1.72) 2
11 OREMEJI 62 (5.81) 199 (9.49) 3
12 ORILE MAGODO 35 (3.28) 104 (4.96) 3
13 ORISA 50 (4.69) 109 (5.20) 2
14 SALAKO 37 (3.48) 205 (9.78) 6
15 UNILAG ESTATE 190 (17.81) 261 (12.45) 1
16 UNITY ESTATE 17 (1.59) 73 (3.48) 4
TOTALS 1067 (100.00) 2096 (100.00) 2
* = 18 uncompleted houses h/H = households per house
Demography information
Magodo CDA, by the end of the study, had detailed information on the number of houses per zone and the number of households per house (Table 2) as well as sex
and age distribution in the zones (Table 3). UNILAG estate had the highest number of houses, 190 (17.81%) and households, 261 (12.45%).
Compared to the zones in the GRA ( Afose, Ayo, Gateway, GRA Zone A, Oremeji, Ore-Ofe and UNILAG Estate) that had only 1 to 2 households per house, zones in the original village (Adebiyi, Folarin, Gbelegbo, Magodo North, Orile Magodo, Salako, Unity Estate) had 3 to 6 households per house. Two houses, known as “civilian barracks” in Salako zone had more than 10 households each with some of the rooms having more than one household.
An attempt to utilize the data collected by medical students during the study period in validating those collected by community youths on the number of houses and households was not conclusive because their figures corroborated those of the youths in only 5 zones. The reasons for discrepancies included the fact that some residents had gone to work and their houses were locked up at the time the medical students collected data. Also some zonal boundaries were mixed up by the students.
The proportion of children less than one and under five years old was lower in high density zones like Magodo North, Orile Magodo, Adebiyi and Salako than in the GRA zones like Afose, GRA Zone A and Oremeji zone. There were altogether more males (53.03%) than females (46.97%). The total population of under five year olds and those above 5 years old gave an idea of the number of
green and yellow home-based records to be procured respectively. The total number of children aged 5 to 18 years gave an estimate of the population expected in primary and secondary schools. Oremeji zone had the highest proportion of adult males, 312 (56.12% for the zone or 34.36% of the total Magodo population).
TABLE 3: POPULATION BY ZONE, SEX AND AGE GROUP, MAGODO COMMUNITY, WARD A, IKOSI-ISHERI LGDA, LAGOS STATE, 2007.
No. ZONE < 1 <5 5-18 TOTAL
>18
TOTAL
>5
TOTAL FOR ZONE
GRAND TOTAL
M F M F M F M F M F M F
1. ADEBIYI 4 4 72 71 109 76 273 201 382 277 454 348 802 2. AFOSE 56 60 79 87 161 135 285 222 446 357 525 444 969 3. AGILITI 11 25 26 50 50 77 100 107 109 184 209 234 259 493
4. AYO 0 0 2 1 7 4 17 15 24 19 26 20 46
5. FOLARIN 21 14 85 75 109 121 270 202 379 323 464 398 862 6. GATEWAY 41 22 72 61 113 92 213 197 326 289 398 350 748 7. GBELEGB 13 15 28 19 27 25 108 91 135 116 163 135 298 8. GRA ZONE
A
36 47 96 87 118 112 258 203 376 315 472 402 874
9. MAGODO NORTH
7 5 22 30 46 38 159 109 205 147 227 177 404
10. ORE-OFE 6 5 67 46 19 15 11 16 30 31 97 77 174
11. OREMEJI 44 81 129 97 199 198 312 244 511 442 640 539 1179 12. ORILE
MAGODO
2 6 26 25 24 36 116 152 140 188 166 213 379
13. ORISA 53 47 78 74 81 77 95 81 176 158 254 232 486 14. SALAKO 15 17 43 49 68 63 217 212 285 275 328 324 652 15. UNILAG
ESTATE
16 17 35 49 90 93 237 208 327 301 362 350 712
16. UNITY ESTATE
3 2 46 43 37 26 43 35 80 61 126 104 230
342 (48.
17) 368 (51.
83) 930 (51.
84) 864 (48.
16) 1285 (51.
48) 1211 (48.
52)
2721 (54.
22)
2297 (30.
57)
4006 (53.
31) 3508 (46.
69) 4936 (53.
03)
4372 (46.
97)
9308 (100.00) TOTALS 710
(7.63)
1794 (19.27)
2496 (26.82)
5018 (53.91)
7514 (80.73)
9308 (100.00)
M = male F = Female
These figures could not be cross-checked with those of the National Population Council which refused to release its own figures because of the legal tussle with Lagos State government on the census results of Year 2006. The detailed
breakdown of the populations of Isheri and Olowora communities were not calculated because their youths did not complete collection of their information.
Facility Health Manpower
At the time of the baseline situation analysis, the newly constructed Health Post in Olowora had no staff while the Health Post in Magodo had only two Community Health Promoters providing services only on Wednesdays and Saturdays. A CHEW from the PHC clinic in Isheri complemented them on Wednesdays but was irregular because of staff shortages at the ward PHC clinic.
The ward’s PHC clinic located in Isheri was inadequately staffed when compared with national guidelines. The centre, even though it served the whole ward had only one Community Health Officer (CHO), one Community Health Extension Worker, one Junior Community Health Extension Worker, one Environmental Officer and one Population Officer. There was no doctor because only one served 6 LGDA and was usually at one of the LGDA offices.
The only private medical hospital in Magodo community started functioning about eighteen months before the commencement of this study. It had one doctor and 3 nurses. Isheri had 1 private hospital/maternity with 1 doctor and 3 nurses while Olowora/Omole Phase 11 had 3 facilities. Two of them had 2 doctors and 3 nurses each while one had only 2 nurses and no doctor at the time of visitation.
The only government owned PHC clinic (the Ward Health Centre) was located in Isheri. An extensive portion of the fence that had fallen was repaired through community effort during the period of this study. The clinic had no water supply and no electricity. The newly constructed clinic at Olowora for public-private partnership where the National Health Insurance Scheme is to be operated was not staffed at the time of this study. The clientele in both communities were more from the low income group because, according to health care providers, many of the middle/high income groups patronized government and private facilities outside the ward.
Community-Based Health Manpower
Community Health Promoters trained by BASICS 11-Nigeria project (4 out of 10 in Magodo, 3 out of 10 in Isheri and 3 out of 10 in Olowora) were still assisting the LGA only during National Immunisation Days activities. A total of 7 out of these were still functioning in the communities at the time of this study. One of the 2 in Olowora died before mobilization activities commenced fully for the study in her community. The Magodo CDA took up responsibility for the CHPs remuneration during the study and through its Health Sub-committee and the CHP, established a data management infrastructure.
Static Facility Records
The PHC clinic staff kept records mostly in notebooks rather than the NHMIS forms and on forms provided by an International agency, COMPASS. They had forms that contained information on:
General Out-Patient Records (Daily Record of Work on Child Welfare (old and new cases) and Immunisation). Information from the notebooks is
transferred monthly to the LG form, “SUMMARY OF ACTIVITIES AT PRIMARY HEALTH CARE CLINIC AND IN THE COMMUNITY”.
DIARRHOEA AND ARI REPORTING FORM.
FORM 2HF-2 (MONTHLY RECORDS OF TRACER DISEASES AND OUT-PATIENT ATTENDANCE IN THE HEALTH FACILITY).
FORM C.IF/001. COMPASS REPORTING FORMAT: HEALTH FACILITY.
This is a form supplied by an International Partner organization, COMPASS, a USAID International Partner to obtain data on family planning, ante-natal and delivery services, Immunisation and outreach sessions.
The clinic did not have any information on the target population, and birth records were kept by a “Population Officer” who filled birth registration forms only for babies brought to the clinic and whose mothers requested for the service. Also duplicates of records given to COMPASS staff were not kept by the clinic.
The only records available on deaths were two “LETTERS OF PERMIT FOR HOME BURIAL” written in 2004. Population Officers from the LGDA also inspected the community periodically for burials done without permission. They were not aware and had no records on five deaths, all among adults, that occurred in the Magodo community in the previous two months. There were no records of deaths in Isheri, Olowora and Omole Phase 2.
Private Health Facility Records
The ward had more private (7) than government (3) facilities. Data were collected by 5 private facilities’ on self-designed record forms or registers rather than on