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The 12-Pillar Clinical Governance Approach: Strengthening health systems in Nigeria

Professor Joseph Ana, Africa Centre for Clinical Governance Research & Patient Safety

The 12-Pillar Clinical Governance Approach to quality and safe healthcare was piloted in 2004 after a first ever comprehensive needs / situation analysis of the healthcare delivery system for the 3.1 million population of Cross River State, Nigeria.

The baseline assessment revealed a failing system plagued by appalling weakness across all indicators/domains for performance, safety and quality. Maternal, under-5 child, and infant mortality were 800 per 100,000 deliveries, 245 deaths per 1000 births, and 100 deaths per 1000, respectively. Sanitation, indiscipline, truancy, poor attitude and behavior of staff to patients, corrupt practices, frequent out of stock of essential medications, lack of basic and advanced equipment, erratic electricity and lack of potable water were contributing to these alarming statistics. There was no regular continuing professional development for staff to remain updated in their fields. Frequent strikes and inter-professional disharmony in the sector perpetuated the bad health indices, and until 2014, Nigeria had no National Health Act to provide a framework for improving its health system.

A response to address a weak health system

Since 2004, Health Resources International (HRI) West Africa has worked with public (state Ministries) and private facility owners to strengthen hospitals and reverse the trends described above. Our goal was to markedly improve routine immunization, reduce HIV prevalence in Cross River state, and improve staff attitude, patient satisfaction and care outcomes. We aimed to do this by introducing a new clinical governance approach. The National Council on Health formally approved our 12 Pillar approach at its meetings in Jalingo, Taraba State in 2006 and Abuja FCT in 2007, and recommended that other states should also adopt this approach. Three former ministers of health have consecutively declared that ‘Nigeria needs Clinical Governance’ of the type (12-Pillars) that we are promoting for training institutions, health facilities and policy makers.

A comprehensive approach to effective service delivery for developing countries.

The Cross River State Ministry of Health pilot in 2004/5 showed that the 7 Pillars of Clinical Governance, as described by Dr. Gabriel Scally and Prof Sir Liam Donaldson in the United Kingdom in 1998, could not be transferred to a developing country like Nigeria without essential contextual domestication. We found that five additional pillars (see below) were needed to ensure effective and sustainable quality of service.

The goal of the 12-Pillar Clinical Governance Approach is to reduce the disease burden, eliminate inequalities, reduce especially maternal and child morbidity and mortality, and increase life expectancy and quality of life across age and gender. The 12 Pillars approach is an innovative, evidence-based framework to deal with the chronic challenges in Nigeria’s health system. It uses contextual understanding and collaboration between all health practitioners, and all government and non-government stakeholders to optimize the health benefits of government policies.

Why 12 Pillars Clinical Governance for developing countries

The 12 Pillars are: *Policy/Law, *Funding Mix, *Infrastructure,*Equipment, *Utilities and Ambience, Clinical Effectiveness, Audit, Risk Management, Education and Training, Patient and Public involvement (PPI), Information and IT (ICT), and Facility and staff management. The asterisks highlight the essential five components are often missing in developing countries. By adding these to the original seven pillars, we created the 12-Pillar Clinical Governance Approach. Institutionalization of the Approach led to a Health in All Policy (HiAP) in Cross River State in Governor Donald Duke’s administration.



Why the policy matters

For more than 150 years, Nigeria’s health system has defied every effort to take it into the top league of global health systems, leading to unacceptable rates of maternal and child mortality rates and poor health outcomes for the population generally. Nigeria accounts for about 2% of the world population yet contributes 10% of maternal, infant and child mortality because of its failing health system. And although the HRI needs assessment focused on Cross River State, we know it is no exception to all the other 35 states and Federal capital Territory (Abuja).

Where the homegrown 12-Pillar Clinical Governance Approach has been introduced in Nigeria, whether in public or private health facilities, the positive outcomes have been rapid, including a stronger health system anchored on best ethics, professional conduct and practice leading to Accreditation and Quality Marker Awards, concomitant cost control and sustaining quality and safe care.

Reviews of an evaluation of the pilot (which were published in the book titled ‘Whole system change of failing health systems’) were positive. The pilot defined the 12-Pillar Clinical Governance Approach as a ‘comprehensive amalgam of context-aware processes that ensure quality and safe outcome in health care by protecting patients and supporting practitioners in tandem’.

The 12 Pillars approach recognizes that the health and well being of the citizen is influenced by factors beyond direct health intervention, including level of education, income, housing, work place conditions and ambience, infrastructure, culture and religion. In turn, these are determined by social, environmental, economic and policy factors. Government policies therefore have significant direct and indirect impact on the health of the population, including around issues relating to accessibility, affordability, disparity and equity. It engenders multidisciplinary and multi-sectoral collaboration to achieve better results.

Joseph AnaProfessor Joseph Ana

BM.BCh (UNN), FRCSEd, FRSPH, JtCertRCGP-UK, DFFP (RCOG)-UK, DipUrology-UK, Cert.ClinGov.UK


Visit Website:      email: hriwestafrica [at]

Fig.1 Credit:, 7 Elements of Clinical Governance

Fig.2 Original Credit: – Adapted by: 12 Pillar Clinical Governance

Health Worker Training Program Translated into Hausa and Yoruba

This post first appeared on the Medical Aid Films web site here and has been adapted for this site. 

mPowering and partners Medical Aid Films, Instrat and Digital Campus are delighted to launch a suite of 11 maternal and child health films in two new languages – Yoruba and Hausa – to support the development of an innovative health worker training programme in Nigeria.

Using a tablet-based curriculum, and working closely with the Ondo State Primary Health Care Development Board, this program is sharing life-saving information focused on maternal and child health.

Hausa and Yoruba are among the most widely spoken languages in Africa, used by over 70 million native speakers, and by many millions more as a second or third language.  This suite of films will transform access to vital knowledge about maternal and child health in West Africa.

By clicking on the links below, you can watch or download the films in full.

Local-language content is just the beginning of opportunities to scale this programme across Nigeria.  Plans are underway with Ondo State Primary Health Care Development Board to expand the pilot significantly to cover more facilities in the State.  Meanwhile screenings have started in Kano State, northern Nigeria, using innovative solar powered Wi-Fi hubs in partnership with Outernet, with further possible programmes being planned.

Our thanks to the leadership from Ondo State, and to Instrat, Medical Aid Films and Digital Campus for their support for this work helping transform access to knowledge and training that saves lives.

We would be happy to talk with Ministries, training institutions, NGOs and others about how to adapt this content for your health workers. You can reach us at


Zero Mothers Die App Launches

Zero Mothers Die, a global partnership with UNAIDS to reduce maternal mortality through mobile technology initiatives, is very proud to partner with mPowering Frontline Health Workers on the new Zero Mothers Die App, which has been launched on the first-year anniversary of ORB by mPowering.

ZMD Image 1

The Zero Mothers Die App, or ZMD App, is a source of essential maternal, newborn and child health (MNCH) information for pregnant women, new mothers as well as frontline health workers who provide MNCH care to their community.

ZMD Pic 2Thanks to the ORB by mPowering platform, the ZMD App is able to provide access to a unique mix of instructional training videos, online courses, patient education materials and other multimedia resources to help improve the capacity of frontline health workers to deliver effective maternal, newborn and child care to their communities. All material was sourced from ORB by mPowering, an impressive library of mobile-optimized multimedia content for the training of health workers in maternal, newborn and child health issues.

We congratulate mPowering on the first year anniversary of ORB, and look forward to more tools and content to come to empower frontline health workers around the globe.

This post was written by Zero Mothers Die. About Zero Mothers Die and the ZMD App:

Zero Mothers Die is a partnership initiative by Advanced Development for Africa, Millennia2025 Foundation, UniversalDoctor Project, Global Partnership Forum, UNAIDS and other key partners. For more information, visit:

The ZMD App has been developed by the Zero Mothers Die global partnership initiative, which seeks to deploy mobile technology solutions to reduce maternal and newborn mortality across the globe.


Mobile Kunji: a job-aid for community health workers in India that’s changing health behavior at scale

This post originally appeared on the BBC Media Action website here

New Delhi, 8 February 2016:

The results of an impact evaluation of BBC Media Action’s award-winning mhealth service, Mobile Kunji, have been shared today at the Social and Behavior Change Communication (SBCC) Summit in Ethiopia, and published online.

“Mobile Kunji has the power to strengthen the most important yet the weakest link in the behaviour change communication – that between a community health worker and the marginalized communities she serves” said Andy Bhanot, Head of Research at BBC Media Action, India.

“Early data on the impact of Mobile Kunji looks very promising”, continued Mr Bhanot. “It shows improvement in the levels of engagement between community health workers and families, which in turn has resulted in greater awareness, more positive attitudes and self-efficacy, and higher adoption of healthy behaviours.”

Mobile Kunji is a free audio-visual job aid designed to improve the quality of engagement between community health workers (CHWs) and families, and the take-up of healthier behaviors by new and expecting mothers.

The results of the Mobile Kunji Usage and Engagement Study, commissioned by BBC Media Action, and carried out by Indian Market Research Bureau (IMRB)  in Bihar in 2014, indicate that exposure to Mobile Kunji is positively associated with:

• Significant increases in the knowledge, confidence and credibility of CHWs.
• Significant improvements in the quality of CHWs’ interactions with new and expecting mothers.
• Significantly greater levels of knowledge of life-saving preventative health behaviours among new and expecting mothers.
• Significantly higher adoption of life-saving preventative health behaviours by new and expecting mothers

Mobile Kunji was first launched in Bihar, India in 2012, as part of the transformational Ananya programme. Ananya is a collaboration between the Bill and Melinda Gates Foundation and the Government of Bihar to reduce maternal and infant mortality rates in the state.

Learn more:

Video: families in Bihar talk about how Mobile Kunji has changed their lives.

Infographic: explore how Mobile Kunji is changing knowledge, attitudes, self-efficacy and practice in Bihar.

Video: learn more about the science and craft that went into developing Mobile Kunji.

Download: the full Mobile Kunji Usage and Engagement Study.

Our World’s Healthy Future Needs Community Health Workers

By Katie Taylor (USAID), with Nazo Kureshy (USAID) and Lesley-Anne Long (mPowering Frontline Health Workers)

We live in extraordinary times. In 1960, 22.2% of all children in developing countries – one out of every five – died before the age of 5. Today, we are within reach of ending preventable child deaths. Across developing countries, when compared with fifty years ago, people are living longer, more people are educated, there are fewer wars, and there is an unprecedented drop in both the number and rates of people living in extreme poverty.

At the same time, Ebola and Zika are drastic reminders of our human frailty and the need for vigilance and responsiveness – in all countries, and at all levels of care, from global down to every community, every family. The survival and safety of the women and children of the world require us to find ways to link families and communities to the knowledge, behaviors and treatments that can help them survive, thrive, and transform for the better the world they live in.


Unlocking the potential of community health workers: a multi-pronged approach

As part of this effort, a group of 50 development practitioners, thinkers, experts, and funders came together in Wilton Park in England this week seeking to unlock the potential of community health workforces (CHW) in Africa, post-Ebola. Ministry and NGO practitioners presented models developed and being improved in Sierra Leone, Liberia, Ghana, Guinea, Rwanda, Mali, Malawi, India, Uganda, Senegal, and beyond.

Three thoughts emerge:

  • Inspiring models of community health workforces already exist – which smart, experienced people are striving to make even better, through a variety of means, including policy improvements, strengthening supervision, leveraging technology, and introducing long-term domestic financing.
  • There is not yet a systematic, simple way of actively sharing good practices across countries; we need to be able to compare and contrast solutions that could potentially be replicated and scaled faster, smarter, or more affordably, if we could leverage regional or global resources.
  • We have not yet cracked the nut of financing. Making the Case for CHWs offered key principles and stressed the urgent need for national governments and development partners to substantially increase investment in Community Health Workers as part of integrated health care systems. We need financing solutions to be shared, adopted and adapted, as well as spur thinking on new ones.

A framework for community health

My colleagues and I shared a first version of a Community Health Framework with participants to jumpstart a “common language” on community health. This first framework highlights some laudable models and tools in a way that is simple to navigate and understand. It acts as an interactive learning tool that can help practitioners and ministries better appreciate why we should care about community health, how to approach and think about community health, and where to find successful models and examples. The framework also offers a way of looking at and acting in a common ecosystem – any country, whatever its circumstances, in order to be successful, will need to think about both help-specific and health-enabling factors, as well as ensuring resources, access, and agency.

We urge our colleagues to consider leveraging this common language in their own work, so we can begin to find commonalities and ways to better scale and replicate. We urge adopting a common language also as a way of facilitating faster, more iterative, dynamic learning within and across models. This in turn may better help us to develop financing solutions across CHW models.

What’s the role of civil society?

Just as we must think about community health workers as an integral part of the wider health system, we should also understand the critical role that civil society has to play in improving the health of populations.

Civil society engagement is recognized to be vital to achieving the Sustainable Development Goals – evidence suggests that supporting active civil society engagement promotes equity and access to improved health service delivery and health outcomes. Moreover, the new Global Strategy in support of Every Woman Every Child calls for the engagement of all sectors of society to end preventable deaths of women, children, and adolescents and ensure that all can thrive and reach their potential.

It’s a time to be bold

“The acute crisis of Ebola many be over but sustained crisis and emergency still exists” – this was the warning we heard at Wilton Park. We cannot afford not to invest in community health workforce development. Strong political will and leadership, smart investment and coordinated planning are just a few of the critical components. The private sector has much to offer – both in terms of investment and bringing strong business models for sustainable solutions.

This is the time to be bold and to be practical. Over the last three days we started to set out broad principles to achieve strong community health workforce development. As we close the conference this afternoon, I am inspired by the commitment and passion that we heard about and experienced in the room. As one of our colleagues said, “It is not easy; it requires collaboration and determination, but we know what needs to be done – now let’s go and do it”.