ORIGINAL

Niger J Paed 2014; 41 (3):163 - 169

Fatiregun AA

Alonge TO

Rukewe A

An assessment report on an

immunization clinic located in a

tertiary institution in Ibadan

Etukiren E

Chidinma U

Adejugbagbe AM

DOI:http://dx.doi.org/10.4314/njp.v41i3,3

Accepted: 11th February 2014

Abstract Objectives: The aims of

(BCG) vaccine, which peaked in

2011, other vaccines’ coverage

peaked in 2009, after which there

was a decline. The highest dropout

rate was recorded in 2007, while

the rates between 2009 and 2010

were <10%, but the BCG and mea-

sles drop out rates were >10% for

the 5-year period. For the adult

immunizations, yellow fever re-

corded the highest coverage rate,

while the lowest rate was recorded

for tetanus toxoid dose 5 (TT5).

The vaccines that were most often

in short supply included Diphthe-

ria- pertusis-tetanus, Hepatitis B,

yellow fever, oral polio, and cere-

brospinal meningitis vaccines.

Although good-quality supplies,

equipment and consumables were

observed, there was no inventory

of these items. There were evident

interpersonal communication and

community mobilization as well as

capacity building for staff.

the assessment report were to ap-

praise immunization system com-

ponents and review vaccination

coverage between January 2007

and December 2011 at the Uni-

versity College Hospital (UCH)

immunization clinic.

Methods: The immunization

clinic has an annual target popula-

tion of 997 (for children < one

year of age) and 1246 (for preg-

nant women), which were used in

this assessment. The data collec-

tion method used included; Key

informant - interview, administra-

tion of a semi-structured question-

naire, records review and observa-

tions during immunization ses-

sions.

Results: The UCH immunization

clinic mainly offers fixed sessions

and only provides outreach ser-

vices when there is a need, such

as during outbreaks. However,

there are no records of vaccine-

preventable diseases being moni-

tored. The coverage rate for

nearly all of the vaccines was

greater than 100% of the esti-

mated target population for the

hospital. Except for the coverage

rate of Bacille Calmette Guerin

Fatiregun AA

(

)

Department of Epidemiology and

Medical Statistics, Faculty of Public

Health, University of Ibadan.

Nigeria.

Email: akinfati@yahoo.com

Alonge TO, Rukewe A, Etukiren E,

Chidinma U, Adejugbagbe AM

Department of Orthopaedics & Trauma,

University College Hospital, Ibadan

Nigeria.

Conclusion: The assessment

showed there was progress in the

provision and administration of

immunization based on available

resources. There is, however, the

need to improve documentation of

clinic activities.

5

,6

Introduction

measles, neonatal tetanus, and whooping cough . Nige-

ria’s child’s immunization coverage has remained low

over the past decade. The low coverage has been identi-

fied to be attributed to weak health structures and sys-

tems, inadequate funding by government, over depend-

ence on donor funds, withdrawal of funds and lack of

Immunization remains the primary strategy for the pre-

vention and control of common childhood diseases, es-

pecially in the developing world . Prevention of child

1

mortality through immunization is one of the most cost-

effective public health interventions in use in resource-

7

ownership at the community level. However, Nigeria,

2

poor settings . Childhood immunizations have dramati-

like many countries in the African region, is making

efforts to reduce disease burden from vaccine-

preventable diseases (VPDs) by strengthening the health

system in general and routine immunization system and

cally reduced the incidence rates of debilitating and

3

,4

sometimes lethal diseases . In developing countries,

immunization programmes prevent approximately two

million deaths per year, which would have resulted from

8

services in particular . Five operational (service deliv-

1

64

ery, quality vaccine supply, logistics support, surveil-

lance for VPDs, and advocacy and communication) and

three supportive (sustainable financing, programme

management, and human and institutional resources)

components of the immunization system have been

increasing on a daily basis. However, no appraisal of the

immunization coverage and system activities has been

undertaken since inception.

National immunization objectives

7

identified for improvements . To strengthen the service-

delivery components of the immunization system, for

example, the country adopted the reaching every district

The main national immunization objective was to de-

velop and promote immunization programmes geared

towards the reduction of childhood morbidity and mor-

tality through adequate immunization coverage of all at-

(

RED) approach of the World Health Organization and

renamed it the reaching every ward (REW) approach to

reflect the administrative structure in Nigeria. In this

approach, five strategic components (with expected ac-

tivities) were identified for improvements. These include

9

risk populations . The specific objectives of the national

immunization programme were as follows: Improve and

sustain routine immunization coverage of all antigens to

90% by the year 2020, in agreement with the national

vision; Achieve, through quality supplemental activities,

interruption of polio transmission by the end of 2009,

and total eradication by the end of 2013; Eliminate ma-

ternal and neo-natal tetanus by the end of 2010; Prevent,

detect, control, and eliminate the occurrence of out

breaks of CSM, measles, yellow fever, and any other

VPDs in all parts of the country; and₉ reduce childhood

mortality due to immunizable disease .

1

.

Planning and management of resources, through

quarterly micro or detailed planning for human,

material and financial resources, and

2

.

Improving access to immunization services through

establishment or re-establishment of fixed, outreach

and mobile immunization sites. Other strategic

components are

3

4

.

Supportive supervision through onsite or on-the-job

training,

Community links with service delivery through

regular meeting between community and health

staff, and

Mission/Vision of the UCH immunisation clinic

5

.

Monitoring and use of data for action through, cov

Mission/Vision of the UCH immunization clinic is to

render excellent and prompt immunization services in a

suitable environment.

erage/dropout reviews, dose charting, mapping of popu

lation in each facility and categorizing health facility

based on access and utilization of services.

Objectives: The objectives of the UCH immunization

clinic are as follows: reduce the mortality and morbidity

rate arising from communicable diseases, especially

childhood killer diseases, through active immunization

of members of staff and their families in UCH, including

registered members of the community; investigate the

effectiveness of preventive measures (health education,

counseling, contact tracing, home visits, and surveil-

lance) offered to control the infectious disease on a quar-

terly basis; support and participate in the global and na-

tional targets/programmes in the eradication of the dis-

eases; and to study default rates among clients and find

solutions to the identified problems on a quarterly basis.

The improvement plans for each of the immunization

system components, expected activities including task

description, and monitoring indicators at the health fa-

cilities, ward, local govern₇_-m₁₀ent, state and National lev-

els have been described . Improving immunization

coverage will require regular assessment of the immuni-

zation delivery system to determine if programme objec-

tives are being met, to identify problems and causes of

low coverage and to plan activities to increase cover-

7

,10

age

.

The National Programme on Immunization (NPI) was

initiated with a vision of achieving sustainable immuni-

zation service delivery through community ownership,

Objectives for conducting the assessment

7

community operated and community driven strategies .

Consistent with the above vision; the University College

Hospital (UCH) immunization clinic was opened to at-

tend to the immunization needs of hospital staff.

The general objective was to appraise the immunization

system components and review vaccination coverage

between January 2007 and December 2011 at the Uni-

versity College Hospital (UCH) Immunization clinic, so

as to use the findings to make recommendations.

History of the immunization clinic

The centralized immunization clinic of UCH was for-

merly referred to as the staff immunization clinic. The

clinic was opened to attend to the vaccination needs of

staff members and their dependants. As a result of the

small target population, many doses of vaccines were

usually left over after each vaccination session and the

liquid vaccines had to be returned to the state vaccine

store. It was observed later that many UCH patients/

clients were requesting administration of one vaccine or

another. The decision was thus made in 1990 that the

immunization clinic should serve other registered people

in the clinic. Since then, the clinic attendance has been

Specific Objectives: The specific objectives were as

follows: to determine immunization coverage data in the

clinic; identify the strengths of the services; and deter-

mine constraints to achieving the program objectives

using the immunization system approach.

1

65

Methodology

Results

Catchment area and target population

The findings of the evaluation were as follows:

University College Hospital is located in the Ibadan

North Local Government Area (LGA) of Oyo state. The

LGA has a population of 374,948 (2011 estimate) based

on 2006 census estimates and is divided into 12 admin-

istrative wards. The wards that make up the LGA in-

clude Oke-Are, Nalende, Yemetu, Agodi, Bashorun,

Sabo, Sango, Ago-Tagba, Old Bodija, Samonda, and

Agbowo. UCH is located within the Old Bodija ward,

which has a population of 41,245. Only three health

facilities are recognized as immunization clinics in the

ward (UCH, Institute of Child Health [also within

UCH], and the Obasa Health Facility). The UCH clinic

had an annual target population of 997 for children

Service delivery

The services provided by the clinic include the follow-

ing: Infant welfare clinic; Yellow card processing; TB

screening; Child and adult immunization; and outreach

programs. The UCH immunization clinic mainly offers

fixed sessions and only provides outreach services when

there is a need, such as during outbreaks. The clinic is

open throughout the week (Mondays to Fridays) be-

tween 8am and 5pm. The largest number of clients is

seen on Wednesday and Thursday because all of the

vaccines are administered to the clients, unlike other

days. Public health nursing personnel and doctors from

the Family Medicine Department attend to the medical

needs of clients on every clinic day. The vaccines ad-

ministered include the following: Monday (BCG, HBV,

OPV, and other special/non-routine vaccines); Tuesday

(yellow fever and TB screening); Wednesday (BCG,

HBV, OPV, DPT, HIB, and non-routine vaccines);

Thursday (BCG, HBV, OPV, DPT, HIB, measles, and

TT); and Friday (special vaccines, child welfare, and TB

screening).

<

1year of age, and 1246 for pregnant women, as ob-

tained from the LGA immunization unit. The communi-

ties served by the UCH clinic include Awosika, Adeyi,

Abedo, Osuntokun, Ondo, Ajibade, Obasa, Awolowo,

Ekiti, and Coca-Cola.

Data collection and instrument

The information gathered during the assessment was

both qualitative and quantitative on the five operational

and the three supportive components of the immuniza-

tion system. Three methods of data collection were used

during the assessment, and include the following: Re-

cord review, extracting data on the vaccines used, and

vaccination coverage from immunization records from

January 2007 and December 2011; Interviews, discus-

sion, and probing of the head of the immunization clinic

using a semi-structured interviewer administered ques-

tionnaire adapted from the WHO assessment question-

naire, with categories based on the operational and sup-

portive components of the immunization service deliv-

ery, including, vaccine supply, disease surveillance, lo-

gistic and advocacy, capacity building, and financial

management; and Observations during immunization

sessions

For fixed sessions, planning is continuous and daily due

to the daily administration of vaccines. Work plans are

non-existent in the clinic, and all of the standard data

management tools are not available. Specifically, only

an improvised immunization register and the child

health card are available, while the tally sheet, immuni-

zation summary sheet, and immunization coverage

monitoring chart are not available. Thus, monitoring for

dropouts, vaccine wastage, categorization, and prioriti-

zation is nearly impossible. The form for recording ad-

verse events following immunization (AEFI) are not

available, thus there is no method for tracking AEFI and

none has been reported in the past five years.

The staffs administer the vaccines correctly (the correct

site, route, and dose). The staff practice injection safety

and dispose of used syringes/needles immediately into

the safety box. The staffs record each vaccine on the

child immunization card correctly, but do not tally cor-

rectly on the tally sheet. The immunization registers

used are ordinary notebooks, and thus are not correctly

filled out and there are no mechanisms to track vaccine

doses that are due or to track defaults. The staffs are

aware of the standard operating procedures and neces-

sary forms to complete if there is a report of an AEFI,

but the forms are not available.

Data Analysis

Data on immunization coverage for the five year period

was entered into Microsoft excel. In order to compare

the trends in the coverage rates, the percentage coverage

for infants and adults vaccines were computed for the

period the review covered. The cumulative monitoring

charts for DPT1 & DPT3, BCG & Measles were also

computed, as well as their dropout rates.

Ethical consideration

Immunization coverage for the five year period

Permission to carry out the assessment was obtained

from the Chief Medical director of the University Col-

lege hospital. Permission to use the records of the immu-

nization clinic was obtained from the head of the unit.

The coverage rate for nearly all of the vaccines was

>100% as a result of the low yearly target population of

the hospital estimated by the LGA from the census

population of the ward where the hospital is located.

Except for the coverage rate of BCG, which peaked in

2

011, other vaccine coverage peaked in 2009, after

which there was a decline (Figure1). The DPT1-DPT3

1

66

dropout rate was almost the same as the BCG- measles

dropout rate; the highest dropout rate was recorded in

Fig 4: Immu-

nization cov-

erage for

2

007, while the rates between 2009 and 2010 were

adults over the

<

>

10%, but the BCG and measles drop out rates were

10% for the 5-year period (Fig 2 and Table1). For the

5

-year period.

adult immunizations, yellow fever recorded the highest

coverage rate, while the lowest rate was recorded for

tetanus toxoid dose 5 (TT5; Fig 3).

Fig 1: Vaccine

coverage for

the 5-year

period

Fig 5: Coverage

for other child-

hood vaccines

provided in the

clinic in the 5-

year period

Fig 2: Monitoring

chart for cumula-

tive DPT1 and 3

for the 5-year

period

Vaccine supply

The routine immunization vaccines were collected from

the LGA by the health facility staff two times per

month. Auto-disable syringes, which are bundled with

the vaccines were also collected from the LGA and were

used to administer vaccines and disposed using safety

boxes. Vaccines were available during immunization

sessions. The vaccines that were most often in short sup-

ply included DPT, HBV, YF, OPV, and CSM. Only

those vaccines that had not expired and those in vaccine

vial monitor (VVM) stages 1 and 2 were used for immu-

nization. After each session, HBV and DPT were re-

turned to the refrigerator, while YF and measles were

discarded in line with the multi dose vaccine policy.

Table 1: DPT1-DPT3 and BCG-measles dropout rates for the

5

-year period in the UCH Immunization clinic

Year 1

Year 2

Year

3

Year

4

Year 5

%

DPT 1

DPT3

Drop out/

70.2

48.7

30.5

117.4

110.5

5.9 (Cat1)

121.4

116.7

3.9

105.8

106.9

-1.1

92.6

80.2

13.4

*Categorization (Cat4)

(Cat1) (Cat1) (Cat2)

%

BCG

Measles

Drop out/

103.0

22.0

78.6

159.5

79.2

50.3

156.4

106.7

29.9

132.3

106.0

19.8

150.7

91.6

39.2

There was no method for vaccine forecasting. Vaccines

and dry stock ledgers were unavailable, thus vaccines

were requested based on the previous records and requi-

sition forms. There were no methods for vaccine utiliza-

tion, waste monitoring and reduction in the clinic, thus

the utilization rates could not be determined. Vaccines

were stored in refrigerators and were handled properly

during administration.

*Categorization (Cat2)

(Cat2)

(Cat2) (Cat2) (Cat2)

Category 1: Good access good utilization

Category 2: Good access poor utilization

Category 3: Poor access good utilization

Category 4: Poor access poor utilization

Fig 3: Monitor-

ing chart for

cumulative

BCG and mea-

sles for the 5-

year period

Disease surveillance

The clinic does not maintain records of vaccine prevent-

able diseases (VPDs) and thus cannot determine if there

is a reduction or otherwise, in the number of cases.

Other variables, such as the incidence of VPD, the num-

ber of cases of non-polio acute flaccid paralysis, measles

outbreaks, cases investigated, and determining if the

incidence of disease and coverage rate correlate could

1

67

not be determined. Monthly immunization coverage

reports were sent to the LGA, but there was no record of

feedback from the LGA.

clinic. The target set for UCH is 83 clients per month,

but because of the nature of the hospital as a tertiary

health facility, the target is almost always exceeded,

even on daily basis, thus accounting for >100% cover-

age recorded by the clinic. Data on the target population

are determined by the LGA based on projections from

the national population census figure. The clinic does

not have a catchment area map for routine immunization

showing all settlements, the population, and the type of

session being used to reach the settlements. Work plans

were not available and there was a lack of information

sharing between the clinic and other departments of the

hospital, especially the VPD record unit.

Logistics

Previously, routine immunizations, such as DPT, OPV,

HBV, yellow fever, and vitamin A were received from

the Jericho state store, but after a decentralization, the

routine immunizations were supplied from the Ibadan

North LGA store. In September 2011, a proposal was

presented to the UCH management for the procurement

of non-routine vaccines, which had been administered to

children in Asia, the US, and many other African coun-

tries, and the same was approved.

The clinic management ensures a good quality supply,

equipment, and consumables, but there is no availability

of stock supplies and consumables inventory. The clinic

has a sufficient amount and well functioning cold chain

materials for effective and efficient service delivery,

including refrigerators, freezers, cold boxes, vaccine

carriers, icepacks, and foam pads. The temperature of

the refrigerators and freezers were monitored to ensure

optimum functioning. When the need for outreach arose,

adequate transport and materials were made available.

Discussion

The UCH immunization clinic mainly offers fixed ses-

sions and only provides outreach services when there is

a need, such as during outbreaks. This falls short of the

1,2,3 strategy for delivering routine immunization sug-

gested by the Expert Review Committee on Immuniza-

tion of the National Primary Health Care Development

9

Agency . The committee recommended that apart from

weekly immunization services at fixed sites, outreach

services are expected to be conducted by a health facility

in areas >5km to the facility but within its catchment at

least twice a month to improve access to immunization

services. The concept of “reaching every ward” (REW)

is meant to ensure that no community, no matter how

remote is denied the opportunity to enjoy routine immu-

nization services. It is therefore, important that commu-

nities that cannot be effectively accessed by use of exist-

ing fixed sites, be reached by using outreach or mobile

immunization services. It was noted that coverage data

are traditionally considered the best indicators of an im-

munization programme's performance because they

reflect the management of access, and utilization of ser-

Advocacy and communication

The health staff communicates effectively with parents

and caregivers, and before administering the immuniza-

tion, the health staffs provide the six key messages to

the parents and caregivers. The health staff have good

interpersonal skills and relate well with the clients. Only

the UCH community is involved in the planning, while

the other communities are not involved. This is a result

of the fact that the clinic was initially established for the

UCH community alone. There were no active attempts

to reach the unreachable, defaulters, and non-users. The

last form of evaluation for the clinic was performed in

2

vices . The immunization coverage rate for nearly all the

2

009.

vaccines in this report was >100%. This was higher than

the coverage goal of the Nigeria comprehensive multi

year plan 2011-2015 of 87.0% of infants for all antigens

Capacity building

7

in the routine schedule by 2015 . This was also higher

At present, nine staffs currently work in the immuniza-

tion clinic, of which six are qualified nurses. There have

been in-service training for the staff on injection safety,

prevention of HIV transmission, and stress management

in the last five years. The staffs were also trained on

calculating and creating the dropout rate chart, but the

staffs do not put the knowledge into practice. The staffs

are knowledgeable about administering vaccinations

correctly and also provide the six key messages to par-

ents/caregivers before administering the vaccines, but

some times the staff do not register the vaccination cor-

rectly in the tally sheet, immunization register, and child

health card. Job performances are regularly evaluated,

but feed back is not provided.

than the WHO-UNICEF estimates for Nigeria for each

vaccine such as; BCG 69%, D₀ PT3 54%, OPV3 61%,

1

HB3 41%, and measles 62% . Nigeria is among the

7

twelve very high-risk countries in the yellow fever belt .

While yellow fever vaccine is currently part of the coun-

try’s routine immunization schedule, the coverage like

other routine immunization vaccines is low and as such

there is a potential danger of large outbreaks of yellow

fever. For the adult immunizations in this report, yellow

fever recorded the highest coverage rate. This differs

from the report of immunization coverage made in a

tertiary teaching hospital in Niger Delta in which yellow

fever/ measles vaccines had the lowest coverage rate 94

1

(17.8%) .

Management

Although the coverage for individual vaccines for in-

fants were high at the clinic, the BCG and measles drop-

out rates were >10% for the 5-year period. Dropouts are

Targets are set by the LGA and are monitored in the

1

68

people who begin the vaccination schedule but fail to

complete it. If a child does not receive all doses for a

specific vaccine required for full protection against a

specific disease, the resources that have been used are

generally regarded as wasted. The main reasons for

dropouts may include: problems relating to dissatisfac-

tion of the quality of service rendered, such as, long

waiting time and failure to give mothers and caregivers

correct information on when and why to come back for

subsequent vaccines/doses. Others include inability of

the health facility to provide uninterrupted service deliv-

ery due to inadequate and timely provision of bundled

vaccines for the catchment area target population and

socio-cultural as well as administrative barriers such as:

religious beliefs, decision making authorization on

health related issues at the family level and irregular

provision of routine immunization sessions at health

facilities or outreach/mobiles services. The REW ap-

proach is expected to develop the capacity of health

workers at health facility level to identify and reduce

dropouts by ensuring quality and un-interrupted services

tion of the Republic of Myanmar (2012-2013) where

logistics operations had been manned and maintained by

dedicated staff at each level of storage and distribution,

as stock management was computerized at the central

cold room but done manually at regions and townships

levels . In 2010, the center for disease control (CDC)

had developed a vaccine tracking system to facilitate

vaccine ordering, inventory manageme₁n₅t, and related

processes for publicly purchased vaccine

1

4

There has not been any form of external funding for the

clinic in the past 5 years unlike in Myanmar where most

of the relevant supplies required for the immunization

programme were supplied by UNICEF and WHO and

the cost of the supply transport and storage up to the

township level was borne by the government (Ministry

of Health) which was the major reason for the success of

the immunization programme (Central expanded pro-

gramme on Immunization, (2012-2013) in this Republic.

The report of a joint WHO/UNICEF mission on vaccine

security in Nigeria had also indicated financial con-

straint due to poor financing of transportation cost of

vaccines at the State and Local Government areas

(LGAs), in addition to poor information management

between states₇and LGAs and poor cold chain capacity

amongst others .

7

at fixed, outreach and mobile sites .

The vaccines that were most often in short supply in-

cluded DPT, HBV, YF, OPV, and CSM. Similar report

had been made by related study in Nigeria, whereby, the

most common vaccines reportedly missed as a result of

short supplies were BCG, OPVO, OPV1, HBV1 and

1

2

DPT1 . The most outstanding reason for missing sched-

uled immunization in this study was lack of vaccine (s).

However, the lack of vaccines as noted may be due to

the inability of the health facility staff to forecast prop-

erly the vaccine needs of the centre, since there was no

report of vaccine shortage in the country during the pe-

riod of the study. The lowest coverage rate was recorded

for tetanus toxoid dose 5 as, this was similarly reported

in a study in Lahore district of Pakistan among mothers

who had delivered within the previous 3 months, less

than a quarter (17%) of the women had received a com-

plete dose of TT 5 injections which is well below the

WHO expected level of vaccination of 100% of the

pregnant women.

Conclusion

The clinic has come a long way in the provision and

administration of immunizations and the clinic is doing

well based on the available resources, but some issues

have not been resolved.

Gaps and challenges

Few clinic activities were shown to be done improperly,

as follows: There was no dropout monitoring chart, thus

utilization and categorization could not be determined;

There was no method of planning or forecasting for both

vaccines, syringes, and safety boxes; There was no re-

cord of use of vaccines and syringes; The immunization

status of children could not be determined from the im-

munization records; There was no record of VPDs, thus

no way of determining if it was on the increase or other

wise; and the monthly/yearly target of the clinic was too

low.

Data management and reporting has been very poor in

the past. However, attempts have been made to improve

data quality and management system by capacity build-

ing of service providers and provision of data tools to all

levels. A survey among 27 countries in 2002 to 2003

had reported some challenges in their immunization

surveillance and monitoring system, such weakness in-

cludes; inconsistent use of monitoring charts, inadequate

monitoring of vaccine stocks, injection supplies and

adverse events, unsafe computer practices, and poor

monitoring of completeness and timeliness of report-

Recommendations

There should be training of staff on planning, forecast-

ing, and proper recording of immunizations. Standard

immunization data tools including tally sheets, immuni-

zation registers, health facility summary sheet, immuni-

zation monitoring charts should be made available. Ef-

fort should be made towards computerizing immuniza-

tion activities in the clinic using standard format. Out-

reaches services should be conducted in line with the

1,2,3 strategy of the NPHCDA to further improve over-

all access to immunization in the hospital catchment

13

ing . This was similar to this report where vaccine and

dry stock ledgers had not been available and there was

no method for vaccine forecasting, also, records of vac-

cine-preventable diseases (VPDs) were not maintained.

The clinic management ensures a good quality supply,

equipment, and consumables, but there was no availabil-

ity of stock supplies and consumables inventory unlike

report made by the expanded programme on immuniza-

1

69

areas. Increase funding and personnel will be required

for this. Analysis of the immunization performance

should be done and reviewed on a monthly basis. Vac-

cines, especially DPT, should be available all the time.

There should be regular supportive supervision of staff

in the clinic to ensure the clinic is administering immu-

nizations properly. The immunization register should be

used to record vaccines given, to make it possible to

calculate the proportion of children fully or partially

immunized. There is a need to synchronize the national

and clinic objectives for effectiveness and efficiency.

Goals set for the clinic should be realistic, time bound

and measurable.

Authors’ contribution

All the authors were involved throughout the course of

the study. Fatiregun A and Alonge T conceived the

study. Initial draft was done by Fatiregun and approved

by all authors.

Conflict of Interest: None

Funding: None

Acknowledgments

The authors are grateful to the staff of the clinics that

provided the information needed for the report.

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