Awakening the Sleeping Giant – How Nigeria is Investing in Women and Children’s Health Nnenna Ihebuzor; Wole Odutolu and Gyuri Fritsche (plus many others)

Awakening the Sleeping Giant –How Nigeria is Investing in Women and Children’s Health

Nnenna Ihebuzor; Wole Odutolu and Gyuri Fritsche (plus many others)BBL 12 November, 2015, Washington DC

Content1. The DIAGNOSIS: what is holding Nigeria down?2. The DESIGN of the Project

two iterations of Performance-based Financing

3. The IMPLEMENTATION of the projectcareful phasing and building local capacity first before expanding

4. PRE-PILOT results5. SCALING-up and early results6. The UNFINISHED REFORM AGENDA

Nigeria

• Federation of 36 States and FCT

• Population: 170 million + • High maternal mortality

(576/100k live births)• High Under 5 mortality

(128/1000 live births)• Low SBA coverage (39%) • High fertility rate (5.7)• Large annual birth cohort

(>6m)• Large variation across

zones; rural-urban location; income; maternal education

Rivers

EkitiOsun

Lagos

Ogun

Oyo

Delta

Bayelsa

OndoEdo

Kogi

Sokoto

Niger

Kwara

Kebbi

Kaduna

Zamfara

Adamawa

AbiaImo

AnambraEnugu

Cross River

Akwa Ibom

Ebonyi

Benue

Taraba

Jigawa

FCT, Abuja

Nassarawa

Katsina

Kano

Gombe

Plateau

Bauchi

Yobe

Borno

Zone Southsouth Southeast Northcentral Southwest Northeast Northwest

Map of Nigeria Showing the Six (6) Geo-Political Zones

ChadNiger

Atlantic Ocean

3

4

Mixed results on health impact U5MR decline but no change on nutrition

2003 2008 20130

50

100

150

200

250

100

75 69

201

157

128125

99.3

73.9

IMR U5MRMDG4 Target

Stunting Wasting Weight for Age

0

5

10

15

20

25

30

35

40

45 42

11

24

41

14

23

37

18

29

2003 2008 2013

Source: National Demographic and Health Surveys – National Population Commission and USAID

Limited Progress on Service Delivery in Nigeria 1990-2013 - NDHS

1990 1999 2003 2008 20130

20

40

60

80

100

Skilled birth attendanceAntenatal Care DPT3 vaccination coverageContraceptive Prevalence Rate (modern methods)

Perc

ent

Inconsistent with decline in MMR

Largely dilapidated health infrastructure and low utilization of health services

Poor management and irrational prescribing lead to large inefficiences

A weak health administration leads to weak or absent supervision

The DIAGNOSIS: what is holding Nigeria down?• Inadequate public financing (high OOP)• Inefficient health investments (building; equipment)• Lack of recurrent budgets (after paying salaries not much remaining)• Rigid human resources management (centralized; ghost workers)• Poor Governance (accountability; transparency; fragmentation)• Poor quality of services• Poor management• Lack of awareness on entitlements (population)• …….

The DESIGN of the project: two iterations of Performance-based Financing• NSHIP $171.5M five year program – IDA $150M; HRITF $21.5M• Covering three States: Adamawa; Nasarawa and Ondo (11.2 million)• Two healthcare financing variants covering 50% of LGA each per state

(i) Performance Based Financing [PBF]: payments based on quantity and quality of services and used for staff bonuses (50%) and facility operations (50%)

(ii) Decentralized Facility Financing [DFF]: payments are half of PBF earnings and used for operational costs only

• Impact evaluation: randomized controlled trial

The design is based on what we know works best currently

• Basic and complementary health packages costed at $2.70 per capita per year (2/3 health center and 1/3 hospital)

• Quality checklists weighted >40% on content of care• Health facility rationalization: primary contract holder and secondary

contract holders• Enhanced autonomy (bank accounts)• Ability to procure drugs with certified distributors (stop CMS

monopoly)• Business plans with ‘investment units’ (priming the pump)

Performance-based Financing is a health reformone part is the provider payment mechanism: the purchase of services conditional on the quality

Providers are paid conditional on the quality of services

PBF is a Governance Operation

• LGA PHC Dept. under Performance contracts • Including the DFF local government authorities

• Quasi-public purchaser (State PHCDA) under Performance contract • TA embedded in Purchaser (TA and counter-verification)• Web-enabled application with a public front end• Start piloting demand side incentive scheme (May 2015)• Start piloting contracting private for profit sector (Sept 2015)• Overarching DLI framework at State and LGA level

PBF DFF

# of LGA Catchment Population

# of LGA Catchment Population

Pre-pilot (December 2011) 3 623, 144

Scale-up phase 1(December 2013/January

2014) 3 646, 9 2, 484, 832

Scale-up phase 2(June 2014) 7 1, 730, 299 9 1, 632, 293

Scale-up phase 3(September/October

2014 13 3, 155, 764 6 1, 272, 892

Scale-up phase 4(December 2014/January

2015) 1 357, 213 1 195, 625

27 5, 044, 766 25 5, 585, 562

The IMPLEMENTATION of the project: careful phasing and building local capacity first before expanding

In RED the PBF pre-pilot LGA’s: start Dec 2011

MPA: Outpatient visits per capita per year

Fufore Ondo East Wamba0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

201220132014

Pre-pilot LGAs: 2012-2014

Overall trend in pre-pilot facilities: 26.7 percentage points

NSHIP 2014 Annual Review Meeting – 15-16 June 2015

MPA: Institutional deliveries: % coverage


10

20

30

40

50

60

70

80

90

100

201220132014

%


Overall trend in PBF facilities: 17 percentage points


MPA: Completely vaccinated child: % coverage



10

20

30

40

50

60

70

80

90

100

201220132014

%


CPA in pre-pilot LGAs 2012-2014Hospitals have autonomy issues

Outpatient visits per capita


Inpatient days


0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

201220132014


50

100

150

200

250

300

350

400

450

2012

2013

2014

Quality in Primary Healthcare Centres

2011-2013 only pre-pilot LGAs

2014 includes scale-up LGAs decrease in average quality

Still improving the quality verification process


General ManagementBusiness Plan

Finance

Indigent Committee

Hygiene and Sterilization

Curative Consultations

Family Planning

LaboratoryIn-patient Wards

Essential Drugs Management

Tracer Drugs

Maternity

EPI and Pre-School Consultation

Antenatal Care

HIV/TB

0

50

100

Health centers average % scores

2011 2012 2013 2014

Evolutions of quality in PHCs in 2014:first scale-up LGAs


Hygeine & SterilizationEPI & Pre-School Consultant

General Management

Business Plan

Finance

Indigent Committee

Curative Consultation

Family PlanningLaboratory

Inpatient Ward


Tracer Drugs

Maternity

Antenatal

HIV/TB

0

50

100

Quarter I Quality Score

Mayo-Belwa

Karu

Ile-Oluji

Hygeine & SterilizationEPI & Pre-School Consultant

General Management

Business Plan

Finance

Indigent Committee

Curative Consultation

Family PlanningLaboratory

Inpatient Ward


Tracer Drugs

Maternity

Antenatal

HIV/TB

0

50

100

Quarter IV Quality Score

Mayo-BelwaKaruIle-Oluji

Quality in General Hospitals

2011-2013 only pre-pilot LGAs

2014 includes scale-up LGAs decrease in average quality

Still improving the quality verification process


General ManagementBusiness Plan

Finance

Indigent Committee

Hygiene and Medical Waste Disposal

Curative Consultations

Family Planning

LaboratoryIn-patient Wards


Tracer Drugs

Maternity

Antenatal Care

HIV/TB

Surgery

0

50

100

General hospitals average % scores

2011 2012 2013 2014

Red are PBF; Green are DFF: phasing in during 2013 and 2014

Scaling up three-State wide

• Build local capacity: • Enugu PBF course June 2011 (2 week intense)• Mombasa PBF courses (2-3 per year 2 week intense > 100) • Internship program during first half 2014 (57 verifiers merit based recruitment;

training for 4 months)• Akwanga PBF course May 2015 (2 week intense)

• Phased approach: • 3 Pre-pilot LGAs December 2011 (420K covered)• 3 additional LGAs during 2013• Gradual scaling up during 2014 (accelerated after July 2014)• Finalized scaling up Jan 2015 (three state wide: 50 LGAs: 11M covered)

2015: first nine months results after full scale-up

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-150%

20%

40%

60%

80%

100%

New outpatient consultation - PBF

National (PBF) AdamawaNasarawa Ondo


20%

40%

60%

80%

100%

New outpatient consultation - DFF

National (DFF) Adamawa Nasarawa Ondo

Institutional deliveries: first nine months results

January February March April May June July August September0%

20%

40%

60%

80%

100%

Normal delivery - PBF

National (PBF) Adamawa Nasarawa Ondo


20%

40%

60%

80%

100%

Normal delivery - DFF


FP modern methods first nine months results


2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

FP: total of new and existing users of modern FP methods -PBF

National (PBF) Adamawa Nasarawa Ondo


2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

FP: total of new and existing users of modern FP methods - DFF


Various coverages for PBF first nine months results


20%

40%

60%

80%

100%

New outpatient consultation Completely vaccinated Child ANC standard visit (2-4)

Normal delivery FP

Deliveries now take place mostly in health centers

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-150

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

0%

2%

4%

6%

8%

10%

12%

14%

Normal Deliveries - GH vs PHCs

PHC Linear (PHC) GHLinear (GH) Percent of GH to Total

Month

Num

ber o

f Del

iver

ies

% o

f GH

Deliv

erie

s to

Tota

l

ANC utilization increase in health centers

Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-150

2,000

4,000

6,000

8,000

10,000

12,000

14,000

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

ANC standard visit (2-4) - GH vs PHCs

PHC Linear (PHC) GHLinear (GH) Percent of GH to Total

Month

Num

ber o

f ANC

visi

ts

% o

f GH

ANC

visit

s to

tota

l

Counter-verification: Patient trace back estimates 73% concordance for services delivered in Nasarawa

NSHIP Joint Mission - August 2015

Reasons for discordance:1. Poor record s management at HF:

absent patient cards at HF, poorly managed patient card system

2. Mis-information from clients: e.g. use of nick-names in communities versus official names at HF

3. Fraudulent practices: HFs recording home visits as services provided at HF

4. Nomadic groups: usually provide name of nearest village to them at the time of accessing services

5. Displaced groups: pockets of communal clashes leading to

Gunduma

MPHCC

GH Wamba

Kwarra PHC

Tattara PHC

M/Gurku MC

Kube PHC

Total

0% 20% 40% 60% 80% 100% 120%

Concordance rates for services delivered: Nasarawa State

% Patients Traced Back

% Traced Back Pa-tients who used HF

QoC counter-verification: results revealed large discordances between ex-ante and ex-post quality scores

Ex-ante• Average Score: 76.1% • Max Score: 98.2%• Min Score: 56.4%• Standard Deviation: 11.2%

Ex-post:• Average score was 40.6%• Max Score: 65.9%• Min Score: 14.1%• Standard Deviation: 16%

Percentage point difference :• Average: 35.5% • Max: 60.7%• Min: 11.5%• Standard deviation: 13.9%

Kwar

ra

Mod

el P

HC

Wam

ba G

H

Gun

dum

a

Kube

Mar

aba

Gur

ka M

C

Tatt

ara

1 1 1 2 2 2 2

0

10

20

30

40

50

60

70

80

90

100

Ex-post quality scores: Nasarawa State

ExAnteExPost

Perc

enta

ge Q

ualit

y Sc

ore

Quality decrease due to better ex-ante reporting by district health teams (due to counterverifications)

Quarter 1 Quarter 2 Quarter 30%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Technical Quality of Care: Quarters I to III, 2015

GH Linear (GH) PHC Linear (PHC)NSHIP Joint Mission - August 2015

Patient Perceived QoC (1/1): Average global perceived quality score is 80% in Nasarawa, 95% in Ondo

NSHIP Joint Mission - August 2015

Drugs Availability• Satisfied except in

GH [even when the pharmacy was assessed as poor]

Reception• Satisfied• Aggregate of mutiple

factors – environment, HCW attitude, cost, etc

Waiting Time• Moderately satisfied• Ranging between

15mins and 1hour ; exceeds 1hr for GH

Perceived Quality of Service

• Satisfied• Dissatisfaction

due to atttitude of HCW

Affordability of Payment

• Unsatisfied• Payments paying

~N1000 per visit [min: N600 ; max N18000]

Patient suggestions for improvement:

1. Provision of utilities (e.g. light, water) and clean [mosquito free] environment2. Structures to provide space for privacy and confidentiality –e.g. for ANC or pediatric care3. Equipment and health supplies – to minimize referrals to other HC4. Staff availability and punctuality to work5. Humanity of Care - empathy

Unfinished reform agenda

• Management strengthening (macro and micro)• Human resources for health reforms (labor market reforms;

distribution)• Autonomy at General Hospital level (drug revolving fund)• Contracting private providers in urban areas (pilots started in Sept

2015)• Explore more community client satisfaction surveys (ICT solutions)

Akwanga May 2015 PBF course: 38 technicians from 11 new States trained in PBF. Expanding Capacity.

Documents

Awakening the Sleeping Giant – How Nigeria is Investing in Women and Children’s Health Nnenna Ihebuzor; Wole Odutolu and Gyuri Fritsche (plus many others)