Awakening the Sleeping Giant – How Nigeria is Investing in Women and Children’s Health Nnenna...
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Transcript of Awakening the Sleeping Giant – How Nigeria is Investing in Women and Children’s Health Nnenna...
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
Fufore Ondo East Wamba0
10
20
30
40
50
60
70
80
90
100
201220132014
%
Pre-pilot LGAs: 2012-2014
Overall trend in PBF facilities: 17 percentage points
NSHIP 2014 Annual Review Meeting – 15-16 June 2015
MPA: Completely vaccinated child: % coverage
Pre-pilot LGAs: 2012-2014
Fufore Ondo East Wamba0
10
20
30
40
50
60
70
80
90
100
201220132014
%
NSHIP 2014 Annual Review Meeting – 15-16 June 2015
CPA in pre-pilot LGAs 2012-2014Hospitals have autonomy issues
Outpatient visits per capita
NSHIP 2014 Annual Review Meeting – 15-16 June 2015
Inpatient days
Fufore Ondo East Wamba0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
201220132014
Fufore Ondo East Wamba0
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
NSHIP 2014 Annual Review Meeting – 15-16 June 2015
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
NSHIP 2014 Annual Review Meeting – 15-16 June 2015
Hygeine & SterilizationEPI & Pre-School Consultant
General Management
Business Plan
Finance
Indigent Committee
Curative Consultation
Family PlanningLaboratory
Inpatient Ward
Essential Drugs Management
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
Essential Drugs Management
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
NSHIP 2014 Annual Review Meeting – 15-16 June 2015
General ManagementBusiness Plan
Finance
Indigent Committee
Hygiene and Medical Waste Disposal
Curative Consultations
Family Planning
LaboratoryIn-patient Wards
Essential Drugs Management
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
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 - 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
January February March April May June July August September0%
20%
40%
60%
80%
100%
Normal delivery - DFF
National (DFF) Adamawa Nasarawa Ondo
FP modern methods first nine months results
January February March April May June July August September0%
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
January February March April May June July August September0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
FP: total of new and existing users of modern FP methods - DFF
National (DFF) Adamawa Nasarawa Ondo
Various coverages for PBF first nine months results
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 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.