An Overview of Nigeria State Health Investment Project (NSHIP) August 27, 2015 Presentation for Ondo State LGA PHC Coordinators

In Nigeria, Health centers suffer from underlying systemic issues 2 What you will see at a primary health care center: Relatively abundant workers (among top in SSA) Chronic stock-outs of essential drugs (Avg. 55%) Lack of minimum equipment (Avg. 25% equipped) Poor sanitation/waste management Idle health workers/absenteeism (Avg. 29%) Correct mgmt. of maternal complication (17.3%) No patients (Avg. 1.5 patients per day) Underlying systemic issues: Fragmentation and poor coordination between federal, state and local govt levels Unclear accountability and poor performance review to strengthen it No incentives to good or poor performance No cash and autonomy at health facilities Source: Service Delivery Indicator (SDI) Survey, 2013

About Results Based Approaches: Any program that rewards the delivery of one or more outputs or outcomes by one or more incentives, financial or otherwise, upon verification that the agreed-upon result has actually been delivered. A form of RBF that departs from simpler types of contracts in setting a fixed price for a desired output and then adding a variable component that can reduce payment for poor performance or increase it for good performance compared to the standard defined in the basic contract. A form of RBF distinguished by three conditions: Incentives are directed only to providers, not beneficiaries Awards are purely financial--payment is a fee for service Payment depends explicitly on the degree to which services are of approved quality. 3 Results Based Financing (RBF) Performance Based Financing (PBF) Performance Based Contracting (PBC) The Nigeria State Health Investment Project addresses health system failures using a combination of results based approaches

Results Based Financing approach in Nigeria: Health service coverage Budget execution Bonus payment Quantity of services delivered Quality scores of the services Supervision HMIS reporting HR management Finance based on.. (Examples) 4 $$ State Govt. Local Govt. Health Centers Federal Govt. Disbursement Linked Indicator (DLI) PBF The government pays for results at multiple levels supported with rigorous internal and external monitoring

RBF will be scaled up across 3 states through phasing approach for rigorous IE Adamawa 21 LGAs Pop 3.6 M Nasarawa 13 LGAs Pop 1.9 M Ondo 18 LGAs Pop 3.9 M PBF 10 LGAs * DFF 10 LGAs PBF 6 LGAs * DFF 6 LGAs PBF 9 LGAs * DFF 9 LGAs ~ 107 facilities ~ 106 facilities ~ 72 facilities ~ 97 facilities ~ 96 facilities * Excluding pre-pilot LGAs Control Taraba State ~ 107 health facilities Control Plateau State ~ 72 health facilities Control Ogun State ~ 97 health facilities PBF will be scaled up to the DFF facilities after 2.5 years and mid-point IE

Performance Based Financing Models Non-state actors contracted to provide certain services Contractors have full responsibility for the delivery of services, employment of staff, management By-passes publicly financed healthcare system 6 Examples: Nigeria Democratic Republic of Congo Rwanda Burundi ‘Contracting-out’ Internal market created for government to purchase services from its own, non-profit and for-profit facilities Contracted non-state actors or co- opted CSO to strengthen Government services – Technical Assistance Technical and financial support from development partners Examples: Afghanistan Senegal Haiti ‘Contracting-in’ GoN has adopted a ‘Contracting-In’ model for Performance Based Financing to health facilities

PBF – Paradigm Change ToFrom Result basedInput based Financing Defined with indicators and monitored Fragmented and unclear Account- ability By health facilities who know what to improve By local governments Investments (Autonomy) Drug supply Purchased by health facilities Distributed from central stores Performance Verified and counter- verified independently Not verified 7 Source: World Bank analysis

NSHIP is funded by: Performance payments to HF Decentralized facility financing Operational costs Technical assistance 8 $150m Credit $20m Grant $1.7m Grant Disbursement Linked Indicators Impact Evaluation Demand side approaches NIGERIA STATE HEALTH INVESTMENT PROJECT International Development Assistance Health Results Innovation Trust Fund

Implementation Arrangement for NSHIP 9

NSHIP is being scaled up after 2 years of pre-pilot implementation 10 ’ DecQ1Q2Q3Q4Q1Q2Q3Q4Q1Q2Q3Q4 Pre-pilot started PBF Pre- pilot PBF Scale- up DLI 6 months payment delays Subcontracting started for 4 services Demand-side interventions pre-pilot Project effectiveness (Aug 2013) +3 PBF LGAs +10 PBF + 9 DFF LGAs TA Agency Almost all DLIs achieved (May 2013) FY 2013 DLI review planned in May + 3 PBF + 9 DFF LGAs

TARIFFS FOR MINIMUM PACKAGE OF ACTIVITIES NoService MPAIndexFeeNMonthly_Target New outpatient consultation 1$0.4282pop/12 2New outpatient consultation by an indigent patient3$ pop/12 *5% 3Minor Surgery10$ pop/12*5% 4Referred patient arrived at the Cottage Hospital10$ pop/12*1% 5Completely vaccinated Child15$6.301,235pop/12 *4.3% 6Growth monitoring visit Child0.7$0.2958pop/12*17.1%* Tetanus Vaccination of Pregnant Women2$ pop/12*4.8% 8Postnatal Consultation4$ pop/12*4.3% 9First ANC visit before 4 months pregnancy5$ pop/12*4.3% 10ANC standard visit (2-4)3$ pop/12*4.3%*3 11Second dose of SP provided to a pregnant woman5$ pop/12*4.8% 12Normal delivery30$12.602,470pop/12*4.8%*80% 13FP: total of new and existing users of modern FP methods10$ pop*22.5%/12*20%*4*90% 14FP: implants and IUDs15$6.301,235pop*22.5%/12*8% *90% 15VCT/PMTCT/PIT test4$ pop/12*7% 16PMTCT: HIV+mothers and children treated acc protocol40$16.803,293pop/12*4.8%*5%*60% 17STD treated10$ pop*5%/12*70% 18New AAFB+ PTB patient75$31.506,174pop/ *151*60%/12 19PTB patient completed treatment and cured200$ ,464Depends on detection rate 20Household visit per protocol10$ Pop / 2 yr / 12 months / 5 persons per household

Performance of the three LGA continues to improve though coverage is still below 20% in Ondo East Outpatient visits per capita – Pre pilot LGA

Completely Vaccinated Child – Pre pilot LGA Greatest achievements have been in immunization coverage likely due to a heightened intensity of efforts by the government (supported by DPs) in routine immunization through SOML and MNCHW…

Institutional deliveries are improving in all three LGA but still below the national average. Institutional deliveries – Pre pilot LGA

There are significant improvements in PMTCT in Nasarawa and Ondo but Adamawa State continues to have challenges. Poor performance of other HIV programmes; lack of supply of test kits to state facilities PMTCT – Pre pilot LGA

After full scale up there has been increase in the utilization of PHC Services on most indicators compare to General hospitals which contribute very little to overall coverage NSHIP Joint Mission - August

General hospital contribution to VCT/PMTCT coverage is ~15%; this was not the trend earlier… GHs initially contributed more to VCT/PMTCT numbers but started to show a decline NSHIP Joint Mission - August

Quality score has been around 70% Adamawa Nasarawa Ondo 18 Overall Score (%)Score Breakdown (1 year Average) Variations exist with general weaknesses in General Mgt, Indigent, Hygiene, Curative Consultation and FP Quality score got flat at relatively low level (~70%)

NSHIP: Quality of care at health centers has improved over the time in PBF Pre –Pilot LGAs

Initial vs Counter verification

Percentage Point Difference between Ex-Ante and Ex-Post Verification Quality

Despite significant improvements, Nigeria remains low in per capita spending Payment per capita “Year” means complete 12 calendar months counting from the month when program started Value for the most recent year is extrapolated if duration is less than 12 months Payment components consist of: Quantity only in Zambia Quantity, quality, and equity bonus in Burkina Faso and Zimbabwe Quantity and quality in all other countries Payment per capita – multi-country comparison Revised calculation with quality bonuses, CPA included: 2012: UD$ : US$ 1.09

Normal delivery, OPD, FP account for over 50% of total bonuses to PHC 23 Overall Actual disbursement (NGN) to LGA per indicator – 2014, Q1 Normal delivery, OPD, FP account for 58% of total quantity bonuses Vaccination and VCH/PMTCT/PIT test also have relatively high portion PBF cost by service (%) – 2014, Q1 14HC in Fufore, 10 HC in Wamba, 9 HC in Ondo East Cash to HC per quarter ~N344,000 (Ondo), N (Nasarawa), N (Adamawa)

Before RBF Pre-pilot also demonstrates significant improvement in quality of care by the health centers After RBF Aggregated quality score Avg. 28% Aggregated quality score Avg. 67% Storage Room Waste Dispo- sal 24

PBF changed key elements of service delivery ToFrom Result basedInput based Financing Defined with indicators and monitored Fragmented and unclear Account- ability By health facilities who know what to improve By local governments Investments (Autonomy) Drug supply Purchased by health facilities Distributed from central stores Performance Verified and counter- verified independently Not verified 25 Source: World Bank analysis

The project aims to benefit ~10 million over 5 years Pilot Half Scale-up Full Scale-up 3 States 33 Local govt Facilities Population 0.4 million5.0 million9.4 million Source: NSHIP IE Concept Note Complete 26

Challenges in Implementation 27 Challenges Ongoing Efforts Delays in procurement of RBF TA for federal approval Lack of resources to lead scale up at federal and state Strengthen SPHCDA human resource pool PBF Internship Program TA fully in Place Implementation capacity Preventing Payment delays Learned that payment delays can deteriorate performance SPHCDA Performance Framework in place Simplify the approval process Broader reforms Health systems issues such as health center staffing/ autonomy, vaccine supply, PHC management Implement PHC Under One Roof Build Broad Partnership Demand-side issues Costs of transportation and user fees deter women from accessing care Social cultural barriers CCT for continuum of MCH services + transport voucher Incentivizing TBA for referrals

Lessons Learnt from PBF in the Public Sector and Implications for the private Sector Changes as a result of PBF Promotes autonomy of the health facilities with opportunities for prompt decision making, mgt. committees and citizens engagement Promotes entrepreneurship Continuous investment in infrastructure and equipment and general maintenance of HFs. changes in health workers attitude to clients, reduced absenteeism and strikes Maintenance of private sector autonomy but with better public sector regulation “The private sector thrives on profit, PBF provides opportunity for more resources Brings advantage to the program as private sector is not known to go on strike 28

Lessons Learnt from PBF in the Public Sector and Implications for the private Sector Changes as a result of PBF Builds or strengthens institutions – WDC, SPHCDA, LGA PHC dept or HA Provides incentives to health workers Better data management because data is tied to payment. Requires good system for verification and counter verification. It also promotes data use. Fund flows is clear – promotes accountability and transparency. Program could use this principle to strengthen regulatory roles and responsibilities of the public sector. Could be used to strengthen data collection and recording in the private sector. Could strengthen financial management in private clinics and hospitals 29

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