NASARAWA STATE REPORT FY2015 DLI, and SPHCDA Assessment.

NASARAWA STATE DISBURSEMENT LINKED INDICATOR(DLI ) The Nigeria State Health Investment Project (NSHIP) has a system of rewards for institutions and service providers involved in the provision of health services to the populace. The reward system for institutions such as the states and local governments is measured in the form of Disbursement Linked Indicators (DLIs). These are parameters that the states and LGAs are supposed to meet to earn the respective bonuses. These parameters are assessed annually and biennially and scored against a bench mark to earn an assigned amount for the respective parameters. Each state and LGAs are assessed separately.

The State DLIs. 1.80% of PBF Health Facilities received every quarterly 2013 payment due to them* outpatient visits p.c. to PBF HFs increases 15% over baseline* 3.Fully immunized children by PBF HF in 2014 increased by 15% over baseline.* PBF HF deliveries increased 15% over baseline* 5.Approved 2014 State health budget (i) uses new chart of accounts, (ii) has been published online 6.State published its & LGA 2014 annual DLI Report Card on SPHCDA &/or SMOH websites 7.State released LGA DLI Grants to 80% of participating LGAs within 2 months of Bank disbursement. _______________ * Pro-rated 3

LGA DLIs 1.LGA approved 2014 health budget uses chart of accounts 2.50% of participating PBF HF have quarterly supervision visits, produce completed checklist* 3.(i) 80% of participating HF reported key indicators to LGA*, (ii) LGA prepared 2014 quarterly HMIS reports 4.LGA (i) has NOT posted/transferred health staff<LGA Salary Grade 7 to participating HF, (ii) has maintained mandatory hiring restrictions unless participating HF staffing below 2012 DLI established baseline 5.All PBF HF purchased drugs have valid (i) NAFDAC registration, (ii) manufacturer’s certificate from manufacturers or suppliers, (iii) annual National Pharmaceutical Council license 4

NASARAWA STATE DISBURSEMENT LINKED INDICATOR(DLI ) FINDINGS 1.WAIVER: RELEASE OF GRANT TO THE LGAs 2.Issues with autonomy of the LGA PHC 3.GHs are improving at a slower rate than the PHCs. 4.Inappropriate distribution of skilled health workers(under staffed) 5.Issues with book keeping and data analysis at the LGAs PHC and health facilities

RECOMMENDATIONS 1.Establish a coaching and mentoring process on financial management and data analysis to the PHCs and LGAs.(responsible persons, follow-up, e.t.c). 2.Hold preparatory workshops after the DLI mission (to clarify amounts allotted to States and LGAs, Improve report writing, Review the requirements of each DLI, Establish sanctions for non-achievement of DLIs especially SDLI#7. 3.Provide a basis for re-definition of technical and non-technical staff for DLI review. 4.An action plan to involve HMBs and improve the uptake of PBF system in the GHs.

5.Engage with States and World Bank to extend coverage through increasing the number of primary contracts or sub-contracting in both PBF and DFF LGAs. 6.Improve record keeping in the LGAs (HMIS reports and Staff list). 7.Improve quality of supportive supervision by the LGAs PHC ( Monthly quality supervisory reports, ISS reports 8.Display graphics of trends in indicators throughout the LGA. 9.Provide support in drug procurement by utilizing the NAFDAC SMS authentication service and requesting from the State a list of Blacklisted pharmacies.

NASARAWA STATE REPORT FY2015 SPHCDA Performance Assessment.

Background NSHIP is a multi-faceted health systems strengthening initiative Series of performance assessments with corresponding bonuses – Health facilities quality assessment – LGA PHC Department performance assessment – SPHCDA PIU assessment – HMB performance assessment

S/NIndicatorWeight 1Quantity verification done60 2Quality evaluation (of HFs?) by LGA done and published15 3Participation in quality evaluations for GHs25 4Utilization of operational data40 5Filing of invoices by the SPHCDA6 6Contract management by the SPHCDA8 7Management of CBOs and CCSS30 8Organization management by the SPCHDA20 9Financial management by the SPHCDA25 10Performance management system by the SPCHDA12 11Continuos TA programme for SPHCDA personnel10 12Secretariat for the monthly extended team meetings10 13Participation in LGA-RBF steering committee meetings10 TOTAL271 % score100% (94%) Performance bonus USD 25, SPHCDA Performance Framework Indicators and Corresponding Weights

Nasarawa State PIU had a almost full score for their performance in the previous six months, i.e 94%. However, a number of indicators were waived or prorated, due to exogenous factors affecting the work of the State PIU, or to the timing of the assessment. Document safeguard – PIU office – PFMU office NSPHCDA PIU has a Statistician embedded as one of its OPM PIU who helped create a detailed feedback plan from the PBF web portal, for verifiers to take back to the HFs. FINDINGS : Good Practices

WEAK AREAS Points lost: The only points that the Nasarawa State PIU lost was for indicator as regards delay in payments whereby they were not able to disburse funds to the health facilities within the allotted timeframe. Internal approval processes bottleneck – Delay in payments – A long internal approval process leading to delays in disbursements to PHCs. Office space for all PIU & RBFTA. The whole PIU is operating from one room within the SPHCDA that houses the State PIU, RBF TA and operational Data. Need for an office manager No agreed indice tool for bonus sharing, using specific criteria Low population coverage of some indicators Tracking of Progress: original activity plans were not followed due to delay in approval making progress difficult to track. Staffing of PIU: Nasarawa State PIU has placed a momentary hold on further engagement of PIU staff due to inadequate work space. NASARAWA STATE SPHCDA ASSESSMENT

RECOMMENDATIONS Fast tracking internal approval processes – Managerial – financial Renovation of the new structure for adequate office space – Opportunity to engage more staff for PIU There is a need for the engagement of an NSHIP administrator that will help prompt decision makers to ensure timely completion of relevant tasks. Need to build the capacity of the M&E Unit and improve data storage from only soft copies to both soft and hard copies. Original activity plan should be stored along with the amended plan for progress tracking Need for engagement of additional health facilities for more population coverage – PBF: primary and subcontract – More DFF health facilities SPHCDA reports should be made to address specific issues based on findings/weaknesses of the PHCs/LGAs.

NEXT STEPS Interaction between NPC, WB and SPHCDA EC on approval processes within the agency for efficient process management. Advocacy visit to the State Government on speedy rehabilitation of allocated accommodation for the SPHCDA. Phased capacity building of the National PIU on data management by the OPM Statistician.

NASARAWA STATE REPORT FY2015 Quality Counter-verification

BACKGROUND PBF Programme ensures that a systematic procedure and process is involved in carrying out the verification exercise, using a set of primary data collection tools for verification This is to ascertain that services that are paid for and provided to patients are actually accessed by the patient. This allows for fraud detection and perception of client satisfaction Convenient sampling was used for LGA selection, pre-pilot and 1st scaled up LGAs selected in order to have minimum of two quarters before December Only two LGAs were sampled per State and CV was done in just 19 out of more than 400 PBF HFs therefore it is not a true measure of the HF population

Lessons Learnt Based on the results from the Counter Verification exercise, it shows that there is a remarkable difference between the Initial quality evaluations and the counter verified quality scores. This gives very high percentage discordances between the initial evaluations quality scores and the counter verification scores

The level of discordance shows that quality evaluation team members were not adequately capacitated and so do not understand the quality check list and how to administer it; Some of them did not always consecrate enough time to conduct the evaluations adequately and in some situations (hard to reach), this was a desk exercise Discordance was generally very high in the pharmacy (essential drugs and tracer drugs), where a lot of training needs to be provided to both the pharmacy attendants and the LGA/HMB evaluators; finance, Business plan, general management, indigents, inpatient, and hygiene There are no quality norms or standardised documentation and this restricts the potential for uniformity in regard to perceptions of clinical and service quality among team members. FINDINGS

On sterilisation, the following issues arose: should antiseptics be used? Boiling on a kerosene stove? Dry heat steriliser? Steam steriliser. No RBF committee has been formed at Wamba General Hospital. The business plan is not approved by the key stakeholders and the SPHCDA. The business plan does not contain a financial plan as well as plan for waste management. Diversion of revenue generated from PBF funds to other accounts(HDRF,HMB).

RECOMMENDATIONS A lot of training needs to be provided to both the pharmacy attendants and the LGA/HMB evaluators; this also relates to finance, business plans, general management, indigents and hygiene as well as understanding the use of indices tool. This training can either be carried out through the long-term or short-term technical assistance offered by the RBFTA team. It is generally recommended that the quality assessment teams in PBF programs be mentored, coached and accompanied in the initial stages of the process. Application of sanctions.

The frequency of the quality counter-verification needs to be three months and the verification visits made a routine activity for the RBFTA state teams and the project implementation units (PIUs). Given the state of the ex-post results, it would be advisable to redo the quality checklists everywhere to ascertain a new starting point (baseline). A high-level discussion needs to be opened between the HMB and NPHCDA plus the World Bank to facilitate better understanding of the roles and responsibilities of the various stakeholders within the NSHIP. In order to give maximum credibility to the results, it will be of utmost importance to continue using multidisciplinary teams for the counter-verification.

DATA ANALYSIS Q1 Nasarawa MPA Quantity Performances Karu and Wamba are doing predominantly better than the other LGA’s but Karu which is the first scale up phase is the best performer while Doma seems to be the lowest performing LGA in all categories. It is also noticed in category’ OPD’,the major services are- New outpatient consultations, Household visits per protocol and Minor surgery.In Maternal Health category, all the LGAs performed relatively the same way except for the PRE-PILOT which performed slightly better especially in tetanus vaccination for pregnant women service. Postnatal consultations and completely vaccinated child indicators are very low. All forms of family planning methods need to be encouraged and recorded.

Nasarawa CPA Quantity Performances o Outpatient consultation by a doctor and In-patient day are the predominant services in this category o First ANC before 4 months pregnancy should be encouraged as it’s performance indicator is pretty low o The pre-pilot LGA is still doing better in the reproductive health category but there is a need to encourage all other services across board here o Karu remains the best performer in Q1 as they received the highest disbursements o Doma is the worst performing LGA according to the report

Nasarawa Quality Performance In MPA Quality Performance – Wamba was the best perfoming LGA – Toto was the worst. In CPA – Akwanga was the best performing LGA – Toto the worst LGA with a score of 49.7%. Financial Disbursements In both MPA and CPA, Karu performed the best with the highest disbursements recorded while Doma the least in the quarter.