Quantity and Quality CV Results Nasarawa State Prepared by Eubert Vushoma And Christine Mukantwali    

Introduction Even though the PBF program has done a lot to improve the service utilization in the sampled facilities, a lot still needs to be done to improve the service quality both technical and client perceived. Quality and Quantity verification done at 7 health facilities in Nasarawa State between April and July 2015

Quality Counter Verification

Methodology Random sampling was done to select 20% of health facilities in Wamba and Karu Respective hospitals automatically included in the sample. Seven Facilities in total were selected (including General Hospitals) The quality check lists were administered by the multi-disciplinary team. Microsoft Excel Templates used for entry and Analysis as follows; Comparison of final score and the ex-ante (Initial Evaluation) scores. Percentage differences between ex-ante (initial) and ex-post (CV) quality scores (PD = (CV – IE)/CV) Average scores ex-ante and ex-post

Findings The average Ex-ante score was 76.1% The average Ex-post score was 40.6% The percentage point difference on average was 35.5% A general discordance in the quality scores between the ex-ante and ex-post evaluations amongst the 15 quality domains (categories). Concordance was highest in the maternal indicators (ANC and Maternity) Discordance was generally very high in the pharmacy (essential drugs and tracer drugs) finance, Business plan, general management, indigents and hygiene.

Quality Scores (Initial vs CV)

Priority Recommendations Urgent need for close mentoring and coaching of the LGA/ HMB evaluation teams The staffs in almost all the facilities need urgent training or fresher's in the following domains General Management Finance Pharmacy/drugs Book keeping (filing) Business plan development Understanding and use of the indices Tool The sanctions previewed in the NSHIP PBF documents should be applied. The periodicity (frequency) for the counter verification needs to be dropped from six months to three months and made a routine activity for the RBF-TA state teams and the PIUs Given the state of the results, it will be advisable to redo the quality checklists everywhere for a new starting point (baseline). The Quality Checklist needs to be revised by a multi stakeholder team (with the HMB and LGAs invited). Explore the possibility of LGA PHC evaluation teams from one LGA assessing the quality of another LGA (Peer assessment). A high level discussion needs to be opened been the HMB and NPHCDA plus World Bank for a better understanding of the roles and responsibilities of the various stakeholders within the NSHIP. For maximum credibility to the results, it will be of utmost importance to continue using multi-disciplinary teams for the counter verification

Progress with Implementation of Recommendations The State RBF TA and the PIU have been part of the Hospital Quality Assessments TA and State verifiers have been reoriented on PBF concepts as identified so that they offer on the Job training to health facilities during monthly verifications Finance training organised by the PFMU Verifiers providing technical support to LGAs during quantity verification Other Strategies In-depth quality data analysis for decision making at State and LGA level Improvements in coaching and mentorship during supportive supervisions (LGAs to PHCs) Improved Supportive supervision by the State to the LGAs

Impact of the Quality CV on Current Scores State Average Quality of Care Decreased from In Quarter 1 To 73% 59% in Quarter 2 PHCs Hospitals 62.27% In Quarter 1 To 59.27% in Quarter 2

Comparative analysis – Ex post, ante and Q2 2015 (Sampled Facilities)   Ex Ante Ex Post Q2 - 2015 Average 74.54% 45.51% 60.79% St Dev 11.74 13.95 12.17 Max 94.38% 62.43% 83.60% Min 56.39% 26.93% 44.80% Statistical Significance of the Means    Ex Ante Ex Post Q2 - 2015 0.001 0.053 0.05

Impact of the CV – Average Quality Score/ LGA

Changes in Scores by Service (State Averages) Hospitals PHCs

Impact of Quality CV on PBF HF Earnings

Quantity Counter Verification CCSs

Introduction The first community household Client Satisfaction Survey for the PBF Program in Nigeria. Progress achieved so far in institutionalizing client tracing within the PBF program. Used a retrospective study design and a theory-based evaluation approach. An assessment of the quality of care from the client perspective January to March 2015 reference period Objectives To determine the authenticity and veracity of the services alleged to have been provided by the health facilities to the population and for which payment has been made To assess the perception of the communities with regards to the quality of health care received from the facility

Methodology The outcome of interest in this survey was the overall perceived quality of care. Used a mixed methods approach (both quantitative and qualitative data) CBO selection and training/contracting A multi-stage sampling method was used to select the sample (Purposive for LGAs and systematic random sampling for clients) Data entry and analysis Excel and SPSS Quality control Ethical Considerations

Perceived Quality of Care  

Concordance The responses were said to be in concordance if; Patient existed Patient visited the facility in the reference period (January to June 2015) At least two of the following conditions are met Patient visited the facility with the same problem as on the diagnosis Patient visited the facility on the same date or Period (a variance of 1 month was allowable) Same age Same card number Same sex The overall percentage concordance was calculated as; Exist = Patient exist Visited = Patient visited the facility in the reference period D = Patient visited the facility with the same problem as on the diagnosis Dt = Patient visited the facility on the same date or Period A = Same age C# = Same card number S = Same sex n = Sample size

Findings The average concordance 73% with minimum of 34% and maximum of 100%. Fraudulent practices on the part of health facilities. The satisfaction scores were higher at the PHCs as compared to the GH. Availability of medicine contributed the most to overall satisfaction whilst payment contributed the least. Waiting time was higher at the hospitals as compared to that at clinics. Patients highlighted the shortage of staff at facilities and the need for authorities to look for solutions to the problem Skilled service provider (Doctor and Nurse) ratio is still low and this has a bearing on the total time each patient spent waiting.

Patients Sampled and interviewed by Health Facility Findings Demographics Concordance Patients Sampled and interviewed by Health Facility Gender of Respondents

Global Quality Perception Global Perceived Quality per facility Perceived Quality of Care per Service MPA Perceived Quality of Care per Service CPA Patients who visited the clinics scored at least 80% quality score for all the services offered at the primary level. Patients who come for “complete vaccinations” were more likely to be satisfied with the overall quality of care as compared to those who come for “ANC”, “OPD”, and “Institutional Deliveries”. Patients who come for assisted deliveries at the secondary level were more satisfied with the service Likelihood of Satisfaction by Factor

Waiting time Average Waiting Time (Minutes) Appreciation of Waiting Time Average Waiting Time per Service - CPA Average Waiting Time per Service - MPA

Availability of Medicines

Cost of Services Perception on affordability of services Average Cost of Services per Facility

Overall Perception on Service quality

Clients suggested actions Provision of utilities and clean environment Structures to provide space for privacy and confidentiality Equipment and health supplies Staff availability Humanity of Care

Lessons learnt Selection and training of CBOs from the communities where the sampled health facilities are based was of utmost importance for the tracing of the clients Challenge in the sampling process due to inadequate and illegible patient information Some of people use nick names and are difficult or impossible to locate. Health facilities do not give clear descriptions of client addresses. Nomads mostly of the Fulani origin provide the name of the nearest village to the place that they are currently staying. Card management at health facilities remain a challenge Clients could express their perceptions about the health facilities in different dimensions

Recommendations Hospitals should establish or strengthen customer care departments that will oversee the effective feedback and reward systems while disciplining providers with unprofessional conduct towards clients. Health workers should provide full address for clients that describe the specific locations of the clients. The methodology for the survey should include Focus Group discussions as highlighted in the PIM

Recommendations Cont ….. There is also need to provide or improve on staff accommodation on site so that patients can always access health care at night in cases of emergencies. Health facilities should be supported to ensure sustained and reliable drug supply and the LGA PHC departments. Health facilities should improve general cleanliness, ensure provision of adequate utilities (water, sanitation, and lighting), and avoid unsanctioned activities in the environs of the facilities such as agriculture.

The End Thank you