Nigeria State Health Investment Project (NSHIP) Nasarawa State STATE TWG meeting: 11TH JANUARY, 2018

STATE BACKGROUND State Population 2,523,592 With growth rate of 3.2% 2 tertiary Hospitals State Population 2,523,592 With growth rate of 3.2% 13 LGAs with 147 political wards 18 Secondary Hospitals 12 Hospitals contracted under PBF 5 Hospitals contracted under DFF 728 Public PHCs 235 PHC contracted under PBF 185 PHCs contracted under DFF 14 Urban PBF (private health clinics)

Presentation outline Project objectives and development indicators Mid term review highlights October 2017 health facility assessment July to September 2017 performance data Results Based Financing (RBF) Demand Side Financing (DSF) Upcoming activities Recruitment of CBOs for CCSS Quality counter verification Technical discussion

Objective of NSHIP To increase the delivery and use of high impact maternal and child health interventions and to improve the quality of care at selected health facilities in the participating states.

NSHIP Development Indicators Proportion and number of 12-23 month old children fully immunized; Proportion and number of births attended by skilled health providers; Average of Health Facility Quality of Care Score; Number of outpatient visits by children under five; and Direct Project Beneficiaries (2,469,175), % of which are female.

Quarter One 2018 Main Activities Submission of 2018 work plan and Approved Monthly service verifications Quality Counter verification completed result being analyzed Recruitment, Training and deployment of CBOs Community Client Satisfaction Survey (CCSS) by CBOs completed and results being analyzed Coaching and mentoring of poor performing health facilities

BMJ: Practical Approach to Care Kit (PACK) RESULTS OF PACK INTERVENTION Accuracy in Clinical Diagnosis and treatment Elimination of poly pharmacy Prompt and appropriate response Every cadre of health care worker is captured with a color code Guide for emergency approach and routine care Covers forty (40) common chronic condition

Demand Side financing Indicators 1. ANC 1-4 2 . Institutional Delivery 3 . Post Natal Consultation 4 . Children Completely Vaccinated 5 . Growth monitoring[1] 6 . Birth registration 7 . Transport Voucher above 10km 8 . Transport voucher below10km

Demand Side financing Distribution of payments by indicator/service - July to September 2017

Demand Side financing

Service Validation discordance rate At least 40% of the data were rejected by verifiers

Performance data Technical quality of care by Domain - MPA

Performance data Technical quality of care by Domain - CPA

Performance data Subsidies paid by type of health facility – July to September 2017

NSHIP MIDTERM REVIEW (MTR) MAIN FINDINGS There is no significant difference between PBF and DFF DFF is more cost effective There is HIGH improvement in both the quality and quantity of healthcare services in both PBF AND DFF HFs More elites/ urban dwellers accessing PHC services

Mid term review Resolutions Financial Prudence Mid term review Resolutions PBF Light will be applied going forward in NSHIP States States to provide funds for conversion of DFF to PBF health facilities and for sustainability Reduction in number of international/external trainings for NSHIP States. Limiting expenditures to project related essentials Disbursement linked indicator to be removed from project design in NSHIP states Subcontracted facilities will remain suspended and HFs reassessed Reallocation of funds between project components Limited finances

Mid term review resolutions contd… Counter verification Frequency CCSS (quantity) and quality counter verification will be conducted quarterly Coverage 100% of health facilities will be counter-verified quarterly

Mid term review resolutions contd.. Claimed vs. verified error margins Mid term review resolutions contd.. If error margin is between +/- 5 and 10%. First offence: retention of 20% of PBF earnings (from verified data) for that indicator for the month under review PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman and SPHCDA Second offence: retention of 50% of PBF earnings (from verified data) for that indicator for the month under review PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman and SPHCDA Third offence: stop purchase of that indicator for the month under review If error margin exceeds +/- 10% First offence: retention of 50% of PBF earnings (from verified data) for that indicator for the month under review PLUS warning in writing to the health facility RBF committee with copy to the LGA chairman and SPHCDA Second offence: stop purchase of that indicator for the month under review

Mid term review resolutions contd… No payment will be made until counter-verification processes are completed and systems put in place Payment of subsides will be quantity conditional on quality Payment of subsides

Mid term review resolutions contd… Ward Development Committees (WDC) Engagement Mid term review resolutions contd… 1 Track drop out for immunization, TB, ANC, HIV 2 Bringing indigent clients to the HF

Poor preforming Health facilities reassessment HF Contracts termination Total of 60 health facilities reassessed for continuity of PBF contract Some 12 health facilities contracts being recommended for discontinuation for the following reasons: Failure to adhere to NSHIP guidelines and service protocols No enabling infrastructure to operate as health facilities (some should actually be declared closed by the SPHCDA) No staff to manage the facilities Community conflicts affecting health delivery

List of HFs for Contract termination and Reasons HF Contracts termination PHC Bassa North PHC Mandara PHC Ashe PHC Kaigbe COE Akwanga Dadu Royal Clinic PHC Malam Anza HF in rented quarters Poor structure and very low patronage Operating in temporary structure and very low patronage Operates on rented apartment and has expired Management interference and non compliance to guidelines Operates in rented apartment, low turn patronage and proximity to contracted PHC Poor structure, non compliance to guidelines and very close to another facility

List of HFs for Contract Termination and Reasons contd… HF Contracts termination Temporary structure, low patronage and mostly locked. Voluntary withdrawal, facility closed Voluntary withdrawal No improvement and non adherence to guidelines Head by a JCHEW and hardly stays in his place of work No permanent structure, community conflict on location of new structure Poor structure and low patronage PHC Dansa Bege Clinic K. Lafia PHC Ankuta PHC Damakasha PHC New Koya PHC Baki Ayini

How to Sustain PBF gains Insurance (Mandatory comprehensive health insurance) to address financial risks to healthcare Basket Funding (State, LGAs, Basic Health Provision Fund and Donors) to support performance payments Performance as a percentage of capitation to address issues of moral hazard, provider induced demand and to address quality issues Generic Drug procurement system (possibly a PPP arrangement with limited state interference, not mandatory, list of other certified suppliers made available) capitalizes on the economics of scale thereby reducing cost of healthcare. State adoption of PBF approach for Health financing complemented by the demand side and supporting the regulatory functions of HMB, SPHCDA and LGA PHC departments

How to Sustain PBF gains continued Advocacy for expansion of PBF to other social sectors Strategic purchasing (to fit into the state priority and available budgets) Direct budget lines to support performance approaches at non contracted health facilities with support from SMOL DLIs and Partners Special intervention funds to support BMJF DLIs 2 year pilot

How to Sustain PBF gains continued Priority to support in service training of staff in relevant areas and continue training of students in areas of skill needs. Further recruitments to focus on areas of skills needs Encouragement of contract Staffing model in all the health facilities with greater health facility responsibilities where there are skills gaps with vetting by the supervisory authority. Exploring collaborative opportunities with local Universities and academia

Prayers: Request for noting of MTR resolutions for application in the state Request for sourcing of up to 25% of NSHIP funds from SOML for Result and other sources to support scale up of PBF to DFF health facilities and for sustainability of the intervention Request for delisting of some contracted health facilities due to very poor Quality, interference, non compliance to guidelines and/or low patronage

Technical discussion

THANK YOU!