1. NIGERIA STATE HEALTH INVESTMENT PROJECT (NSHIP) IN NASARAWA STATE – 2015 HALF YEAR R

2. BACKGROUND/STATE PROFILE  State Population = 2,469,175  LGAs = 13  Political Wards = 147  Public Health Facilities :  Tertiary HF = 2  Secondary HF = 18  PBF Secondary HFs = 8  DFF Secondary HFs = 6  PHCs in the state = 1005: i. PBF HCs = 86 ii. DFF HCs = 73 iii. Private HFs = 277 iv. Other public PHCs being considered for subcontracting where population demands while some are not functional.

3. 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.

4. 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 (number), of which are female (%).

5. PROJECT COMPONENTS The project consists of two components : a.Results Based Financing (RBF) – PBF and DFF. b.Technical Assistance (TA) – State and National The RBF component has two sections: i. Strengthening Service Delivery mainly at the health facility level ii. Strengthening Institutional Performance at the Federal, State and LGA levels. The TA component supports the implementation of the RBF at LGA, State and National levels

6. UPDATE ON NSHIP ACTIVITIES Pre- pilot of PBF in Wamba LGA from December, 2011 Scale up training to all PBF and DFF LGAs in the state. Payment of Investment financing to all contracted health facilities Coaching and Mentoring of health facilities on Business Plan development Monthly Quantity verification of PBF facilities PBF Internship training at Lafia to develop technical capacities for verification Technical and financial Missions by World Bank and National Officials Quarterly LGAs Steering Committees meetings and Assessment of LGAs PHCDs

7. ACTIVITIES CONTINUES Quarterly Payment of Bonuses /subsidies to beneficiaries Participation in quarterly national review meetings Mentoring and coaching on financial and procurement managements Conduct of Technical Working Group and State Steering Committee Meetings Advocacy visits to key stakeholders

8. INITIAL HEALTHCARE CHALLENGES Collapse of DRF System and sell of personal drugs and health commodities Inadequate and de-motivated staff Dysfunctional and inadequate equipment Poor sanitation and waste management Frequent Health Workers Strikes Poor Health Management information System Under utilization of Services Dilapidated or lack of Infrastructure Poor regulatory oversight at all levels Poor Net work coverage in some communities affected service procurement

9. SUCCESS FACTORS o Health facilities financial and managerial autonomy o Regular Supervision o Community Involvement o Decentralized planning and management of resources o Inspiring health workers at grass root level to solve health services problems locally. o Changing Staff behavior o Increase of coverage with outreach services o Infrastructure Improvement

10. CHANGES BROUGHT ABOUT BY RBF Affordable health services prices set in conjunction with the community Improved Healthcare Waste Management Provision of full Service Package at contracted health facilities Improvement in the quality of care Improved Coverage in health Services Improved Health Management Information Systems (HMIS) Motivated workforce

11. EVOLUTION OF INDICATORS

12. t PHC Masaka Average of 3 to 5 delivery by day with room less than 5*5 m2 Extension of maternity and ANC sections after investment payment

13. INSTITUTIONAL DELIVARY

14. Outreach Activity: PHC M/Gongo Screening for malaria, malnutrition and anemia during outreach service

15. QUARTERLY PAYMENTS 2014 S/ N LGAQ1 2014Q2 2014Q3 2014Q4 2014Q1 2015 INITIAL INVESTME NT FINANCING HFs BONUS PHCDHFs BONUSPHCDHFs BONUS PHCDHFs BONUS PHCDHFs BONUS PHCD 1WAMBA10,245,0007,662,563560,00010,774,519560,00010,393,96 7 560,00012,862, 170 560,00017,553, 912 550,000 2KARU 19,629,000 9,899,675843,10016,766,446842,10519,624,36 6 807,50024,811, 073 807,50038, 327, 023 850,000 3DOMA14,597,500NA 3,399,030487,5003,952,6 74 650,0006, 162,420 617,500 4TOTO15,319,000NA 2,305,4 26 487,50013, 002,891 585,000 5NASARA WA 18,590,500NA 4,103,5 31 722,50017, 178,221 720,000 6KOKONA13,549,000NA 3,895,1 13 570,00011, 643,133 600,000 7AKWANG A 14,356,500NA 8,083,1 43 450,0008, 589,065 600,000

16. QUARTERLY PAYMENTS 2014 CONT…… S/NLGAQ1 2014Q2 2014Q3 2014Q4 2014Q1 2015 INVESTMENT FUND HFs BONUS PHCDHFs BONUS PHCDHFs BONUS PHCDHFs BONUS PHCDHFs BONUS PHCD 8KEFFI11,700,000NA 2,925,0001,500,0002,925,00500,0005, 816,256500,000 9N/EGG ON 15,675,808NA 3,918,9521,500,003,918,952750,0009,716,736750,000 10LAFIA15,880,000NA 3,970,0001,800,003,970,000900,00023, 197,329 900,000 11OBI12,247,598NA 6,123,799 500,0008, 926,116500,000 12AWE11,007,432NA 5,503,715500,0006, 370,038500,000 13KEANA10,246,940NA 5,123,470500,0004, 718,358500,000 14HMBNA800,000NA800,000NA800,000800,00800,000

17. The State DLIs. 1.80% of PBF Health Facilities received every quarterly 2013 payment due to them* 2.2014 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.* 4.2014 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 17

18. 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 18

19. KEY LESSONS LEARNED Need for continuous supportive supervision of health facilities Population dynamics in some wards which may require further scale up Motivation has some influence on health facilities staff Need for further managerial and data management capacity building Enhanced community participation and ownership/involvement Engagement of contract staff to cover services and population. Apathy of state and LGAs operators to prepare their DLIs reports

20. RECOMMENDATIONS  Avoidance of health sector strikes  Reconciliation and settlement of all parties involved in communal crisis  Continued managerial coaching/mentoring of health managers  Improvement of rural phone network service coverage by providers  Provision of rural Infrastructures for easier case referral  Enhanced political support  Stronger commitment by state and LGAs to meeting their DLIs obligations and reporting

21. THANK YOU ALL !