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

2. 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

3. Quality Counter Verification

4. 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

5. 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.

6. Quality Scores (Initial vs CV)

8. 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

9. 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

10. 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

11. Comparative analysis – Ex post, ante and Q2 2015 (Sampled Facilities)
Ex Ante
Ex Post Q
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 Q
0.001
0.053
0.05

12. Impact of the CV – Average Quality Score/ LGA

13. Changes in Scores by Service (State Averages)
Hospitals
PHCs

14. Impact of Quality CV on PBF HF Earnings

15. Quantity Counter Verification CCSs

16. 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

17. 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

18. Perceived Quality of Care

19. 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

20. 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.

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

22. 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

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

24. Availability of Medicines

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

26. Overall Perception on Service quality

27. 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

28. 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

29. 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

30. 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.

31. The End Thank you