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

2. 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)

3. 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

4. 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.

5. NSHIP Development Indicators
Proportion and number of 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.

6. 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

7. 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

8. Demand Side financing Indicators1.
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

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

10. Demand Side financing

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

12. Performance data
Technical quality of care by Domain - MPA

13. Performance data
Technical quality of care by Domain - CPA

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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

29. Technical discussion

30. THANK YOU!