1. Helping Nigeria make Rapid Progress Through Performance-Based Financing World Bank June 5, 2014 Health Center Storage Room Before and After Introduction of RBF in Nasarawa 1

2. Outline 1.Background on the Health Sector in Nigeria 2.How Performance-Based Financing works in Nigeria 3.How is PBF being supported in Nigeria 2

3. 1. Background: IMR & U5MR from NDHS 2003-2013 3

4. Total Fertility Rate – NDHS: Very Slow Progress 4

5. Child Nutritional Status 2003-13: No Progress Source: NDHS 2003, 2008, 2013 5

6. Service Delivery 2003-13 in Rural Nigeria: Little Progress, Poor Coverage Source: NDHS 2003, 2008, 2013 6 ANC=Antenatal Care, SBA=Skilled Birth Attendance, CPR=Contraceptive Prevalence Rate

7. Geographical Inequities in DPT3 Coverage: NDHS 2003-2013 7

8. Quality of Care is Problematic – Initial Results of Service Delivery Indicators (SDI) Survey Nearly 30% health worker absenteeism Most health workers do NOT have the knowledge needed to treat important diseases Average public facility sees 1.5 patients/day Essential drugs are mostly NOT available No correlation between drug supply & patient load Nigeria compares poorly to other countries where SDI has been carried out in Africa 8

9. What has NOT worked - “Simple” solutions X Shortage of Health Workers: Ratio of doctors & nurses to population twice the SSA average X Shortage of drugs: Yes a huge problem but no correlation between drug supply & patient volume X Lack of Physical Infrastructure: 67% of population lives within 30 minutes walk of health facility, 85% within 60 minutes X Absolute lack of public investment: Could be higher but bigger issues are efficiency and allocation of resources 9

10. No Correlation between Expenditure & ANC Coverage ANC Coverage % Per Capita Health Expenditure by State (Naira) Source: World Bank Analysis from State PEMFAR/PER/PEFA Reports and NDHS 2008 10

11. 2. Experience with Performance Based Financing (PBF) - Example ServiceNumber Provided Last Quarter Unit PriceTotal Earned Child fully vaccinated 50$2$100 Skilled birth attendance 60$10$600 Curative care patient visit 1,800$0.5$900 Sub-Total $1,600 Remoteness (Equity) Bonus +25%$2,000 Quality bonusScore (50%) x 25% of volume $200 Total$2,200 Use of Funds Drugs and consumables$500 Outreach expenditures$250 Repairs & maintenance of health facility$150 Bonuses to staff in the facility$1,100 Savings$200 11

12. Example of a Quantitative Checklist to determine Quality of Care Score Date of Visit MayAug.Nov.Feb. Availability of Drugs (0-10)77810 Presence of staff (0-10)5689 HMIS implementation (0-10)3355 Village health committee (0-10)58910 Cleanliness of Health Center67810 Quality of delivery care (0-10)6778 Outreach activities (0-10)2568 TOTAL SCORE (out of 70)34435160 TOTAL PERCENT49617386 12

13. 3. Results across 3 pre-pilot LGAs Adamawa Nasarawa Ondo 13 OPD per capitaInstitutional Delivery Payment Delays Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

14. Indicators dependent on outside inputs are more risky Adamawa Nasarawa Ondo 14 Completely Vaccinated ChildNew users of modern FP methods Variable due to issues in cold chain Impressive results to be verified with baseline data Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

15. Quality scores are converging at high level but still have variations across states Adamawa Nasarawa Ondo 15 Quality Score (%)

16. Inputs Outputs Traditional Financing Management autonomy Improved Governance Focus on Quality Operating budget 16 Worker incentives $ Cash $ Clear signals of priorities Systematic Supervision Theory of Change - Why we think PBF works ! HF is a black box Is the FOCUS Verified Data- Stronger M&E

17. 4. How is PBF Being Supported in Nigeria? 3 states are participating in Nigeria State Health Investment Project (NSHIP), Adamawa, Nasarawa, Ondo. 5 year project/program of $150M IDA + $20M HRITF Pre-Pilot started in 2011 in 3 LGAs Being scaled up, now nearly 18 LGAs involved Baseline surveys for Impact Evaluation completed. Will give more indication of success of pre-pilot Substantial interest from other states. 17