1. Awakening the Sleeping Giant – How Nigeria is Investing in Women and Children’s Health Nnenna Ihebuzor; Wole Odutolu and Gyuri Fritsche (plus many others) BBL 12 November, 2015, Washington DC

2. Content 1.The DIAGNOSIS: what is holding Nigeria down? 2.The DESIGN of the Project  two iterations of Performance-based Financing 3.The IMPLEMENTATION of the project  careful phasing and building local capacity first before expanding 4.PRE-PILOT results 5.SCALING-up and early results 6.The UNFINISHED REFORM AGENDA

3. Nigeria Federation of 36 States and FCT Population: 170 million + High maternal mortality (576/100k live births) High Under 5 mortality (128/1000 live births) Low SBA coverage (39%) High fertility rate (5.7) Large annual birth cohort (>6m) Large variation across zones; rural-urban location; income; maternal education 3

4. Mixed results on health impact U5MR decline but no change on nutrition 4 Source: National Demographic and Health Surveys – National Population Commission and USAID

5. Limited Progress on Service Delivery in Nigeria 1990-2013 - NDHS Percent Inconsistent with decline in MMR

6. Largely dilapidated health infrastructure and low utilization of health services

7. Poor management and irrational prescribing lead to large inefficiences

8. A weak health administration leads to weak or absent supervision

9. The DIAGNOSIS: what is holding Nigeria down? Inadequate public financing (high OOP) Inefficient health investments (building; equipment) Lack of recurrent budgets (after paying salaries not much remaining) Rigid human resources management (centralized; ghost workers) Poor Governance (accountability; transparency; fragmentation) Poor quality of services Poor management Lack of awareness on entitlements (population) …….

10. The DESIGN of the project: two iterations of Performance-based Financing NSHIP $171.5M five year program – IDA $150M; HRITF $21.5M Covering three States: Adamawa; Nasarawa and Ondo (11.2 million) Two healthcare financing variants covering 50% of LGA each per state (i)Performance Based Financing [PBF]: payments based on quantity and quality of services and used for staff bonuses (50%) and facility operations (50%) (ii)Decentralized Facility Financing [DFF]: payments are half of PBF earnings and used for operational costs only Impact evaluation: randomized controlled trial

11. The design is based on what we know works best currently Basic and complementary health packages costed at $2.70 per capita per year (2/3 health center and 1/3 hospital) Quality checklists weighted >40% on content of care Health facility rationalization: primary contract holder and secondary contract holders Enhanced autonomy (bank accounts) Ability to procure drugs with certified distributors (stop CMS monopoly) Business plans with ‘investment units’ (priming the pump)

12. Performance-based Financing is a health reform one part is the provider payment mechanism: the purchase of services conditional on the quality

13. Providers are paid conditional on the quality of services

14. PBF is a Governance Operation LGA PHC Dept. under Performance contracts Including the DFF local government authorities Quasi-public purchaser (State PHCDA) under Performance contract TA embedded in Purchaser (TA and counter-verification) Web-enabled application with a public front end Start piloting demand side incentive scheme (May 2015) Start piloting contracting private for profit sector (Sept 2015) Overarching DLI framework at State and LGA level

15. PBFDFF # of LGACatchment Population # of LGACatchment Population Pre-pilot (December 2011) 3 623, 144 Scale-up phase 1 (December 2013/January 2014) 3 646,9 2, 484, 832 Scale-up phase 2 (June 2014) 7 1, 730, 29991, 632, 293 Scale-up phase 3 (September/October 2014 13 3, 155, 76461, 272, 892 Scale-up phase 4 (December 2014/January 2015) 1 357, 2131195, 625 27 5, 044, 766255, 585, 562

18. The IMPLEMENTATION of the project: careful phasing and building local capacity first before expanding

19. In RED the PBF pre-pilot LGA’s: start Dec 2011

20. MPA: Outpatient visits per capita per year Pre-pilot LGAs: 2012-2014 Overall trend in pre-pilot facilities: 26.7 percentage points NSHIP 2014 Annual Review Meeting – 15-16 June 2015

21. MPA: Institutional deliveries: % coverage Pre-pilot LGAs: 2012-2014 Overall trend in PBF facilities: 17 percentage points NSHIP 2014 Annual Review Meeting – 15-16 June 2015

22. MPA: Completely vaccinated child: % coverage Pre-pilot LGAs: 2012-2014 NSHIP 2014 Annual Review Meeting – 15-16 June 2015

23. CPA in pre-pilot LGAs 2012-2014 Hospitals have autonomy issues Outpatient visits per capita NSHIP 2014 Annual Review Meeting – 15-16 June 2015 Inpatient days

24. Quality in Primary Healthcare Centres  2011-2013 only pre-pilot LGAs  2014 includes scale-up LGAs  decrease in average quality  Still improving the quality verification process NSHIP 2014 Annual Review Meeting – 15-16 June 2015

25. Evolutions of quality in PHCs in 2014: first scale-up LGAs NSHIP 2014 Annual Review Meeting – 15-16 June 2015

26. Quality in General Hospitals  2011-2013 only pre-pilot LGAs  2014 includes scale-up LGAs  decrease in average quality  Still improving the quality verification process NSHIP 2014 Annual Review Meeting – 15-16 June 2015

27. Red are PBF; Green are DFF: phasing in during 2013 and 2014

28. Scaling up three-State wide Build local capacity: Enugu PBF course June 2011 (2 week intense) Mombasa PBF courses (2-3 per year 2 week intense > 100) Internship program during first half 2014 (57 verifiers merit based recruitment; training for 4 months) Akwanga PBF course May 2015 (2 week intense) Phased approach: 3 Pre-pilot LGAs December 2011 (420K covered) 3 additional LGAs during 2013 Gradual scaling up during 2014 (accelerated after July 2014) Finalized scaling up Jan 2015 (three state wide: 50 LGAs: 11M covered)

29. 2015: first nine months results after full scale- up

30. Institutional deliveries: first nine months results

31. FP modern methods first nine months results

32. Various coverages for PBF first nine months results

33. Deliveries now take place mostly in health centers

34. ANC utilization increase in health centers

35. Counter-verification: Patient trace back estimates 73% concordance for services delivered in Nasarawa NSHIP Joint Mission - August 2015 Reasons for discordance: 1.Poor record s management at HF: absent patient cards at HF, poorly managed patient card system 2.Mis-information from clients: e.g. use of nick-names in communities versus official names at HF 3.Fraudulent practices: HFs recording home visits as services provided at HF 4.Nomadic groups: usually provide name of nearest village to them at the time of accessing services 5.Displaced groups: pockets of communal clashes leading to

36. QoC counter-verification: results revealed large discordances between ex-ante and ex-post quality scores Ex-ante Average Score: 76.1% Max Score: 98.2% Min Score: 56.4% Standard Deviation: 11.2% Ex-post: Average score was 40.6% Max Score: 65.9% Min Score: 14.1% Standard Deviation: 16% Percentage point difference : Average: 35.5% Max: 60.7% Min: 11.5% Standard deviation: 13.9%

37. Quality decrease due to better ex-ante reporting by district health teams (due to counterverifications) NSHIP Joint Mission - August 2015

38. Patient Perceived QoC (1/1): Average global perceived quality score is 80% in Nasarawa, 95% in Ondo NSHIP Joint Mission - August 2015 Drugs Availability Satisfied except in GH [even when the pharmacy was assessed as poor] Reception Satisfied Aggregate of mutiple factors – environment, HCW attitude, cost, etc Waiting Time Moderately satisfied Ranging between 15mins and 1hour ; exceeds 1hr for GH Perceived Quality of Service Satisfied Dissatisfaction due to atttitude of HCW Affordability of Payment Unsatisfied Payments paying ~N1000 per visit [min: N600 ; max N18000] Patient suggestions for improvement: 1. Provision of utilities (e.g. light, water) and clean [mosquito free] environment 2. Structures to provide space for privacy and confidentiality – e.g. for ANC or pediatric care 3. Equipment and health supplies – to minimize referrals to other HC 4. Staff availability and punctuality to work 5. Humanity of Care - empathy

39. Unfinished reform agenda Management strengthening (macro and micro) Human resources for health reforms (labor market reforms; distribution) Autonomy at General Hospital level (drug revolving fund) Contracting private providers in urban areas (pilots started in Sept 2015) Explore more community client satisfaction surveys (ICT solutions)

40. Akwanga May 2015 PBF course: 38 technicians from 11 new States trained in PBF. Expanding Capacity.