Over the past few years, there has been a marked increase in the volume of empirical evidence on effectiveness of Results-based Financing (RBF) schemes for improving health and nutrition outcomes. While these studies have shown mixed results for different outcomes and service delivery indicators across low and middle-income countries, a body of qualitative studies, based on perceptions of planners, implementers and beneficiaries, has attempted to explain the reasons for the success of such interventions and the barriers to achieving their full potential. Only a handful of studies have explored the implementation fidelity of RBF schemes, thus leaving a gap in the literature for an in-depth understanding of how implementation takes place, why does it deviate from its original plan and what lessons can be derived to further improve the technical design and its execution.
A study conducted as a part of the Mid-term Review (MTR) of the Nigeria State Health Investment Project (NSHIP) aimed to bridge this gap and provide insight on implementation fidelity from a sample of project facilities benefiting from Performance-Based Financing (PBF) and Decentralized Facility Financing (DFF). This study followed a qualitative research methodology, including focused group discussions with beneficiaries in the catchment area of project facilities, in-depth interviews with health workers and supervisors, and key informant interviews with state and federal level stakeholders. It was conducted in nine Local Government Areas (LGAs) – six PBF and three DFF – across the three project states of Adamawa, Nasarawa and Ondo. The nine LGAs were selected based on the principle of maximum variation, using routine monitoring data, such as one high performing PBF, one low performing PBF and an average performing DFF LGA were selected from each state.
Findings from this study suggest that a very high degree of implementation fidelity was achieved at NSHIP facilities. This encompassed all facilities following due contractual procedures mandated by NSHIP’s project design, receiving trainings on PBF and DFF principles, carrying out more frequent and supportive supervision, and creating new institutional arrangements, in the form of management committees. In addition, facilities adhered to developing business and activity plans for setting goals, by using data from the supervisory checklists that guided them for designing implementation strategies. All facilities created a common bank account to carry out financial transactions in a transparent manner and confirmed receiving a “takeoff” grant at the inception to upgrade their structures and amenities in order to be able to participate in NSHIP. All facilities, Local Government Departments, and verification agencies followed new guidelines outlined by NSHIP for data collection, collation and verification. This conformity to the project design and implementation strategy enabled stronger management systems to be reinforced and created a more conducive working environment for health workers to learn, share and work together.
Although NSHIP brought about many positive changes at the facility level, the study also found some gaps in its implementation as well as recurrent challenges deterring it from achieving its full potential. While most respondents praised NSHIP for injecting additional monetary resources in to their health facilities, in a few cases they expressed concerns about delay in receiving these payments. Many respondents from PBF LGAs expressed their dissatisfaction from the process of verification that was carried out at their facilities as they often disagreed with the assessment of the external verifiers and considered that different verifiers did not follow the same standard protocol during their assessment. In terms of institutional structures, the presence of “Indigent Committees” responsible for mobilizing beneficiaries, particularly from extremely disadvantaged communities, for utilization of health facilities was not so pronounced in some areas, though there existed some form of a committee saddled with various responsibilities. In general, the lower cadres of health providers appeared to be less aware of various procedures and mechanisms of NSHIP and were often not involved in the process of developing the business/activity plans. In PBF areas, a few of them reported to not understand the formula through which their performance bonus payments were calculated.
To conclude, the implementation of NSHIP at the time of the MTR followed a high degree of fidelity to its original design resulting in strengthening of management processes, for both PBF and DFF, to carry out implementation plans effectively. As it moves into its next phase, NSHIP needs to work towards improving some of the existing challenges to further improve quantity and quality of service provision. In particular, it needs to revisit the implementation modalities of selected processes, such as timely release of payments, external verification protocols, additional training for junior cadres, and inform potential changes in the technical design to overcome the existing gaps. Moreover, triangulation of findings from this study and the impact evaluation of NSHIP provide a better understanding of the pathways of PBF and DFF effectiveness.