Photo credit: World Bank
Despite relatively high levels of health spending, maternal and child health (MCH) outcomes remain relatively static in Nigeria. The maternal mortality ratio is among the highest in the world with 576 maternal deaths per 100,000 live births, and the under-five mortality rate continues to stagnate at 128 deaths per 1,000 live births (NDHS, 2013). The delivery of critical MCH service either worsened or only slightly improved. For example, skilled birth attendance decreased from 41.8 in 2003 to 38.1 percent in 2013 and the modern contraceptive prevalence rate only increased by 1.8 percent between 2003 and 20013 (NDHS, 2003; NDHS, 2013). Maternal and child health outcomes are further impeded by the poor quality of care: lack of skilled practitioners and supervisory staff, inadequate equipment and insufficient drug supplies impede service utilization, heightening patient dissatisfaction.
This situation is further compounded by stark income and geographic disparities. For instance, only 5.7 percent of women in the poorest wealth quintile deliver with a skilled birth attendant compared to 85.3 percent in the richest wealth quintile (NDHS, 2013). In addition, the health conditions in Northeastern States are among the worst in the country. Compared to Southern states, the under-five mortality rate is 54 percent higher and stunting is 125 percent higher. In addition, service delivery is also substantially poorer than in the South with, for instance, the DPT3 immunization coverage in 2013 only reaching 20.6 percent in the northeast compared to 72 percent in southern zones (NDHS, 2013).
RBF AT A GLANCE
The Nigeria States Health Program Investment Project uses supply-side performance-based financing to deliver a pre-defined package of MCH services, improve the quality of care and enhance equity in Nasarawa and Ondo States as well as in all Northeastern States. Under this scheme, the Federal Ministry of Health – through the National Primary Health Care Development Agency provide technical assistance to the state primary health care development agencies (SPHCDA). The SPHCDA contracts selected primary and secondary healthcare facilities to deliver a pre-defined package of MCH services, improve the quality of care and enhance equity. Based on performance, the State Project Financial Management Units (SPFMUs) disburses Performance-Based Financing (PBF) payments on a quarterly basis after verification. Health facilities can autonomously use these payments to (i) cover operational costs (i.e. about 50 percent); (ii) invest in quality-enhancement measures (i.e. maintenance and repair; drug supply; outreach activities); and to (iii) incentivize health workers (i.e. up to 50 percent).
The Nigeria States Health Program Investment Project also uses PBF to address demand-side constraints and boost service utilization. It uses PBF to provide free pediatric and obstetric care in select Local Government Areas to boost service utilization. The Federal Ministry of Health signs a performance agreement with a Contract Management and Verification Agency (CMVA). In turn, the CMVA subcontracts health facilities to provide free pediatric and obstetric care in select Local Government Areas (LGAs). PBF payments are disbursed quarterly to cover the full costs of pediatric and obstetric services as well as to incentivize health workers. In parallel, to strengthen health service delivery, particularly in northeastern conflict-affected areas, mobile teams are created and contracted to bring services closer to communities. Incentivized services focus on MCH, nutrition, psychosocial support, mental health and community outreach. PBF payments are made quarterly based on the quantity, quantity and equity of services provided.
The ex-ante RBF verification function is led by the National Primary Health Care Development Agency through a third party agent, the RBF Technical Assistant (TA). The RBF TA conducts quarterly assessments of the quantity of services delivered using health facility quarterly reports. To verify quality, Primary Health Care departments in individual LGAs to implement a quality checklist. Conversely, in hospitals, the SPHCDA oversees a peer review mechanism also organized around the administration of a quality checklist.
The ex-post RBF verification is led by civil society organizations contracted to ascertain service utilization and assess patient satisfaction through randomized home-visits. This is supplemented by a quarterly counter-verification of the quantity and the quality of services provided led by an Independent Verification Agent.
Status and achievements
The Nigeria States Health Program Investment Project was rolled out in December 2013. It was restructured in March 2015 to include demand-side interventions and further focus on strengthening service delivery in Northeastern Nigeria.
Today, the PBF component covers over 1433 facilities in 52 LGAs with an estimated population of about 10.5 million. Evidence shows encouraging progress in all three project States between January 2015 and March 2016, with service coverage increasing from 34 to 67 percent; skilled birth attendance doubling from 20 to 44 percent and modern contraceptive use quadrupling from 11 to 40 percent. Further, the quality of services also improved: the quality checklist applied on a quarterly basis found that structural and process quality measures saw rapid and sustained improvements. Finally, PBF facilities achieved good patient satisfaction, with scores reaching 80 percent in Nasarawa State and 95 percent in Ondo State.
In states where strong state leadership exists, both the quality and the quantity of targeted health outcomes show preliminary improvements, along with staff motivation and client satisfaction. However, disparities exist across states and demand-side barriers will need to be addressed.
The experience using operational data shows that this is an effort that requires intensive time commitment and the right technical skills. Recognizing that this can be a challenge for many countries, efforts are underway to develop an online dashboard that standardize the analysis, presentation and utilization of data across the HRITF portfolio. So far this been done through stand-alone dashboards but programs are now making efforts to integrate RBF data with country HMIS.
EVALUATION AT A GLANCE
The impact evaluation focuses on assessing whether the project improves the quality of care and the availability, use, and coverage of maternal, child and reproductive health services and disease control interventions, particularly among the poor. The design is a pre-post comparison.
The baseline survey of the impact is completed, and data collection for the midline review is ongoing.