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Introduction

In 2011, Nigeria launched a Results-Based Financing pilot, covering a population of 500,000 across three Local Government Areas (LGAs). The pilot was implemented in in 33 primary PHCs in Adamawa (Fufore LGA), Nasarawa (Wamba LGA) and Ondo (Ondo East LGA) states. These three LGAs were purposefully selected by the state governments, and the model PHCs for each ward[1] in the LGAs were selected. The pilot states showed early promising results.

Based on the lessons learned, the full scale Nigeria State Health Investment Project (NSHIP) was developed with a $150M IDA loan and a $20 million HRITF grant. Project roll out began in December 2013 and today RBF in Nigeria covers over 900 facilities in 50 LGAs with an estimated population of about 14 million. PHCs in the other LGAs (about 276 PHCs) will be under the decentralized facility financing (DFF) scheme where fixed amount of financial incentives (on average the same level as PBF) will be provided without linkage to performance.

PBF in Nigeria aims to improve health results by providing health facilities autonomy and make them accountable and motivated for results. Under NSHIP, roles of the states and LGAs are clearly defined with their result indicators, and the financial incentives are provided on the achievement of the indicators. PBF also provides direct finance to health centers based on the quantity and quality of services delivered[2], and the PHCs have autonomy in using it to improve health services (minimum 50% of received funds) and allocate it to health workers (up to 50% of received funds).

Report Summary

Objectives
Results of the pre-pilot PBF activities in Adamawa and Nasarawa states suggest that the PBF created large variations in performance among the participating PHCs. This variation in performance is consistent across indicators. One of the hypotheses on the key differentiating factors of good and poor performers in PBF is management practices at the PHCs. This research aims to understand the key differentiating factors of performance between the PHCs under the PBF scheme. Furthermore, this research specifically looks into the relationship between the management practices and the performance in the PBF facilities.

§  The following overall Research Questions were explored in this research:

§  What differentiates the good and poor performers among the PHCs under the PBF scheme?

§  Particularly, what management factors differentiate the performance of the PHCs?

§  Through what mechanisms do these factors affect the performance of the health centers?

This research used a case study approach. More specifically, this study used the extreme or deviant case sampling approach which focuses on unusual cases that provide rich information (Patton, 1990). Two teams of two researchers who speak local languages stayed in two different LGAs under the pre-pilot PBF and analyzed eight PHCs in total. As Adamawa state has been under the “state of emergency” due to the frequent attacks by insurgency, this research was carried out in Nasarawa and Ondo states. All interview data were transcribed and coded with themes based on the Conceptual Framework and findings from the field work, and good and poor performers were compared by each theme.      

Findings
Table 1 summarizes the identified commonalities and differences between high- and low-performing PHCs for each sub-theme. The case study found significant differences between high and low-performers in health center management and community support to health centers. Staff in high-performing health centers are fully aware of the target and actual quantities of key indicators for each month, update their monthly target, compare actual performance with targets and previous months, investigate the reasons for performance drop if any, address problems by involving community and religious leaders, and follow up on the results. In contrast, most low performing PHCs just continued to use the targets provided by supervisors at the beginning of the pre-pilot, and none of the staff could explain the target numbers. Low-performing health centers carry out monthly performance review meetings as mandated by the project, but only one of the four health centers explained a specific action to address stagnant performance. High-performers proactively make efforts to motivate staff through multiple approaches such as informal financial incentives, gifts, coaching, public recognition, and role-modelling of positive behaviors, while such efforts were observed in only one low-performer.

Further, high-performers have multiple pathways through which the health centers receive community patronage, including proactive daily relationship building with community and religious leaders by staff, spontaneous strong support from community leaders (e.g., punishing the use of informal providers), and support from Ward Development Committee as an intermediary between community and health centers. In contrast, all of four low-performers fall short in all of the three elements.   

Counter-intuitively, high-performers tend to be in more remote communities than low-performers. The location appears to be linked with other critical factors that can differentiate the level of community patronage – the more isolated a community is, the more staff have to commit to long, continuous periods of residence in the health center premises. In contrast to the above management factors, no much differences have been observed in planning, financial management and drugs management. In planning, unlike an initial hypothesis, even high-performers do not update monthly, weekly or daily plans. They rather plan and implement additional activities to solve daily issues in dynamic ways, without developing written formal plans.

Conclusions 
These findings suggest that building staff’s management capacity focusing on target setting, performance review and problem solving, and team building can improve performance of health centers. Also, engaging in the above three pathways to gain community support based on the community situations will be critical to improve utilization of PHCs. These findings have been shared with the government, and the project is developing approaches to strengthen management of the PHCs, as well as their community engagement activities, especially to improve the performance of low-performing health centers.

Table 1: Summary of Comparison between High- and Low-Performing PHCs

Theme

Sub-Theme

Difference between high- and low-performers

Context/ Community

(1) Distance and accessibility

Mostly similar

(2) Community income

Mostly similar

(3) Security

Somewhat different

(4) Cultural and social norms

Significantly different

(5) Competition from other providers

Somewhat similar

(6) Support from other partners’ or government’s program

Mostly similar

(7) Qualification of OIC

Significantly different

(8) Other contextual factors

Somewhat different

Health Systems

(1) Stewardship

Somewhat different

(2)  Human resources and staffing

Mostly similar

(3) Supply chain management

Mostly similar

(4) Health center infrastructure

Mostly similar

(5) Bonus administration

Mostly similar

Health Center Management

(1) Planning and Communication of the Plan

Mostly similar

(2) Target Setting and Communication of the Target

Significantly different

(3) Performance Tracking

Somewhat different

(4) Performance Review

Significantly different

(5) Problem Solving

Somewhat different

(6) Pricing of Services

Somewhat different

(7) Use of Performance Bonus

Somewhat different

(8) Financial Management

Mostly similar

(9) Drugs Management

Mostly similar

Community Engagement

(1) WDC engagement

Somewhat different

(2) Community leader engagement

Significantly different

(3) Client recruitment and retention

Somewhat different

(4) Health communication

Somewhat different

(5) Relationship with community members

Somewhat different

(6) Other community engagement

Mostly similar

Staff Management

(1) Staff involvement

Mostly similar

(2) Staff motivation

Significantly different

(3) Role modeling

Significantly different

(4) Team building

Somewhat different

(5) Staff rotation and availability

Significantly different

(6) Staff assignment

Mostly similar

(7) Staff training

Mostly similar

(8) Staff coaching

Mostly similar

(9) Performance evaluation and bonus allocation

Somewhat different

 

[1] There is one model PHC for each ward in Nigeria.

[2] Quantity bonus is calculated by the number of 21 basic health services (Annex 1 for the list) delivered multiplied by incentive for each service. Quality bonus is calculated by the percentage (out of 100%) achieved in the quality checklist multiplied by 25% of total quantity bonuses of the quarter.

 

  • Nigeria State Health Investment Project: Qualitative Study on Key Differentiating Factor for Performance Under Performance-Base
    Size: 1.4 MB

Resource Information

Document Type: (PDF) Download
Countries: Nigeria
Date of Publication: March 2015

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