Helping Nigeria make Rapid Progress Through Performance-Based Financing World Bank June 5, 2014...
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Transcript of Helping Nigeria make Rapid Progress Through Performance-Based Financing World Bank June 5, 2014...
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Helping Nigeria make Rapid Progress Through Performance-Based Financing
World BankJune 5, 2014
Health Center Storage Room Before and After Introduction of RBF in Nasarawa
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Outline1. Background on the Health Sector in Nigeria2. How Performance-Based Financing works in
Nigeria3. How is PBF being supported in Nigeria
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1. Background: IMR & U5MR from NDHS 2003-2013
2003 2008 20130
50
100
150
200
250
100
75 69
201
157
128125
99.3
73.9
IMRU5MRMDG4 Target
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Total Fertility Rate – NDHS: Very Slow Progress
1990 2003 2008 20130
1
2
3
4
5
66
5.7 5.7 5.5
5
Child Nutritional Status 2003-13: No Progress
Stunting Wasting Weight for Age0
5
10
15
20
25
30
35
40
45 42
11
24
41
14
23
37
18
29
200320082013
Source: NDHS 2003, 2008, 2013
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Service Delivery 2003-13 in Rural Nigeria: Little Progress, Poor Coverage
2003 2008 20130
10
20
30
40
50
60
70
80
90
100
5.7 6.5 5.7
50.646.4 46.5
27.1 27.722.7
12.8
27 24.9
ANC
SBA
DPT3
CPR
Source: NDHS 2003, 2008, 2013
ANC=Antenatal Care, SBA=Skilled Birth Attendance, CPR=Contraceptive Prevalence Rate
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Geographical Inequities in DPT3 Coverage: NDHS 2003-2013
2003 2008 20130
10
20
30
40
50
60
70
80
90
100
North CentralNorth EastNorth WestSouth EastSouth SouthSouth West
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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
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What has NOT worked - “Simple” solutions
XShortage of Health Workers: Ratio of doctors & nurses to population twice the SSA average
XShortage 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
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No Correlation between Expenditure & ANC Coverage
0.0 500.0 1000.0 1500.0 2000.0 2500.0 3000.00
10
20
30
40
50
60
70
80
90
100
ANC
Cove
rage
%
Per Capita Health Expenditure by State (Naira)
Source: World Bank Analysis from State PEMFAR/PER/PEFA Reports and NDHS 2008
2. Experience with Performance Based Financing (PBF) - Example
Service Number ProvidedLast Quarter
Unit Price Total Earned
Child fully vaccinated 50 $2 $100Skilled birth attendance 60 $10 $600Curative care patient visit 1,800 $0.5 $900Sub-Total $1,600Remoteness (Equity) Bonus +25% $2,000Quality bonus Score (50%) x 25% of volume $200
Total $2,200Use of Funds Drugs and consumables $500Outreach expenditures $250Repairs & maintenance of health facility $150Bonuses to staff in the facility $1,100Savings $200 11
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Example of a Quantitative Checklist to determine Quality of Care Score
Date of Visit May Aug. Nov. Feb.
Availability of Drugs (0-10) 7 7 8 10Presence of staff (0-10) 5 6 8 9HMIS implementation (0-10) 3 3 5 5Village health committee (0-10) 5 8 9 10Cleanliness of Health Center 6 7 8 10Quality of delivery care (0-10) 6 7 7 8Outreach activities (0-10) 2 5 6 8TOTAL SCORE (out of 70) 34 43 51 60TOTAL PERCENT 49 61 73 86
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3. Results across 3 pre-pilot LGAsAdamawaNasarawaOndo
OPD per capita Institutional Delivery
Payment DelaysPayment Delays
12 2 4 6 8 10 12 2 4 6 8 10 120.00
0.10
0.20
0.30
0.40
0.50
0.60
0.70
0.80
0.90
12 2 4 6 8 10 12 2 4 6 8 10 120%
10%
20%
30%
40%
50%
60%
Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)
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Indicators dependent on outside inputs are more riskyAdamawaNasarawaOndo
Completely Vaccinated Child New users of modern FP methods
12 2 4 6 8 10 12 2 4 6 8 10 120%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%Variable due to issues in cold chain
12 2 4 6 8 10 12 2 4 6 8 10 120%
5%
10%
15%
20%
25%
30%
35%
40% Impressive results to be verified with baseline data
Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)
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Quality scores are converging at high level but still have variations across states
AdamawaNasarawaOndo
Quality Score (%)
Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '12 Q1 '13 Q2 '13 Q3 '13 Q4 '13 -
10
20
30
40
50
60
70
80
90
100
26
51
66 64
45
57
66 67 67
21
65
81 84 83 83 87 86 85
41
52
69 67 70 65 66 68
76
%
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Inputs
Outputs
Traditional Financing
Results-Based Financing
•Management autonomy•Improved Governance• Focus on Quality •Operating budget
•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
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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.