The Adamawa Primary Health Care System

Dr Abdullahi Dauda Belel

Chairman, Adamawa SPHCDA, Nigeria

Shun Mabuchi, Health Specialist, WB

24th April 2014 1

Presentation Outline

Background Information

PBF Introduction

Progress in implementation

Results

What’s Responsible?

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In Nigeria, Health centers suffer from underlying systemic issues

What you will see at a primary health care center: • Relatively abundant workers (among top in SSA) • Chronic stock-outs of essential drugs (Avg. 55%) • Lack of minimum equipment (Avg. 25%

equipped) • Poor sanitation/waste management • Idle health workers/absenteeism (Avg. 29%) • Correct mgmt. of maternal complication (17.3%) • No patients (Avg. 1.5 patients per day)

Underlying systemic issues: • Fragmentation and poor coordination between

federal, state and local govt levels • Unclear accountability and poor performance

review to strengthen it • No incentives to good or poor performance • No cash and autonomy at health facilities

Source: Service Delivery Indicator (SDI) Survey, 2013

Nigeria has been a largest contributor of maternal and child mortality

Description

• 33,000 women each year

• An estimated 70% of these deaths are preventable

• ~ 1 million deaths each year

SOURCE: FMOH Presentation (NDHS 2008), Rajaratnam et al. 2010, UN Report 2012

Maternal mortality rate (100k live births)

Infant mortality rate (1000 live births)

Under 5 mortality rate (1000 live births)

14%

8%

9%

Nigeria’s global share

157 104

75 65

545 500

Nigeria vs. SSA

Nigeria Sub-Saharan Africa

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NSHIP aims to address the systemic issues by financing for results and monitoring rigorously

Project Approach in Nigeria (US$ 170 M, 5 years, 3 States)

• Health service coverage • Budget execution • Bonus payment

• Quantity of services delivered • Quality scores of the services

• Supervision • HMIS reporting • HR management

Finance based on.. (Examples)

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$$

$$

$$

State Govt.

Local Govt.

Health Centers

Federal Govt.

Disburse-ment linked indicator (DLI)

PBF

Main Driver

NSHIP is being scaled up after 2 years of pre-pilot implementation

’11 2012 2013 2014 Dec

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Pre-pilot started

PBF Pre-pilot (36 facilities)

PBF Scale-up

DLI

6 months payment delays

Subcontracting started for 4 services

Demand-side interventions pre-pilot

Project effectiveness (Aug 2013)

+3 PBF LGAs

+3 PBF LGAs

TA Agency

Almost all 2011-12 DLIs achieved (May 2013)

FY 2013 DLI review planned in May

Scope of data analysis

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Adamawa Background Information

Adamawa State is located in Northeast of Nigeria

Projected 2014 Population of 3,87m

Has 21 LGAs and 226 Wards

Among the 5 poorest States in Nigeria

A major contributor to the Nigeria’s poor health indicators

Health sector has very minimum private sector participation while the public facilities are in a deplorable State

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8

Background Information

The entire sector is currently under reform, using PBF as a strategy

The State is piloting PBF for GON but adopted it as strategy for strengthening the health system

Focused primarily on strengthening the Ward Health System (WHS) and Primary Health Care Under One Roof (PHCOUR)

Ensuring that funds are made available at the service points, guided by deliberate and focused plans

MNCH is placed at the frontline in PBF design and its scale up is supported by EU-UNICEF

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Background Information

Implementation arrangements is aligned to the attainment of the NSHDP’s objectives

Pre-Pilot evaluation revealed encouraging results and further clarified areas for immediate and long term adjustments for the scale up

10

Demsa

Fuf ore

Gany e

Girei

Gombi

Guy uk

Hong

Jada

Lamurde

Madagali

Maiha

May obelwa

Michika

Mubi North

Mubi South

Numan

Shelleng

Song

Toungo

Yola North

Yola South

PBF Introduction

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PBF

PBF scale up

DFF

Progress in Implementation

Key Officers: SMOH, ADPHCDA trained on PBF In Mombasa-Kenya and Enugu-Nigeria

Pre-Pilot (Fufore LGA) was chosen Rural LGA – Pop ~ 240,160 Political Wards: 11 A Cottage Hospital (Secondary HF)

Baseline assessment of HFs and Communities done

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Progress in Implementation

15 HFs selected: 14 HCs for MPA & 1 GH for CPA

Management structures at LG level constituted and inaugurated (2012) LG RBF Steering Committee WDCs HF RBF Committees (both HCs & Hospital) IMC (both HCs & Hospital)

Bank Accounts for both HCs & Hospital opened

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Minimum Package of Activities

14

Complimentary Package of Activities

15

Effective

Affordable

• Deliveries in HF • Malaria Cases Treated • Immunized Childred,

etc

• Result Based Financing

•Quality Services

•Quantity Services

CPA

Institutional arrangements

16

Results

Success story of Mayo Ine Ward

Success story

Success story

Mayo-Ine health centre went from 4 deliveries per month to 45 deliveries per month within a six-month period

It has sustained that rate over the rest of the year, and this means that, for its entire sub-district population, it had gone from delivering10% of pregnant women to delivering 100% of all expected deliveries in its health facility.

Mayo-Ine health center has effectively reached universal coverage for institutional deliveries.

Success story

So what happened in Mayo-Ine?

As you can imagine, there must have been a tremendous change from what was there before.

The changes led to its staff working harder, going out to villages and talking to the population.

The staff involved the local community and traditional leaders in convincing the population to use its services.

The health facility received autonomy and a bank account and learned to manage money.

Working hours were changed from Monday to Friday 8 am to 4 pm to 24/7. One additional staff, a lab assistant, was hired.

Success story

The staff purchased drugs and medical materials from certified distributors; it purchased new equipment, repaired the broken fence, the windows, repaired the toilets, and fixed the waste disposal.

The changes led to health workers linking to their health posts and using these also to provide services, to provide growth monitoring, and vaccinations

Patients who would come would be prescribed essential drugs according to protocols which made it more affordable for them

The district health team came frequently for supervision, and provided targeted feed-back using a checklist.

Technical assistance from the State Primary Health Care Development Agency ensured that health staff was coached in using money, in managing their staff and in using new strategies to improve their health services.

Success story

Success story

And most difficult of all: health workers convinced all pregnant women, all of them, to come and deliver in their health facility.

The health staff changed their attitudes to patients, ensured that the equipment was there, that the environment in which they had to deliver was nice, that it had water, sanitation, a bed with clean sheets and a pleasant atmosphere.

Women who delivered did not have to pay any more for drugs or needles or to bring maternity pads.

In fact, women who delivered were given small items such as maternity pads, and clothes for their babies.

Success story

The health workers did the hardest thing of all: to regain the trust of the population by convincing them to use the public health services again and to use it for all their health needs.

Today, Mayo-Ine health center is a beacon for Fufore LGA, for Adamawa State, and also for Nigeria.

If Mayo-Ine can do it, in this far outpost of Nigeria, then anybody can do it.

Key improvements

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Increase coverage across the 3 PBF States

Adamawa Nasarawa Ondo

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Institutional Delivery

0%

10%

20%

30%

40%

50%

60%

12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

Adamawa Nasarawa Ondo

Qua

lity

Scor

e (%

)

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

- 10 20 30 40 50 60 70 80 90

100

Q4'11

Q1'12

Q2'12

Q3'12

Q4'12

Q1'13

Q2'13

Q3'13

Q4'13

Quality scores are converging at high level but still have variations across states

Key project indicators has been demonstrating encouraging results (1/3)

Adamawa Nasarawa Ondo

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OPD per capita per year Institutional Delivery (% coverage)

Payment Delays Payment Delays

0.00

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%

12 2 4 6 8 10 12 2 4 6 8 10 12Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

North East average 20%

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Key project indicators has been demonstrating encouraging results (2/3)

Adamawa Nasarawa Ondo

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Completely Vaccinated Child (% coverage)

New users of modern FP methods (%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 2 4 6 8 10 12 2 4 6 8 10 12

Variable due to issues in cold chain

0%

5%

10%

15%

20%

25%

30%

35%

40%

12 2 4 6 8 10 12 2 4 6 8 10 12

Remarkable achievement (North East average 3%)

Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32) 3

Key project indicators has been demonstrating encouraging results (3/3)

Adamawa Nasarawa Ondo

First ANC visit before 4 months pregnancy (% coverage)

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

12 2 4 6 8 10 12 2 4 6 8 10 12

Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

2-5 Tetanus Vaccination of Pregnant Women (% coverage)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12 2 4 6 8 10 12 2 4 6 8 10 12

3

In contrast, a few indicators suggest challenges to address through broader approaches/partnerships

Adamawa Nasarawa Ondo

PMTCT: HIV+ mothers and children born to are treated according protocol (%)

0%

10%

20%

30%

40%

50%

60%

12 2 4 6 8 10 12 2 4 6 8 10 12

- Other factors (PMTCT center, supply, etc.) may influence - Critical review of reasons and potential partnership (e.g., GF)

VCT/PMTCT/PIT test (Standardized to Avg. population of 3 LGAs)

0

200

400

600

800

1000

1200

1400

1600

1800

12 2 4 6 8 10 12 2 4 6 8 10 12

Good achievement (3-5 per day)

3

Deeper look at data suggests large variations in performance among health centers

Number of Institutional Delivery in Fufore (Adamawa), standardized by average catchment population

• Before PBF, all PHCs were equally at very low levels

• With PBF, some achieved 100% coverage while others are struggling without major improvements

-

20

40

60

80

100

120

140 Pariya HC

Chigari HC

Dasin Hausa HC

Farang HC

Ribadu HC

Furore MCH HC

Choli HC

Gurin HC

Malabu HC

Karlahi HC

Wuro Bokki HC

PBF started

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A qualitative case study suggested the importance of community engagement and health center management

Determinants Non-Determinants

• Community engagement (e.g., involve community leaders, daily visits, individual follow-ups and incentives for use of facility)

• Mangers’ management capacity (e.g., full staff involvement, improve staff environment, rigorous performance review)

Identified determinants and non-determinants of performance (preliminary)

• Level of staffing (best performers lack staff)

• Remoteness of facilities (best performers are very rural)

• Technical qualifications of OIC (community worker manage well)

• Business planning (none use it effectively yet)

35 Source: Preliminary report of qualitative case study on key determinants of performance

Focused management strengthening of the PHCs has potential to improve performance significantly – Adamawa partners with UNICEF/EU to address it

Adamawa Nasarawa Ondo

From (2011) To (2013)

Significant improvement has been observed in many areas, with a few areas of consistently low scores

Detailed indicator review for Adamawa revealed issues beyond Facilities in the areas with consistently low scores

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Staffing issues

Infrastructure issues

Issues that needs federal/state leadership

• FP Staff • Lab technician

• Fence • EPI fridge

• ARI protocol, malaria treatment, treatment with antibiotics < 30%, IMCI, nutritional status

• Indigent committee • Prescription form for essential drugs

Staffing and infrastructure issues influence other scores in the same section (e.g., the entire section can be zero without staff or EPI fridge)

Examples Uncontrollable Areas

Maximum scores without state/LGA/partner support on above areas will be 80-85%

NSHIP pre-pilot has been achieving significant improvements with very low marginal additional investment

$0.00$0.50$1.00$1.50$2.00$2.50$3.00$3.50

Year 1 Year 2 Year 3 Year 4

Paym

ent p

er c

ap

ita

“Year” means complete 12 calendar months counting from the month when program started Value for the most recent year is extrapolated if duration is less than 12 months Payment components consist of: • Quantity only in Zambia • Quantity, quality, and equity bonus in Burkina Faso and Zimbabwe • Quantity and quality in all other countries

Payment per capita – multi-country comparison

Health Expenditure per capita in Nigeria: US$161.4 (2012)

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Key challenges and next steps

Challenges/Findings Possible next steps

• Scaling-up PBF requires large amount of capacity at state and federal levels

• Procurement of technical assistance • Innovative approaches to increase

state capacity (e.g., internship) Scale up capacity

Payment delays

• Payment delays deteriorate performance significantly

• Simplify the approval process • Develop payment tracking system • Hold stakeholders accountable with

performance framework/DLIs

Broader reforms

• As PBF improves services, issues such as demand-side barriers, health center staffing, vaccine supply, health center management emerge as bottlenecks

• Combine targeted intervention (e.g., transport voucher)

• Strengthen the engagement with the federal/state government

• Link with others in broader reforms and capacity building

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Lessons Learned

• Providing autonomy, operational cash and result-focus can improve the performance of health centers significantly

• Policy and technical champions can make PBF as efficient service delivery platform

• Success of PBF hinges on how well and quickly we can learn from implementation and improve approaches

• Robust operational data and targeted qualitative researches provide tremendous opportunities for us to identify and problem-solve implementation issues

• Strengthened learning functions will challenge us on our capacity to adapt approaches in dynamic ways

• Having a pilot period allows intensive learning and improvement

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What’s Responsible?

Many factors but mainly Political will supporting change by the State Governor Having clear institutional arrangement with separation of

functions Having PHC Under One Roof and empowering the PHC

Agency with autonomy Strong mentoring (and WB TA support) and follow-up

programme by the SPHCDA using the PBF Manual Autonomy given to the facilities to improve their staff

strength, engage communities and utilize cash to solve immediate needs

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Thank you

PLEASE VISIT US @: http://nphcda.thenewtechs.com & http://adsphcda.org.ng

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