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Helping Nigeria make Rapid Progress Through Performance-Based Financing

Helping Nigeria make Rapid Progress Through Performance-Based Financing

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Helping Nigeria make Rapid Progress Through Performance-Based Financing

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  1. Helping Nigeria make Rapid Progress Through Performance-Based Financing World Bank June 5, 2014 Health Center Storage Room Before and After Introduction of RBF in Nasarawa

  2. Outline • Background on the Health Sector in Nigeria • How Performance-Based Financing works in Nigeria • How is PBF being supported in Nigeria

  3. 1. Background: IMR & U5MR from NDHS 2003-2013

  4. Total Fertility Rate – NDHS: Very Slow Progress

  5. Child Nutritional Status 2003-13: No Progress Source: NDHS 2003, 2008, 2013

  6. Service Delivery 2003-13 in Rural Nigeria: Little Progress, Poor Coverage ANC=Antenatal Care, SBA=Skilled Birth Attendance, CPR=Contraceptive Prevalence Rate Source: NDHS 2003, 2008, 2013

  7. Geographical Inequities in DPT3 Coverage: NDHS 2003-2013

  8. 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

  9. What has NOT worked - “Simple” solutions • Shortage of Health Workers: Ratio of doctors & nurses to population twice the SSA average • Shortage of drugs: Yes a huge problem but no correlation between drug supply & patient volume • Lack of Physical Infrastructure: 67% of population lives within 30 minutes walk of health facility, 85% within 60 minutes • Absolute lack of public investment: Could be higher but bigger issues are efficiency and allocation of resources

  10. No Correlation between Expenditure & ANC Coverage ANC Coverage % Per Capita Health Expenditure by State (Naira) Source: World Bank Analysis from State PEMFAR/PER/PEFA Reports and NDHS 2008

  11. 2. Experience with Performance Based Financing (PBF) - Example

  12. Example of a Quantitative Checklist to determine Quality of Care Score

  13. Adamawa 3. Results across 3 pre-pilot LGAs Nasarawa Ondo OPD per capita Institutional Delivery Payment Delays Payment Delays Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

  14. Adamawa Indicators dependent on outside inputs are more risky Nasarawa Ondo Completely Vaccinated Child New users of modern FP methods Impressive results to be verified with baseline data Variable due to issues in cold chain Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

  15. Adamawa Quality scores are converging at high level but still have variations across states Nasarawa Ondo Quality Score (%)

  16. Theory of Change - Why we think PBF works! TraditionalFinancing Results-BasedFinancing Health Facility • Cash $ • Clear signals of priorities • Systematic Supervision $ Is the FOCUS • Worker incentives • Management autonomy Inputs • Improved Governance • Focus on Quality • Operating budget HF is a black box • Verified Data- Stronger M&E Outputs

  17. 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.