Helping Nigeria make Rapid Progress Through
Performance-Based Financing
Health Center Storage Room Before and After Introduction of RBF in Nasarawa
World Bank
June 5, 2014
1
Outline
1. Background on the Health Sector in Nigeria
2. How Performance-Based Financing works in
Nigeria
3. How is PBF being supported in Nigeria
2
1. Background: IMR & U5MR from
NDHS 2003-2013
250
200
201
157
150
128
125
100
100
99.3
75
IMR
U5MR
MDG4 Target
73.9
69
50
0
2003
2008
2013
3
Total Fertility Rate – NDHS: Very Slow
Progress
6
6
5.7
5.7
1990
2003
2008
5.5
5
4
3
2
1
0
2013
4
Child Nutritional Status 2003-13:
No Progress
45
40
42
41
37
35
29
30
24
25
23
2008
18
20
2013
14
15
2003
11
10
5
0
Stunting
Source: NDHS 2003, 2008, 2013
Wasting
Weight for Age
5
Service Delivery 2003-13 in Rural Nigeria: Little
Progress, Poor Coverage
100
ANC=Antenatal Care, SBA=Skilled Birth Attendance, CPR=Contraceptive Prevalence Rate
90
80
70
60
50
50.6
ANC
46.4
46.5
40
30
20
10
0
27.1
SBA
27.7
22.7
27
DPT3
CPR
24.9
12.8
5.7
6.5
5.7
2003
2008
2013
Source: NDHS 2003, 2008, 2013
6
Geographical Inequities in DPT3
Coverage: NDHS 2003-2013
100
90
80
70
North Central
60
North East
50
North West
40
South East
30
South South
South West
20
10
0
2003
2008
2013
7
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
8
What has NOT worked - “Simple”
solutions
X Shortage of Health Workers: Ratio of doctors &
nurses to population twice the SSA average
X Shortage 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
9
No Correlation between Expenditure
& ANC Coverage
ANC Coverage %
100
90
80
70
60
50
40
30
20
10
0
0.0
500.0
1000.0
1500.0
2000.0
2500.0
Per Capita Health Expenditure by State (Naira)
3000.0
Source: World Bank Analysis from State PEMFAR/PER/PEFA Reports and NDHS 2008
10
2. Experience with Performance
Based Financing (PBF) - Example
Service
Number Provided
Last Quarter
Unit Price
Child fully vaccinated
Skilled birth attendance
Curative care patient visit
Sub-Total
Remoteness (Equity) Bonus
Quality bonus
50
60
1,800
$2
$10
$0.5
Total Earned
$100
$600
$900
$1,600
+25%
$2,000
Score (50%) x 25% of volume
$200
Total $2,200
Use of Funds
Drugs and consumables
Outreach expenditures
Repairs & maintenance of health facility
Bonuses to staff in the facility
Savings
$500
$250
$150
$1,100
$200
11
Example of a Quantitative Checklist
to determine Quality of Care Score
May
Date of Visit
Availability of Drugs (0-10)
7
Presence of staff (0-10)
5
HMIS implementation (0-10)
3
Village health committee (0-10) 5
Cleanliness of Health Center
6
Quality of delivery care (0-10)
6
Outreach activities (0-10)
2
TOTAL SCORE (out of 70)
34
TOTAL PERCENT
49
Aug.
Nov.
7
6
3
8
7
7
5
43
61
8
8
5
9
8
7
6
51
73
Feb.
10
9
5
10
10
8
8
60
86
12
3. Results across 3 pre-pilot LGAs
OPD per capita
0.90
Payment Delays
Adamawa
Nasarawa
Ondo
Institutional Delivery
Payment Delays
60%
0.80
50%
0.70
0.60
40%
0.50
30%
0.40
0.30
20%
0.20
10%
0.10
0.00
0%
12 2 4 6 8 10 12 2 4 6 8 10 12
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)
13
Indicators dependent on outside inputs are more risky
Completely Vaccinated Child
100%
90%
80%
New users of modern FP methods
40%
Variable due to
issues in cold
chain
Adamawa
Nasarawa
Ondo
35%
Impressive
results to be
verified with
baseline data
30%
70%
25%
60%
50%
20%
40%
15%
30%
10%
20%
5%
10%
0%
0%
12 2 4 6 8 10 12 2 4 6 8 10 12
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)
14
Quality scores are converging at high level but still have
variations across states
Adamawa
Nasarawa
Ondo
Quality Score (%)
100
90
80
81
70
69
66
65
60
30
20
83
41
83
87
86
85
76
67
64
70
65
66
68
67
67
57
52
51
% 50
40
84
45
26
21
10
Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '12 Q1 '13 Q2 '13 Q3 '13 Q4 '13
15
Traditional
Financing
$
Inputs
HF is a
black box
Theory of Change - Why
we think PBF works!
Is the FOCUS
•Worker incentives
•Management autonomy
•Improved Governance
• Focus on Quality
•Operating budget
• Cash $
•Clear signals
of priorities
• Systematic
Supervision
• Verified Data- Stronger
M&E
Outputs
16
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.
17