Annual Results and Impact Evaluation Workshop for RBF - Day Five - Qualitative Learning on RBF - Nigeria Case Study
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Annual Results and Impact Evaluation Workshop for RBF - Day Five - Qualitative Learning on RBF - Nigeria Case Study



A presentation from the 2014 Annual Results and Impact Evaluation Workshop for RBF, held in Buenos Aires, Argentina.

A presentation from the 2014 Annual Results and Impact Evaluation Workshop for RBF, held in Buenos Aires, Argentina.



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Annual Results and Impact Evaluation Workshop for RBF - Day Five - Qualitative Learning on RBF - Nigeria Case Study Presentation Transcript

  • 1. Qualitative learning on RBF Nigeria Case study Shun Mabuchi, Health Specialist, WB/ Lekan Olubajo, NPHCDA H E A LTH R ESU LTS IN NOVATION TRUS T FU N D
  • 3. RBF in Nigeria combines the PBF at health centers and DLIs to state and local governments Results Based Financing Approach in Nigeria •  Increase in services •  Budget execution •  Bonus payment •  Quantity of services delivered •  Quality scores of the services •  Supervision •  HMIS reporting •  HR management Finance based on.. (Examples) 3 $$ $$ $$ State Govt. Local Govt. Health Centers Federal Govt. DLI PBF
  • 4. Coverage has been increasing significantly, but further improvement is required Inst Deliveries Vaccination FP 2012 Coverage of health services in Pre-Pilot facilities in Adamawa state (%) 0 5 10 15 20 25 30 35 40 45 Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct •  Significant improvement from very low baseline in all indicators •  The is a good contrast with low DHS 2013 results in the North East (institutional delivery 20%, vaccination 14%, FP 11%) •  However, the overall utilization is still 30-40% 4
  • 5. Detailed look at the operational data revealed the large variations in performance across Health Centers Institutional Delivery in Adamawa, normalized by 100,000 population •  Before PBF, all health centers were equally at very low levels •  After the PBF, some facilities achieved 100% coverage while others struggle with limited improvement - 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 Kabilo HC Saint Mary's Clinic HC Mayo-Ine HC 5
  • 6. This performance variation across health centers also exists in quality of care 0 10 20 30 40 50 60 70 80 90 Dec Mar Jun Sep Dec Mar Jun Sep Malabu HC Wuro Bokki HC Farang HC Furore MCH HC Gurin HC Karlahi HC Kabilo HC Mayo-Ine HC Pariya HC Dasin Hausa HC Ribadu HC Choli HC •  The quality score overall improves even in low performers •  However, the difference between high and low performers increased from 23% to 30%Range: ~23% Range: ~30% Quality Score (%) in pre-pilot health centers in Adamawa state 6
  • 7. (Brainstorming) What can be the causes of this large variation in performance across health centers? Community Demand/ Support •  Culture, information, perceptions •  Access to health centers •  Affordability to receive services Health Systems •  Leadership and governance •  Financing, human resources, supply chain •  Stewardship (supervision, training) PBF Design and Implementation •  Autonomy to health centers •  Performance based payment •  Verifications Health Center Management •  Community engagement •  Team management •  Planning, performance management •  Other management (e.g., finance, drugs) •  Increased demand to receive health services •  Better facilities •  Motivated staff •  Better relations with communities •  More use of health service •  Better quality score •  Better health outcomes •  More perfor- mance bonuses •  More finances to further improve health centers Conceptual Framework of PBF Performance Improvement 7
  • 9. Exercise: Design qualitative research(es) to understand the key determinants of performance under PBF •  To identify critical factors that affect performance of health centers under PBF and design interventions to further improve performance Objective Exercise In groups, •  Define research question(s) to achieve above objective •  Design qualitative research(es), answering: i.  What are factors you will look into? ii.  What approaches will you use? iii.  Who/what will be the targets of the research? iv.  What are your hypotheses on findings and how you plan to use the results? 9
  • 10. Outline •  BACKGROUND •  EXERCISE •  DE-BRIEFING 10
  • 11. Nigeria team engaged with two qualitative studies Research question Areas to look into 1. Demand-side barrier analysis 2. Case study on key determinants •  What are the barriers to service utilization in the PBF facilities? •  What differentiate the good and poor performers under the PBF scheme? •  Transport, service fee, culture/perception/ information barriers •  Competition of alternatives •  Health center management •  Contextual factors •  Health systems factors (e.g., supervision) Approa- ches •  Interview and focus group •  High and low performers •  Interviews, document review, direct observations •  Best and poorest performers Potential use •  Design demand-side interventions •  Devise management support to poor performers 11
  • 12. Demand-side barrier analysis revealed priority issues Demand -Side Barriers Transport Cost Major Barriers Found through Qualitative Analysis Community/ Culture Priority demand side intervention • Transport Voucher Possible approaches Services Competi- tion Availability Cost Predictability of cost Hospitals Traditional providers Community support Cultural factors Magnit ude Controll ability High High High Med High High High High Varies Low Varies Med High High Varies Med • Community transport team • Maternal shelter • CCT • Predictable/discounted pricing (supply-side) • N/A • Incentives for referral to PHCs (supply-side) • Community engagement (supply-side) • Communication and community involvement 12
  • 13. Research findings have been translated into demand- side interventions with additional financing Transport Voucher CCT •  ANC standard visit (1-4) •  Institutional delivery •  Postnatal consultation •  Vaccination of children •  Growth monitoring •  Referred services provided by hospitals Proposed Transport Voucher and CCT •  ANC standard visit •  Institutional delivery •  Postnatal consultation •  Fully immunized child •  Growth monitoring •  Birth registration 13 Implementation Arrangements •  Use the result reporting, verification and payment systems for PBF •  Leverage motivated health workers to distribute vouchers/CCT
  • 14. Case study on determinants suggests the importance of community engagement and OIC management Determinants Non-Determinants •  Community engagement (e.g., involve and reward community leaders, daily visits, incentivise for use of facility) •  OIC’s management capacity (e.g., full staff involvement, improve staff environment using performance bonus, rigorous performance review) Identified determinants and non-determinants (preliminary) •  Level of staffing (best performers lack staff) •  Remoteness of facilities (best performers are very rural) •  Technical qualifications of OIC (many community health workers manage facilities well) •  Business planning (none use it effectively yet) 14
  • 15. Adamawa state used the results in programming the UNICEF’s technical assistance Agreed priority activities by UNICEF in the next 4 years (15 million Euro) •  Community engagement •  Management capacity building of health centers •  Technical training (e.g., IMCI) for quality improvement (QI) •  Packaged QI support •  Indigent support •  Health financing plan support (MTEF, state strategy, budgeting, etc.) •  Identify the needs and promote the cold chain improvement •  Potential support on community based PBF •  DLI implementation Urgent Long-term Core opportunit ies Additional opportunit ies “Main Activities” “Long-term support” “Quick wins” “Potential support” 15
  • 16. Key Lessons Learned •  RBF performance hinges on how well and quickly we can learn from implementation and improve our approaches •  Qualitative research can provide a powerful insights and evidence in devising effective approaches •  Identifying right research questions and clear plan to use the research results are required to make the qualitative research meaningful 16