The Adamawa Primary Health Care System
Dr Abdullahi Dauda Belel
Chairman, Adamawa SPHCDA, Nigeria
Shun Mabuchi, Health Spe...
Presentation Outline
 Background Information
 PBF Introduction
 Progress in implementation
 Results
 What’s Responsib...
In Nigeria, Health centers suffer from underlying systemic issues
What you will see at a primary health care center:
• Rel...
Nigeria has been a largest contributor
of maternal and child mortality
Description
• 33,000 women
each year
• An estimated...
NSHIP aims to address the systemic issues by financing for
results and monitoring rigorously
Project Approach in Nigeria
(...
NSHIP is being scaled up after 2 years of pre-
pilot implementation
’11 2012 2013 2014
De
c
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 ...
Adamawa Background Information
 Adamawa State is located in Northeast of Nigeria
 Projected 2014 Population of 3,87m
 H...
8
Background Information
 The entire sector is currently under reform, using PBF as a
strategy
 The State is piloting PBF ...
Background Information
 Implementation arrangements is aligned to the
attainment of the NSHDP’s objectives
 Pre-Pilot ev...
Demsa
Fuf ore
Gany e
Girei
Gombi
Guy uk
Hong
Jada
Lamurde
Madagali
Maiha
May obelwa
Michika
Mubi North
Mubi South
Numan
Sh...
Progress in Implementation
 Key Officers: SMOH, ADPHCDA trained on PBF In
Mombasa-Kenya and Enugu-Nigeria
 Pre-Pilot (Fu...
Progress in Implementation
 15 HFs selected: 14 HCs for MPA & 1 GH for CPA
 Management structures at LG level constitute...
Minimum Package of Activities
14
Complimentary Package of Activities
15
Effective
Affordable
• Deliveries in HF
• Malaria Cases Treated
• Immunized Childred,
etc
• Result
Based
Financing
•Qualit...
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 peri...
Success story
 So what happened in Mayo-Ine?
 As you can imagine, there must have been a tremendous change
from what was...
Success story
 The staff purchased drugs and medical materials from certified distributors; it
purchased new equipment, r...
Success story
Success story
 And most difficult of all: health workers convinced all
pregnant women, all of them, to come and deliver i...
Success story
 The health workers did the hardest thing of all: to regain
the trust of the population by convincing them ...
Key improvements
27
Increase coverage across the 3 PBF States
Adamawa Nasarawa Ondo
28
Institutional Delivery
0%
10%
20%
30%
40%
50%
60%
12 1 ...
Adamawa Nasarawa Ondo
QualityScore(%)
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
-
1...
Key project indicators has been
demonstrating encouraging results (1/3)
Adamawa
Nasarawa
Ondo
30
OPD per capita per year I...
Key project indicators has been demonstrating encouraging
results (2/3)
Adamawa
Nasarawa
Ondo
31
Completely Vaccinated Chi...
Key project indicators has been demonstrating encouraging
results (3/3)
Adamawa
Nasarawa
Ondo
First ANC visit before 4 mon...
In contrast, a few indicators suggest challenges to address
through broader approaches/partnerships
Adamawa
Nasarawa
Ondo
...
Deeper look at data suggests large variations in
performance among health centers
Number of Institutional Delivery in Fufo...
A qualitative case study suggested the
importance of community engagement and
health center management
Determinants Non-De...
Adamawa Nasarawa Ondo
From (2011) To (2013)
Significant improvement has been observed in many areas,
with a few areas of c...
Detailed indicator review for Adamawa revealed issues
beyond Facilities in the areas with consistently low scores
37
Staff...
NSHIP pre-pilot has been achieving significant improvements with
very low marginal additional investment
$0.00
$0.50
$1.00...
Key challenges and next steps
Challenges/Findings Possible next steps
• Scaling-up PBF requires large
amount of capacity a...
Lessons Learned
• Providing autonomy, operational cash and result-focus can
improve the performance of health centers sign...
What’s Responsible?
 Many factors but mainly
 Political will supporting change by the State Governor
 Having clear inst...
Thank you
PLEASE VISIT US @:
http://nphcda.thenewtechs.com
&
http://adsphcda.org.ng
42
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Providing Health in Difficult Contexts: Pre-Pilot Performance-Based Financing Experiences in Adamawa State in North-East Nigeria

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A presentation delivered during the RBF Health Seminar,
"Providing Health in Difficult Contexts: Pre-pilot Performance-Based Financing Experiences in Adamawa State in North-East Nigeria" on April 24, 2014. It highlights the experiences from the Adamawa Performance-based financing (PBF) Pilot, the challenges faced, the early results and how the pilot is leading the way for improved coordination and sustainable health system changes.

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Providing Health in Difficult Contexts: Pre-Pilot Performance-Based Financing Experiences in Adamawa State in North-East Nigeria

  1. 1. The Adamawa Primary Health Care System Dr Abdullahi Dauda Belel Chairman, Adamawa SPHCDA, Nigeria Shun Mabuchi, Health Specialist, WB 24th April 2014 1
  2. 2. Presentation Outline  Background Information  PBF Introduction  Progress in implementation  Results  What’s Responsible? 2
  3. 3. 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
  4. 4. 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 4
  5. 5. 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) 5 $$ $$ $$ State Govt. Local Govt. Health Centers Federal Govt. Disburse- ment linked indicator (DLI) PBF Main Driver
  6. 6. NSHIP is being scaled up after 2 years of pre- pilot implementation ’11 2012 2013 2014 De c 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 6
  7. 7. 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 7
  8. 8. 8
  9. 9. 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 9
  10. 10. 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
  11. 11. 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 11 PBF PBF scale up DFF
  12. 12. 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 12
  13. 13. 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 13
  14. 14. Minimum Package of Activities 14
  15. 15. Complimentary Package of Activities 15
  16. 16. Effective Affordable • Deliveries in HF • Malaria Cases Treated • Immunized Childred, etc • Result Based Financing •Quality Services •Quantity Services CPA Institutional arrangements 16
  17. 17. Results
  18. 18. Success story of Mayo Ine Ward
  19. 19. Success story
  20. 20. 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.
  21. 21. 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.
  22. 22. 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.
  23. 23. Success story
  24. 24. 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.
  25. 25. 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.
  26. 26. Key improvements
  27. 27. 27
  28. 28. Increase coverage across the 3 PBF States Adamawa Nasarawa Ondo 28 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)
  29. 29. Adamawa Nasarawa Ondo QualityScore(%) 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
  30. 30. Key project indicators has been demonstrating encouraging results (1/3) Adamawa Nasarawa Ondo 30 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 12 0% 10% 20% 30% 40% 50% 60% 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) North East average 20% 30
  31. 31. Key project indicators has been demonstrating encouraging results (2/3) Adamawa Nasarawa Ondo 31 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
  32. 32. 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
  33. 33. 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
  34. 34. 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 34
  35. 35. 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
  36. 36. Adamawa Nasarawa Ondo From (2011) To (2013) Significant improvement has been observed in many areas, with a few areas of consistently low scores
  37. 37. Detailed indicator review for Adamawa revealed issues beyond Facilities in the areas with consistently low scores 37 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) ExamplesUncontrollable Areas Maximum scores without state/LGA/partner support on above areas will be 80-85%
  38. 38. 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 Paymentpercapita “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) 38
  39. 39. 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 39
  40. 40. 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 40
  41. 41. 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 41
  42. 42. Thank you PLEASE VISIT US @: http://nphcda.thenewtechs.com & http://adsphcda.org.ng 42

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