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

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

2. Outline
• BACKGROUND
• EXERCISE
• DE-BRIEFING
2

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

8. Outline
• BACKGROUND
• EXERCISE
• DE-BRIEFING
8

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

17. Thank You
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