1

Helping Nigeria make Rapid Progress Through Performance-Based Financing

World BankJune 5, 2014

Health Center Storage Room Before and After Introduction of RBF in Nasarawa

2

Outline1. Background on the Health Sector in Nigeria2. How Performance-Based Financing works in

Nigeria3. How is PBF being supported in Nigeria

3

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

2003 2008 20130

50

100

150

200

250

100

75 69

201

157

128125

99.3

73.9

IMRU5MRMDG4 Target

4

Total Fertility Rate – NDHS: Very Slow Progress

1990 2003 2008 20130

1

2

3

4

5

66

5.7 5.7 5.5

5

Child Nutritional Status 2003-13: No Progress

Stunting Wasting Weight for Age0

5

10

15

20

25

30

35

40

45 42

11

24

41

14

23

37

18

29

200320082013

Source: NDHS 2003, 2008, 2013

6

Service Delivery 2003-13 in Rural Nigeria: Little Progress, Poor Coverage

2003 2008 20130

10

20

30

40

50

60

70

80

90

100

5.7 6.5 5.7

50.646.4 46.5

27.1 27.722.7

12.8

27 24.9

ANC

SBA

DPT3

CPR

Source: NDHS 2003, 2008, 2013

ANC=Antenatal Care, SBA=Skilled Birth Attendance, CPR=Contraceptive Prevalence Rate

7

Geographical Inequities in DPT3 Coverage: NDHS 2003-2013

2003 2008 20130

10

20

30

40

50

60

70

80

90

100

North CentralNorth EastNorth WestSouth EastSouth SouthSouth West

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

XShortage of Health Workers: Ratio of doctors & nurses to population twice the SSA average

XShortage 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

10

No Correlation between Expenditure & ANC Coverage

0.0 500.0 1000.0 1500.0 2000.0 2500.0 3000.00

10

20

30

40

50

60

70

80

90

100

ANC

Cove

rage

%

Per Capita Health Expenditure by State (Naira)

Source: World Bank Analysis from State PEMFAR/PER/PEFA Reports and NDHS 2008

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

Service Number ProvidedLast Quarter

Unit Price Total Earned

Child fully vaccinated 50 $2 $100Skilled birth attendance 60 $10 $600Curative care patient visit 1,800 $0.5 $900Sub-Total $1,600Remoteness (Equity) Bonus +25% $2,000Quality bonus Score (50%) x 25% of volume $200

Total $2,200Use of Funds Drugs and consumables $500Outreach expenditures $250Repairs & maintenance of health facility $150Bonuses to staff in the facility $1,100Savings $200 11

12

Example of a Quantitative Checklist to determine Quality of Care Score

Date of Visit May Aug. Nov. Feb.

Availability of Drugs (0-10) 7 7 8 10Presence of staff (0-10) 5 6 8 9HMIS implementation (0-10) 3 3 5 5Village health committee (0-10) 5 8 9 10Cleanliness of Health Center 6 7 8 10Quality of delivery care (0-10) 6 7 7 8Outreach activities (0-10) 2 5 6 8TOTAL SCORE (out of 70) 34 43 51 60TOTAL PERCENT 49 61 73 86

13

3. Results across 3 pre-pilot LGAsAdamawaNasarawaOndo

OPD per capita Institutional Delivery

Payment DelaysPayment Delays

12 2 4 6 8 10 12 2 4 6 8 10 120.00

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 10 120%

10%

20%

30%

40%

50%

60%

Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

14

Indicators dependent on outside inputs are more riskyAdamawaNasarawaOndo

Completely Vaccinated Child New users of modern FP methods

12 2 4 6 8 10 12 2 4 6 8 10 120%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Variable due to issues in cold chain

12 2 4 6 8 10 12 2 4 6 8 10 120%

5%

10%

15%

20%

25%

30%

35%

40% Impressive results to be verified with baseline data

Assumption: Estimated crude birth rate (per 1000 pop): Adamawa (51), Nasarawa (38), Ondo (32)

15

Quality scores are converging at high level but still have variations across states

AdamawaNasarawaOndo

Quality Score (%)

Q4 '11 Q1 '12 Q2 '12 Q3 '12 Q4 '12 Q1 '13 Q2 '13 Q3 '13 Q4 '13 -

10

20

30

40

50

60

70

80

90

100

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

%

16

Inputs

Outputs

Traditional Financing

Results-Based Financing

•Management autonomy•Improved Governance• Focus on Quality •Operating budget

•Worker incentives

$• Cash $•Clear signals of priorities• Systematic Supervision

Theory of Change - Why we think PBF works!

HF is a black box

Is the FOCUS

• Verified Data- Stronger M&E

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.