Qualitative learning on RBF Nigeria Case study

Shun Mabuchi, Health Specialist, WB/ Lekan Olubajo, NPHCDA

H E A LT H R E S U LT S I N N O VAT I O N T R U S T F U N D

Outline

•  BACKGROUND

•  EXERCISE

•  DE-BRIEFING

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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)

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$$

$$

$$

State Govt.

Local Govt.

Health Centers

Federal Govt.

DLI

PBF

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

Ja

n Fe

b M

ar

Apr

M

ay

Jun

Jul

Aug

S

ep

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

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

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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

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(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

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Outline

•  BACKGROUND

•  EXERCISE

•  DE-BRIEFING

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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?

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Outline

•  BACKGROUND

•  EXERCISE

•  DE-BRIEFING

10

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

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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

Magnitude

Controllability

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

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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

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Implementation Arrangements •  Use the result reporting, verification and payment systems for PBF •  Leverage motivated health workers to distribute vouchers/CCT

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)

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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”

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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

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Thank You

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