My experience as a doctor who practiced actively in this country did not prepare me for the shock I had during the preparation of the Nigeria State Health Investment Project. I had worked for three years in the public sector at the beginning of my career but then spent more than a decade in the private sector. I had not imagined the decay in public infrastructure – leaking roofs, heaps of garbage, broken down equipment, and stock-outs of drugs and disposables for months on end in public health centers. The general morale of frontline health workers was low and some ingenious workers were actually buying their stock of drugs to provide services for patients. Not surprisingly, the utilization of health services was low and the quality of service appalling.
The situation in Wamba, a Local Government Area in Nigeria’s Nasarawa State was in line with this general picture across many parts of Nigeria. The average patient load was only 5 to 30 per month, with 2 to5 deliveries. The Wamba community had no voice in the management of health centers and there was general apathy. The facilities were overstaffed, yet very little was working. My greatest concern was complacency – nobody seemed to care. I hate to say this but a Rwandan consultant working on the project innocently asked the question ‘when did the war end here?’ That was how bad it was and there was a general concern that performance-based financing (PBF), a new approach to financing frontline health centers that had worked very well in Rwanda, was not going to work in Nigeria. But we would not know until we tried and try we did.
With initial funding from the participating states – Adamawa, Nasarawa and Ondo –we began a pilot operation in November 2011. World Bank staff, Rwandan consultants and our government partners rolled up our sleeves, built the capacity of local government staff and health providers, engaged local communities, and supplemented government resources. Health centers started to receive funds directly based on the quantity of essential services they delivered and the improved quality of care. This encouraged health centers to focus on delivering results, and the new funds enabled them to improve their services. Health facilities now enjoy semi-autonomy with their own bank accounts. They procure drugs from certified distributors and use 50 percent of their performance bonuses to maintain facilities while 50 percent is for incentives to health workers.
Fifteen months down the line, the story has changed completely in these pilot sites. The number of patients increased by 200 to 300 percent in Nasarawa and Adamawa states. Similarly, coverage of institutional deliveries increased from 12 percent to 28 percent in Adamawa; 11 percent to 34 percent in Nasarawa State; and 17 percent to 33 percent in Ondo State. The project helped the health centers gain the communities’ confidence by significantly improving the availability of drugs and equipment and the level of sanitation and patient care. Dr. Gabriel Attai of Wamba General Hospital recently attested to the fact that ‘because of better environment, patient turn out has increased from 5 to10 per day before to 70 to100 on average’. You can watch people in Wamba sharing their experiences in this short video.
For me this is a Lazarus experience, primary healthcare was dead in Local Government Areas like Wamba but Performance-Based Financing resuscitated it and brought it back to life. Dr. Ado Mohammed, Executive Director of the National Primary Healthcare Development Agency (NPHCDA) calls PBF a “game-changer”. I agree with him. Beyond the numbers, there has also been outstanding improvement in quality of care. Facilities are cleaner, waste is managed better, and patients can use working toilets and bathrooms. Essential drugs are available now in the centers with the worst stock-outs. Delivery rooms are clean with modern equipment. Also, workers are motivated by performance incentives and better supervision. Lastly, there is community ownership to the extent that some communities have provided additional infrastructure in PBF facilities.
A few months ago, I visited some of the PBF facilities in Wamba with the Nigerian Minister of State for Health, Dr. Muhammed Ali Pate. We had earlier visited other non-PBF facilities, so the difference was striking. The PBF-supported General Hospital in Wamba has become a beehive of activity. Nigeria hopes to expand PBF. Our greatest aspiration is to scale up PBF in the next six months to over 9 million people. This may be the new approach to the science of delivery in the health sector in Nigeria.