Performance-Based Financing boosts quality of health care in Nigeria


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Results Based Financing Brings Better Healthcare to African Countries

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.



Ayodeji Oluwole Odutolu

Senior Health Specialist in the Africa Region at the World Bank

Dr, Magnus Azuine
August 08, 2013

Henry Longfellow once said that “The heights by great men reached and kept were not attained in sudden flight but, they while their companions slept, they were toiling upwards in the night.” You have been able to show that Performance-Based Financing did boost quality of health care in Nigeria. I wish you can go through the extrac effort of selling this life saving intervention to the Nigerian government. With strong convinctions like you have, I am sure the lives you help save will be a rewarding experience.

finance india
August 02, 2013

good and useful information shared!!!

Biodun Awosusi
August 10, 2013

Dear Dr Ayodeji Oluwole,
This is an impressive account of how PBF has transformed health service delivery in target communities in Nigeria, and the plan to expand the practice to reach more people.Kudos to you and the team!
I am curious to find out the challenges faced by the hospital managers and health workers these facilities? What did they do to overcome them? Is Rwanda's success readily transferable to Nigeria? How do we hope to sustain this financing method in the face of dwindling aid and irregular domestic budget for health?
Look forward to your response!

July 29, 2013

Thank you for sharing your perspective on the Nigeria health PBF. It is heartening to see the rapid and positive changes that your pilot is bringing as hope for other countries that are also considering implementing the PBF approach.

Oluwasola Olanipekun
July 30, 2013

Iam happy to read this piece and it brought a lot of smile to my face and some hope too. I did a health facility survey some years ago while I was working with Life Vanguards an ngo based in Osogbo,Osun State, what we saw was terrible, dilapidated buildings, poor facilities, poor morale among health workers and worst still unwillingness among the local people to even go for health care in these facilities.
With this PBF I am hopeful that things will actually change. However there is need for caution here, we need to ensure that the management of the PBF are transparent and accountable by putting in place measures to ensure there is process of self reporting and verification. It might also be a good practice to actually detach this processes from the politics within government circle.

Chukwuemeka Okonkwo
August 20, 2013

This effort is commendable. More can be achieved if State and Federal Subsidy and Reinvestment Fund Programme (SURE-P) on health are utilised accordingly. There should be drive for partnership with the conveners of MCH in both state and Federal of SURE-P and more importantly a briefing with Dr. Christopher Kolade and State Govenors to get the SURE-P funds into use. You have the platform and model is working so far (can be improved till it becomes best practice). So there is no need for the managment of SURE-P to be reinventing the will. That is waste of resources and time. Kudos to you and your team.

Lucy Musyoka
August 18, 2013

This is quite informative and lessons learnt for the Kenyan context ! I agree with you that PBF is an important intervention for consideration as an engine for quality improvement especially in resources constraint setting.
Well done for this milestone .
Keep well

Surgeons in India
August 21, 2013

Thank you for sharing your perspective on the Nigeria health PBF. It is heartening to see the rapid and positive changes that your pilot is bringing as hope for other countries that are also considering implementing the PBF approach.

November 08, 2013

I appreciate the information shared on PBF as a strategy for increasing the quality of care and delivery of maternal and child health interventions especially in the primary health facilities. The pilot study has revealed improvement in health especially in Nasarawa and Adamawa States. However, evaluation of the strengths and challenges encountered while planning and implementing this strategy should be considered as different parts of Nigeria are faced with different cultural diversity and health inequalities. This will further help in effective implementation of PBF in other states in Nigeria efficiently.

June 20, 2014

Dear Dr Ayodeji,
I found this article quite interesting, as it details a lot of my observations of the medical facilities available in Lagos and other states.
What do you think people with time on their hands can do to help improve the PBF facilities across country.