Quarter 2 Implementation

Background

The implementation of performance based financing in Borno state through the Additional financing Nigeria state health investment project began about a year ago, amidst the ongoing armed conflict in some parts of the state. Bell Dome consult Limited in Jere LGA in the beginning of second quarter 2018, rolled out a strategic plan to strengthen this implementation through regular coaching and mentoring of HFs, LGA PHCD, HMB and state PIU. Also ensuring regular verifications of data generated in the health facilities and promoting high quality health service delivery.

As part of the ambition of the project and favorable results from feasibility assessment conducted in the state, additional LGAs were identified for scale up and trainings of the HF managers, with their ward Development committee members was conducted for Askira Uba, Magumeri, Kaga and Biu. In addition, Bayo, Shani, Kwakusar, Hawul were mapped and baselines conducted for progressive scale up.

Additional financing Nigeria state Health investment project seeks to rebuild and strengthen the health care systems in the North eastern states of Nigeria. In this goal, Borno state which is the epicenter of the conflict in the North east with very low health indices especially RHMNC+A, is benefiting strongly from the project. The ongoing conflict continues to pose threats to the progress and reducing access especially in the northern part of the state. Scale up of AFNSHIP in Borno state to the relatively calm southern LGAs present the opportunities to make rapid palpable progress in the intervention.

Executive summary

The Additional financing Nigeria State Health investment Project, since introduction in Borno state has ensured the quarterly evaluation of the contracted health facilities in selected LGAs. This core mandate of the LGA PHCD is designed to guarantee objective evaluation of the impact of routine supervision, coaching and mentoring servicers provided to the health facilities. Since the inception of BDCL contract in the state, the firm has ensured clear implementation of this component in the project and development of quality improvement plans by these supervisors. These quality improvement plans continue to remain a guide to the health facility managers in the delivery of high quality maternal and child health services, alongside the minimum package of activities as stipulated in their contracts. A slow increase in the quality scores of these health facilities according to their Domains have continuously spurred the need to continue strategic coaching and mentoring sessions to the health facilities in the selected LGAs.

Bell Dome consult Limited is currently allocated Jere, Askira Uba, Hawul, Shani and Magumeri LGAs in Borno State. Among these LGAs, Jere LGA remains the active LGA currently producing and implementing PBF. The other four have signed contracts but are yet to receive investments Credits to commence production.

As at the end of the second quarter, the contracted PHCCs in Jere LGA are yet to receive the first quarter subsidies to begin implementing some proposals in their QIP, especially the need to close the poor human resources gaps in most health centers. Sustained effort to keep using the available human resources in these facilities has contributed to slow progress in some domains such as ANC, OPD, Deliveries and essential drug management. 

Jere LGA has two contracted HFs still located in volatile unstable communities, regularly faced with threats and attacks. They are Molai General Hospital and Zabarmari PHCC. Zabarmari PHCC has consistently shown poor growth in both quality and quantity despite coaching and mentoring supports. This was linked to the height of threats the facility staff and manager are faced with, so much that some services are not allowed in the community by the Armed opposition group. Molai General hospital is located at one of the entrance route to Sambisa forest this secondary health care center was vandalized, but has undergone some renovations in Q2. These sites remain poorly accessible during some peak periods.

Contracted private hospitals in Jere LGA such as Rahama, Royal specialist and Taimakon Jama form the week spots in the project with consistently poor adherence to the best practices of the project and intentional refusal to adopt transparent financial management and submission of NHMIS data in some instances to the LGA. Among the public hospitals, Mashamari and Jiddari PHCCs performed poorly in financial management and lacked transparency. This led to the replacement of the manager of Mashamari PHCC by the LGA PHCD.

Second quarter 2018 activity profile in LGAs allocated to Bell Dome consult limited is still centered on Jere LGA, where production is currently ongoing. The other LGAs of Askira Uba, Magumeri, Hawul, and Shani  are set to commence full activity in the third quarter as contracts have been signed and training of health facility staff is ongoing.

Jere LGA, one of the pilot LGAs in the state began full implementation of PBF a year ago with the support of the technical team. As part of the early designs, it was centered on the concept of NSHIP as adopted from the pilot states. This concept encouraged the progress and volume of data generated in the first three quarters of their activities. A retrospective study of these data showed minimal verification with resultant high level of approved data purchased during these periods. AFNSHIP model introduced in the second quarter of 2018 with the arrival of BDCL to strengthen the implementation in Jere LGA and additional LGAs, brought modifications to the existing model, which was lavished with extensive verification and improved criteria for purchase of generated data. These modifications created a resultant fall in the volume of approved data as will be seen in the graphs below. Sanctions on data produced in the form of error margins (10%) further reduced the volumes of approved data and consequently reduced the quarterly earnings the HFs were accustomed to. In so many instances, these new steps are slowly been processed by the contracted HFs through regular coaching and mentoring by the BDCL teams, on the need/strategies to improve the quality of data generated. A common error observed among the health facilities is the under reporting/over reporting of data generated.

RESULTS

Among the 17 contracted HFs in the LGA, of the 15 MPAs, Fori PHCC was the best performing health facility in Q2 and Taimakon Jamaa the least performing based on the quality scores for MPAs and Umaru shehu specialist hospital the best performing among the two CPAs. Besides the quality scores of these HFs, Fori has consistently shown best performance in the key MPA domains and services in quantity of services, closely followed by Jiddari, Mairi, COCCIN eye and Dalori quarters . The poor performing HFs were Royal, Taimakon Jamaa, Rahama and Zabarmari PHCCs.

RECOMMENDATION

Need to conduct human resources redistribution in Jere LGA in favor of contracted health facilities, to support the nascent phase of PBF project implementation, with potentials to finance the remunerations of additional staff. Also promoting this redistribution in newly contracted LGAs.

CHALLENGES

  • Inadequate appropriate minimal human resources for health to implement the training offered during coaching and mentoring, in critical areas such as OPD, DELIVERY AND ESSENTIAL DRUG MANAGEMENT.
  • Unpredictable security situation in and around Molai General hospital and Zabarmari PHCCs.
  • Cultural resistance to Family planning services in most communities especially Zabarmari PHCC.

CONCLUSION

Second quarter 2018 ended with full introduction of AF NSHIP best practices among all contracted HFs in Jere LGAs. A resultant increase in the quality of care and data generated was recorded. Lessons learned from the field during this quarter have shapened the strategy and approach to developing the capacities of the contracted HFs in LGAs under BDCL