The Additional financing Nigeria state health investment project (AF-NSHIP), through its performance based financing (PBF), have sustained steady increase in rebuilding and strengthening health care delivery in Borno state North east Nigeria. This state remains the epicentre of the on-going Boko Haram conflict that has displaced over two million Nigerians in the state. In second quarter of 2017, the state began implementing PBF in two LGAs in the state capital as pilot sites and areas with more security guarantee. These LGAs showed marked improvement in rebuilding the poor infrastructures and began providing the much needed quality health care service to the citizens and displace population living in host communities and IDP camps. The ambition of rebuilding and strengthening the health care system in Borno state replicated the Model in additional two LGAs in the southern part of the state (Askira Uba and Biu) and two in the northern part of the state (Magumeri and Kaga) by the end of quarter three.
Being the second report of this kind since Bell Dome Consult Limited was engaged in Quarter two as CMVA covering Jere LGA, and additional two LGAs of Askira Uba and Magumeri by the end of third quarter, these LGAs were mapped and baseline carried out successfully. A total of three LGAs with thirty one contracts were signed: Seventeen (17) in Jere, fourteen (13) in Askira Uba and one (1) in Magumeri. These contracted health facilities were distributed among certified verifiers at a ratio of 1:10 (One verifier covering 10 health facilities). While the key staff of BDCL continue to support the implementation at all levels.
Jere LGA with 17 contracted health facilities, comprising of public, private and faith based clinics began implementing PBF in April of 2017 with a total catchment population of 583091 and additional unspecified population of IDPs in the host communities.
Askira Uba LGA with 13 contracted Health facilities, comprising of both public and faith based clinics began implementing PBF in third quarter of 2018 with a total catchment 420,967 With no records of displaced population into these catchment areas, most displaced population have returned to their place of origin.
Magumeri LGA with one contracted Health facility, a public primary health MCH centre began implementing PBF in Third quarter of 2018with catchment population of 21,580 serving both displaced population within this catchment area and much more from neighbouring communities. This MCH remains the most functional health institution in the LGA with a recent plethora of INGO in the area providing some see vertical interventions.
The additional two LGAs enrolled in third quarter 2018 were without investment credit for the significant part of the third quarter, following delays from banking regulations on conditions for opening a corporate account, with most WDC representatives failing to present valid means of identification.
Health systems strengthening which is at the very core of the AFNSHIP intervention was scaled up into additional accessible LGAs in Borno state, in which BDCL now serves the implementation in addition to Jere LGA, Magumeri and Askira Uba LGA. All three LGAs had quality evaluations conducted by the LGA PHCD supervisors who were trained and certified by the NPHCDA.
Jere LGA upon its fourth evaluation since it began to implement PBF showed an improved quality score across contracted PHCCs with an average of 47.3% as against the previous quarter of 34%. Some weak domains in the quality score check list reoccurred as it was in the previous quarter, such as financial management. This domain was consistently visited at all health facilities by the BDCL team, requesting health facility managers to engage an account clerk/some person different from the health facility managers to ensure proper documentation of the financial activities in the health facilities. In Jere LGA, few health facilities have made great progress while some are still lagging behind. The additional LGAs of Askira Uba and Magumeri whose health facilities just received their first investment credit by the end of the third quarter are encouraged to engage account clerks early to avoid the set back that comes with wanting to handle cash and other administrative activities by the health facility managers alone. Askira Uba LGA upon completion of its first quality evaluation as seen in the statistics below had an average quality score of 22.7% as against the base line scores of 9.5%. These health facilities have shown significant improvement in the quality of care after one quarter, despite delayed payment of investment credit. Magumeri LGA upon completion of its first quality evaluation as seen in the statistics below had an average quality score of 32.58% as against the base line scores of 8%. The health facility has shown significant improvement in the quality of care after one quarter, despite delayed payment of investment credit.
The state government in its intervention declared free healthcare for all especially women and children following the impoverishing effect of the conflict on its citizens. This kind gesture has forced the contracted health facilities to continue making huge investments in drugs and consumables to serve the massive population in the state capital and other contracted LGAs in the south with subsidies obtained from AF NSHIP. All these are administered free of charge to patients negating the self-sufficiency/sustainability underscoring the PBF model.
Verification of all quantity data and Evaluation of the Jere, Magumeri and Askira Uba PHCD performance frame work of third quarter was conducted by BDCL, amounting to 70.17%, 57.40% and 43.37% respectively as counter verified by the Independent verification Agency in the state, a difference of less than 10% in score was recorded across all LGAs. Together with the HSCL, BDCL conducted the quarterly performance frame work of the Hospital management board in the state through a series of processes using the approved checklist and arrived at a total score of 74.84%. A process that was also counter verified by the IVAs and had a less than 10% difference. In Jere, Askira Uba, Magumeri LGA PHCD and HMB performance frame work evaluation, the average quality scores of the HFs greatly influenced the outcome of the performance of both.
The quarter has not been without challenges from several areas in the project, such as delays in making subsidy payments to the newly contracted HF in Magumeri and Askira Uba, poor communication among regulators at the state level, increasing movement of internally displaced persons in the state, uncoordinated activities of INGO in the state which often leads to falsification of data by both patients and HFs, Difficult private/public health facility owners who are bent on resisting the principles of transparency and accountability in the project design.
In the face of increasing insecurity in some part of Jere LGA such as Zabarmari and Molai communities, Askira Uba LGA such as Ngohi, Uvu and Moussa where five contracted health facilities in total are, BDCL is promoting community outreach services to increase the population coverage of these areas within the safe zones.
A total of 31,351,247 Naira was generated by all contracted health facilities in Quarter two (Jere LGA only) and 72,405,618 Naira was generated by Jere in Quarter three about 100% increase. Magumeri LGA generated the total sum of 221,571 NGN in Quarter three while Askira Uba contracted HFs generated the total sum of 3,016,402 in quarter three.