Quarter 4 Implementation

Executive summary

Bell Dome consult Limited (BDCL) is a public health and health care financing expert with vast experience in the performance based financing. Since April of 2018, BDCL has continued to serve as CMVA technical support to Borno state primary health care Development Agency. A context with plethora of INGOs and reoccurring armed conflict has made access to some parts of the state very complex.

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 displaced 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.  In the fourth quarter of 2018, Borno state scaled up into additional four LGAs in the southern part of the state. These LGAs are Hawul, Shani, Kwaya kusar and Bayo. Bell Dome Consult Limited was allocated Hawul and Shani LGAs during which certified verifiers were immediately deployed to support the implementation of the project.

Being the third report of this kind since Bell Dome Consult Limited was engaged in Quarter two 2018 as CMVA covering Jere LGA, and additional four LGAs of Askira Uba, Magumeri, Hawul and Shani by the end of fourth quarter, these additional LGAs were mapped and baseline carried out successfully. A total of five LGAs with fifty contracts signed: Seventeen (17) in Jere, fourteen (13) in Askira Uba, Hawul (10), Shani (9) 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.

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, are Magumeri, Askira Uba, Hawul and Shani LGAs. All five LGAs had quality evaluations conducted by the LGA PHCD supervisors who were trained and certified by the NPHCDA.

The quarter under review witnessed alarming findings of financial misappropriation among some contracted health facilities in the pilot LGAs. This unpleasant exposition resulted in freezing of all contract accounts in the state pending all audit findings were published. Several weeks into these findings, the Borno state primary health care development agency in close collaboration with Bell Dome consult limited carried out in-depth financial management training exercise across all the contracted LGAs. The bank account of contracted health facilities in the scale up LGAs were released for access while the pilot LGAs were still frozen.

As the scale up LGAs continue to make great strides in the quality of care and implementation of PBF, Askira Uba and Magumeri LGAs embarked on intensive renovations of some health facilities, namely; Magumeri MCH, Wamdeo, Uba, Family support dispensary and Mussa PHCCs. These facilities received marked facelift, with resultant improvement in the quality scores of everyone of them.

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 population of 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 2018 with 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 vertical interventions.

Hawul LGA is located in the southern region of Borno state with an initial contracted number of health facilities of Ten (10). These health facilities are widely distributed across a large geographical region, with high number of hard to reach health facilities such as Hyera PHCC, kidang and Pyelathlabo PHCCs. This LGA has one private contracted health facility (Kanadi) with significant coverage along the periurban areas of the LGA. These ten health facilities currently serve 443508 people in the LGA.

Shani LGA is a a border LGA with Adamawa State to the south East and Gombe state to the West. This LGA was part of the second scale up LGA with nine contracted health facilities across the entire LGA. This LGA is fragmented by large water bodies and by mountain corridors that make it very complex to access some contracted health facilities. Bell Dome consult limited has consistently maintained regular presence to build capacity. These contracted health facilities cover a catchment population 370,780.

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 LGAs are Hawul and Shani LGAs. All five LGAs had quality evaluations conducted by the LGA PHCD supervisors who were trained and certified by the NPHCDA.

Jere LGA upon its fourth quarter 2018 quality evaluation showed an improved quality score across contracted PHCCs with an average of an average of 55.8% as against 47.3% in Q3 and 34% in Q2. 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 such as Royal specialist hospital (A private hospital in the LGA that went further to request discontinuation of PBF intervention in his hospital). Askira Uba LGA upon completion of its second quality evaluation as seen in the statistics below had an average quality score of 60.35% as against 22.7% obtained in third quarter and 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 second quality evaluation as seen in the statistics below had an average quality score 54.73% as against the previous quarter of 32.80% and against the base line scores of 8%. The health facility has shown significant improvement in the quality of care after two quarter, despite delayed payment of investment credit.

Hawul and Shani LGAs conducted their first quality evaluation of the contracted health facilities in fourth quarter. The contracted health facilities made marked improvement in the quality as against the baseline score obtained in Q3. The Q4 average quality score for Hawul and Shani LGAs are 23.26% and 23.47 % respectively.

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 performance Evaluation of Jere, Magumeri, Hawul, Shani and Askira Uba PHCD for fourth quarter was conducted by BDCL, amounting to 76.43%, 84.85%, 41.15%, 41.85% and 76.68% 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 46.63%. A process that was also counter verified by the IVAs and had a less than 10% difference.

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 Hawul, Shani and Magumeri, 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. The private contracted health facilities have expressed displeasure in the community identification of some influential clients, who would prefer to keep their identities and hospital history very private. These categories of clients have insisted their details not divulged to the CBOs.

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 Jere LGA during Quarter two and 72,405,618 Naira was generated by Jere in Quarter three about 100% increase. In quarter four, Jere LGA generated a total sum of 93,529,955 NGN 30% increase in quarterly earning. In Fourth quarter 2018 Magumeri LGA generated the total sum of 1,743,455 NGN as against 221,571 NGN in Quarter three. Askira Uba contracted HFs in quarter four 2018 generated the total sum of 21,888,334 NGN as against 3,016,402 in quarter three.  Hawul LGA upon completion of fourth quarter generated the total sum of 1,611,981 NGN. Shani LGA upon completion of fourth quarter activities had generated the sum of 2,897,249 NGN.