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Improving healthcare in Nigeria: focusing on results

Improving understanding of performance-based financing incentives within Nigeria’s primary healthcare systems

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Mike Naylor,

The country remains widely off-track towards meeting the health-related Sustainable Development Goals (SDGs), with only limited progress made towards delivering key healthcare interventions. As part of the World Bank-funded Nigeria State Health Investment Programme (NSHIP), we are providing technical assistance to support the development of results-based financing mechanisms within three pilot states. The team designed and implemented Performance-Based Financing (PBF) programmes working with stakeholders at the state, local government, and individual health facility level to determine performance indicators, set targets, and build administrative and oversight capacity. Robust monitoring and evaluation systems will be developed to measure impact and provide a basis for the scaling-up of successful interventions.

Challenges

Despite recent progress, the quality and quantity of public and private health services in Nigeria remains low. Large sectors of the population are still excluded from access to basic, affordable primary healthcare.

Historical models of financing based on incremental inputs are still widely adopted throughout the country and there is an urgent need to promote reforms that increase the focus on results and address ineffective incentive structures. The issue is compounded by a lack of capacity at local government levels, where responsibility for the coordination of high-impact primary healthcare services lies.

This project was established to address these challenges through the introduction of performance-based financing and capacity-building initiatives aimed at improving the quality and coverage of primary healthcare services in Nigeria

Our approach

Our team of experts have piloted a number of performance-based financing (PBF) tools within three target states - Ondo, Nasarawa, and Adamawa. This involved a flexible approach, adapting different mechanisms to the realities of each state health system and working with stakeholders at the state, local government, and individual health facility levels.

Ensuring the sustainability of reforms is a key focus of the project. The team worked closely with senior state leaders, State Primary Healthcare Development Agencies (SPHCDA), and other health system stakeholders, providing capacity building support to promote knowledge transfer and local ownership of reforms. Civil society organisations and research institutions were also engaged in monitoring the impact of different interventions to encourage greater accountability within the sector.

Specific activities included:

  • designing implementation strategies to deliver PBF financing programmes in three states;
  • providing technical assistance with the operationalisation of PBF programmes including the establishment of technical support units in each state;
  • designing and implementing capacity building programmes including training for health facility staff;
  • contributing to the design of impact evaluations incorporating household surveys and qualitative research; and
  • supporting the development of a communications strategy promoting wider public engagement.

Outcomes

This project provides crucial insights into the role of results-based management tools in promoting effective primary healthcare services in Nigeria. Lessons learnt from these large-scale pilots will act as an evidence base to inform the rapid scale-up successful interventions and their roll-out across other states.

Over the longer term, these reforms aim to improve the quality and coverage of care provided by primary health facilities in Nigeria by promoting more strategic, cost-effective purchasing and staff development in line with pre-agreed performance indicators.

In addition, by engaging local community stakeholders in the monitoring and verification of service delivery, the project creates a platform for greater social accountability, supporting a more inclusive, targeted model of healthcare that meets the need of communities and contributes towards the country’s wider development goals.

Areas of expertise