Nigeria Health Sector Renewal Investment Program.pdf

Nigeria Health Sector Renewal Investment Program

… towards a healthy and prosperous Nigeria Now !

- Discussion Draft, November 6, 2023

World Bank Health, Nutrition, and Population Global Practice

NIGERIA HEALTH SECTOR RENEWAL INVESTMENT PROGRAM

Introduction A Vision for Nigeria’s Health Sector Framework for Nigeria Health Sector Renewal

Financing and Organization of Services Decentralized Facility Financing Operationalizing a Vulnerable Group Fund Strengthening Community Based Health Services Improving Quality of Care Harmonized TA support for BHCPF

Enabling Systems for Improved Outcomes Improving Commodity Security National Emergency Medical Service and Ambulance Scheme Digital in Health

Health Security

Governance, Financing and Accountability Defragmenting Sector Financing for Improved Efficiency Federal-State Partnership for Improved Ownership and Accountability Citizens Engagement and Social Accountability

Introduction

The Government of Nigeria has set out a Strategic Vision for the Health Sector [2023-2026]

Introduction A Vision for Nigeria’s Health Sector Framework for Nigeria Health Sector Renewal

Financing and Organization of Services Decentralized Facility Financing Operationalizing a Vulnerable Group Fund Strengthening Community Based Health Services Improving Quality of Care Harmonized TA support for BHCPF

Enabling Systems for Improved Outcomes Improving Commodity Security National Emergency Medical Service and Ambulance Scheme Digital in Health

Health Security

Governance, Financing and Accountability Defragmenting Sector Financing for Improved Efficiency

6WHOSDGs OtherSource: Presidential Commitment1. International Health Regulations (IHR) capacity and health emergency preparedness

2. Being determined

Reduce financial pain

Reduced out-of-pocket spend

Increased and more effective government spend

Reduced financial burden for the poor specifically

Health financing

Population with impoverishing health expenditure

Health insurance coverage

Government health expenditure as a proportion of total health expenditure per capita

For ALL Nigerians

All have access

..regardless of income group, there are good health outcomes

Access

Health facility density and distribution

Equity

Coverage of essential health services

Zero dose children

Difference in [select outcomes]2 between different regions and income groups

Save lives

Less death

Mortality

Life expectancy at birth

Mortality rates

▪ Maternal

▪ Neonatal

▪ Under 5

▪ Attributable to cardiovascular disease, cancer, diabetes, or chronic respiratory disease

This means

Measured by

Reduce physical pain

Improved quality of life

Improved quality of care

Quality of life

DALYs (overall)

Quality of care (QoC)

HRH Density

▪ Medical doctors

▪ Nursing and midwifery personnel

▪ Community health workers

Patient satisfaction rates with PHC services

People voice survey scores

Note: additional quality of care metrics to be added after QoC framework developed

Produce health

Reduced risk factors for communicable & non-communicable diseases

Reduced prevalence of non-communicable and communicable diseases and reproductive, maternal, neonatal, child, adolescent, and nutritional (RMNCH+AN) conditions

Risk factors (Prevalence)

Obesity

Insufficient physical

Activity

Non-communicable diseases (Incidence)

Cancer

Cardiovascular diseases

Diabetes and kidney diseases

Communicable diseases

(Incidence)

Malaria

Diarrheal diseases

HIV

TB

Immunization

Penta 3 coverage

% of children 0-12 months fully immunized

RMNCH+AN

Contraceptive prevalence

Antenatal care coverage

Skilled birth attendance

Postnatal care (newborn)

Stunting and wasting

Adolescent birth rate

Health Security:

IHR1 Score

7-1-7: early detection and response

Local production:

Net imports of generics and medical devices

The Strategic Vision for the Health Sector will be guided by progress in key outcomes

Social Accountability and Citizens Engagement

Medical industrialization

Nigeria Health Sector Renewal investment Program

Basic Health Care Provision Fund (BHCPF)

Financing

Private Sector

Basic Health Care Provision Program: Sector Wide Approach

Data

Digital in health

NGR INDUSTRIALIZATION

FUND

Decentralized Facility Financing

Vulnerable Group Fund Secondary care

Tertiary & Quaternary

Care Medical and

Public Health Emergencies

Fund

Public Health

Measures through Community-Based

Service Delivery

Commodities

Governance

Human Resources for

Health

The program comprises of the BASIC HEALTHCARE PROVISION PROGRAM and the HEALTHCARE

INDUSTRIALIZATION PROGRAM. The BHCPP will be managed through a sector wide program via real or notional pooling of all available funds. The Nigeria healthcare industrialization fund will be a specially dedicated pool of funds to drive investment in the healthcare value chain.

HEALTH SECURITY

THE NIGERIA HEALTH SECTOR RENEWAL INVESTMENT PROGRAM IS “BUSINESS UNUSUAL”

If Nigeria is to make progress, traditional “business-as-usual” models will not lead to progress in the following key areas…..

1. ANTENATAL COVERAGE

2. SKILLED BIRTH ATTENDANCE

3. STUNTING/WASTING

4. ADOLESCENT BIRTH RATE

5. ZERO DOSE CHILDREN

6. PENTA 3 COVERAGE

7. % OF CHILDREN 0-12 MO FULLY IMMUNIZED

8. HEALTH INSURANCE COVERAGE

9. PATIENT SATISFACTION WITH PHC SERVICES

THE BASIC HEALTHCARE PROVISION PROGRAM OF THE NHSRIP ADRESSES ALL OF THE ABOVE

U5MR

IMR

NMR

MMR

TFR

STUNTING

Financing and Organization of Services

A Vision for Nigeria’s Health Sector

Framework for Nigeria Health Sector Renewal

Financing and Organization of Services

Decentralized Facility Financing

Operationalizing a Vulnerable Group Fund

Strengthening Community Based Health Services

Improving Quality of Care

Harmonized TA support for BHCPF

Enabling Systems for Improved Outcomes

Improving Commodity Security

National Emergency Medical Service and Ambulance Scheme

Digital in Health

Health Security

Governance, Financing and Accountability

Defragmenting Sector Financing for Improved Efficiency

Federal-State Partnership for Improved Ownership and Accountability

Leveraging the instrument of DECENTRALIZED FACILITY FINANCING, the program will aim to improve the service readiness of 17,000 PHCs and 774 secondary facilities to deliver Universal Primary Healthcare {to be delivered free to beneficiaries}

1. Aspire to expand to at least 2 PHC per ward BEmONC ready/certified; at least 1 higher level facility or CEmONC using the hub and spoke model. Expansion will be driven by evidence, with locations of higher needs prioritized

2. The LGAs will be categorized into three tiers (lowest to highest) and equity calculations will be reflected in funds transferred to the PHCs

3. Investment fund for facility upgrade to meet minimum requirements for a functional PHC

4. Payment of bonuses to facilities for meeting periodic quality of care targets

5. Transportation for pregnant women

6. Health worker’s incentives (additional payment to workers in rural/hard-to-reach communities)

7. Operations funds, made up of a fixed component and another that depends on the number of clients served. Ops funds will be increased to support facilities to engage healthcare workers on a need basis and buy essential commodities for the provision of a free package of healthcare services.

8. Funding to improve routine HMIS at facility level and TA support to facilities

The DFF package would include the following services below, targeting about 7m pregnancies and over 6m new births annually:

▪ ANC

▪ Child-Birth

▪ PNC

▪ FP

▪ IMCI*

▪ Nutrition

▪ NCD–screening {HYPERTENSION & DIABETES MELLITUS }

CEMONC

Facility

Client

Midwives

Client

PHC PHC

PHCPHC

referral

WDCs

Midwives

Client

Client

Midwives

Midwives

CHIPS

CHEWs

CHIPS

CHEWs

CHEWs

CHIPS

CHEWs

CHIPS

WDCs

WDCs WDCs

FEATURES

Success factors:

▪ Effective community Demand Creation interventions

▪ Strong accountability/governance structure and processes

▪ Quality data (routine service delivery and financial data)

Geospatial mapping will inform the additional public PHC, and also future expansion paths by subnational governments

1. ACCESS: Healthcare facilities usually clustered around urban areas, while rural areas had few and scattered health facilities. The further away one travels, the sparser healthcare facilities become.

2. EQUITY: Urban areas also have better availability of infrastructure, such as better road networks, as well as population density.

3. Stratify facilities based on geospatial and poverty data.

The DFF arm reflects equity considerations

We recognize:

• Some facilities are in hard-to-reach locations

• Do not attract the right healthcare workers

• Coverage has been low

• Disease burden is higher

• Poverty is higher

To address this:

• Investment funds (one-off payment) will not be equal. Hard-to-reach locations with poor facilities will receive more funds.

• Transportation disbursement will use the ratio of 4:3:2

• Incentives will be paid to healthcare workers working in rural and hard-to-reach locations

• Operational funds will be a function of the number of persons reached. The table below summarizes the three categories and the possible amount each will receive for year 1.

S/N Cost Item Tier 1 Tier 2 Tier 3

1 Investment Fund 15,000,000.0 11,250,000.0 7,500,000.0

2 Transportation 4,800,000.0 3,600,000.0 2,400,000.0

3 Operations 4,800,000.0 4,800,000.0 4,800,000.0

4 Health Care workers incentives 1,080,000.0 540,000.0 -

Total 25,680,000.0 20,190,000.0 14,700,000.0

Explainer for the figures in the table are estimates and for illustration purposes only

INVESTMENT FUND:

This is a one-off fund to upgrade the facilities. Actual will be based on the gaps identified when facility gap analysis has been conducted.

Estimates are based on IMPACT project experience, which aims to make facilities functional and not necessarily level 2 PHC.

TRANSPORTATION:

Estimates informed based on what NEMSA currently pays (N2,500 per capita). Tier 1 will however get more, and facilities that serve more clients will also get more.

OPERATIONS FUND:

The estimate is based on what some facilities shared as the cost of running a PHC quarterly. The cost has two components: Fixed and variable cost.

The fixed is about N250,000. A more robust and country costing may to be conducted before commencement.

BONUSES TO

HEALTHCARE

WORKERS in rural/hard-to-reach communities: This is estimated at N30,000 per HCW in a rural location.

DFF: ADDRESSING LEAKAGES AT THE FRONTLINES

The risk of increasing funds to facilities is corruption, LGAs, SPHCDA

Increasing Accountability in BHCPF 2.0

1. WDCs: Leverage their important supervisory role over the PHC system for accountability.

2. Financial autonomy with performance incentive: Linking performance with incentives to pay staff bonuses and make facility improvements.

3. TA (PFMOs): Hands-on support to PHCs on basic bookkeeping, capacity building of LGA finance focal persons and auditing of the fund, and sufficiency of supportive supervision by LGHA and State

4. Independent Verification Arrangements & Leveraging technology to record and validate client data and PHC management

5. Use CSOs/NGOs: Collaboration with entities such as BudgIT/ONE campaign have used technology tools such as social media and easy-to-understand infographics to explain the Nigerian budget to ordinary citizens, expose gaps in the data, and push the three tiers of government to provide more information about public finances and spending, including in the health sector.

>>> REWARDS AND SANCTIONS as central to shifting institutional behaviour<<<

THE NHIA ACT OF 2022 PROVIDES AN OPPORTUNITY FOR PROGRESS,

FURTHER PRIORITIZING THE POOR AND VULNERABLE

Consolidate existing funds to implement a more impactful arm.

FMOH implements the CHF. NHIA implements other extra budgetary initiatives all could be implemented under the SIF

CRF FROM FG OWN REVENUES IS LIMITED

AND NIGERIA’S GOVERNMENT HEALTH SPENDING AS % OF GDP THE LOWEST IN THE WORLD

(0.5%) IS UNLIKELY TO EXCEED 1% IN NEXT 3 YEARS, AS REVENUE-TO-GDP ALSO AMONG

LOWEST (7%)

Government health spending (% of GDP) Government revenue (% of GDP)

NIGERIA NEEDS TO MAKE BOLD DECISIONS ON SCALE-UP OF NHI ON ITS PATHWAY TO UHC

SPRINT /MDR/

SCENARIO BENEFIT PACKAGE PROVIDER PPM

SCENARIO FOUR UMHC & CHILD ADMISSIONS +

RTAS +

CHF

PUBLIC

PRIVATE

CASE BASED*

SCENARIO

THREE

UMHC & CHILD ADMISSIONS +

SELECTED NCDS

PUBLIC

PRIVATE

CASE BASED

SCENARIO TWO UMHC & CHILD ADMISSIONS PUBLIC

PRIVATE

CASE BASED

SCENARIO ONE UNIVERSAL MATERNAL

HEALTHCARE {UMHC}

PUBLIC

PRIVATE

CASE BASED

NIGERIA HEALTH FACILITY DELIVERY (15 -24YRS) IS VERY LOW, WORSE IN

RURAL AREAS AND NE, COMPOUNDED IN AREAS WITH LOW TRANSPORT

AVAILABILITY AND AMONGST HIGHRISK PREGNANCIES

OVERALL FACILITY DELIVERY 33.72% {39% OVERALL}

HEALTH FACILITY DELIVERY SOUTHEAST ~ 77% NORTHEAST ~ 16%

ANC VISITS AT LEAST 4 ~ 52% NO ANC ~ 28%

PLACE OF RESIDENCE URBAN ~ 54% RURAL ~ 26%

COMMUNITY TRANSPORT HIGH ~ 60% LOW ~ 20%

NUMBER OF CHILDREN BORN 1 ~ 42% 4-7 ~ 23%

SERVICE READINESS IMPROVEMENTS WILL BE COMPLEMENTED BY FULL ACTIVATION OF THE

VULNERABLE GROUP FUND FOR UNIVERSAL MATERNAL CARE AND CHILD HOSPITAL ADMISSIONS

SCENARIO ONE

~30% of babies in LMICs are born at primary care clinics compared to 2% of babies in HIC (Gage 2019)

UNIVERSAL MATERNAL HEALTHCARE purchased through CEmONC facilities:

• Provides financial protection to one of the most vulnerable populations

• Enrollees are self-identifying mitigating potential fraud and short-term challenges with national identity systems

• Shifting deliveries to higher level facilities which are better resourced with strong referral and can guarantee both comprehensive emergency obstetric care, as well as emergency newborn care quality

• Shift away from PHCs could lead to decreased case load, improved access and quality for antenatal and postnatal care and other services delivered at PHC level

• Hub- and spoke- approach will allow for full continuum of care from community-basd interventions - education and counselling, other demand side interventions e.g. transport vouchers, CCT to at PHC level (ANC, PNC, FP) to higher level facilities

NIGERIA ACCOUNTS FOR A QUARTER OF ALL NEONATAL AND CHILD DEATHS IN SSA AND IS

NOW THE COUNTRY WITH THE HIGHEST NUMBER OF UNDER-FIVE DEATHS IN THE WORLD

SCENARIO TWO

Based on the 2003 and 2018 Nigeria Demographic and Health Survey (NDHS) findings, Nigeria’s under-five mortality rate declined over the 15 years from 201 per 1000 live births to 132 per 1000 live births.

However, the neonatal mortality rate only slightly declined, from 48 per 1000 live births in 2003 to 39 per 1000 live births in 2018.

The North West zone has the highest under-five mortality rate at 187 per 1000 live births, and the South West zone is lowest, at 62 per 1000 live births.

The North West and North East zones together accounted for 65 percent and 72 percent of the deaths in the neonates and children aged 1–59 months deaths.

ZONE % NN % U5

NW 40 50

NE 26 23

NC 15 14

SW 5 3

SE 8 7

SS 7 5

DEMOGRAPHIC

CHARACTERISTICS OF U5 DEATHS

THE NW AND NE SHOULD BE PRIORTIZED FOR SCENARIO TWO

Cause-specific neonatal mortality Main causes of deaths in children aged 1–59 months

At the current coverage levels, a tier of Community Based Health Services could significantly boost coverage and deepen promotive, preventive and simple curative measures as a complement to the Basic Package of Health Services delivered at facility level

Create Demand for PHC Services

Improve health seeking behaviour of individuals and households

1. Conduct home visits to clients

2. Encourage clients to seek care (for ANC, sick school aged-children, sick adolescents, sick adult males & females, elderly) at PHCs

3. Mobilize communities for outreaches and campaign activities

Social Behaviour Change Communication

Interpersonal communication & counselling:

1. Pregnant women to attend ANC services

2. Improve dietary (MIYCN), adolescent nutrition and care practices

3. Encourage caregivers to take children under-5 for vaccination

4. Provide counselling and screening services for NCDs

5. Birth spacing

Public Health and Social Measures

1. Seasonal Malaria Chemoprophylaxis (Mass distribution of ACTs)

2. Mass distribution of LLINs

3. Improve WASH practices in households (sanitation, hygiene, food prep; Menstrual Hygiene Management)

3. Screening for and referral of suspected TB cases

4. Boost infection prevention and control measures

5. Community surveillance and notification

Preventive and Simple Curative MNCH services

1. Use ICCM to treat basic cases of Malaria, Diarrhoea, fast breathing in children under-5

2. Administration of Zn/ORS, Albendazole to under-5 children

3. Administration of MMS to pregnant women & MNP to children under-5; Detection of malnutrition and referral

4. Short-acting contraceptives (Condoms, Mini pills, Combined Oral Contraceptive pills)

5. Administration of Chlorhexidine for cord care to new-borns

6. Administration of misoprostol to pregnant women during unavoidable home delivery to prevent PPH

7. First aid and trauma management

Referral & Follow-up Visits

1. Identify clients requiring care in health facilities (NCDs, TB, HIV, Hepatitis, FP/LARCS, etc.) and refer

2. Follow-up on clients receiving care in facilities to ensure they are improving otherwise encourage them to return to health facility for additional care

3. Refer community members as appropriate to receive care for NCDs, Mental health

4., and community-based treatment of cases with directly observed therapy (DOT)

Facility based services will be complemented by a phased and targeted approach to boosting demand creation, promotive, preventive and simple curative services at the frontlines Minding the gap at frontlines CLARIFY ANATONMY OF FRONTLINE

WORKFORCE

Option 1: Retrain all existing Community Health

Practitioners (CHPs) Option 2: Boost quantum of CHPs at the frontlines 2a: Absorption of existing CHPs (CHEWS) 2b: Strengthen CHIPS program as a

COMPLEMENT not SUBSTITUTE to CHEWS (rationalize, standardize and certify competencies, upskill, improve remuneration, supervision, etc.) + expand the scope of work as a complement to other facility-based CHW PLUS mop-up existing unemployed CHWs

Option 3: Alternative state preference: Engage private entities for service provision

**Investment in production of Midwives and CHPs will be done as a parallel track and across board to ensure availability of appropriate HCW at facilities

9.57

31.22

41.41

CHIPS (Current Scenario) CHIPS Expansion (10 per ward) CHIPS Expansion (10 per ward +5 per ward in 50% of the wards)

CHIPs per 100,000 Population

44.40

75.59 142.9

CHEWs/CHO CHEWs/CHO Expansion SSA Global

CHEWs/CHO per 100,000 Population

The options take into cognizance wide variability in HRH availability and distribution, and geographical access across states

1. States that can demonstrate sufficient numbers and distribution of CHW

2. States that can demonstrate sufficient numbers and distribution of CHPs but has significant populations in hard-to-reach areas

3. States that cannot demonstrate sufficient numbers and distribution but can prove sufficient numbers of

CHEWS in circulation additional CHW

4. States that cannot demonstrate sufficient numbers and distribution and cannot prove sufficient numbers of CHEWS in circulation

5. All states need to pursue concrete CHP production and sustainable financing plan

KEY CONSIDERATIONS FOR STATE FLEXIBILITIES

Retrain only

Contracting out

Recruit and retrain additional CHEWS which may be complemented by CHIPS

Enroll, upskill CHIPS to complement

Link to states incentive framework and fiscal transfers and federal-state partnership MoUs

For states operationalizing a rationalization of CHIPS

• Skilled health workers are those who have had structured training for a period of time (usually at least 1 – 2 years).

• CHIPS will be upskilled by receiving 3 – 6 months training in the first instance with incremental periodic training over 1-2 years. This does not make them equivalent to CHEWS

Skill set/competencies

• E-learning platforms will be created to serve as flexible learning opportunity for CHIPS Agents.

• Time bound competency-based tests will be carried out at certain intervals to ascertain quality of service each CHIPS Agent is providing

• After minimum training requirements achieved, facilitate linkages for career advancement

Training and Career Advancement

• Maintain minimum qualification and improve system and standards for recruitment

• Sustained financing for remuneration through subnational commitment as “match” to BHCPF allocation

• Clear scope of work/ job description that effectively links community to facility-based services

Recruitment and deployment

• The stipend will be increased to NGN35,000 in keeping with the economic realities and motivate them to do the desired scope of work

• Other state recognition systems [based on competency tests]; put more prestige into the system

Remuneration

• Need to fast track activation of Community-Based Health Information Management System (CBHMIS)

• Transition CHW personnel to electronic data reporting system Data management

Moving from strictly structural quality measures to a combination of structure, process, and outcome quality measures

Slide 28

WE PROPOSE A COMPREHENSIVE APPROACH FOR OPERATIONALIZING QUALITY

IMPROVEMENT FOR IMPACT

*Slide from a presentation by J Peabody “Quality of Care Policy Dialogues”, 12 November 2019, Bishkek, Kyrgyzstan

Information about process can be obtained from medical records, interviews with patients and practitioners, or direct observations of healthcare visits.

Physical facility, equipment, and human resources, as well as organizational characteristics such as staff training and payment methods.

Includes changes to health status, behavior, or knowledge as well as patient satisfaction and health-related quality of life.

Structure Process Outcomes

Structure → Process →Outcome

*Slide from a presentation by J Peabody “Quality of Care Policy Dialogues”, 12 November 2019, Bishkek, Kyrgyzstan

Policy Levers:

Access:

Coverage, Benefits

Patient-level Engagement, Behavior, Adherence

Health Care Access

Structure, Systems, Human

Resources

Process, Clinical Care

Provider:

Clinical skill, adherence to guidelines, diagnostic accuracy, communication

Equity

1. Platform Level:

Aggregate System

2. Provider Level Practice, Behavior

Political Factors

Institutional Factors

Social/Cultural Factors

Environmental Factors

Health Outcomes

3. Payment Systems

Shift from QUALITY OF CARE broad focus on infrastructure to also include sharp focus on competency-based improvements in content/process of care

Information about process can be obtained from medical records, interviews with patients and practitioners, or direct observations of healthcare visits.

Physical facility, equipment, and human resources, as well as organizational characteristics such as staff training and payment methods.

Includes changes to health status, behavior, or knowledge as well as patient satisfaction and health-related quality of life.

Structure Process Outcomes

1. Patient Exit Interviews

• Self-reported status; response bias;

anchoring bias

2. Formal Testing-Licensing

• Single best answer questions; gaming

3. Claims/Administrative Data

• Non-clinical

• Patient level variation

4. Direct Observation

• Hawthorne effect

5. Medical Chart Abstraction

• The current standard, inaccurate and time consuming

6. Standardized Patient

• The gold standard but hard to reproduce

7. Simulations, vignettes

• Validated, lead to change; need to be used more

LEVERAGING EXISTING TOOLS TO IMPORVE QOC SUCH AS THE

ALMANACH IN ADAMAWA

From paper to Android:

SUMMARY OF QOC MEASURES IN BHCPF2.0

STRUCTURE

NORMS &

STANDARDS:

BEMONC/CEMONC

CERTIFICATION

PROCESS

1. Simulations/

2. vignettes.

3. Decision making tools such as

ALMANACH.

4. SAFE CARE

methodology.

5. QOC based on case-based payments.

OUTCOMES

Patient satisfaction and patient experience surveys.

DIGITAL TRANSFORMATION

(LEVERAGING TECHNOLOGY

FOR QOC):

(Leveraging technology for QOC):

Harmonization of all digital systems

HARMONIZED TA FOR BHCPF STATE SUPPORT

STANDARDIZED AND QUALITY ASSURED TA

PROGRAM OF WORK AGREED UNIVERSALLY AND WILL BE

DEMAND DRIVEN.

NO MORE ORPHAN STATES

KNOWLEDGE AND LEARNING DONE IN A COHERENT AND

ORGANIZED MANNER.

TRANSITION TO BHCPF 2.0 – DFF

BHCPF

1. Allocation of Operational funds: Equal across all facilities.

2. Number of PHC facilities/ward: One

3. Facility assessment: Take off assessment Not linked to a standard criteria..

4. Package of services: Lack of clarity

5. Quality of care: Defined not enforced. Public PHCs are empaneled by NHIA regardless of available infrastructure.

6. Quantum of operational grants: N300K per quarter.

7. TA: Varying technical capacities to deliver on SP functions ~ reimbursements, quality framework

BHCPF 2.0

1. Allocation of Operational funds: Based on tier classification. Disadvantaged

PHCs receives more.

2. Number of PHC facilities/ward: Two. Second facility chosen based on burden of disease and need.

3. Facility assessment: Facility must be either BEMONC OR CEMONC.

4. Package of services: UNIVERSAL BASIC PACKAGE OF SERVICES INCLUDING

DELIVERIES

5. Quality of care: Performance incentives linked to quality.

6. Quantum of operational grants: N900K per quarter.

7. Referral network: Linkage with BEMONC and EMS gateway.

8. Facility upgrade: One-off investment (2 PHCs per ward and 1 CEMONC Facility per LGA)

9. ACCOUNTABILITY:

A. Part of the incentive framework will also include element of performance

(IVA).

B. Provider reimbursements based on verifiable outcomes.

C. Strengthened Fiduciary framework

10. RESULTS FRAMEWORK:

11. TA: Harmonized TA program.

12. Leverage the CHIPS/CHEW to generate demand, provide promotive, preventive and simple curative services

TRANSITION TO BHCPF 2.0 {VGF}

BHCPF

1. Beneficiary identification: Different states are using different beneficiary identification and enrollment systems.

2. Unclear Health Benefit package: Lack of clarity on what the BMPHS is following the OM/guideline revision.

3. Multiple Benefit packages: BHCPF has introduced another benefit package into a crowded ecosystem of

BP.

4. Unclear Fiscal Sustainability Plan: Are you enrolling the same beneficiaries or adding new beneficiaries ?

5. Reimbursements ~ FFS + CAPITATION

6. TA: Varying technical capacities to deliver on SP functions ~ reimbursements, quality framework

BHCPF 2.0

1. No beneficiary identification. Self-selection.

2. Equity considerations: Mostly the PVH will use.

3. Empanelment with a Strong focus on Quality.

A. Empanelment based on Facility classification ~

BEMONC/CEMONC

B. Referral network ~ tight linkage with BEMONC and EMS gateway

4. Reimbursement: CASE BASED with focus on Quality.

5. ACCOUNTABILITY:

A. Part of the incentive framework will also include element of performance (IVA).

B. Provider reimbursements based on verifiable outcomes.

C. Strengthened Fiduciary framework

6. RESULTS FRAMEWORK:

7. TA: Harmonized TA program.

8. Leverage the CHIPS/CHEW to generate demand.

CBHS, DFF AND VGF PROVIDING THE RATIONALE FOR PROGRESS TOWARDS UHC

Enabling Systems for Improved Outcomes

A Vision for Nigeria’s Health Sector

Framework for Nigeria Health Sector Renewal

Financing and Organization of Services

Decentralized Facility Financing

Operationalizing a Vulnerable Group Fund

Strengthening Community Based Health Services

Improving Quality of Care

Harmonized TA support for BHCPF

Enabling Systems for Improved Outcomes

Improving Commodity Security

National Emergency Medical Service and Ambulance Scheme

Digital in Health

Health Security

Governance, Financing and Accountability

Defragmenting Sector Financing for Improved Efficiency

Federal-State Partnership for Improved Ownership and Accountability

The National Emergency and Ambulance Services Scheme will be leveraged to address the second delay in reaching health facilities for maternal care

New Rural EMS Program Arrangement Through NEMSAS working with NPHCDA

Program will deploy three service models to respond to urgent medical emergencies, all of which use 112 or mobile-cellular & call centre technology to connect local EMS operators and community members as first responders.

1. Local Government Area (LGA)-Wide Rural Ambulance Service Model: Through SEMSAS, contracting a private sector operator covering a specific catchment population. Operators will deploy trained staff using BLS tricycles to deliver emergency care during patient transport to LGA hospitals.

2. Rural Transport for Maternity Services: Local vehicle fleets, designated community members and commercial drivers in trained basic first aid and skilled to offer transport for maternity-related services.

3. Decentralized Community-based Model: A hybrid model combining LGA-wide and maternity services outsourced to local private and commercial transport operators for maternity care based on location and catchment population.

Fragmented Supply Chain Management System

Commodities procured by different entities and operation distinct supply chains

Unlikely to be achieved with a Nat. stock out rate of 48%

Most commodities externally financed

Expenditure for essential medicines and oxygen.

Inadequate access to oxygen in hard-to-reach areas

Increased and timely availability of critical and essential commodities

Decreased stock out rates including at the last mile

Modulated costs of commodities

Supply chain efficiency

Ensure comprehensive quality care

Improve quantification and inclusion of commodities for vertical programs in federal budget

Strengthen National Supply Chain Integration Program for improved efficiencies – private sector contracting

Boost local production of essential medicines and other commodities through Medical

Industrialization Fund

Ramp-up establishment of PSA plants in each senatorial district.

Strengthen transportation systems in hard-to-reach areas

Market shaping engagement for distinct set of commodities e.g. MNP

An integrated approach leveraging private sector engagement to ensure commodity security across all levels of care

Supply Side Investments and Demand Side Financing

• Colleges of

Medicine

• Schools of Nursing and Midwifery

• Colleges of Health

Technology

• Sustainable financing strategy

• Decentralized Financing

• Drive efficiency through P4P for specific cadres/services

• Continuous Education and Professional Development – upskilling and certification of lower cadres of health workers

• Pay for performance and support for hard-to-reach areas

PRODUCTION DEPLOYMENT RETENTION

HR System Responding to Health Needs

MONITORING:

Active maintenance of HRH Registry and National and State Health Workplace Profile

A long-term strategic effort to boost the stock of Human Resources for Health will be employed across the HRH value chain for PHC

• National and Subnational HRH Policies – Health Workforce Recruitment, Retention, Performance Management

• HRH Workplan including incentive for health worker deployed to hard-to-reach areas and priority locations

• Ethical Migration Framework and Agreements

MOH

Capability: Top Talent

Program

PERFORMANCE MGT

• Incentive and Recognition Program

• Implementation of Facility Level Biometric Systems

In the near/short term: Producing midwives for Universal Maternal Health Care Overproduction of midwives to address immediate needs……

MIDWIVES TRAINING FUND:

1. INFRA UPGRADE FOR PUBLIC SECTOR SCHOOLS OF NURSING

~ WITH THE AIM OF DOUBLING ADMISSIONS {ADDITIONAL

HOSTELS, CLASSROOMS, TOP UP FOR TEACHING STAFF}.

2. MIDWIVES TRAINED POSTED TO CEMONC FACILITIES FOR A

DEFINED PERIOD OF TIME.

3. EXPAND PRIVATE SECTOR TRAINING AS WELL, WITH SIMILAR

APPROACH.

Medium/long term: Increase the production capacity of medical schools/post graduate levels

A strong Digital in Health effort can facilitate a move beyond “electronic” to real forms of Digital

Health Security

Introduction

A Vision for Nigeria’s Health Sector

Framework for Nigeria Health Sector Renewal

Financing and Organization of Services

Decentralized Facility Financing

Operationalizing a Vulnerable Group Fund

Strengthening Community Based Health Services

Improving Quality of Care

Harmonized TA support for BHCPF

Enabling Systems for Improved Outcomes

Improving Commodity Security

National Emergency Medical Service and Ambulance Scheme

Digital in Health

Health Security

Governance, Financing and Accountability

Defragmenting Sector Financing for Improved Efficiency

Adopt a sector wide approach to ensuring adequacy of core capacities to prevent, detect and respond to public health emergencies

Early Warning Systems (Integrated Disease Surveillance and Response (IDSR):

Indicator-based surveillance

• Event-based

Surveillance (EBS)

• Community-based surveillance (CBS)

• Serological Surveillance

• Genomics Surveillance

• Cross-Border Surveillance

• Interoperable surveillance system across One Health

• Subnational strengthening

Public Health Laboratory Network

• Invest in a cohesive tiered-laboratory network of reference, zonal and subnational public health laboratories with full diagnostic network optimization and biomedical engineering support.

Health Emergency Preparedness and Response:

• Pandemic-ready Public Health Emergency Outbreak Response (“Rainy day’) Fund

• National Stockpile (national & zonal) – warehouse, commodities, equipment, end-to-end information management systems

• Risks Communication and Community Engagement (subnational and national)

• Strengthening multi-hazard approach to preparedness and readiness for Public Health Emergencies (Multi sectoral)

Digital Transformation (Leveraging technology for health security):

(Leveraging technology for health security):

SORMAS deployment (all health facilities - public and Private) Information management systems (enterprise solutions, data protection, cybersafe) Inter-operability of human, animal and environment health surveillance systems Harmonization of all digital systems

Governance, Financing and Accountability

Introduction A Vision for Nigeria’s Health Sector Framework for Nigeria Health Sector Renewal

Financing and Organization of Services Decentralized Facility Financing Operationalizing a Vulnerable Group Fund Strengthening Community Based Health Services Improving Quality of Care

Enabling Systems for Delivery and Improved Outcomes Improving Commodity Security National Emergency Medical Service and Ambulance Scheme Digital in Health

Health Security

Governance, Financing and Accountability Defragmenting Sector Financing for Improved Efficiency

A socially accountable health care system for a healthy and productive population

Increase client power through feedback mechanisms

Patient protection and safeguarding patient experience

Service Delivery Transformation to enhance patient safety, client responsiveness, client satisfaction, right to information through citizen engagement

➢ SERVICOM + Consumer Protection Council+ Quality Assessment body constitute Quality Commission (Ombudsman) to ensure patient satisfaction, optimal patience experience adherence to Patients' Bill of Rights and function as quasi-independent ombudsman

➢ Leveraging community led institutions to institute a grievance redressal mechanism through the WDC structure and technology platforms

➢ SQUATS

➢ Enhance the functioning of Health Facility Management Committees in terms of service planning, resourcing, delivery, responsiveness and client satisfaction

Federal, State, LGA:

➢ Public disclosure on use of resources and sector performance National Health Poverty Index including Patients Voice Survey

➢ Public disclosure of audited financial records/resource tracking

Facilities:

➢ Price, package and quality score declaration and publication by health facilities

Traditional and Religious Institutions

Enhance transparency

➢ Increase accountability, transparency, awareness and civil engagement through

➢ Dialogue with citizens, CSOs and CBOs

➢ Creating space for civil society engagement through information sharing

➢ Engaging with media as service accelerators to amplify citizen voices

➢ Engaging citizens and CSOs in policy-making processes

Establish social compact between government and citizens

Invigorate a government- and citizen-led effort to ensure social accountability and amplified citizen’s voice in the delivery of health services

Conclusion/Summary

Annex

Proposed methodology for outcome indicators and their targets

Methodology for identifying core outcomes Methodology for setting targets

For each element of the mission… save lives reduce both physical and financial pain and produce health for all Nigerians

Best-in-class indicators were identified based on:

SDG1 indicators

Presidential commitments for Health2

To fill any gaps: WHO recommended indicators and other “gold-standard” indicators

Indicators were filtered by data availability and frequency of collection

1. Sustainable Development Goals

2. Outcome indicators from Presidential commitments are included here; other indicators are included in output and input indicator list

3. Low and Middle Income Countries

Step 1:

Step 2:

ILLUSTRATIVE

10-year historical trend1

2 Baseline performance on outcome indicator

3 Est. 2027 performance if historical trend continues

4 Est. 2027 performance if Nigeria can achieve more aspirational improvement rates seen in LMICs3 from when they were at Nigeria’s starting point

Maternal mortality rate (per

100,000 live births)

2014 16 18 20 22 24 26 2027

1,000

1,050

1,100

1,150

Years

Outcome Indicator for Nigeria2

Baseline case1

Median

High

Low

Peer set of LMICs i.e., countries that were once at the same point as Nigeria today Target setting for maternal mortality rate

1. Increase at same rate as 2009 – 2019 for Nigeria

2. Most recent data available for 2019. Numbers for 2020 to 2023 calculated based on past CAGR of -0.2%

997.0

905.4

753.8

1073.0

Mortality rate, Maternal (per

100,000 live births)

Start year End year Start valueEnd value CAGR

Rwanda 2000 2010 1007 385.8 -9.1%

Sierra Leone 2007 2017 1125 520.3 -7.4%3

Ethiopia 2000 2010 952.8 634.7 -4.0%3

Guinea-Bissau 2002 2012 1136 758.2 -4.0%

Afghanistan 2004 2014 1115 785.4 -3.4%

Guinea 2000 2010 970.9 740.7 -2.7%

Central African Republic 2006 2016 1116 877.4 -2.4%

Somalia 2000 2010 1097 963.2 -1.3%

South Sudan 2008 2018 1138 1275 1.1%2

Lesotho 2009 2019 1096 628.9 3.5%

Source: WHO, WorldBank

High

Median

Low

Nigeria’s CAGR (2009 – 2019)

-0.2%

Current performance (2019):

BENCHMARKING PERFORMANCE FOR IMPROVEMENT OF KEY HEALTH OUTCOMES

Average, “top 10%”, and best country performance on annual reduction of mortality over 3 years (applied to Nigeria’s current baseline)

Maternal mortality Under-five mortality

BENCHMARKING PERFORMANCE FOR IMPROVEMENT OF KEY HEALTH OUTCOMES

Average, “top 10%”, and best country performance on annual reduction of stunting and TFR over 3 years (applied to Nigeria’s current baseline)

Stunting Total fertility rate