Nigeria Targeted State High Impact Project - PowerPoint Presentation

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Nigeria Targeted State High Impact Project

(TSHIP)

Review of Primary Health Care Budgeting and Financing in Bauchi and Sokoto States, 2009-2013

Slide2

Acknowledgements

TSHIP Dr. Nosa Orobaton “ Abubakar Maishanu “ Habib Sadauki “ Benson Ojile

“ Goli Lamiri “ Usman Al-RashidAbubakar MuazuNurudeen LawalJohn Snow, Inc.Matthew Osborne-SmithAlexander Nosnik

LEAD-RTI Project Musa Wamakko

Grace OkechukwuConnect-To-HealthDr. Ibukun Ogunbekun “ Tiwalade Awosanya

Prepared by Connect-To-Health, LLC (May 2014)

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Acronyms

CSO - Civil Society OrganizationFP/RH - Family Planning/Reproductive HealthLEAD - Leadership, Empowerment, Advocacy and DevelopmentLGA - Local Government Area

LGSC - Local Government Service CommissionMDG - Millennium Development GoalMNCH - Maternal, newborn and Child HealthNDHS

- National Demographic and Health SurveyNGO

– Non Governmental OrganizationNHIS - National Health Insurance SchemeNHMIS - National Health Management Information System

NPHCDA

- National

Primary Health Care Development Agency

RTI - Research Triangle InstituteSMOH - State Ministry of HealthSMOLGA - State Ministry for Local Government

Affairs

TSHIP

– Targeted State High Impact ProjectWHO - World Health OrganizationWMHCP - Ward Minimum Health care Package

Prepared by Connect-To-Health, LLC (May 2014)

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Overview

Five (5)-year project financed from grants from the USAIDLaunched in 2009Managed by

consortium of 5 organizations with John Snow, Inc. (JSI) as Prime ContractorCovers all 20 LGAs in Bauchi and 23 LGAs in Sokoto StateProject focuses on improving and supporting

:Maternal, newborn and child health (

MNCH)Family Planning/Reproductive Health (FP/RH) Quality of health care

Community engagement

Effective

health systems

Prepared by Connect-To-Health, LLC (May 2014)

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Characteristics of Target Population

Targeted states have weak socio-economic and health profiles: High Infant Mortality Rates (109 and 91 per 1,000 live births in Bauchi and Sokoto states, respectively)Only 1% of children aged 12-23 months were fully immunized in both states in 2008

Births supervised by skilled attendant = 16% (Bauchi) and 5% (Sokoto)High rates of youth unemployment and poverty

Weak health systems – poor infrastructure, skewed human resource distribution, unpredictable financing poor quality of care

Prepared by Connect-To-Health, LLC (May 2014)

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In 2009-2012: TSHIP and LEAD-RTI project assisted LGAs to develop strategic and operational plans and improve budgeting

processAdditional support is required in the medium term to build institutional capacity at state and LGA levelsStudy Rationale

Prepared by Connect-To-Health, LLC (May 2014)

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Review trends in budget allocation, appropriateness and timeliness of release of funds for MNCH and FP/RH, and the adequacy of budgetsProject budgetary requirements for delivery of MNCH and FP/RH services in LGAs in Bauchi and Sokoto states from 2013 to 2015

Determine availability of funds for and gaps in resource allocation to MNCH and FP/RH services and commodities by govt. and partnersSpecific Objectives

Prepared by Connect-To-Health, LLC (May 2014)

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Methods

Quantitative and Qualitative approaches were used to obtain information – mostly the formerSampling technique:Convenience sampling with uniform criteria adopted for both states to enhance representativeness and comparability of findingsData comprised the following:

MNCH service delivery data (2012) – were used to segment LGAs into low, medium and high utilization categoriesHealth finance (revenue & expenditure) data

– covering the period 2009 to 2013

Health service utilization data (2012) – from 3 PHC centers and 6 HCs per LGA making a total of 12 HFs per stateCosting of PHC services – standard costs for scaling up health MDGs were adopted

in the absence of costed WMHCP

#

Prepared by Connect-To-Health, LLC (May 2014)

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Methods

  

Table 1: Profile of Selected LGAs, 2012

 

 

Bauchi State

 

Sokoto State

 

 

S/N

 

Dass

 

Katagum

 

Ningi

 

Bodinga

Sokoto South

#

 

Wamakko

&

1

Senatorial District

South

North

Central

South

North

North

 

2

 

Mid-year population (total)

 

107,397

 

353,404

 

462,327

208,126

243,129

214,029

3

Number of PHC centers4523134Other health facilities - clinics, dispensaries, maternity clinics@  27 32 50 26 16 405% of expected births that occurred in health facility 42% 20% 14% 4% 69%61%6Deliveries per midwife per month - - - 31 32 39

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Budgeting

Current ApproachIncrementalism: next year’s budget = this year’s budget multiplied by a factor for revenue as well as expenditureTotal budget = Capital + Recurrent (Personnel +

Overheads)StrengthsClear guidelines on assumptions underlying budgets given – circular from SMOLGA usually stipulates assumptions and scaling factor to be used; LG councils are expected to comply

Guidelines also given on proportion to be allocated to capital and recurrent expenditure – for 2013 budget, capital expenditure was

pegged at 40-45% of actual revenues in previous year

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Budgeting

WeaknessesLack of consistency in reporting format among LGAs and between LGAs & State – makes comparability of budgets difficultScaling factor applied to budgets bears little relationship to previous year’s

performance or planned/strategic shifts in future service offeringsPHC departments submit budget proposals but may not be invited to defend proposals – practice varies across LGAs

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Budgeting

How well did LGA councils adhere to 2013 Budget Guidelines?  For

Dass and Katagum LGAs (Bauchi State):A fifteen percent (15%) increase was applied across the board using 2012 actuals as base Capital expenditures were kept at 40% of total budget estimate 

Capital health expenditure estimates were 13% higher than 2012 actuals – this is tolerable considering that

actual expenditures in 2011 were 102% of approved estimates Overall, the findings are positive, suggesting that the investment in training of budget officers is bearing fruit

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

Evidence, mostly from Bauchi State, show that:LGA revenues come mainly from federal govt. allocations – these account for >95% of total revenues (Chart 1 below)Internally Generated Revenue (IGR)

is very low and declining - averaged only 2% of annual total revenue

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

Approved Estimates vs. Actual ExpendituresGap between approved budgets and actual expenditures (budget variance) is large and fluctuates widely from year to year

In Sokoto State, actual state expenditure (all sectors) stood at around 44% of approved estimates for 2010 and 2011Spending pattern appears more predictable at LGA

level – in Katagum LGA,

actual health spending averaged 97% of approved estimates in 2010-2012

(

Chart

2)

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

Table 2: Select Health Finance Indicators for Bauchi State, 2012

  

S/N

 

 

Indicator

LGAs

 

Dass

 

Katagum

 

Ningi

 

i

Total LGA expend. per capita (ALL sources) - constant 2005 naira

 

4,573

 

7,237

 

-

ii

Capital costs as % of total LGA expenditure

 

47%

 

43%

 

-

iii

Hlth. expend. per capita - constant 2005 naira

 

-

 

1,135

 

-

iv

Capital health expenditure as % of total health expenditure

 

-

 

23%

 

-

v

Personnel

costs as % of recurrent health expenditure

 

-

 

62%

 

-

 

vi

Overhead costs –

Approved

2013 vs. 2012

 

-6%

 

-4%

 

-

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

In Katagum LGA:Approx. 18-20% of total LGA expenditure was allocated to health (2010–2012); surpassed national benchmark of 15%

Health spending per capita grew by 3% per year from ₦1,031 in 2010 to ₦1,135 in 2012 – equivalent to

an average of US$7.0 in real terms or US$12.5

in purchasing power parity (PPP) termsPersonnel costs averaged only 45% of total health expenditures (2011-2012) or 61% of recurrent health budgets – leaves a good margin for overhead costs

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

The evidence suggests an upward trend in PHC financing.Overall, spending per head is low

but comparable to what other low-to-lower middle income countries spend (Table 3)

Table 3:

District-level Health Spending in Select Countries

 

 

S/N

 

 

Country

 

 

Currency Code

 

Health Expenditure per Capita

National Currency

 

US$

1

Ghana (2008)

GHC

5.52

5.22

2

Indonesia (2006)

IDR

62,332

6.23

3

Nigeria (

2010-12)

NGN

1,072

6.96

4

Pakistan (2005/06) - Low

PKR

15

0.25

 

- High

PKR

181

3.02

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

Likewise in Dass LGA:Total expenditure (all sectors) was up 73% (2009-2012) – increase is attributed largely to growth in capital expenditures and overhead costs, which rose by 60% and 105%, respectively

Capital expenditure vote was overspent by 22% but only 76% of recurrent vote was spent (2009-2012) – probably due to inability to fill staff vacancies

For both LGAs:

Total actual expenditures (All Sectors) were in the range of 100% of total revenues received (see Chart 3 below)

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

Finding is consistent with claims made by LGA officials that they had no difficulty consuming allocated fundsIt is, perhaps, the strongest indication yet that more funds need to flow to this level to accelerate

developmentObvious limitation is that LGAs have virtually no slack – they are not in a position to respond to emergencies or take advantage of opportunities that may arise in any given

year

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

Data from Sokoto State indicated that:On the average, the State Govt. spent 6 out of every 10 naira received in revenue between 2009 and 2011

(Chart 4)Whereas, actual spending on all sectors was just around 44% of forecasts for FY2010 and 2011, actual personnel expenditures

averaged 80% of forecast

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Expenditure Trends

Actual capital health expenditure as % total capital expenditure shrank from 4.6% to 2.9% (2010-2011)

In Bauchi State :Percentage-wise and in per capita terms, health spending at State level appeared even lower than that at LGA level In FY2010 and 2011, Total

health expenditures at 6 months averaged only ₦470 per head (Table 1

above)If the pattern held true for the entire year, per capita spending would be just ₦940 or US$5.8 (PPP)

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: What is Money Spent On?

InfrastructureCapital projects development is joint State/LGA affair - LGAs contribute 40% and

state government, 60% of total costs but the state largely controls the purseMultiple partners construct/rehabilitate PHC units and supply medical equipment but central coordination is weak – potential for duplication of assets and waste is considerableInadequate

provision for (incremental) recurrent costs of new projects

is a growing concern – undermines sustainability of service improvements

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: What is Money Spent On

?Human Resources In general, greater balance is seen in allocations to HR vs. the other two major cost categories (i.e. capital and overheads)LGA

personnel costs grew at a relatively slow pace between 2009 and 2012 despite salary increase for public sector workersIn Dass LGA, personnel costs as share of total LGA expenditures hovered around 60

%, whereas,Katagum LGA saw a decline from 57% to 48%

(due in part to greater scrutiny over payroll accounts)

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: What is money spent on?

Drugs, vaccines & medical supplies Spending on drugs, vaccines and medical supplies is very low – accounted for only 3% of combined health expenditures for 2011 and 2012 in Katagum

LGA (Approved estimates)Drug Revolving Funds (DRFs) have not curbed supply chain problems:In many LGAs, DRF is a push, not pull

systemIn one community, the seed stock of

drugs supplied cost more per dose than in retail pharmaciesIn others, items supplied did not match health facility requests

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: What is Money Spent On

?OverheadsPHC facilities and LGA health depts. receive grossly insufficient funding:

Bagarawa PHC (Bodinga LGA, Sokoto State) reports monthly imprest of ₦10,000 whereas Takatuku Health Center in same LGA claims to not receive anyState

policy favors shifting resources from capital to overhead but response is mixed

– approved estimates for Overheads in 2013 relative to 2012 ranged from -6% in Dass and Sokoto South LGAs to +6% in Wamakko LGAWDCs bridge gaps in funding - in Sokoto South LGA, health facility needs costing more than ₦10,000 are referred to the WDC, which raises

needed funds

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: What is

Money Spent On?

Communal bore hole in health clinic premises, Sokoto South LGA – maintained by the WDC

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: LGA Budgets vs. Health Sector Strategic Plan

To examine how close LGAs came to meeting medium-term health financing goals, estimates of per capita and total health expenditures

from the following sources were compared:Local government council annual budgets (Actuals only)Costed annual operational plans extracted from LGA health sector strategic plans

Cost estimates for scaling up the MDGs.

Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Findings: LGA Budgets vs. Health Sector Strategic Plan

To finance the operational plan solely from own resources, Dass LGA would have needed to commit more than

one-third (36%) of total annual revenues for 2011 to the health sector alone – a somewhat unlikely propositionThe proportion would drop to one-quarter if the LGA covered 69% of costs as proposed in the plan with

the state government and development partners contributing 5% and 26%, respectively

Prepared by Connect-To-Health, LLC (May 2014)

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Findings: Cost of Scaling-up MDGs

Despite improvements in funding, health spending in Katagum LGA appeared not to have kept pace with population needDeficit was of the order of US$2.86 (approx. ₦450) per inhabitant by FY 2012

Put in context, the deficit is almost half (48%) of the average amount spent per head per year by the

Bauchi State government to provide health care in

FY2010 & 2011Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Findings: Cost of Scaling-up MDGs

Even so, Katagum had met 72% of financing requirement for health MDGs as at 2012. Shortfalls in spending could thus be bridged via:Modest increase in spending annually to keep pace with inflation and population growthReview of investment priorities, and

Reduction in waste - especially in relation to infrastructure and human resource developmentPrepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Looking Ahead

Ample resources are available locally to support better planning, budgeting and management of PHC:Inventory of health facilities, equipment and human resources

in both states have been done and gaps quantifiedGIS mapping of health facilities in Sokoto State has been completedHR policy

and strategic plan developed for Bauchi State

Health sector strategic plans covering 2010-2015 developed by LGAs in Bauchi StateNation-wide mapping of health resources is on-going (courtesy of HS 20/20 project)

Tremendous opportunity exists currently to fast-track attainment of the MDGs!!

Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Recommendations

Cost of Minimum PackageReview costing of WMHCP (first done in 2007) – disseminate revised estimates widelyRevise LGA estimates for scaling up the MDGs – use data specific to Nigeria to refine MDG unit costs pending revision of cost of WMHCP

Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Recommendations

Quality of Budgets Apply health service utilization data generated from facility-based and outreach services to improve demand forecasts and better plan infrastructure and human resource developmentFurther disaggregate social sectors data – separate health spending from education and other

subsectorsEnsure adequate provision for recurrent costs of proposed capital projectsPrepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Recommendations

Quality of Budgets Show actual revenues and expenditures for preceding period

in proposed budgets with lag period no further than 2 years (e.g. 2014 budget to display actuals for FY2013 or 2012)Institute budget performance reviews

as part of the budget development processReclassify expenditures

on drugs and medical supplies as “recurrent” rather than “capital”Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Recommendations

Resource ManagementEstablish formal platform for partners/stakeholders to meet quarterly or half-yearly to review investment priorities

Use GIS mapping to improve resource planningRationalize types and numbers of health facilitiesTo simplify management of health services particularly in such situations where technical/management capacity is limitedTo make the health system “leaner” and more functional

Reallocate Human Resources

– a difficult but necessary step to complement investment in infrastructure and equipment

Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Recommendations

Financing OptionsAdvocate for independent review of local government joint accounts – engage policy makers and key stakeholders in candid search for optionsRevisit Community Based Health Insurance –

cost is still an issue; according to the NDHS (2008):56% of women aged 15-49 years stated that finance was a barrier to accessing care for self41% cited the likelihood of not getting drugs, and36% felt distance was an issue

Define health finance indicators for LGA-level reporting on the NHMIS

Initiate discussion with the FMOH on data requirement, indicators and benchmarksEnlist the help of other partners

Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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References

Ashir G, Doctor H, and Afenyadu, G. 2013. Performance based financing and uptake of maternal and child health services in Yobe State, Nigeria. Global Journal of Health Science; 5(3): 34-41Bauchi State Ministry of Health. (2012). Human resources for health policy and planning, 2012-2015 (second draft), May 2012Minis H, Jibrin A. (2011). An analysis of intergovernmental flows for local services in Bauchi and Sokoto States. LEAD project, RTI, Research Triangle, NC

Ministry of Health, Sokoto (2012) Standard Estimates for Health Resources Availability and Needs for Sokoto State, 2012Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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References

National Bureau of Statistics (2012). Millennium Development Goals performance tracking survey result. 2012 Abuja, NigeriaNational Planning Commission. Nigeria Millennium Development Goals (MDGs): Countdown Strategy 2010:2015National Population Commission and ICF Macro. (2009). Nigeria Demographic and Health Survey 2008: Key findings. Calverton, Maryland, USA: NPC and ICF Macro

Targeted State High Impact Project (TSHIP). (2010). Health facility rapid assessment: baseline survey report. TSHIP Central Project Office, BauchiWHO. (2009). Constraints to Scaling Up Health related MDGS: Costing and Financial Gap Analysis. WHO, Geneva

Prepared by Connect-To-Health, LLC (May 2014)

Prepared by Connect-To-Health, LLC (Apr. 2014)

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Prepared by Connect-To-Health, LLC (May 2014)

Thank You!