nigeria targeted state high impact project (tship)

Nigeria: Targeted State High Impact Project

Nigeria Targeted State High Impact Project(TSHIP)Review of Primary Health Care Budgeting and Financing in Bauchi and Sokoto States, 2009-2013

1AcknowledgementsTSHIPDr. Nosa Orobaton Abubakar Maishanu Habib Sadauki Benson Ojile Goli Lamiri Usman Al-RashidAbubakar MuazuNurudeen Lawal

John Snow, Inc.Matthew Osborne-SmithAlexander NosnikLEAD-RTI Project Musa WamakkoGrace Okechukwu

Connect-To-HealthDr. Ibukun Ogunbekun Tiwalade Awosanya

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

Valuable comments were received from Joseph Monehin and John Quinley (USAID)For inquiries, please, send email to: [email protected]

2AcronymsCSO - Civil Society OrganizationFP/RH - Family Planning/Reproductive HealthLEAD - Leadership, Empowerment, Advocacy and DevelopmentLGA - Local Government AreaLGSC - Local Government Service CommissionMDG - Millennium Development GoalMNCH - Maternal, newborn and Child HealthNDHS - National Demographic and Health SurveyNGO Non Governmental Organization

NHIS - National Health Insurance SchemeNHMIS - National Health Management Information SystemNPHCDA - National Primary Health Care Development AgencyRTI - Research Triangle InstituteSMOH - State Ministry of HealthSMOLGA - State Ministry for Local Government AffairsTSHIP Targeted State High Impact ProjectWHO - World Health OrganizationWMHCP - Ward Minimum Health care Package


OverviewFive (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 State

Project focuses on improving and supporting:Maternal, newborn and child health (MNCH)Family Planning/Reproductive Health (FP/RH) Quality of health careCommunity engagement Effective health systems


Others in the consortium are:

Centre for Education, Development and Population Activities (CEDPA)Futures Group International, LLC (Futures Group)JHPIEGOManagement Strategies for Africa (MSA)4Characteristics of Target PopulationTargeted 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


Health status indicators are extracted from Nigeria Demographic and Health Survey (NDHS) 2008

5In 2009-2012: TSHIP and LEAD-RTI project assisted LGAs to develop strategic and operational plans and improve budgeting process

Additional support is required in the medium term to build institutional capacity at state and LGA levels

Study RationalePrepared by Connect-To-Health, LLC (May 2014)

A PowerPoint presentation was one of the outputs to facilitate advocacy and dialogue with local, state, and federal govt. officials, traditional/religious leaders and other stakeholders6Review trends in budget allocation, appropriateness and timeliness of release of funds for MNCH and FP/RH, and the adequacy of budgets

Project 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 partners

Specific ObjectivesPrepared by Connect-To-Health, LLC (May 2014)

The review excluded accounting, audit and financial management practices at State and LGA levels7MethodsQuantitative and Qualitative approaches were used to obtain information mostly the former

Sampling technique:Convenience sampling with uniform criteria adopted for both states to enhance representativeness and comparability of findings

Data comprised the following:MNCH service delivery data (2012) were used to segment LGAs into low, medium and high utilization categories

Health 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 state

Costing 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)

Major Criteria:

Availability and ease of obtaining data from LGA level 3 LGAs per State were selected for in-depth reviewPolitical criterion reasonably satisfied sample comprised of one LGA per Senatorial District (SD) in Bauchi State but only two (SDs) were represented in Sokoto State.Health service utilization data (2012) - extracted from health facility records and State-level health information system (HIS)Qualitative Information - comprised of semi-structured, open-ended interviews with:-Officials of State Ministry of Local Govt. Affairs (SMOLGA)-Local Govt. Council officials-Health facility staff & members of WDCs-NGOs and development partners (WHO, UNDP-CGS)Discussions centered on constraints to the delivery and utilization of PHC services

#: Average costs were extracted from the inter-agency work reported in the publication "Constraints to Scaling Up Health related MDGS: Costing and Financial Gap Analysis, WHO, Geneva, Sept. 2009

8MethodsTable 1: Profile of Selected LGAs, 2012Bauchi StateSokoto StateS/NDass KatagumNingiBodingaSokoto South#Wamakko&1Senatorial DistrictSouthNorthCentralSouthNorthNorth2Mid-year population (total)107,397353,404462,327 208,126 243,129 214,029 3Number of PHC centers4523134Other health facilities - clinics, dispensaries, maternity clinics@ 2732502616405% of expected births that occurred in health facility42%20%14%4%69%61%6Deliveries per midwife per month---313239Prepared by Connect-To-Health, LLC (May 2014)

9

Findings: BudgetingCurrent ApproachIncrementalism: next years budget = this years budget multiplied by a factor for revenue as well as expenditure

Total 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


For Year 2013, Sokoto State LGAs were to project Internally Generated Revenue (IGR) at 115% of actual collections for 2012 while externally sourced revenue was put at 110% of preceding years receipts10Findings: BudgetingWeaknessesLack of consistency in reporting format among LGAs and between LGAs & State makes comparability of budgets difficult

Scaling factor applied to budgets bears little relationship to previous years performance or planned/strategic shifts in future service offerings

PHC departments submit budget proposals but may not be invited to defend proposals practice varies across LGAs


In general, it is difficult to find/extract data on Actual revenue and expenditure where available, data for different budget heads span different quarters in a given year. Data entry/validation proved very time-consuming

11Findings: BudgetingHow 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 baseCapital expenditures were kept at 40% of total budget estimateCapital health expenditure estimates were 13% higher than 2012 actuals this is tolerable considering that actual expenditures in 2011 were 102% of approved estimatesOverall, the findings are positive, suggesting that the investment in training of budget officers is bearing fruit


12Findings: Expenditure TrendsEvidence, 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 revenuePrepared by Connect-To-Health, LLC (May 2014)

13Findings: Expenditure TrendsApproved 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 2011

Spending pattern appears more predictable at LGA level in Katagum LGA, actual health spending averaged 97% of approved estimates in 2010-2012 (Chart 2)


14Findings: Expenditure TrendsTable 2: Select Health Finance Indicators for Bauchi State, 2012S/NIndicatorLGAsDassKatagumNingi i Total LGA expend. per capita (ALL sources) - constant 2005 naira 4,5737,237- 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%- vPersonnel costs as % of recurrent health expenditure -62%-viOverhead costs Approved 2013 vs. 2012-6%-4%-Prepared by Connect-To-Health, LLC (May 2014)

Incompleteness of data limited ability to complete profiles for other LGAs15Findings: Expenditure TrendsIn Katagum LGA:Approx. 18-20% of total LGA expenditure was allocated to health (20102012); 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) terms

Personnel costs averaged only 45% of total health expenditures (2011-2012) or 61% of recurrent health budgets leaves a good margin for overhead costs


PPP constant 2005 prices were calculated using deflator and conversion factor obtained from the World Bank database, July, 201316Findings: Expenditure TrendsThe 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 CountriesS/NCountryCurrency CodeHealth Expenditure per CapitaNational CurrencyUS$1Ghana (2008)GHC5.525.222Indonesia (2006)IDR62,3326.233Nigeria (2010-12)NGN1,0726.964Pakistan (2005/06) - LowPKR150.25 - HighPKR1813.02Prepared by Connect-To-Health, LLC (May 2014)

Sources:Couttolenc B. (2012). Decentralization and governance in the Ghana Health Sector: A World Bank Study. World Bank, Washington, DCHeywood P, Harahap N. (2009). Public funding of health at the district level in Indonesia after decentralization sources, flows and contradictions. Health Research Policy and Systems, 16 Apr. 2009Findings of this review - the figure quoted is average for 2009-2012Lorenz C, Khalid M. (Undated). Regional Health Accounts for Pakistan provincial and district health expenditures and the degree of districts fiscal autonomy. Paper for the 5th Annual Conference, Pakistan Society of Development Economists, 16-18 March 201017Findings: Expenditure TrendsLikewise 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)

18Findings: Expenditure TrendsFinding 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 development

Obvious 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


19Findings: Expenditure TrendsData 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


20Findings: Expenditure TrendsActual 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)


In Sokoto State, capital health expenditure in 2011 was just 23% of the level in 2010 mirroring sharp decline in overall capital expenditures not exactly a favorable development

21Findings: 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 purse

Multiple partners construct/rehabilitate PHC units and supply medical equipment but central coordination is weak potential for duplication of assets and waste is considerable

Inadequate provision for (incremental) recurrent costs of new projects is a growing concern undermines sustainability of service improvementsPrepared by Connect-To-Health, LLC (May 2014)

Central coordination of capital projects is weakThere is no formal forum for partners to discuss investment prioritiesPotential for duplication of effort and over-supply of some assets was a concern raised by practically every key stakeholder interviewed. Inadequate provision for (incremental) recurrent costs of projects is a growing concern LGAs are expected to meet the recurrent cost of MDG projects from own budgets but the provision tends to be inadequate

22Findings: 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)


Lower personnel costs may be due to in part to greater scrutiny over payroll accounts (including staff audits)

Note that reduction in capital spending in favor of overhead costs can have indirect positive effect on human resources improvements to the physical environment of work can bring about higher patient and health worker satisfaction which translate to higher utilization and lower rates staff turnover

23Findings: 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 system

In one community, the seed stock of drugs supplied cost more per dose than in retail pharmacies

In others, items supplied did not match health facility requests


Comments on DRFs reflect the views of health facility staff and WDC members interviewed as part of the review24Findings: What is Money Spent On?Overheads

PHC 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 any

State 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 LGA

WDCs bridge gaps in funding - in Sokoto South LGA, health facility needs costing more than 10,000 are referred to the WDC, which raises needed fundsPrepared by Connect-To-Health, LLC (May 2014)

Experience varies across LGAs but in general, health facilities do not receive imprest fundsWDC partnership with health facilities is vital to keeping the health facilities open25Findings: What is Money Spent On?

Communal bore hole in health clinic premises, Sokoto South LGA maintained by the WDCPrepared by Connect-To-Health, LLC (May 2014)

26Findings: LGA Budgets vs. Health Sector Strategic PlanTo 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 plansCost estimates for scaling up the MDGs.

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

27Findings: LGA Budgets vs. Health Sector Strategic PlanTo 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 proposition

The 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


28Findings: Cost of Scaling-up MDGsDespite improvements in funding, health spending in Katagum LGA appeared not to have kept pace with population need

Deficit 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 & 2011


MDG unit cost estimates are extracted from the publication: WHO. (2009). "Constraints to Scaling Up Health related MDGS: Costing and Financial Gap Analysis. WHO, Geneva29Findings: Cost of Scaling-up MDGsEven 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 development


Going by the MDG estimates, all LGAs in Bauchi State would have needed to spend a total of 8.85 billion to scale-up PHC services in 2012; for Sokoto State, the amount was 7.00 billionAt the time of preparing this report, there was no information to determine the amount that was actually spent by the States

30Looking AheadAmple 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 StateHealth 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 (Apr. 2014)

HS 20/20 = Health Systems 20/20 Project managed by Abt Associates31RecommendationsCost of Minimum PackageReview costing of WMHCP (first done in 2007) disseminate revised estimates widely

Revise LGA estimates for scaling up the MDGs use data specific to Nigeria to refine MDG unit costs pending revision of cost of WMHCP


Unit cost estimates can be obtained from the WHO (with assistance from the FMOH) or from the Nigeria MDG program32RecommendationsQuality 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 development

Further disaggregate social sectors data separate health spending from education and other subsectors

Ensure adequate provision for recurrent costs of proposed capital projects


33RecommendationsQuality 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 process

Reclassify expenditures on drugs and medical supplies as recurrent rather than capitalPrepared by Connect-To-Health, LLC (May 2014)Prepared by Connect-To-Health, LLC (Apr. 2014)

34RecommendationsResource Management

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

Use GIS mapping to improve resource planning

Rationalize 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


Joint forum will reduce potential for duplication of assets; SPHCDAs can facilitate this processGIS review the criteria for rehabilitating health facilities and constructing new ones to ensure optimal population catchmentRationalize HFs streamlining plant and equipment makes economic sense from a production standpoint; processes become streamlined as do labor, training and supervision requirements; quality control also becomes easier with fewer moving partsStaff Reallocation should be based not solely on established staff : population ratios but also on the pattern of use of health services in the preceding 12-24 months35RecommendationsFinancing Options

Advocate for independent review of local government joint accounts engage policy makers and key stakeholders in candid search for options

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

36ReferencesAshir 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): 34-41

Bauchi State Ministry of Health. (2012). Human resources for health policy and planning, 2012-2015 (second draft), May 2012

Minis 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, 2012


37ReferencesNational Bureau of Statistics (2012). Millennium Development Goals performance tracking survey result. 2012 Abuja, Nigeria

National Planning Commission. Nigeria Millennium Development Goals (MDGs): Countdown Strategy 2010:2015

National 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, Bauchi

WHO. (2009). Constraints to Scaling Up Health related MDGS: Costing and Financial Gap Analysis. WHO, Geneva


To obtain the full version of the report, please, contact:

JSI Research & Training Institute, Inc., 44 Farnsworth Street, Boston, MA 02210-1211; Tel: +1-617 482-9485

Chief of Party, TSHIP Nigeria, Plot 8, Off Danfodio Street, GRA Bauchi, PO Box 4037, Bauchi State, Nigeria; Tel: +234-77-830-741 38Prepared by Connect-To-Health, LLC (May 2014)

Thank You!

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