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

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Presentation on theme: "Review of Primary Health Care Budgeting and Financing in Bauchi and Sokoto States, 2009-2013."— Presentation transcript:

1 Review of Primary Health Care Budgeting and Financing in Bauchi and Sokoto States,

2 Acknowledgements TSHIP Dr. Nosa Orobaton “ Abubakar Maishanu “ Habib Sadauki “ Benson Ojile “ Goli Lamiri “ Usman Al-Rashid Abubakar Muazu Nurudeen Lawal John Snow, Inc. Matthew Osborne-Smith Alexander Nosnik LEAD-RTI Project Musa Wamakko Grace Okechukwu Connect-To-Health Dr. Ibukun Ogunbekun “ Tiwalade Awosanya Prepared by Connect-To-Health, LLC (May 2014)

3 Acronyms CSO - Civil Society Organization FP/RH - Family Planning/Reproductive Health LEAD - Leadership, Empowerment, Advocacy and Development LGA - Local Government Area LGSC - Local Government Service Commission MDG - Millennium Development Goal MNCH - Maternal, newborn and Child Health NDHS - National Demographic and Health Survey NGO – Non Governmental Organization NHIS - National Health Insurance Scheme NHMIS - National Health Management Information System NPHCDA - National Primary Health Care Development Agency RTI - Research Triangle Institute SMOH - State Ministry of Health SMOLGA - State Ministry for Local Government Affairs TSHIP – Targeted State High Impact Project WHO - World Health Organization WMHCP - Ward Minimum Health care Package Prepared by Connect-To-Health, LLC (May 2014)

4 Overview Five (5)-year project financed from grants from the USAID - Launched in Managed by consortium of 5 organizations with John Snow, Inc. (JSI) as Prime Contractor - Covers 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 care - Community engagement - Effective health systems Prepared by Connect-To-Health, LLC (May 2014)

5 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 months were fully immunized in both states in 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)

6 In : 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 Rationale Prepared by Connect-To-Health, LLC (May 2014)

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

8 Methods Quantitative 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)

9 Methods Table 1: Profile of Selected LGAs, 2012 Bauchi State Sokoto State S/N Dass Katagum Ningi Bodinga Sokoto South # Wamakko & 1Senatorial DistrictSouthNorthCentralSouthNorth 2 Mid-year population (total) 107, , , , , ,029 3Number of PHC centers Other health facilities - clinics, dispensaries, maternity % of expected births that occurred in health facility 42% 20% 14% 4% 69%61% 6Deliveries per midwife per month Prepared by Connect-To-Health, LLC (May 2014)

10 Findings: Budgeting Current Approach Incrementalism: next year’s budget = this year’s budget multiplied by a factor for revenue as well as expenditure Total budget = Capital + Recurrent (Personnel + Overheads) Strengths Clear 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)

11 Findings: Budgeting Weaknesses Lack 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 year’s 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 Prepared by Connect-To-Health, LLC (May 2014)

12 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)

13 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)

14 Findings: Expenditure Trends  Approved Estimates vs. Actual Expenditures Gap 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 (Chart 2) Prepared by Connect-To-Health, LLC (May 2014)

15 Findings: Expenditure Trends Table 2: Select Health Finance Indicators for Bauchi State, 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 % -4% - Prepared by Connect-To-Health, LLC (May 2014)

16 Findings: Expenditure Trends In Katagum LGA: Approx % 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) terms Personnel costs averaged only 45% of total health expenditures ( ) or 61% of recurrent health budgets – leaves a good margin for overhead costs Prepared by Connect-To-Health, LLC (May 2014)

17 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$ 1Ghana (2008)GHC Indonesia (2006)IDR62, Nigeria ( )NGN1, Pakistan (2005/06) - LowPKR HighPKR Prepared by Connect-To-Health, LLC (May 2014)

18 Findings: Expenditure Trends  Likewise in Dass LGA: Total expenditure (all sectors) was up 73% ( ) – 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 ( ) – 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)

19 Findings: Expenditure Trends Finding is consistent with claims made by LGA officials that they had no difficulty consuming allocated funds It 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 Prepared by Connect-To-Health, LLC (May 2014)

20 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)

21 Findings: Expenditure Trends Actual capital health expenditure as % total capital expenditure shrank from 4.6% to 2.9% ( ) 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)

22 Findings: What is Money Spent On? Infrastructure Capital 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 improvements Prepared by Connect-To-Health, LLC (May 2014)

23 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 workers ₋ In 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)

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

25 Findings: 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 funds Prepared by Connect-To-Health, LLC (May 2014)

26 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)

27 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)

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

29 Findings: Cost of Scaling-up MDGs Despite 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 Prepared by Connect-To-Health, LLC (May 2014) Prepared by Connect-To-Health, LLC (Apr. 2014)

30 Findings: Cost of Scaling-up MDGs Even so, Katagum had met 72% of financing requirement for health MDGs as at Shortfalls in spending could thus be bridged via: - Modest increase in spending annually to keep pace with inflation and population growth - Review of investment priorities, and - Reduction in waste - especially in relation to infrastructure and human resource development Prepared by Connect-To-Health, LLC (May 2014) Prepared by Connect-To-Health, LLC (Apr. 2014)

31 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 quantified GIS mapping of health facilities in Sokoto State has been completed HR policy and strategic plan developed for Bauchi State Health sector strategic plans covering developed by LGAs in Bauchi State Nation-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)

32 Recommendations Cost of Minimum Package Review 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 Prepared by Connect-To-Health, LLC (May 2014) Prepared by Connect-To-Health, LLC (Apr. 2014)

33 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 development Further disaggregate social sectors data – separate health spending from education and other subsectors Ensure adequate provision for recurrent costs of proposed capital projects Prepared by Connect-To-Health, LLC (May 2014) Prepared by Connect-To-Health, LLC (Apr. 2014)

34 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 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 “capital” Prepared by Connect-To-Health, LLC (May 2014) Prepared by Connect-To-Health, LLC (Apr. 2014)

35 Recommendations Resource 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 facilities - To simplify management of health services particularly in such situations where technical/management capacity is limited - To 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)

36 Recommendations Financing 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 years stated that finance was a barrier to accessing care for self - 41% cited the likelihood of not getting drugs, and - 36% 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 benchmarks - Enlist the help of other partners Prepared by Connect-To-Health, LLC (May 2014) Prepared by Connect-To-Health, LLC (Apr. 2014)

37 References Ashir G, Doctor H, and Afenyadu, G Performance based financing and uptake of maternal and child health services in Yobe State, Nigeria. Global Journal of Health Science; 5(3): Bauchi State Ministry of Health. (2012). Human resources for health policy and planning, (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 Prepared by Connect-To-Health, LLC (May 2014) Prepared by Connect-To-Health, LLC (Apr. 2014)

38 References National Bureau of Statistics (2012). Millennium Development Goals performance tracking survey result 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 Prepared by Connect-To-Health, LLC (May 2014) Prepared by Connect-To-Health, LLC (Apr. 2014)

39 Prepared by Connect-To-Health, LLC (May 2014) Thank You!


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