Is strategic purchasing a feasible mechanism in the publicly funded health system of Nigeria

Is strategic purchasing a feasible mechanism in the publicly funded health system of Nigeria? Ibe OgochukwuHealth Policy Research Group, University of Nigeria. Enugu CampusiHEA, Milan; Tuesday 14 July, 2015Team membersEnyi Etiaba, Nkoli Ezumah, Obinna Onwujekwe

Overview of tax funded health services• Health care provision is a concurrent responsibility

of all three-tiers of government in Nigeria

• Tax revenues pooled at the federal level are shared between the three tiers and each tier of government has autonomy over allocation and utilization of their resources

• States also generate taxes through internally generated revenue and State allocations to health are used by the State Ministry of Health (MoH) to purchase health services for their citizens

Overview of tax funded health services

• The District Health System model has been adopted as the structure for health service delivery in the state

• Funds are transferred to public facilities mostly in the form of commodities and global budgets

• Revenues are generated internally (IGR) within health facilities and a proportion retained at the facility level for service delivery

Key actors in public health sector

Findings: government-purchaser relationship

• Clear policy and regulatory frameworks exists to guide the MoH towards a more strategic purchasing approach (MTSS, SSHDP, annual budgets and annual operational plans)

• Periodic review of MoH by House of Assembly (house committee on health) to examine progress in budget implementation

Findings: government-purchaser relationship

• Clear policy and regulatory frameworks exists to guide the MoH towards a more strategic purchasing approach (MTSS, SSHDP, annual budgets and annual operational plans)

• Periodic review of MoH by House of Assembly (house committee on health) to examine progress in budget implementation

• Other mechanisms to ensure efficient fund utilization include legislative process for resource re-allocation, proposals to secure release of budgeted funds

Findings: government-purchaser relationship

• Inefficient bureaucratic processes constrain timely release of approved funds

• Weak monitoring of budget performance ‘Emphasis on matching expenditure to budget’

“Well ... there is [government] performance monitoring but that is along economic planning, budget and all that and strictly not in health services” (IDI, Government purchaser, 02).

“We do have targets in our mid-term plan but we don’t actually audit the state Ministry of Health to say how well they are delivering the work. The commissioner might come out and say he did this or that but nobody actually goes to crosscheck it” (IDI, government policy maker, 04)

Purchaser-provider relationship

• Various tools are employed to enhance efficient and quality service delivery, for example:• monitoring of providers by SHB; • supervision and monitoring by departments and

special programmes in MoH;• provision of job aides; • strategic recruitment of human resources;• improvement of facilities through retained IGR; • central procurement of drugs

Purchaser-provider relationship

• Some of these have provided limited incentives for efficient service deliveryHuman resource challenges (skill & scope)

determines what services are provided No direct cash remittance for capital costs

from MoH & inability to generate and track IGR, limit funds available for service delivery

Purchaser-citizens relationship

• Formal mechanisms for engaging citizens include using Facility Health Committees (FHCs) to understand local health needs, feed back information on service needs and areas for service improvements

• Key influences on implementation include:• Lack of clarity on communication channels• Poor motivation of FHC due to absence of formal incentives• Skewed representation of community needs (voice of the

poor not heard)

Purchaser-citizens relationship

• Service to citizens based on perceived needs (top-down), benefit package not regularly updated to accommodate emerging needs

• Poor community awareness (of rights & responsibilities) and sense of ownership

Policy implications

• To promote and strengthen strategic purchasing in public health system• Government needs to go beyond the usual budget

development process to focus on equitable and efficient use of resources and impact of health services.

• Strong enforcement of procedures and incentives that encourage provider performance.

• The purchasers need to empower citizens and communities on their rights and strengthen mutual accountability to encourage citizen participation.

www.wpro.who.int/asia_pacific_observatoryhttp://resyst.lshtm.ac.uk@RESYSTresearch

The research is a collaboration between RESYST and the Asia Pacific Observatory on Health Systems and Policies.

RESYST is funded by UK aid from the UK Department for International Development (DFID). However, the views expressed do not necessarily reflect the Department’s official policies.

More information: http://resyst.lshtm.ac.uk/research-projects/multi-country-purchasing-study