Stakeholders in the health sector drawn from across the North West states and Yobe as well as development institutions and partners gathered in Kaduna under the auspices of the Saving One Million Lives Program for Results (SOMLP4R) from the 16th to the 17th of August 2016 for better understanding and peer review toward the operationalization of the program with a focus on the states within the zone. This follows the successful approval of plans by the States for the SOMLP4R and receipt of an initial disbursement of $1.5m.
The program, sponsored by MNCH2 program, had in attendance the Executive Governor of Kaduna State, the Honorable Minister of Health and the Permanent Secretary of the Ministry on the opening day of the event in a demonstration of the much required political will to drive the performance for results program.
The meeting kicked off with an opening remark by the Permanent Secretary of the Federal Ministy of Health, Hajiya Binta Lami Adamu Bello who stressed that the SOML program was a performance based financing program which she summed up as “No results, No further payments.”
Dr. Benjamin Loevinsoh, Chief of Health, Nutrition and Population at the World Bank who started the series of other goodwill messages explained the reasons behind the World Bank’s embrace of the SOMLP4R program which he described as ordinarily difficult.
Dr. Loevinsoh explained the philosophy of the SOML program was around these cardinal points; Robust Measurement of Results, Responsibility of States, Competition, Relevant Performance not absolute and Reducing Risk.
He however noted that states will compete against themselves based on their own baseline as progress and improvement is of the most importance to them.
The National Team Lead of the MNCH2, Dr. Salma Anas-Kolo said that the SOMLP4R aligns with her Program’s mandate to drastically reduce maternal deaths and improve survival rate. She stressed that the country, Nigeria, contributes more than 10% of the global burden and highlighted that about 70% of the burden in Nigeria is brought by the 6 North West states. Dr. Anas Kolo called for an integrated approach to deliver MNCH services using Primary Health Centers (PHCs) as the platform and called for increased government funding. She commended the Kaduna state government saying that the program has witnessed a lot of significant improvement in the state, especially in the area of human resources.
“If by 2019, MNCH2 in collaboration with Government and relevant partners are able improve maternal health and strengthen health systems in the North West region, the overall health indices in Nigeria will improve’, she said.
Prof. J.I.Brian Adinma, the President of the Society of Gynaecology & Obstetrics of Nigeria (SOGON) pledged the association’s support of the program and identified four areas of support; Research, Clinical Services, Advocacy and Training of Manpower, which it can offer.
The Minister of Health, Prof Isaac Adewole delivered a keynote address to the stakeholders noted that the SOMLP4R had disbursed a performance based grant of $1.5m each to 36 states and the FCT in the health sector. He said the program is motivated by the desire to pay for results rather than paying for processes and reimbursing activity. He said the program had 6 major pillars and 2 enablers that can change health outcomes in Nigeria. He outlined the pillars as; Maternal New Born and Child Health, Childhood Essential Medicines and increasing treatment of Childhood diseases, Improving Child Nutrition, Immunization, Malaria Control and Elimination of Mother to Child transmission (eMTCT) of HIV and the enablers as Promoting Innovation and use of ICT and improving Supply and Distribution Chain. The minister who said that the states receive 82% of the grant said further disbursement will be made based on 5 Disbursement Linked Indicators.
Governor Nasir El-Rufai of Kaduna State in his brief remark thanked the Hon. Minister and assured him of his commitment to the SOMLP4R. He emphasized his state’s commitment to complete the process of establishing PHCUOR and announced efforts by his government to improve the 255 PHCs and 23 comprehensive health centres in his state as well as other efforts related to the indicators such as encouraging routine immunisation through meetings with Local Government Chairs and Traditional Rulers.
“We welcome SOMLP4R and embrace it, I and other North West governors are committed to improving healthcare in our states, ” Malam El-Rufai said.
He Requested the FG to support states to implement the SBHIS so as to reduce out of pocket spending and enable the poor and vulnerable afford medical care.
The opening session was brought to an end with a vote of thanks by Dr. Mrs. Adebimpe Adebiyi who thanked the Governor, Minister for taking the bull by the horn and leading the program as well as reserved thanks for the other people in the state. She urged the Kaduna state governor to impress on other states the need to adhere to the philosophy of the SOMLP4R.
The business session commenced with a presentation by Dr. Jibrin Suleiman who presented the objective of the meeting which includes to update the capacity of States on the SOMLP4R as well as how more funds can be earned and a peer review of state plans – aligning them with current realities as well as best practices – as well as to highlight the program structure and determine the readiness of the states to implement.
The National Program Coordinator, Dr. Ibrahim Kana made a quick presentation about how the SOMLP4R functions. He stressed the need for states to conduct Bottleneck Analysis (BNA) and took time to explain the steps involved in carrying out a BNA. He said that the business as usual approach is no longer attractive and has no place in the SOMLP4R.
MNCH2 Pledge support to SOML, States
The National Team Leader of the MNCH2 program, Dr. Salma Anas-Kolo presented the integrated delivery approach of the program beginning with the background as well as the vision and the outcomes, impact of the MNCH2 program. She noted that the use of integrated approach to services delivery increases uptake and satisfaction with RMNCH services. She stressed that the program understands that working with local institutions, partners, values and community systems always yields better results. She pledged the support of the MNCH2 to the operationalization of the SOMLP4R program in the zone through the provision of support to the states in the area of Governance ; Support for PHCUOR, Service Delivery, Demand Creation, Evidence Based Decision Making and Accountability systems and Human Resource capacities among others.
Dr. Salma identified the risks to include Low Revenues and Fiscal crisis at state levels, Foreign Exchange fluctuations, and Insecurity in the region, but noted that the political will is now increased in the region. She encouraged the participants to share lessons emanating from their respective states among each other.
Performance and Rewards
The World Bank Representative, Dr. Temitope Akintunde made a presentation on how states can earn more funds through the 5 Disbursement Level Indicators (DLIs) which are specific measures against which performance will be determined for rewards as stated earlier by the Honorable Minister. She detailed the DLIs including their definition and measurement metrics and guided the participants with a cheat sheet which included timing for implementation for each against a smart survey which she said will be used to determine progress. Dr. Akintunde however noted that Sustainable performance will require more than quick wins and stressed on the need to combine short term interventions and quick wins with comprehensive, mid to long term intervention plans that address maternal and child health outcomes and overall health system performance.
The DLIs are listed as follows;
- Increasing Utilization (Quantity) of High Impact Reproductive and Child Health and Nutrition Interventions (100% to States) – 61%
- Increasing Quality of High Impact Reproductive and Child Health and Nutrition Interventions (100% to States) – 11%
- DLI 3: Improving M&E Systems and Data Utilization (Federal and State) – 16%;
- DLI 4: Increasing Utilization and Quality of Reproductive and Child Health and Nutrition Interventions Through Private Sector Innovation – 4%
- DLI5: Increasing Transparency in Management and Budgeting for PHC (Federal & States) -8%
She disclosed that the zonal and the National champions will receive an additional $ 500,000 and $ 1 million respectively.
The participants the grouped to complete the task of calculating performance over 1 and 2 years from baseline and made presentations from participating states while questions, observations and contributions were made by all.
Key observations from the presentations are;
- Beneficiary states all required the Program Implementation Manual for SOMLP4R
- Issues around the account; currency denomination, where accounts should be domiciled and operation with emphasis on the need to clearly designated SOMLP4R account signatories to avoid complications in implementation.
- A well illustrated organogram for setting up Steering Committee as well as the PMU
- The organogram for setting up the steering committee as well as the PMU should be clearly illustrated
- The % of partners as well as state government contribution to the SOML P4R should be clearly illustrated
- States with uncompleted work plan should ensure this is done
- The need for knowledge sharing between desk officers/state program managers and support from the FMOH SOML team
- A constitutional issue was raised on the PHCUOR and flagged as an issue that needs to be addressed.
Business Session Day 2
The second day of the meeting began with a recap by the rapporteur who stressed on the quality of deliberations on the opening day of the meeting.
Dr. Jibrin Suleiman, program officer of the SOMLP4R took charge of the meeting and made a detailed presentation of the administrative structure of the SOMLP4R. He began with a recap of the key principles of the program and went on to explain the implementation arrangements of the program at both Federal and State level. He noted that the Minister or the Commissioner and Permanent Secretary at the Federal and State levels must head the Program Steering Committee (PSC) and the Technical Consultative Group (TCG), respectively. He suggested key members of the TCG to include the DFH, DPH (NMEP &NASCP), DHPRS, DFDS, DFA, NPHCDA, NHIS while the PSC will include the heads of relevant agencies and departments in SOML-related interventions; State Commissioners of Health, Federal Ministry of Finance and Development Partners. Dr. Suleiman noted that the Program Development Indicators are both quantitative and qualitative and highlighted the role of Independent Verification Agents who are responsible for verifying the results and subsequent payments to states.
Dr. Suleiman said it was the responsibility of States to create awareness for the SOMLP4R through continuous program advocacy and communication, to prepare plans for use of initial investment funds and future program funds by focusing on bottleneck analysis of PHC delivery and potential innovations to introduce as well as performance management, tracking and improving the indicators of SOML related services. He also stated that states were responsible for constant engagement with development partners and NGOs in the state. He said that the program is ultimately more impactful with the establishment of SPHCDAs and the transfer of the PHC workers. He added that opportunities with private sector on PPPs should be explored.
This was followed by the presentation on the Financial Management System by Okara Dogara which explained the funds flow arrangement, signatories and detailed the purpose of the Special Fund Account (SFA) and the Program Fund Account (PFA). He outlined a simple fund flow arrangement for the state including account openings and approvals of expenditure plan as well as the accountability framework for the program and the audit at the Federal Level. He added that the SOMLP4R funds were an addition not a substitution of the budget for health. While insisting on strict adherence to financial regulations and allocation of resources, he noted that states enjoyed reasonable flexibility in how they utilize the funds.
A presentation on Performance Assesment in the SOMLP4R by Dr. Chima was also delivered. He said that the objectives of the assessment was to provide quantifiable description of state performance towards meeting program targets, he highlighted that it is important to frequently track changes in performance and encourage timely modifications to help states improve results and qualify for rewards. He said that Leadership & Governance, Programmatic Oversight, Financing and Perceptions on Programmes and Progress were the domains of the Performance Management Assessment. He also explained the concept of an Internal Performance Assessment described as “Self Assessment” and provided explanation of the framework for the quantitative supervisory tool to be implemented.
The participants were given the opportunity to ask questions and make their own contributions, the issues, contributions and interventions made include;
- State Program Managers requested for Information to be passed to them
- For more cooperation and partnership with the FMOH SOML PMU
- Better Clarification on the operation of the funds between the CBN and commercial banks
- MNCH2 strategy towards supporting the States operationalize SOML to include updating of plan, advocating for membership of steering committee
- Agreed to share documents on legal framework for PHCUOR and present case in support to higher authorities
The 2 day meeting was to be brought to an end with remarks by MNCH2 National Team Leader, Dr. Salma Anas-Kolo who appreciated the FMOH and the States for participating and for allowing MNCH2 to be part of what they are doing. She stressed on the Issue of trust and transparency. “The bottom line is trust. The most important thing is to make it work,” she said.
She insisted that the PHC must be represented fully even beyond the program level. She maintained that it is very critical and cited the template of one time health minister Prof. Ransome Kuti, whose vision she said remains valid. She said that services must be taken to where it is well needed and that the program must be well positioned in the PHC. “We cannot set up another parallel system and expect to make it work,” she concluded.
The National Program Coordinator of the SOMLP4R thanked Dr. Salma Anas-Kolo and the MNCH2 for the immense support and partnership. He advised the states that that the money should be left in the Central Bank and details the legal risks associated with keeping the funds in commercial banks. All monies should be denominated in Dollar as he says it is safer.
Dr. Kana addressed the issue on knowledge sharing raised by some of the participants, saying, “we are going to create platform for communication and sharing experiences with other State Program officers.”
He said that the SOMLP4R has an exit strategy as he insisted that the major concept of the program is not the $500m. He said it is about results, embarking on cost benefits analysis and imbibing the Performance for Results Philisophy “it is our hope that we must institutionalize Performance management,” he said.
Dr. Mrs. Adebimpe Adebiyi, the Director of Family Health who thanked the participants on behalf of the Honorable Minister of Health, brought the event to an end. She noted that the feedback, peer reviews and experience were encouraging and charged the participants to perform and make results happen in their states as that is the bottom line.