Operations and Challenges of Performance-Based Financing Among the Health Workers at The Health Facilities in Nasarawa State, Nigeria

Background Performance-based financing (PBF) is the transfer of the financial and material goods required for taking measurable actions or achieving a predetermined performance target and is an innovative method targeted at strengthening weak health systems in lowand medium-income countries. Methods A descriptive, cross-sectional survey was conducted on a representative sample of health workers in public primary and secondary health facilities that are implementing PBF in Nasarawa State using both qualitative (key informant interviews) and quantitative methods (structured questionnaires). 315 respondents were selected using a multistage sampling technique. In addition, eight key informants (purposively selected from the selected healthcare institutions) were interviewed. Results Of the respondents, 159 from the primary health facility submitted that PBF is effective, 41 described the method as poor while 101 saw the method as being good. The interviewed key informants noted that PBF has made a positive impact in the case of infrastructure, staff motivation and, consequently, service quality. Major challenges identified were with implementation of PBF due to poor infrastructure, inadequate manpower, poor funding and delays in the payment of subsidies to health facilities. Conclusion Despite the plethora of challenges militating against the effective deployment of PBF, the method has made a significant positive impact on the state of the health care facilities in Nasarawa state. We recommend adequate funding, regular manpower training and development for enhancing the state of the healthcare facilities in the state. Corresponding Author: Saka Mohammed Jimoh E-mail:< sakamj@unilorin.edu. ng > https://orcid.org/0000-0003-2653-6420 Received: 28 Apr 2021, Accepted revised version: 29 Nov 2021 Published: 31 Dec 2021 Competing Interests: Authors have declared that no competing interests exist © Authors. This is an open-access article distributed under a Creative Commons Attribution-Share Alike 4.is0 International License (CC BY-SA 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are attributed and materials are shared under the same license. Journal of the Postgraduate Institute of Medicine 2021; 8(2): E163 1-15 http://doi.org/10.4038/jpgim.8348 2 Introduction Performance is the accomplishment of a given task measured against preset standards of accuracy, completeness, cost and speed. In a contract, performance is deemed to be the fulfillment of an obligation in a manner that releases the performer from liabilities under the contract [1]. The goal of most organizations is to encourage high performance from its workforce without compromising the quality of services being delivered. Healthcare is the maintenance or improvement of health through diagnosis, treatment or prevention of disease, illness, injury or other physical and mental impairments in human beings. Healthcare related services are delivered by healthcare professionals (providers and practitioners) in the field of medicine, dentistry, midwifery, nursing, pharmacy, psychology and other health professions. It includes the work done in providing primary health care, secondary health care and tertiary health care, as well as in the public health services [2]. A good health system delivers quality services to all people, when and where they need them. The exact configuration of services varies from country to country, but in all cases requires a robust financing mechanism; a well-trained and adequately paid workforce; reliable information on which to base decisions and policies; well-maintained facilities and technologies and logistics to deliver quality medical services [2]. Healthcare financing system is a process by which revenues are allocated from primary and secondary sources, such as out-of-pocket payments (OOP), indirect and direct taxes, donor funding, co-payment, voluntary repayments and mandatory repayments, which are accumulated in fund pools so as to share risk across large population groups and using the revenues to purchase goods and services from public and private providers for identified needs of the population, for example, fee for service, capitation, budgeting and salaries etc. [3]. The way a country finances its healthcare system is a critical determinant for reaching universal health coverage [4]. Performance-based financing (PBF) may be defined as ‘’the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target” [5]. It is a health systems approach with an orientation on results defined as quantity and quality of service outputs. This approach entails making health facilities autonomous agencies that work for the benefit of health-related goals. It is also characterized by multiple performance frameworks for the regulatory functions, the performance purchasing agency and community empowerment. PBF applies market forces but seeks to correct market failures to attain health gains, while at the same time aims at cost-containment and a sustainable mix of revenues from cost-recovery, government and international contributions [6]. PBF is a flexible approach that continuously seeks to improve through empirical research and rigorous impact evaluations which lead to best practices. Health Service Packages: Complementary Package of Activities PBF health service packages are carefully designed to respond to health problems facing the Nigerian population. The PBF service packages are based on 14 years of incremental Journal of the Postgraduate Institute of Medicine 2021; 8(2): E163 1-15 http://doi.org/10.4038/jpgim.8348 3 experience gained on purchasing services through PBF. The services have the highest potential to contribute to meeting universal health coverage targets. PBF is an innovative, results-oriented approach that incentivizes providers based on their achievement of agreed-upon, measurable performance targets. Incentives include financial payments of bonuses and public recognition [7]. Similar incentivizes can also be used to motivate people in the community to use services in the health facility. For example, diapers may be given to a mother who gives birth in the health facility or food stuff to patients who have completed a full course of tuberculosis treatment, PBF can thus increase the use and quality of healthcare services, stabilize or decrease the cost of these services, support the effective use of limited resources, encourage community participation and improve staff motivation, morale and retention [8]. PBF is a form of results-based financing pioneered in countries such as Cambodia, Rwanda and Burundi to extremely good effect. Several other countries have begun to experiment with this approach including Zambia, Cameroon, Zimbabwe and now, Nigeria. PBF is helping to create better, more inclusive and more accessible healthcare services and it is an important component of achieving universal health coverage [9]. There are three broad areas where PBF and universal health coverage intercept. These areas are; defining the basic, complementary and delivering these packages; expanding the coverage of health services in the general population, especially for the poorest and improving access to quality health services. The study seeks to assess and compare the practices of PBF among healthcare workers in primary and secondary healthcare facilities in Nasarawa State, Nigeria. The study aimed to contribute to the body of knowledge on health care financing and to stimulate intellectual discussion by public health experts and policy makers on its long-term viability and sustainability, and possible nationwide adoption of PBF as an alternative to healthcare financing in Sub-Saharan Africa. Methodology This study was carried out in Nasarawa State, North Central Nigeria. Nasarawa State was carved out of the old Plateau State on October 1, 1996, with Lafia as the capital. It is located at coordinates 832N 818E/8.533N 8.3000E and has 13 local government areas. It has a population of 2,040,112 (2006 Census) and a total area of 27,117Km. The State is bounded in the north by Kaduna State, in the west by Abuja Federal Capital Territory, in the south by Kogi and Benue States and in the east by Taraba and Plateau States. Due to its proximity to the Federal Capital Territory, Abuja, there are varied ethnic groups from all over the country. Major ethnic groups are Eggon, Alago, Gwari, Mada and Hausa-Fulani. The state is reputed to have large deposits of solid minerals (salt, barite, bauxite) mined largely in a small scale, Journal of the Postgraduate Institute of Medicine 2021; 8(2): E163 1-15 http://doi.org/10.4038/jpgim.8348 4 often illegally. Agriculture is the mainstay of the economy as the population is involved largely in subsistence farming. It has two tertiary care hospitals (Dalhatu Araf Specialist Hospital, Lafia and Federal Medical Center, Keffi), 17 General Hospitals (twelve of which are operating PBF), 728 Primary Health Centres (PHCs) (235 are PBF sites) and tens of private hospitals, maternities and clinics (there 14 PBF private sites). All General Hospitals in Nasarawa State are implementing some form of PBF as one of the three pilot states. In the same vein, at least one primary health care centre per ward in each Local Government Area (LGA) implements the same program. The study design was a descriptive, cross-sectional survey using both qualitative and quantitative data. The quantitative data was collected using structured questionnaires while a key informant interview was adopted for the qualitative component. The study population were all categories and cadres of health care workers in public primary and secondary health facilities that are implementing PBF in Nasarawa State. Healthcare workers in tertiary or private healthcare and public health workers not implementing the PBF program were ex