If You Build It, They Will Come? Lessons on Barriers to Service Use at PBF Facilities in Nigeria

Results-based financing (RBF) has been used to great effect to improve the efficiency and quality of health facilities across the developing world. These improvements, however, do not always reach the most vulnerable and marginalized households; they continue to face a variety of barriers in accessing the services offered at RBF health facilities. This has been the case in Nigeria, where an RBF program was implemented in 2012. Curious to better understand these barriers, the Nigeria task team for RBF commissioned a qualitative study. The results of this study ultimately revealed four barriers that prevent some Nigerian households from using services at the improved health facilities. This information is now being used to inform the design of demand-side interventions that help to overcome these barriers and improve access to health care.

Nigerian State Health Investment Project

To improve the country’s lagging maternal and child health indicators, the Government of Nigeria launched the Nigeria State Health Investment Project (NSHIP) in 2012. NSHIP is a five-year, $171 million program funded by the World Bank. The Bank’s International Development Association (IDA) contributed $150 million and its Health Results Innovation Trust Fund, the Bank’s vehicle for results-based financing (RBF) for health, provided $20 million.

NSHIP is being piloted in the states of Adamawa, Ondo, and Nasarawa, and covers a population of approximately nine million. The program aims to increase the delivery and utilization of maternal and child health services and improve the quality of care provided at health facilities. To achieve these objectives, NSHIP employs two RBF approaches: disbursement-linked indicators at the state and Local Government Area (LGA) levels and performance-based financing (PBF) at the health facility and LGA levels. Both RBF approaches ultimately aim to strengthen the health system’s service delivery and institutional performance. With the purpose of building PBF capacity and adapting the program to the local context, a pre-pilot of the PBF program was implemented in one LGA in each of the three pilot states.

Results of the pre-pilot show that PBF was successful in addressing most supply-side challenges in service delivery and increased the service utilization by 5-10 times. Service utilization, however, has still remained low in absolute terms and has varied significantly across states. To understand why service uptake at PBF health facilities was low and varied, researchers carried out a qualitative study in 22 health facilities in the two LGAs included in the pre-pilot: Wamba in Nasarawa and Ondo East in Ondo. The researchers used semi-structured group discussions and key informant interviews to investigate the different barriers that communities encountered in utilizing health services. They also explored what changes could be made to the PBF scheme to make it more responsive to community needs and thus improve service uptake.

Barriers to Service Utilization in Two Nigerian LGAs 

The researchers discovered that four barriers to PBF facility and service utilization were common to both Wamba and Ondo East, though the severity of the barrier varied across communities. These barriers include transportation challenges, paying for health services and drugs, political and ethnic divisions, and cultural norms.

Transportation Challenges. The cost of transportation was frequently cited as a barrier to the use of health services at PBF facilities. A one-way ride on a commercial motorbike from the Owena Tepo catchment area (Ondo East) to the PBF facility costs 400 Naira. In Kwabe (Wamba), it is 200 Naira. Such transportation costs often exceed the cost of the treatment, itself, and can be prohibitively expensive for households if the trip is made multiple times over the course of a woman’s pregnancy.

Even if households can afford transportation to the PBF facility, it can be difficult to find when it is needed. The researchers noted that the lack of available transportation is a service utilization barrier common to women who go into labor or require referrals for complicated cases at night. For particularly isolated communities, the availability of transportation presents a barrier to service use on a regular basis. Many taxis and commercial motorbikes will not collect residents of the more remote villages in the Epe catchment area (Ondo East); residents must walk an hour to the PBF health facility, purchase drugs from traveling vendors, or forgo treatment all together.

The researchers observed that the poor transportation infrastructure in Ondo East and Wamba presents another barrier to service utilization at PBF facilities, especially for residents in remote or mountainous catchment areas, like Owena Tepo or Yashi Madaki (Wamba). Roads in both LGAs are generally unpaved and in terrible condition. In the rainy season, they are often impassable. For women in labor, these poor road conditions make a taxi or motorbike ride to a PBF facility almost unbearable— if possible at all.

Paying for Health Services and Drugs.  Many households have great difficulty in finding the upfront resources to pay for treatment. Paying the full cost of treatment—even if the costs are nominal—at the time of service places a heavy financial burden on households. The researchers noted that households, particularly those in the Epe catchment area, instead use the services of traditional birth attendants (TBAs), church-based midwives, and traditional healers. These providers tend to be more expensive than the PBF facilities, but are often preferable because they accept credit and in-kind payments.

The cost of drugs, the unpredictability of their costs, and a lack of a transparent fee structure are also notable barriers to service uptake in PBF facilities. Paying for both the services of a health professional and for medication can place a heavy financial burden on households. Consequently, households will often bypass the PBF facility for the more direct and less costly option of a pharmacist or mobile drug vendor. The researchers also found that service utilization declines at PBF facilities when their free-drug schemes end. For example, the use of services at the Otobo PBF facility (Ondo East) decreased significantly once it stopped offering free medication. The unpredictability of drug prices at PBF facilities and the absence of a transparent fee structure, moreover, do not allow households to budget for their visits, which further deters their use of services.

Ethnic Ties and Political Divisions. Ethnic ties were identified a barrier to service use at some PBF facilities. The researchers found that households from non-majority ethnic groups, like the Ibo in Otepo, often bypass PBF clinics in favor of alternative providers. Indeed, there is evidence that Yoruba-majority Village Health Committees have excluded individuals from other ethnic or non-native groups, which often discourages service use among these groups.

Researchers also observed that political divisions interfere with service uptake. In some catchment areas, ward committees are divided along political lines. A political party at a community in Ondo East, for instance, has highly politicized the ward committee, which has impacted the delivery and use of services of the PBF facility.

Cultural Norms and Traditions. Cultural norms, especially religious and spiritual beliefs, can have a powerful effect on whether or not households use PBF facilities. Some pregnant women in Epe, for instance, seek the services of church-based midwives. These midwives view their work as a divine calling and claim to have the power to foster the spiritual well-being of the mothers and children in their care. Other women opt to deliver with the help of TBAs, who profess the ability to protect against evil spirits. TBAs in Owena Tepo have also been known to “curse” PBF facilities and providers, which discourages households from using their services.

Recommended Interventions to Boost Service Uptake

Based on their findings, the researchers identified a set of common but flexible interventions that would tackle the service utilization barriers across the LGAs. They also emphasized the importance of accounting for the nuances in each catchment area when developing the interventions.

To overcome the transportation-related barriers, researchers offered two recommendations: the introduction of a transportation voucher system and the construction of maternal shelters at particularly remote PBF facilities. A transportation voucher system—which is already under discussion in Ondo East— would ensure that women in labor would always have access to the transportation to deliver at PBF facilities. The voucher system would function like this: a pregnant woman would receive a voucher for transport to a PBF facility. At the time of her delivery, she would call a driver to take her to the facility, and pay using the voucher. The driver would then cash-in his voucher at the facility or through mobile payment system. Drivers would be incentivized to participate in the system; they would earn higher fares to make up for lost business and gain public recognition for their efforts. Interestingly, voucher was preferred by community members over cash transfer, as it does not involve upfront out-of-pocket cash payment.

Constructing maternal shelters—or opening in-patient beds to expecting women— at the remote PBF facilities would make institutional deliveries more accessible for women living in especially isolated villages. Maternal shelters would effectively remove the service utilization barriers of unavailable transportation and poor transportation infrastructure. This intervention has been successfully used to improve maternal and child health outcomes around the developing world.

The researchers recommended three interventions to overcome the service uptake barriers related to paying for health services and drugs. The first is to develop a flexible payment system at PBF facilities, specifically one that would allow households to make payments over time. Such a system would incentivize households to utilize quality services, while lessening their financial burden. The second is to work with PBF facility staff to improve households’ knowledge of drug costs and their ability to budget for health expenses, and the third is to make the costs clearer on notice boards at the facilities. Working with facility staff and more clearly delineating costs will help to remove the information and knowledge barriers associated with paying for drugs.

Overcoming the service utilization barriers related to ethnic ties, politic divisions, cultural norms and tradition requires nuanced interventions. These interventions must respect the specific traditions and norms of the different catchment areas but also effectively dismantle the barriers that they create. For example, to encourage households to use PBF facilities instead of TBAs and church-based midwives, the researchers recommended that these alternative providers be integrated into the primary health care system. The current policy of the Government of Nigeria does not permit engaging with these alternative providers. However, opening discussions about their integration into the formal health care system would be an important first step in encouraging households to use PBF facilities. Possibilities for integrating these alternative providers into the system include training them to recognize maternal and child health complications, incentivizing them to make referrals to PBF facilities, and allowing them to be participate during deliveries at PBF facilities.

The researchers did not provide formal recommendations for addressing the service utilization barriers caused by ethnic ties and political divisions. However, they presented some evidence that PBF facilities are already taking action to surmount these barriers. The Officer in Charge at the PBF facility in Owena Tepo, for instance, reached out to a group of non-native Ibos, who were not using the PBF facility; she attended a community meeting and stayed for a meal, a sign of respect and acceptance. Her actions resulted in a significant uptake in the Ibo’s use of the PBF facility, and demonstrate possible approaches for bridging the service gap between ethnic groups.

Lessons from the Nigeria Experience

The RBF experience in Nigeria shows that improving the efficiency and quality of health facilities does not always result in increases of service use among the most vulnerable and marginalized and that complementary demand-side interventions are often needed. Identifying and understanding the complexities of barriers to service utilization is critical for designing interventions that ensure that health facilities—and systems, more generally—appropriately respond to community needs. As such, the HRITF has committed an initial $1.7 million to pilot some of the recommended demand-side interventions at the RBF facilities included in the study. If the interventions are successful, they will be scaled up across Wamba, Ondo, and Nasarawa with HRITF funding.