Almost all policymakers and few providers described a two-tier purchasing system, in which, the PDPD is the primary purchaser; and the State Health Board (SHB) that manages service provision, the secondary purchaser. Policymakers explained that the PDPD and SHB usurped the roles of Steering Committee and State Implementation Committee respectively. It was observed that the Steering Committee met only twice in 7 years; first, to ratify policy change in reimbursement procedure and secondly, to approve use of evidence of tax payment policy. Health facility committee (HFC) leaders were not aware of the roles of FMCHP committees in purchasing but explained that fee-exempt MCH services co-existed with a fee-paying public health system.
Most policymakers and providers noted that there is no system for selecting and accrediting health facilities involved in delivery of the FMCHP. The HFC leaders were not aware of how health facilities are selected. Policymakers claimed that the FMCHP is implemented in all publicly owned health facilities across all the Local Government Areas of the state, but some HFC leaders and providers observed that some health facilities were no longer implementing the FMCHP. One provider observed, “I don’t provide any free maternal health and child health services here, because the centre’s name is not among the centres that are performing free maternal and child healthcare programme” (Provider 13, District B).
Participation and consensus orientation
The benefit package design was not participatory. Participants of all categories held the view that the decision to transit from automatic service entitlement to use of evidence of tax payment as rationing strategy did not involve the district stakeholders. A healthcare provider noted that “There was a memo directing providers that clients coming for free maternal and child health services must provide evidence of tax payment before receiving free care” (Provider 9, District B). Most HFC leaders argued that if HFCs were consulted when formulating evidence of tax payment policy, they would have suggested alternative strategies for identifying eligible target beneficiaries.
Lack of clarity about the position of primary health care (PHC) coordinators and Local Health Authority (LHA) Secretaries limited their involvement in the FMCHP and remittance of their share of service costs. A policymaker attested: “there has always been this confusion about who PHC coordinators, HOD Health and LHA secretaries were” (Policymaker 1, PDPD). A district-level policymaker explained that “since state-level policymakers stopped involving Local Health Authority Secretaries in the reimbursement process, the Local Health Authority Secretaries became aloof” (Policymaker 14, District A).
Rule of law
Most policymakers and providers stated that unclear procedure and delayed reimbursement procedure constrained provider payment. Three types of reimbursement delays – delay in submission of provider claims, delay in vetting and approval of claims, and delay in transferring funds to providers were revealed, which necessitated revision of the reimbursement standards. Even though most HFC leaders stated that they were not involved in the reimbursement procedure, few HFC leaders indicated that providers no longer submit claims due to unpredictable reimbursement.
The delay in reporting claims was attributed to weak provider capacity to fill reimbursement forms, understaffing of health facilities and lack of support from district-level officials. It was explained that at inception, Local Health Authority (LHA) Secretaries supported providers to complete and submit FMCHP claims. However, there was a change from reimbursement through the district-level structures to direct facility reimbursement of FMCHP service expenditure and crediting of providers’ drug account at the central medical store for FMCHP expenditure on drugs. Consequently, the district officials withdrew facilitation of claims’ preparation and submission after direct facility reimbursement was introduced. As one provider observed:
“HODs are not usually available and they are required to sign the invoice. The district chiefs are also required to endorse the claims. These are the protocols that must all be observed before you submit the invoice to Enugu…and the process takes such a long time” (Provider 1, District A).
Policymakers stated that vetting of FMCHP expenditure claims was done as an ad hoc exercise and had no budget line to defray administrative costs nor provide incentives to the vetting team. Members of the vetting team were frequently transferred. Policymakers and providers observed that quality assurance visits to health facilities by vetting team to “verify that expenditure claimed in the reimbursement forms corresponded with facility records” (Policymaker 8, SHB) further adds to the delay. In addition, providers mentioned that “scrutinizing volumes of claims submitted from all health districts by one central vetting committee took time” (Provider 14, District B).
The delay in transferring funds to providers resulted from delay in approving vetted claims and transfer of funds from the PDPD to the State Health Board. Policymakers observed that the Chief Executive Officer of the Ministry of Health (commissioner) “sat as an approving authority for the Steering Committee” (Policymaker 1, PDPD), and reimbursement depended on “whether the commissioner was willing to approve funds” (Policymaker 6, SHB). Consequently, the reimbursement “timelines stipulated in the free care programme guidelines were not met and reimbursements took more than six months after vetting” (Policymaker 2, PDPD).
Most policymakers and providers indicated that the evidence of tax payment policy was poorly implemented in health facilities. Most providers stated that they resumed charging user fees since many users are unable to provide evidence of tax payment. District-level policymakers and providers interpreted evidence of tax payment to mean “tax clearance” (Policymaker 14, District B), “tax receipts for three years” (Provider 9, District B), payment of some money at the facility level in lieu of tax (Provider 1, District A) or presentation of “pay slip or Gen 35” (confirmation of public sector employment) (Provider 15, District B). Even though one HFC leaders observed that clients who are not civil servants are required to pay some money in lieu of tax, most HFC leaders claimed that the evidence of tax payment policy was not implemented in their health facilities because “we (citizens) find it difficult to pay taxes” (HFC leader 2, District A) and health workers do not create sufficient awareness about the taxation policy among users as “providers capitalised on the taxation policy to close the chapter of free MCH services” (HFC leader 6, District B).
Most policymakers spoke of the limited transparency in the business practices of the State Health Board in reimbursement of providers. For example, vetting officers were accused of inflating claims before recommending claims to the PDPD for approval. The PDPD constituted a Financial Monitoring Committee to provide oversight on disbursement of approved claims to health facilities and central medical store by the SHB. However, the State Health Board resisted financial oversight from the Financial Monitoring Committee. One policymaker revealed that, “They instructed us that we (State Health Board) should never issue cheque to any facility without reporting to them, the so-called monitoring committee. We told them that we don’t know them. As soon as the money hits the account, we finish what we are supposed to do, we issue cheques to the facilities” (Policymaker 8, SHB).
Participants of all categories claimed that the criteria and procedure for allocation of resources to health facilities are unclear. Most providers and HFC leaders claimed that the programme have collapsed since users still incurred out-of-pocket expenditure for basic maternal and child health services and drugs. “It is already failing. No child between zero and five years is treated freely, no pregnant woman is treated freely, and no delivery is done freely in this facility” (HFC leader 4, District A). It was explained that resource allocation to providers have not been based on needs. For example, providers “have enough equipment…but the manpower and the space and infrastructure are lacking” (Provider 14, District B) and “when one visited a health facility drug store, one would see certain drugs that their half-life was about to expire, yet they were supplied” (Policymaker 12, District B). Moreover, providers’ drug revolving fund (DRF) stocks were depleted due to delayed- or non-reimbursement of FMCHP drug expenditure.
Equity and inclusiveness
All participants claim that more rural dwellers than urban residents were excluded from free maternal and child health services. Policymakers attributed this to the skewed distribution of health workers to urban districts, which resulted in shortages of health workers in rural health facilities. “The distribution of health workers is more in favour of urban facilities, whereas rural facilities are starved of highly skilled staff” (Policymaker 10, SHB). Providers stated that more health facilities in rural areas than urban areas have stopped providing free maternal and child health services following unpredictable provider payment. HFC leaders indicated that the policy of presenting evidence of tax payment resulted in lower use of free care services in rural districts than in urban districts.
Effectiveness and efficiency
Some state-level policymakers stated that the Ministry of Health used FMCHP funds for purposes beyond the scope of the FMCHP. In the words of one policymaker “if approval for maternal and child health-related program has been received from the Governor and is not cash-backed, we normally fund such programs from FMCHP pool” (Policymaker 4, PDPD). In contrast, some district-level policymakers claim that FMCHP funds are misappropriated by public officials. A district-level policymaker stated that “Some people decided to put their hands into that money and take away a chunk of it and that created a lot of problems” (Policymaker 11, District B).
Some state-level policymakers and providers pointed out that LHA secretaries misused funds in LHA accounts meant for health facilities to replenish DRF items used for free care services during the early years of implementation. One provider observed that “Cheques were coming straight to the LHA secretaries, and the cheques were supposed to be cashed and used to buy drugs, but somewhere along the line, some LHA secretaries tampered with the fund and the drug revolving fund stocks were de-capitalized” (Provider 12, District B).
Many policymakers and providers further indicated that some service providers inflated claims in three ways – by billing beyond fee schedule, overreporting attendance and inclusion of services beyond scope of facilities or the FMCHP. A provider attested “when they were paying the bill, one of our colleagues said, you people don’t know that you have to write names so that your money will come up” (Provider 12, District B). HFC leaders were not aware of fund management in FMCHP but observed that monitoring of provider performance was irregular. One HFC leader said: “you hardly see supervisors from the local government. The occasional supervisors we see are those of SURE-P and PATHS2 (development partners)” (HFC leader 4, District A).
Participants of all categories stated that HFCs did not participate in formulating and implementing evidence of tax payment policy and provider payment system. A service provider stated that “there was a circular issued by the Board directing that entitlement to free maternal and child health services be based on presentation of tax clearance” (Provider 2, District A). On the other hand, they explained that HFCs and civil society organisations have argued for removal of evidence of tax payment. Participants of all categories also stated that most service providers lacked service charters and complaint box. Where service charter existed, most service providers were not creating sufficient awareness about service charters. In the words of one respondent, “It is not just developing service chatter and pasting in the facility, it should be drummed into the ears of people” (Policymaker 10, SHB).
Information and intelligence
Most policymakers and providers explained that reimbursement processes are paper-based and neither driven by information and communication technology nor integrated into the state health management information system. Also, some policymakers, few providers and one HFC leaders explained that changes in the referral system and provider payment procedure were informed by analysis of data on reimbursement of providers and procurement at the central medical store. Initially, provider drug costs were paid through LHA secretaries, but currently “providers collect drugs from the central medical store equivalent to approved facility expenditure on drugs” (Policymaker 1, PDPD).
Policymakers and HFC leaders stated that providers rationed free care services and attended more promptly to clients that pay out-of-pocket than those seeking free care services. One policymaker noted that “We have had to sanction one or two providers for collecting money from a patient instead of treating the patient under the free MCH programme” (Policymaker 1, PDPD). Most providers explained that they resumed charging fees due to unpredictable reimbursement which resulted in the depletion of their drug revolving fund stocks needed to provide fee-exempt services. HFC leaders, nonetheless, argued that “health workers do not support free services” (HFC leader 12, District B) because the FMCHP reduced providers’ opportunity for informal payments. Few policymakers and providers claimed that service users referred to the State Teaching Hospital were denied access to free maternal and child health services “using all manner of subterfuge to convert them into fee paying patients” (Policymaker 6, SHB). Few providers also claimed that users requiring emergency care were exempt from evidence of tax payment before initiation of care. In contrast, HFC leaders argued that providers withheld care from needy clients because they are unable to present evidence of tax payment.