The SOML Program for Results (PforR) is a Federal Government of Nigeria maternal and child health program, supported by the World Bank that provides incentives based on achievement of results (health outcomes) and helps to drive institutional processes needed to achieve these results. The Program, which seeks to catalyze change in the way health business is done by focusing on results and governance will be financed by a US$500million International Development Association (IDA) credit to the Federal Republic of Nigeria over a period of 4 years.
About 900,000 children and mothers die every year in Nigeria, largely from preventable causes. Over the last decade the trend in health, nutrition, and population outcomes in Nigeria has been mixed. There has been a 36% decline in the last 10 years in the under-5 mortality rate (U5MR) and a 31% decline in infant mortality rate in the same period. However, the overall outcomes are not commensurate with the huge investments that have been made in health.
The SOML Initiative was launched by the President of Nigeria in October 2012 in response to the poor health outcomes in the country, particularly for mothers and children. SOML represents a bold attempt to improve maternal and child health outcomes so that they are more in keeping with the country’s level of wealth. It also intends for the health sector to contribute to the economic and social development of Nigeria instead of being a drag on growth.
The program focuses on six important aspects (“pillars”) of maternal newborn and child health (MNCH) that can save lives and two ‘enablers’ . The pillars are: (1) Improving Maternal, Newborn and Child Health; (2) Improving routine immunization coverage and achieving polio eradication; (3) Elimination of Mother to Child Transmission of HIV; (4) Scaling up access to essential medicines and commodities; (5) Malaria control; (6) Improving child nutrition. The two enablers include (7) strengthening logistics and supply chain management and (8) promoting innovation and use of technology to improve health services.
The FGON’s program document for SOML plainly states that “Continuing business as usual is not a viable option.” It goes on to stress that SOML represents “a shift in focus from inputs to focusing on results and outcomes.” The SOML program is also predicated on the fact that “bold innovations and changes in the approach to delivery in the sector are necessary.”
The SOML program involves: (i) re-orienting the discussion of service delivery to results rather than just inputs; (ii) clearly articulating strategic priorities for the FGON and the rest of the health sector and strengthening the long term commitment to improving the delivery of these high impact interventions. It does not say that other interventions are unimportant, just that the selected intervention (“pillars”) are priorities that should get the first call on resources, effort, and attention; (iii) establishing a limited set of clear and measurable indicators by which to track success; (iv) strengthening data collection so that these indicators can be measured more frequently and more robustly; (v) bolstering accountability so that managers and health workers at all levels are engaged, encouraged, and incentivized to achieve better results; and (vi) fostering innovations that increase the focus on results and include greater openness to working with the private sector.
The SOML Program for Results
To help catalyze the focus on results, the World Bank is supporting the FGON’s SOML program through a PforR operation. The SOML PforR rewards federal and state governments based on their performance in increasing utilization of maternal and child health interventions.
Instead of focusing on inputs, the PforR is designed to disburse against measurable results. States are the greatest beneficiaries of the program, receiving up to 82% of the total credit sum as incentive for improved performance under the various disbursement linked indicators (DLIs).
Under the SOML PforR, states will be rewarded for their performance based on objective indicators using data from household and health facility surveys as well as achievement of certain process indicators related to implementation of a performance management system; and consolidation of primary health care (PHC) management and resources under one institution.
States get rewarded for improvements in performance from their own baseline. States in each geopolitical zone are also ranked according to their performance and the best performing state, ‘zonal champion’ receives an additional bonus. Similarly, the best performing state in the country ‘national champion’ receives an additional performance bonus.
The Federal Government will also be rewarded for its performance related to conduct of household and health facility surveys and dissemination of the results; technical assistance for a performance management system that builds capacity at state level; establishment of an innovation fund; and publication of a consolidated budget execution report covering all income and expenditures for PHC.
This PforR will help with setting technical standards and establishing protocols as well as providing technical guidance and supports to States and service providers. Furthermore, the Pfor R will help strengthen fiscal federalism and encourage the Federal-State relationship to become a results-based partnership.