Background

Nigeria, with a total fertility rate (TFR) of 5.3, is projected to reach a population of 379 million by 2050, potentially making it the fourth most populous country globally.^[1] The population explosion will likely heighten the country’s socio-economic burden if unchecked. To address this, Nigeria is dedicated to broadening access to Reproductive and Maternal Health (RMH) services, which has been demonstrated through numerous policy commitments over the years. In 2011, the federal government introduced free Family Planning (FP) commodities at public health facilities, financed through a basket fund for FP commodity procurement. This initiative was backed by a substantial budget allocation for contraceptive procurement, initially set at $3 million annually and subsequently increased to $4 million in 2018.[2] In 2021, the Nigerian government fortified its dedication by committing to allocating a minimum of 1% of the national and state health budgets annually to strengthen family planning financing. [3]

However, despite the country’s efforts towards improving its RMH program, several gaps still need to be addressed. These include limited access to modern contraceptive methods, inadequate healthcare infrastructure, misconceptions about family planning, limited availability of essential medical equipment, and shortage of skilled healthcare providers. Consequently, Nigeria grapples with a critically high maternal mortality ratio of 512 per 100,000 live births[1] as against 223 per 100,000 live births recorded globally[2]. Antenatal care coverage is vital, yet just 67% of ANC visits in the country are with a skilled provider. Similarly, the contraceptive prevalence rate in the country is 17%—a sharp contrast to the global average of 65%. Only 50.7% of births are assisted by a skilled birth attendant compared to the global average of 86%.[3] These emphasize the need for enhanced maternal health services and interventions.

Financial constraints contribute significantly to the dire RMH gaps as they undermine the delivery of quality reproductive health services and hinder the country’s ability to meet the growing demand for reproductive health services. These constraints include inadequate fund allocation, dependence on donor funding, inefficient use of resources, policy and governance issues, and so on. Most of these issues can be addressed with proper financial planning.

Financial modelling empowers decision-makers to provide quantitative insights into the funding requirements, cost projections, revenue streams and impacts of the RMH program. Financial modelling tools offer a structured framework to monitor and evaluate financial performance against predetermined targets. This is particularly crucial for optimizing the limited RMH resources as they enable stakeholders to make informed and evidence-based RMH decisions.

Clinton Health Access Initiative (CHAI) engaged Development Governance International (DGI) Consult to develop a financial model for reproductive health in Nigeria to enhance its financial modelling capabilities for reproductive health and support the country to accurately project the costs required to achieve its reproductive health goals.

Approach

The processes involved in the development of financial model for RMH are described below.

Stakeholder Engagement and Situational Assessment

The activity commenced with an inception meeting with federal-level stakeholders to determine the scope of RMH at the federal level. The scope covers comprehensive sexual health education, family planning, safe motherhood, safe abortion services, vesicovaginal fistula, sexual/gender-based violence, and cervical cancer. This was followed by a situational assessment of the federal-level RMH landscape, which provided insight into the available policy thrusts, initiatives and gaps in the federal RMH program.

Development of RMH Financial Modelling Tool 

The financial modelling tool was developed using Avenir’s OneHealth Tool (OHT). It allows users to cost various RMH interventions. It is also useful for cost-effectiveness analyses to determine the impact of different interventions and funding scenarios on health outcomes. It is a user-friendly tool accessible to a wide range of stakeholders. The tool development process is described below:

1. Adapting the OneHealth Tool: The OHT was used to create the RMH financial modelling tool, which covers all intervention areas within the scope of the RMH program in Nigeria. The tool was designed to project the financial elements, costing and impact of the Nigerian RMH program.
2. Individual Consultations: When the tool was being developed, relevant Federal Ministry of Health (FMoH) officials, donors, and implementing partners were consulted to agree on the structure and assumptions of the RMH financial modelling tool.
3. Stakeholders’ Reviews: After the draft financial modelling tool was developed, a two-day stakeholder engagement meeting was held in February 2024 with the FMoH’s Reproductive Health Division and other stakeholders to review it. Feedback from the engagement was used to improve the quality and efficiency of the financial modelling tool.

Training and Capacity Building of Relevant FMoH Officials

The relevant officers in the Ministry of Health were trained in the use of the financial modelling tool. The processes involved are explained below.

1. Development of Standard Operating Procedure: A Standard Operating Procedure (SOP) was developed. The document details the process of developing the RMH modelling tool and how to operate it. It contains guidelines for operating the RMH financial modelling tool, outlining the navigation guides, assumptions, potentials, and key factors considered in its creation.

• Training: A 3-day training on the RMH Financial modelling tool was held in March 2024 to build the capacity of relevant RMH officers in the Ministry of Health on financial modelling. The training captured the installation and setting up, configuration and data entry process for the RMH modelling tool. It also included sessions on result interpretation, impact analysis and budget mapping. At the end of the training, participants demonstrated the ability to utilize the tool for modelling exercise through a simulation exercise that was used to test their proficiency.

Group picture of participants after the training workshop

Development of RMH Financial Strategy

An RMH financial strategy was co-created with selected government and non-governmental RMH stakeholders. The strategy was necessitated by the need to optimally utilize the modest RMH financing available in the country.  The strategy development began with a SWOT analysis, the output of which was then converted to the central themes of the RMH financial strategy as described below:

1. SWOT Analysis: During the stakeholder review workshop, participants identified the National RH program’s strengths, weaknesses, opportunities, and threats (SWOT) through group work.
2. Financial Strategy Development: The financing-related outputs from the SWOT analysis were used to identify central themes, which were extracted and discussed with relevant stakeholders in a co-creation exercise with the RH Division of the FMoH. The three central themes identified are the expansion of fiscal space for RMH, optimization of RMH resource allocation, and strengthening of RMH governance and coordination. These themes formed the basis of the RMH financial strategy development.

Application of the Modelling Tool

The Financial modelling tool is versatile and can play a significant role in resource allocation, program design, resource mobilization, among others as described below.

a) Resource Allocation: The tool’s ability to present outcome impacts on people’s lives, and present funding gaps empowers stakeholders to contrast financial scenarios, enabling data-driven decision-making. This facilitates the effective presentation of persuasive arguments and justification of resource allocations.

b) Program Design: The dynamic nature of the model facilitates justifying changes in financial plans due to shifting priorities, required service areas, or unforeseen circumstances. The ability to clearly articulate and justify changes enhances flexibility in program design.

c) Resource Mobilization: Insights generated from the RMH financial modelling tool can be used to implement targeted resource mobilization. This will help to prioritize investments in high-impact RMH interventions based on the cost-effectiveness analyses conducted through the tool.

d) Policy Advocacy: The tool enables a proactive approach for evaluating policy impacts to identify possibilities for increased outcomes and the ability to allocate resources more effectively based on detailed financial analyses. This analysis provides compelling argument with a clear direction to policy makers, lessening risks associated with financial miscalculations.

Beyond the functions mentioned above the RMH financial modelling tool can also be utilized to ensure accountability and effective health systems planning.

Conclusion

The development of the RMH financial modelling tool represents a significant milestone for the country in the journey toward financial stability and strategic decision-making in the federal RMH program. By leveraging meticulous analysis and robust modelling capabilities, the tool empowers stakeholders with the insights necessary to identify cost-effective interventions and manage risks efficiently. The RMH financial modelling tool streamlines RMH budgeting and forecasting processes and enhances the ability of RMH officers to assess various scenarios and make timely informed decisions. Its user-friendly interface and customizable features ensure accessibility across different departments, fostering collaboration and alignment towards national RMH priorities.

Recommendations

Based on the modelling exercise’s findings and outcomes, the following measures are proposed to harness the RMH financial modelling tool’s full potential to drive evidence-based decision-making, optimize resource allocation, and ultimately improve reproductive and maternal health outcomes across the country.

a. Continued Capacity Building: Sustain efforts in building the capacity of RMH officers within the Ministry of Health to ensure the effective utilization and management of the RMH financial modelling tool.

b. Monitoring and Evaluation: Implement a robust monitoring and evaluation framework to assess the impact of the RMH financial modelling tool on decision-making processes, resource allocation, and RMH outcomes. Periodic reviews and assessments will facilitate continuous improvement of the tool’s functionalities.

c. Scaling of the RMH financial modelling tool: Recognizing the potential for broader impact, strategize scaling the RMH financial modelling tool to the 36 states of Nigeria. Develop a roadmap for adapting and customizing the tool to suit the unique needs and contexts of each state, ensuring consistency in data standards and modelling methodologies.

References

1. National Population Commission (NPC) [Nigeria], ICF: Nigeria Demographic and Health Survey 2018. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF.2019
2. https://www.who.int/news-room/fact-sheets/detail/maternal-mortality/?gad_source=1&gclid=CjwKCAjw5Ky1BhAgEiwA5jGujpylufZcbSeJ6T1OMDyXGxP1fagE76k2clr8ojNWoFR7NbkFtgkaGxoCaCIQAvD_BwE
3. Nigeria Demographic Health Survey (NDHS), 2018.
4. Roadmap For Sustainable Financing of Family Planning Commodities in Nigeria
5. https://articles.nigeriahealthwatch.com/nigeria-commits-to-allocating-a-minimum-of-1-of-the-national-and-state-health-annual-budgets-to-increase-financing-for-family-planning-by-2030-at-global-event-to-mark-the-next-decade-of-the-fp2030-par/