FOR OFFICIAL USE ONLY
Report No: PADHP00116
INTERNATIONAL DEVELOPMENT ASSOCIATION
PROGRAM APPRAISAL DOCUMENT
ON A
PROPOSED CREDIT
IN THE AMOUNT OF US$500.00 MILLION
AND ON A
PROPOSED GRANT
IN THE AMOUNT OF US$70.01 MILLION
FROM THE GLOBAL FINANCING FACILITY FOR WOMEN, CHILDREN AND ADOLESCENTS
MULTI-DONOR TRUST FUND
TO THE
FEDERAL REPUBLIC OF NIGERIA
FOR A
PRIMARY HEALTHCARE PROVISION STRENGTHENING (HOPE-PHC) PROGRAM
September 5, 2024
Health, Nutrition and Population Global Practice
Western and Central Africa Region
This document has a restricted distribution and may be used by recipients only in the performance of their official
duties. Its contents may not otherwise be disclosed without World Bank authorization.
CURRENCY EQUIVALENTS
(Exchange Rate Effective July 31, 2024)
Currency Unit = Nigerian Naira (NGN)
NGN 1660 = US$1
Regional Vice President: Ousmane Diagana
Regional Director: Trina S. Haque
Country Director: Ndiame Diop
Acting Practice Manager: Carolyn J. Shelton
Olumide Olaolu Okunola, Ritgak Asabe Sarah Tilley Gyado, Owen K.
Task Team Leaders:
Smith
ABBREVIATIONS AND ACRONYMS
ACT Artemisinin-Based Combination Therapy
ANC Antenatal Care
ANRIN Accelerating Nutrition Results in Nigeria
BEmONC Basic Emergency Obstetric and Newborn Care
BHCPF Basic Health Care Provision Fund
BHCPF SOC Basic Health Care Provision Fund State Oversight Committee
BHCPP Basic Health care Provision Program
CBN Central Bank of Nigeria
CEmONC Comprehensive Emergency Obstetric and Newborn Care
CHW Community Health Worker
CIFF Children’s Investment Fund Foundation
CHEW Community Health Extension Worker
CMHSW Coordinating Minister of Health and Social Welfare
CPF Country Partnership Framework
CRI Corporate Results Indicator
CRVS Civil Registration and Vital Statistics
DCP-3 Disease Control Priorities Project
DPG-Health Development Partners Group for Health
DFF Decentralized Facility Financing
DHIS-2 District Health Information System 2
DIME Development Impact
DLI Disbursement Linked Indicator
DLR Disbursement Linked Result
DMA Drug Management Agency
EC Eligibility Criteria
EDGE Excellence in Design for Greater Efficiency
EFCC Economic and Financial Crimes Commission
EMS Emergency Medical Services
EPR Emergency Preparedness and Response
E&S Environmental and Social
ESCP Environmental and Social Commitment Plan
ESSA Environmental and Social Systems Assessment
FASTR Frequent Assessments and Systems Tools for Resilience
FCDO Foreign, Commonwealth and Development Office
FCT Federal Capital Territory
FPFMD Federal Project Financial Management Department
FGN Federal Government of Nigeria
FHW Frontline Health Worker
FM Financial Management
FMBEP Federal Ministry of Budget and Economic Planning
FMOH&SW Federal Ministry of Health and Social Welfare
FSA Fiduciary System Assessment
GDP Gross Domestic Product
GFF Global Financing Facility
GHG Greenhouse Gas
GRM Grievance Redress Mechanism
GRS Grievance Redress Service
HCI Human Capital Index
HIV Human Immunodeficiency Virus
HMB Hospitals Management Board
HMSH Honorable Minister of State for Health
HNP Health, Nutrition and Population
HOPE Human Capital Opportunities for Prosperity and Equality
HOPE-BED Human Capital Opportunities for Prosperity and Equality—Education
HOPE-GOV Human Capital Opportunities for Prosperity and Equality —Governance
HOPE-PHC Human Capital Opportunities for Prosperity and Equality —Primary Healthcare Provision
Strengthening Program
HRH Human Resources for Health
ICPC Independent Corrupt Practices Commission
IFR Interim Financial Report
IFSA Integrated Fiduciary Systems Assessment
IPF Investment Project Financing
IVA Independent Verification Agency
LARC Long-Acting Reversible Contraceptive
LGA Local Government Area
M&E Monitoring and Evaluation
MAMII Maternal Mortality Reduction Innovations Initiative
MDAs Ministries, Departments and Agencies
MDTF Multi-donor Trust Fund
MICS Multiple Indicator Cluster Survey
MMS Multiple Micronutrient Supplements
MOC Ministerial Oversight Committee
NCD Non-Communicable Disease
NCDC Nigeria Center for Disease Control and Prevention
NDC Nationally Determined Contribution
NDHS National Demographic and Health Survey
ND-GAIN Notre Dame Global Adaptation Index
NEMSAS National Emergency Services and Ambulance Scheme
NHIA National Health Insurance Authority
NHSRII Nigeria Health Sector Renewal Investment Initiative
NPCU National Program Coordinating Unit
NPHCDA National Primary Health Care Development Agency
NSC National Steering Committee
OAGF Office of the Accountant General of the Federation
OAuGF Office of the Auditor General for the Federation
PAD Program Appraisal Document
PAP Program Action Plan
PDO Program Development Objective
PEF Program Expenditure Framework
PFM Public Financial Management
PforR Program-for-Results
PHC Primary Health Care Center
POM Program Operations Manual
PPR Pandemic Preparedness and Response
PPSD Project Procurement Strategy for Development
PSH Permanent Secretary for Health
RMNCAH-N Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition
SCO SWAp Coordinating Office
SDG Sustainable Development Goal
SMoH State Ministry of Health
SOML Saving One Million Lives
SOP Standard Operating Procedure
SORT Systematic Operations Risk Tool
SPHCDA State Primary Health Care Development Agency
SSC SWAp Steering Committee
SSHIA State Social Health Insurance Agency
SWAp Sector-wide Approach
TA Technical Assistance
TWG Technical Working Group
UHC Universal Health Coverage
UNCITRAL United Nations Commission on International Trade Law
UNICEF United Nations Children's Fund
USAID United States Agency for International Development
VGF Vulnerable Group Fund
VSL Value of Statistical Life
VVF Vesico-Vaginal Fistula
WASH Water, Sanitation and Hygiene
WHO World Health Organization
The World Bank
Nigeria Primary Healthcare Provision Strengthening Program (P504693)
TABLE OF CONTENTS
DATASHEET....................................................................................................................................... ii
I. STRATEGIC CONTEXT ..................................................................................................................1
A. Country Context ................................................................................................................................ 1
B. Sectoral and Institutional Context .................................................................................................... 2
C. Relationship to the CPF and Rationale for Use of Instrument .......................................................... 5
II. PROGRAM DESCRIPTION ............................................................................................................8
A. Government Program ...................................................................................................................... 8
B. Theory of Change .............................................................................................................................. 9
C. PforR Program Scope ..................................................................................................................... 10
E. Program Development Objective (PDO) and PDO Level Results Indicators ................................... 13
III. PROGRAM IMPLEMENTATION .................................................................................................. 16
A. Institutional and Implementation Arrangements .......................................................................... 16
B. Results Monitoring and Evaluation ................................................................................................ 18
C. Disbursement Arrangements .......................................................................................................... 18
Paris Alignment ....................................................................................................................................... 22
B. Fiduciary ......................................................................................................................................... 22
C. Environmental and Social .............................................................................................................. 24
D. Gender ........................................................................................................................................... 25
V. RISKS ....................................................................................................................................... 25
ANNEX 1. RESULTS FRAMEWORK MATRIX ........................................................................................ 28
ANNEX 2. TECHNICAL ASSESSMENT .................................................................................................. 46
ANNEX 3. SUMMARY FIDUCIARY SYSTEMS ASSESSMENT .................................................................. 58
ANNEX 4. SUMMARY ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT .................................... 60
ANNEX 5. PROGRAM ACTION PLAN .................................................................................................. 64
ANNEX 6. IMPLEMENTATION SUPPORT PLAN ................................................................................... 68
ANNEX 7. INVESTMENT PROJECT FINANCING COMPONENT .............................................................. 70
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@#&OPS~Doctype~OPS^dynamics@padpfrbasicinformation#doctemplate
DATASHEET
BASIC INFORMATION
Project Beneficiary(ies) Operation Name
Nigeria Nigeria: Primary Healthcare Provision Strengthening Program
Does this operation have an IPF Environmental and Social Risk
Operation ID Financing Instrument
component? Classification (IPF Component)
Program-for-Results
P504693 Yes Low
Financing (PforR)
@#&OPS~Doctype~OPS^dynamics@padpfrprocessing#doctemplate
Financing & Implementation Modalities
[ ] Multiphase Programmatic Approach (MPA) [✓] Fragile State(s)
[ ] Contingent Emergency Response Component (CERC) [ ] Fragile within a non-fragile Country
[ ] Small State(s) [✓] Conflict
[ ] Alternative Procurement Arrangements (APA) [ ] Responding to Natural or Man-made Disaster
[ ] Hands-on Expanded Implementation Support (HEIS)
Expected Approval Date Expected Closing Date
26-Sep-2024 30-Jun-2029
Bank/IFC Collaboration
No
Proposed Program Development Objective(s)
The Program Development Objective is to improve utilization of quality essential health care services and health system
resilience in the Federal Republic of Nigeria.
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Organizations
Borrower: FEDERAL REPUBLIC OF NIGERIA
Implementing Agency: FEDERAL MINISTRY OF HEALTH
Contact: DAJU KACHOLLOM
Title: MRS
Telephone No: 08033119400
Email: kachiedaju@gmail.com
@#&OPS~Doctype~OPS^dynamics@padfinancingsummary#doctemplate
COST & FINANCING (US$, Millions)
Maximizing Finance for Development
Is this an MFD-Enabling Project (MFD-EP)? No
Is this project Private Capital Enabling (PCE)? No
SUMMARY
Government program Cost 3,665.29
Total Operation Cost 570.01
Total Program Cost 525.00
IPF Component 45.01
Total Financing 570.01
Financing Gap 0.00
Financing (US$, Millions)
World Bank Group Financing
International Development Association (IDA) 500.00
IDA Credit 500.00
Non-World Bank Group Financing
Trust Funds 70.01
Global Financing Facility 70.01
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IDA Resources (US$, Millions)
Guarantee
Credit Amount Grant Amount SML Amount Total Amount
Amount
National
Performance-Based 500.00 0.00 0.00 0.00 500.00
Allocations (PBA)
Total 500.00 0.00 0.00 0.00 500.00
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Expected Disbursements (US$, Millions)
WB Fiscal Year 2025 2026 2027 2028 2029
Annual 60.42 138.76 135.09 135.75 100.00
Cumulative 60.42 199.18 334.27 470.01 570.01
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PRACTICE AREA(S)
Practice Area (Lead) Contributing Practice Areas
Health, Nutrition & Population Education; Governance
CLIMATE
Climate Change and Disaster Screening
Yes, it has been screened and the results are discussed in the Operation Document
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SYSTEMATIC OPERATIONS RISK- RATING TOOL (SORT)
Risk Category Rating
1. Political and Governance ⚫ High
2. Macroeconomic ⚫ High
3. Sector Strategies and Policies ⚫ Moderate
4. Technical Design of Project or Program ⚫ Moderate
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5. Institutional Capacity for Implementation and Sustainability ⚫ Substantial
6. Fiduciary ⚫ High
7. Environment and Social ⚫ Moderate
8. Stakeholders ⚫ Substantial
9. Overall ⚫ High
@#&OPS~Doctype~OPS^dynamics@padpfrcompliance#doctemplate
POLICY COMPLIANCE
Policy
Does the project depart from the CPF in content or in other significant respects?
[ ] Yes [✓] No
Does the project require any waivers of Bank policies?
[ ] Yes [✓] No
Legal Operational Policies Triggered?
Projects on International Waterways OP 7.50 No
Projects in Disputed Area OP 7.60 No
ENVIRONMENTAL AND SOCIAL
Environmental and Social Standards Relevance Given its Context at the Time of Appraisal
E & S Standards Relevance
ESS 1: Assessment and Management of Environmental and Social Risks and
Relevant
Impacts
ESS 10: Stakeholder Engagement and Information Disclosure Relevant
ESS 2: Labor and Working Conditions Relevant
ESS 3: Resource Efficiency and Pollution Prevention and Management Not Currently Relevant
ESS 4: Community Health and Safety Not Currently Relevant
ESS 5: Land Acquisition, Restrictions on Land Use and Involuntary Resettlement Not Currently Relevant
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Nigeria Primary Healthcare Provision Strengthening Program (P504693)
ESS 6: Biodiversity Conservation and Sustainable Management of Living Natural
Not Currently Relevant
Resources
ESS 7: Indigenous Peoples/Sub-Saharan African Historically Underserved
Not Currently Relevant
Traditional Local Communities
ESS 8: Cultural Heritage Not Currently Relevant
ESS 9: Financial Intermediaries Not Currently Relevant
NOTE: For further information regarding the World Bank’s due diligence assessment of the Project’s potential
environmental and social risks and impacts, please refer to the Project’s Appraisal Environmental and Social Review
Summary (ESRS).
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LEGAL
Legal Covenants
Sections and Description
Financing Agreement, Schedule 2, Section I.A, paragraph 1.1.1(a): The Recipient shall, not later than three (3) months
after the Effective Date, establish and thereafter maintain throughout the implementation of the Operation, a joint
inter-ministerial steering committee at the federal level (the “National Steering Committee” or “NSC”) responsible for
providing high-level guidance, advice, and strategic oversight on the HOPE series of operations with functions,
composition and resources satisfactory to the Association, as further detailed in the Operations Manual.
Financing Agreement, Schedule 2, Section I.A, paragraph 1.1.3 (a):The Recipient shall, not later than three (3) months
after the Effective Date, establish and thereafter maintain throughout the implementation of the Operation, a
coordination unit for the Operation (the “National Program Coordination Unit” or “NPCU”) within the SWAp
Coordination Office, with functions, composition, and resources satisfactory to the Association.
Financing Agreement, Schedule 2, Section I.D, paragraph 2 (a): The Recipient shall: (i) not later than ninety (90) days
after the Effective Date, engage an independent verification agency or independent verification agencies (“Independent
Verification Agent(s)” or “IVA(s)”), as the case may be, under terms of reference(s) satisfactory to the Association.
Per ESCP, the Recipient will hire one environmental specialist and one social specialist no later than one month after the
effective date and maintain the position throughout project implementation.
Per ESCP, a Labor Management Procedures shall be prepared, disclosed, consulted, and adopted no later than three
months after the effective Date and implemented throughout the Project lifecycle.
Per ESCP, the Recipient will establish the grievance mechanism no later than three (3) months after the effective date
and thereafter maintain and operate the mechanism throughout project implementation.
Per ESCP, an E&S Screening Checklist shall be developed no later than three months after the effective date and
implemented by the SPIUs during project implementation to screen activities for E&S impacts.
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Conditions
Type Citation Description Financing Source
The GFF Grant Agreement
has been executed and
Effectiveness Article V, Section 5.01(a) delivered and all conditions IBRD/IDA, Trust Funds
precedent to its
effectiveness or to the right
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of the Recipient to make
withdrawals under it (other
than the effectiveness of
the Financing Agreement)
have been fulfilled;
The Recipient has
established the NPCU and
appointed or hired the
NPCU staff, other than the
environmental and social
Effectiveness Article V, Section 5.01(b) IBRD/IDA, Trust Funds
specialist, in accordance
with the provisions of
paragraph 3(b) of Section
I.A of Schedule 2 to the
Financing Agreement; and
The Recipient has adopted
the Operations Manual in
accordance with the
Effectiveness Article V, Section 5.01(c) IBRD/IDA, Trust Funds
provisions of Section I.C of
Schedule 2 to the Financing
Agreement.
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I. STRATEGIC CONTEXT
A. Country Context
1. Nigeria, Africa's most populous country and home to the second-largest population living below US$2.15 per day,
possesses substantial untapped economic potential yet is one of the least developed nations globally. Nigeria is among
the largest economies in Africa, with a gross domestic product (GDP) of approximately US$363 billion in 2023, but over 40
percent of its population live in poverty. Economic growth over the past decade has not maintained pace with population
growth: real income per capita in 2023 was US$2,455, lower than US$2,490 recorded in 2010. Nigeria’s key development
constraints include the high dependence on oil, insufficient economic diversification and inclusive growth, and a poor
scorecard on good governance and service delivery including investments in human capital. As a diverse federation of 36
autonomous states and 220 million people, federal-state coordination is a challenge. Pathways for development include
improving economic governance and generating more trust in State institutions, boosting government investments in
human capital, expanding social assistance programs to sustain the move away from fuel subsidies, and improving
opportunities for the young and entrepreneurial to diversify the economy and invest in inclusive economic growth.
2. Elections in 2023 brought in a new President and administration committed to improving macroeconomic stability
and addressing fiscal and debt vulnerabilities due to low revenues and a dependence on global oil prices.
Macroeconomic stability steadily deteriorated over the past decade leading to an increasing difference between official
and parallel market exchange rates, a shortage of foreign exchange, and high inflation. Confronted with a fragile economic
reality, the new administration that took office in May 2023 made two critical macro-fiscal reforms: the increase in the
price of gasoline or premium motor spirit which was subsidized at a fiscal cost of 2.2 percent of GDP in 2022, and the
liberalization of the exchange rate. These policies are expected to help boost revenues from 6.7 percent of GDP in 2022
to 8.6 percent of GDP in 2024. Nonetheless, the fiscal deficit is projected to remain above 3 percent of GDP for 2024-2027.
This fiscal outlook limits scope for essential public investments and services and highlights the urgent need to mobilize
domestic revenues to shore-up fiscal sustainability and provide funding for government investments in inclusive and
sustainable development.
3. The economic and fiscal outlook continues to be vulnerable to shocks and oil-dependence and to the challenges
associated with improving governance of the State. In recent years, the economy has been hit by the COVID-19 pandemic,
a fall in global oil prices, increasing insecurity, and weak domestic oil production. The post-COVID recovery was short-lived
with real GDP growth dropping from 3.6 percent in 2021 to 3.1 percent in 2022-2023, due to low oil production, flood-
related low agricultural output, and the disruptive currency demonetization policy instituted in Q1-2023. The fiscal space
is limited by the need to service debts (101.5 percent of revenues in 2022) and vulnerable to fully realizing the fiscal
transfers from the oil and gas sector, thus restricting public investments. Long-standing perceptions of corruption and
other governance challenges such as weak institutions and limited transparency and accountability also dampen business
sector confidence.
4. Climate change threatens development gains in Nigeria, with a disproportionate impact on the poor. Nigeria is
highly vulnerable to climate shocks, including extreme heat, floods, and drought, all of which are predicted to become
more frequent and severe with climate change. The country has low adaptive capacity to address climate change, ranking
154 out of 185 countries on the Notre Dame Global Adaptation Index (ND-GAIN) of climate vulnerability and readiness.1
Climate change already has negative impacts on the country’s economic growth, with an estimated GDP loss of between
6 percent and 30 percent by 2050, worth an estimated US$100–460 billion, due to climate change.2
1 Notre Dame Global Adaptation Initiative (NDGAIN), Readiness Index, 2021: https://gain.nd.edu/our-work/country-index/rankings/
2 Department for International Development. 2009. Impact of Climate Change on Nigeria’s Economy.
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B. Sectoral and Institutional Context
5. Nigeria’s youthful population represents a vast reservoir of human capital waiting to be tapped, but the country’s
low score on the Human Capital Index (HCI 2020) undermines this potential. Nigeria’s HCI of 0.36 implies that a child
born in Nigeria today is expected to achieve only 36 percent of his/her potential productivity by age 18 if she had attained
a complete education and optimal health. This falls below the Sub-Saharan African average of 40 percent, as well as
regional comparators such as South Africa (43 percent), Ghana (45 percent), and Kenya (55 percent). If Nigerian children
were to reach their full educational and health potential, the country’s per-capita GDP could be 2.8 times higher.
6. Nigeria ranks among the bottom five or ten countries globally on most key health indicators. Life expectancy, at 54
years, is the third lowest in the world. Under-five mortality is the second highest globally, at 114 per 1,000 live births, while
maternal mortality is third highest in the world, at over 1,000 per 100,000 live births.5 These numbers translate to over
800,000 deaths among children under five and about 80,000 maternal deaths each year. Nigeria therefore accounts for
one out of six child deaths globally, and one out of four maternal deaths.6 The prevalence of stunting among children
under five is 37 percent, one of the 10 highest rates in the world, with long-term implications for human development.
The same is true of the total fertility rate, which at 5.3 births per woman is down only slightly from its 1990 level of 6.0.
Nigeria is in the early stages of the epidemiological transition, with non-communicable diseases (NCDs) accounting for 24
percent of total deaths and posing a growing burden.5
7. Nationwide health indicators mask profound economic disparities. A child in the poorest wealth quintile is over three
times more likely to die under the age of five than a child in the richest wealth quintile. At the same time, nearly every
Nigerian state—including the richest—lags far behind the global average for under-five mortality at their income level
(measured by state gross national income per capita). If Nigeria’s second-richest socioeconomic quintile was a country
(with a population over 40 million), its under-five mortality rate would rank among the 10 highest globally and far behind
the target set out in the Sustainable Development Goals (SDGs).
8. Nigeria’s health system is characterized by huge geographical disparities . The states in the Northern geopolitical
zones have a worse performance than those in the Southern geopolitical zones on maternal mortality and other health
outcomes.3 For example, a woman living in the North-East is 10 times more likely to die during childbirth than a woman
living in the South-West. The disparities in these regions influence their levels and determinants of maternal mortality. For
instance, some northern states like Kano in 2008 had a maternal mortality ratio of 1600 deaths per 100,000 livebirths,4
while 1049 deaths per 100,000 livebirths were reported in Zamfara state.5 The North South differentials are characterized
by socio cultural factors, women in the North are less likely to give birth at health facilities,6 and many in some northern
states, live far from health centers which are plagued by severe shortages of health workers compared to the South of
Nigeria.7
9. Shortcomings in access to essential health services and quality of care are major drivers of poor health outcomes.
Skilled birth attendance has increased only marginally, from 39 percent in 2008 to 43 percent in 2018.8 Childhood
immunization coverage remains a significant challenge, with diphtheria, pertussis, and tetanus Pentavalent vaccine (DPT-
3/Penta-3) coverage estimated at 57 percent. As of 2020, Nigeria had the largest number of zero-dose children in the
3 Wall LL. Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria. Stud Fam Plan. 1998;29:341–
59.
4 Galadanci H, Idris S, Sadauki H, Yakasai I. Programs and policies for reducing maternal mortality in Kano state Nigeria: a review. Afr J Reprod Health. 2010;14:31–6.
5 Doctor HV, Olatunji A, Findley SE, Afenyadu GY, Abdulwahab A, Jumare A. Maternal mortality in northern Nigeria: findings of a health and demographic
surveillance system in Zamfara state, Nigeria. Trop Dr. 2012;42:140–3.
6 Ononokpono DN, Odimegwu CO. Determinants of maternal health care utilization in Nigeria: a multilevel approach. Pan Afr Med J. African Field
Epidemiology Network. 2014;17:2.
7 McDermott R, Cowden J. Polygyny and violence against women. Emory Law J. 2015;64(6):1767-814. http://law.emory.edu/elj/content/volume-64/
issue-6/articles-and-essays/polygyny-violence-against-women.html.
8 Nigeria Demographic and Health Survey, 2018
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world,9 with the estimated number of zero- or missed-dose children increasing to 3.1 million from 3.0 million the previous
year. The quality of healthcare services in Nigeria remains suboptimal and compares poorly with peers. For example, the
availability of essential equipment within health centers in Nigeria is 33 percent, compared to 89 percent in Tanzania and
84 percent in Kenya.10 Clinical competence is similarly weak: only 43 percent of clinical conditions in Nigeria are accurately
diagnosed, compared to 69 percent in Tanzania and 67 percent in Kenya.11 A national assessment of maternal deaths and
near misses at hospitals reported that over 90 percent of mothers arrived in critical condition, but still the median time
between diagnosis and critical intervention was 60 minutes;12 in 21.9 percent of cases, it was over four hours. Shortages
in human resources for health (HRH) and health infrastructure, along with a chronically weak supply chain and poor referral
systems, intensify these service delivery challenges.13
10. Several barriers impede access to good quality healthcare services for persons with disabilities. These individuals
often require specialized and general health services, but they may not receive them due to systemic and attitudinal
barriers. The attitudes of health professionals have a detrimental effect on the mental health and psychosocial well-being
of disabled patients, rendering them more susceptible to abuse, injuries, and diseases. It is common for healthcare
providers to administer medication to patients with disabilities without obtaining their consent, contravening the ethical
principles governing their conduct. Moreover, patients are often perceived as exaggerating their symptoms due to
healthcare providers’ insufficient knowledge on effectively managing patients with disabilities. Consequently, individuals
with disabilities may experience mistreatment from caregivers, whether consciously or unconsciously, directly, or
indirectly.14
11. Government health spending as a share of GDP ranks the lowest in the world, at 0.5 percent. This translates to about
US$14 per capita, of which less than 20 percent (US$2.62 per capita) is allocated to primary care. Low levels of health
financing severely limit the country’s ambition to achieve universal health coverage (UHC). For example, this allocation is
a fraction of global estimates of the cost of providing an essential health service package in countries at Nigeria’s income
level, with two recent estimates falling between US$70 and US$80 per capita. It is also far less than the estimated cost of
a basic primary care package in Nigeria (about US$14 per capita). A major constraint on health spending is the overall low
level of government revenue, at about 7 percent of GDP, exacerbated by the low prioritization of health within the budget,
at 4 percent. The low priority placed on public health spending is particularly evident at the state level, due in part to low
rates of budget execution. As a result of low government health spending, household out-of-pocket expenditures account
for almost 75 percent of total health spending in Nigeria, the fourth-highest share in the world.15
12. Nigeria’s poor health outcomes and weak health financing environment are linked to its complex federal
arrangements. Nigeria’s constitution provides for a vertical revenue-sharing formula across federal, state, and local
governments and centrally controlled special funds. This has resulted in federal fiscal dominance and financially weak
states. Furthermore, the constitutional allocation of roles and responsibilities in healthcare is unclear across all levels of
government, with all levels playing a role in delivery of essential primary healthcare services. Consequently, there are
accountability challenges, especially at the lower levels. Also, in the face of limited fiscal space, subnational entities in
Nigeria face difficult policy choices, such as prioritizing the expansion of priority basic services and population coverage.
The government has used conditional fiscal transfers through the Basic Healthcare Provision Fund (BHCPF) in the health
sector to transfer resources and influence policy since 2017 with mixed results.
9 World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) estimate of National Immunization Coverage (WUENIC).
10 World Bank. 2016 Nigeria Service Delivery Indicators Survey.6.
11
Ibid.
12 https://obgyn.onlinelibrary.wiley.com/doi/10.1111/1471-0528.13450
13 ibid
14 Ayub, A. O., and A. J. Rasaki. 2021. “Barriers in Accessing Healthcare Services by Patients with Disabilities in Nigerian Hospitals.” Gusau International Journal of
Management and Social Sciences 4 (1): 280–296.
15 https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=NG
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13. External development assistance accounts for about 10 percent of Nigeria’s total health spending but represents
less than the sum of its contributions due to significant fragmentation. There are many multilateral, bilateral, and
philanthropic development partners in the health sector in Nigeria, with a complex array of inputs (for example, financing
technical assistance (TA) and commodities), geographical distribution (focus states and federal government), sectoral
priorities, and institutional arrangements (for example, monitoring and evaluation (M&E) frameworks, public financial
management (PFM) practices, and authorizing structures). This fragmented approach places a transactional and
prioritization burden on government authorities and undermines long-term sustainability.
14. Climate change further threatens Nigeria’s health system and jeopardizes health outcomes and is already impacting
health in the country.16 Climate change s exacerbating transmission of water and vector borne diseases in the country.
Transmission of malaria, the leading cause of under-five mortality in Nigeria,17 is linked to rising temperatures and changes
in precipitation due to climate change.18 Drought has affected food production, with 31.5 million people estimated to be
severely food insecure in 2023.19 Food insecurity due to climate change is contributing to burgeoning rates of stunting and
wasting in children under-five, at 37 percent20 and 7 percent,21 respectively. Climate change, particularly increased
flooding, also debilitated the country’s health system. For example, severe floods in 2022 destroyed 30 medical facilities
in the hardest-hit state of Jigawa alone.22 It is estimated that, by 2050, the health impacts of climate change in Nigeria will
total US$399 billion in economic costs.23
15. Nigeria’s key UHC initiative in recent years was the BHCPF, a specific-purpose intergovernmental fiscal transfer for
health established by the National Health Act of 2014. The BHCPF is an earmarked fund for health to be financed with no
less than 1 percent of the Government’s Consolidated Revenue Fund.24 In 2018, BHCPF implementation commenced
through a grant from the Global Financing Facility (GFF). The original design was only partly pursued and, while
implementation has since restarted, there are constraints to its effective implementation. First, the quantum of resources
from the BHCPF translates to less than US$0.25 per capita in most years, an insufficient amount to make a major impact.
Second, there are governance challenges with respect to implementation and accountability mechanisms for funds at the
national and subnational levels. Third, effective utilization of funds at the state level is hampered by weak coordination
and limited capacity to plan and implement the Basic Healthcare Provision Program (BHCPP). Under new leadership, the
BHCPF will be redesigned as part of the broader Nigeria Health Sector Renewal Investment Initiative (NHSRII) and will be
a key financing vehicle for the broader BHCPP. As part of the health sector reform, the first sector-wide approach (SWAp)
in the health sector in Nigeria will be adopted to channel public and development partners resources, improve
coordination, and reduce inefficiencies.
16. The strategic partnership between the World Bank and the government is set to play a pivotal role in the
implementation of these health sector reforms. Given the scale of the challenge and the limited resources available,
transforming Nigeria’s health system will require embracing a “business unusual” approach. Strengthening primary
healthcare is not only about enhancing service delivery, but also about instituting significant changes in the governance of
16 Adebanke L. Adebayo. 2022. “Mitigating Climate Change Effects on Maternal and Prenatal Health in Nigeria.” In The Nature, Causes, Effects and Mitigation of
Climate Change on the Environment, edited by Stuart A. Harris. IntechOpen; Godpower C. Michael, and Musa Dankyau. 2022. “Climate Change and Primary Health
Care in Sahelian Kano, Nigeria.” Afr J Prim Health Care Fam Med 14 (1):3745; Oluwatimilehin, Isaac Ayo et al. 2022. “Assessment of the Impact of Climate Change on
the Occurrences of Malaria, Pneumonia, Meningitis, and Cholera in Lokoja City, Nigeria.” Regional Sustainability 3 (4): 309–18.
17 O.O. Ayoola, et al. 2005. “A five-year review of childhood mortality at the UCH, Ibadan.” West Afr. J. Med. 24(2): 175–79.
18 Badaru, Yahaya Usman, et al. 2014. “Rainfall Variations as the Determinant of Malaria in the Federal Capital Territory Abuja, Nigeria .” J. Environ Earth Sci. 4 (20):
149–59; Oluwatimilehin, Isaac Ayo, et al. 2022. “Assessment of the Impact of Climate Change on the Occurrences of Malaria, Pneumonia, Meningitis, and Cholera in
Lokoja City, Nigeria.” Regional Sustainability 3 (4): 309–18.
19 Cadre Harmonise for Identification of Risk Areas and Vulnerable Population in the Sahel and West Africa March 2024: Nigeria.
20 UNICEF. The Challenge: Malnutrition is a direct or underlying cause of 45 percent of all deaths of under-five children.
21 USAID. 2021. Nigeria Nutrition Profile.
22 Abdulrakib Abdulrahim et al. A catastrophic flood in Nigeria, its impact on health facilities and exacerbations of infectious diseases. PAMJ - One Health. 2022;9(21).
10.11604/pamj-oh.2022.9.21.38023.
23 World Bank. 2024. Climate and Health Economic Valuation (CHEV) tool: Nigeria. This figure is drawn on the SSP3 scenario.
24 National Health Act, 2014.
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the health sector. Recognizing this dual need, the government has requested the World Bank to finance a series of
interdependent operations this operation-Human Capital Opportunities for Prosperity and Equality—Primary Healthcare
Provision Strengthening Program (HOPE-PHC Program, P504693), along with the crosscutting HOPE-Governance (HOPE-
GOV; P181476) and HOPE Basic Education (HOPE-BED; P507001). The HOPE-GOV operation, with a focus on governance,
aims to contribute to: (a) increasing the availability and effectiveness of financing for basic education and primary
healthcare; (b) enhancing transparency and accountability for basic education and primary healthcare; and (c) improving
recruitment, deployment and performance management of basic education teachers and primary healthcare workers by
federal, state, and local government. This is a critical step toward ensuring the sustainability of all health programs. HOPE-
PHC Program, focusing on primary healthcare service delivery, is designed to contribute to the reorganization of primary
healthcare and the prioritization of cost-effective interventions. This will be instrumental in improving access to good-
quality, essential health services, thereby laying a solid foundation for a more robust and resilient health system in Nigeria.
HOPE-BED will support reforms in the basic education sector. The interdependencies between HOPE-GOV and HOPE-PHC
are shown in Figure 1 below.
Figure 1. Relationship between HOPE-GOV, HOPE-PHC and HOPE-BED
C. Relationship to the CPF and Rationale for Use of Instrument
17. The Nigeria Human Capital Opportunities for Prosperity and Equity—Primary Healthcare Provision Strengthening
(HOPE-PHC) Program is aligned with the core objectives of the World Bank’s Nigeria Country Partnership Framework
(CPF) FY21-25 (Report No. 153873-NG) and Performance and Learning Review (Report No. 185161-NG)25 First, it aligns
with Core Objective 3: Improve Primary Healthcare, which is focused on enhancing the quality and coverage of public
health services and sustainable financing for health through the BHCPF. Second, it aligns with Core Objective 1: Increase
Domestic Revenues, Improve Quality of Public Expenditures and Enhance Debt Management, which seeks to strengthen
federal–state coordination and accountability within Nigeria’s fiscal federalism framework. In coordination with the
Nigeria HOPE-GOV operation, the HOPE-PHC Program will also contribute to Core Objective 1, Complementary Priority 2:
25 https://documents1.worldbank.org/curated/en/526171611619063445/pdf/Nigeria-Country-Partnership-Framework-for-the-Period-FY21-FY25.pdf
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Enhance the Effectiveness, Transparency and Accountability of Public Institutions and Systems for Service Delivery. Third,
the HOPE-PHC Program, with its predominant focus on women and young children through the delivery of reproductive,
maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) services, deepens the CPF’s drive to reduce
gender gaps and inequities.
18. The CPF states that Nigeria’s vast development agenda calls for, among other steps, investment in human capital
and harnessing the demographic dividend. Of particular importance is maximizing women’s potential contributions,
especially with respect to the health, education, and life chances of adolescent girls and women in the north, where gender
gaps are wider than elsewhere in the country. This is due to more restrictive social norms; issues around fragility, conflict,
and violence; and weaker overall economic development. Both the Nigeria Systematic Country Diagnostic26 and the CPF
call for concerted action on gender gaps to close the north-south divide in human capital outcomes; reduce fragility,
conflict, and violence; accelerate per-capita income growth; and improve Nigeria’s overall development trajectory.
19. The HOPE-PHC Program will contribute to the World Bank’s regional and global agenda. With the world’s second
highest number of deaths among children under five and the sixth-largest population in the world, Nigeria will play a major
role in contributing to key goals, such as the reduction of under-five mortality (as captured in the new World Bank
corporate scorecard) and the new commitment to support countries in delivering good-quality essential health services
to 1.5 billion people by 2030. The HOPE-PHC Program is also aligned with the objectives of the Africa Human Capital Plan:
Powering Africa’s Potential Through its People, to which it will contribute by scaling up financing for health, tackling critical
human capital challenges, leveraging technology and innovation, and strengthening partnerships. The HOPE-PHC Program
will address interdependent climate and health challenges by proactively integrating climate resilience into health systems
planning and infrastructure. The HOPE-PHC Program is aligned with the goals of the Paris Agreement (Section IV and
Climate Technical Note).
20. The rationale for World Bank support of the HOPE-PHC Program is based on the centrality of human capital to
Nigeria’s future employment opportunities, productivity, economic development, and poverty reduction. The HOPE-
PHC Program is an important complement to previous and ongoing interventions through the World Bank’s Health,
Nutrition and Population (HNP) portfolio in Nigeria, including operations that have utilized the HOPE-PHC Program for
Results (PforR) mechanism. The Saving One Million Lives (SOML) PforR Program (US$500 million, P146583), which closed
in October 2019, supported efforts to increase the utilization and quality of high-impact reproductive, child health, and
nutrition interventions. The ongoing Accelerating Nutrition Results in Nigeria (ANRIN) Project (US$225 million, P162069)
supports an increase in the utilization of good-quality, cost-effective nutrition services for pregnant and lactating women,
adolescent girls, and children under five, building knowledge on primary healthcare systems and multisectoral linkages.
Through its interventions, specifically under its Component 2: expanding the implementation of the redesigned BHCPF by
leveraging Decentralized Facility Financing (DFF), the Immunization Plus and Malaria Progress by Accelerating Coverage
and Transforming Services - IMPACT (P167156) Project has been laying the critical foundation for HOPE-PHC. After
approval of its currently proposed restructuring, the IMPACT Project will further support HOPE-PHC by reprogramming
additional resources to further expand the implementation of the BHCPF.
21. The outcomes from previous HNP interventions have been mixed, with coverage of some health interventions
stagnating at low levels but impressive results in critical areas, such as polio eradication. A lesson learned from the SOML
PforR is that policies formulated for adoption by states require collaboration across all levels of government. Other lessons
suggest that, given Nigeria’s fiscal structure, innovative reforms that hold lower levels of government accountable should
be linked to fiscal transfers. The HOPE-PHC Program builds on a determined high-level leadership and political
26https://documents1.worldbank.org/curated/en/891271581349536392/pdf/Nigeria-on-the-Move-A-Journey-to-Inclusive-Growth-Moving-Toward-a-Middle-Class-
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commitment to health reforms across the political class, aligning its timeline with the political cycle (2024–2028) to
capture this opportunity.
22. The HOPE-PHC Program provides a platform for a SWAp, leveraging significant additional resources to support a
critical agenda. Following the compact signed by all orders of government in Nigeria and development partners, the SWAp
was established by the FMOH&SW in 2023. Most partners have started aligning their resources with the priorities outlined
in the SWAp compact and are members of the thematic technical working groups set up to actualize the approach. Several
partners have started processing agreements to align their financing with the SWAp, with three of such entities already
completing the process. The World Bank has a clear comparative advantage to serve as the anchor organization for the
first-ever SWAp in Nigeria, as it brings a long history of supporting this approach in health and other social sectors across
the globe. In addition, the World Bank has provided significant resources to Nigeria’s health sector reforms over the last
decade, through which significant lessons have been learned on sector governance, health systems performance, and
health financing, among others. A SWAp will provide the leverage to deepen federal–state dialogue for additional
domestic resource mobilization and better accountability for results. Providing joint platforms for planning, delivery,
monitoring, and accountability will drive efficiency, transparency, and accountability for health spending and key inputs
and processes. By aligning development partner financing with the government’s own resources, the HOPE-PHC Program
will foster convergence around a common set of results in building a resilient and sustainable primary healthcare system.
23. The PforR instrument is considered appropriate for the HOPE-PHC Program. There is explicit interest in shifting the
focus from inputs to results, with a stronger focus on accountability for results, given the complex institutional federal
system. In addition, there is a need to incentivize government ownership and accelerate the implementation of critical
reforms and policies in the health sector, all of which support the NHSRII’s goal of serving as an anchor for a SWAp.
Furthermore, the PforR design recognizes the need to make more efficient use of limited resources in a context where
improvements in performance will require leveraging state and local government autonomy, boosting accountability, and
aligning development assistance for health. A standalone Investment Project Financing (IPF) operation would be extremely
transaction-intensive, given the national scope. However, a complementary smaller IPF component will allow the National
Program Coordinating Unit (NPCU) to carry out targeted TA and procurement of critical consultancies to address states’
capacity needs, targeted support to lagging states and ensuring government capacity is in place to assure that inputs are
well-designed, and that sufficient quality assurance is provided, including on the verification of the results. As such, the
HOPE-PHC Program adopts a hybrid PforR and IPF approach.
24. A new political constellation and lessons from past reform experiences have been incorporated into Program design
to inject fresh hope into Nigeria’s health sector outlook. First, there is an unprecedented level of stakeholder alignment
around health reform, as evidenced by the federal compact signed in December 2023 by all states and by Federal
Government of Nigeria (FGN). Second, there is greater focus on addressing upstream governance issues that significantly
constrain sectoral prospects, especially in the realm of PFM and human resources at the state level, which are the focus
of the HOPE-GOV operation. Third, the SWAp modality, which is new to Nigeria, will serve to de-fragment the external
assistance architecture and overcome inefficiencies that have plagued the sector in the past. In addition to these macro-
level shifts, the HOPE-PHC Program includes several important service delivery innovations that were not part of previous
reform efforts. These include the purchasing of Comprehensive Emergency Obstetric and Newborn Care (CEmONC)
services, digital health platforms, expansion of community health service delivery, commodity security, and a focus on the
complementarities of supply and demand-side efforts and different levels of care.
25. The HOPE-PHC Program is consistent with Nigeria’s updated (2021) Nationally Determined Contributions (NDCs) ,27
the Nigeria Energy Transition Plan,28 Nigeria’s Long-Term Vision for Low-Carbon Development 2050,29 and the National
27 UNFCCC (United Nations Framework Convention on Climate Change). 2021.Updated Nationally Determined Contribution (NDC) for Nigeria
28 Nigeria Energy Transition Plan, 2021.
29 2050 Long Term Vision for Nigeria, November 2021.
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Adaptation Strategy and Plan of Action.30 Nigeria has committed to a national target of reducing greenhouse gas (GHG)
emissions by 20 percent by 2030 compared to the business-as-usual scenario.31 HOPE-PHC will finance energy efficient
health facility refurbishment and solar power purchases consistent with this. The HOPE-PHC Program supports Nigeria’s
policies to manage climate risks, as identified by the National Council on Climate Change and the Federal Ministry of Health
and Social Welfare (FMOH&SW), to mainstream climate actions nationally to achieve GHG emissions reduction targets
and promoting community resilience to reduce vulnerability to climate change through both the improvement of health
services, which are highlighted as critical to climate change adaptation, and climate actions incorporated throughout the
operation including financing climate change emergency preparedness planning and the development of a National Health
Adaptation Plan (HNAP).32 The HOPE-PHC Program supports Nigeria’s commitment to climate adaptation in the health
sector, as articulated in the National Strategic Health Development Plan II,33 including developing the capacity to respond
to climate health emergencies and climate-sensitive diseases, including NCDs; building resilience in vulnerable
communities; and developing climate-resilient health systems.34
II. PROGRAM DESCRIPTION
A. Government Program
26. The proposed PforR Program is grounded in the NHSRII, an ambitious and transformative initiative launched in
December 2023 with a view to improving Nigeria’s health outcomes and economic potential by drastically reducing
maternal and under-five mortality rates. The BHCPP, driven by the BHCPF, established by the National Health Act of 2014
is an integral pillar of the NHSRII. By investing in service readiness, frontline health workers (FHWs), and evidence-based
interventions, the BHCPP aims to unlock Nigeria’s human capital potential. In addition, to exploit the economic potential
embedded in the healthcare value chain, the Presidential Initiative for Unlocking Healthcare Value Chain (Nigeria
Healthcare Industrialization Program), will be delivered through a dedicated pool of funds and private sector partnerships
to fast-track Nigeria’s ambitions in tertiary healthcare and local manufacturing. Overall, the NHSRII presents a call to action
for the international development community and all levels of government to build a robust coalition to help Nigeria save
lives, boost its human capital, build a platform for medical industrialization, and improve the efficiency and impact of its
public and development financing. The HOPE-PHC Program is also consistent with the National Strategic Health
Development Plan II (2018–2022), Medium-Term National Development Plan 2021–2025, and Agenda 2050.
27. The BHCPP’s essential benefit package prioritizes cost-effective services, focusing on reproductive health, maternal
care and nutrition, childhood illnesses, and NCD screening. A discrete package of promotive, preventive, and simple
curative interventions will be delivered at the community level, complementing facility-based primary healthcare services.
The estimated cost of achieving full coverage of 57 primary care services under the BHCPP is US$14 per capita annually,
more than currently available government resources. Achieving this goal will therefore require careful consideration of
the pace of the planned scale-up and of service priorities. To consolidate investments, the BHCPP proposes to: (a) expand
Primary Health Centers (PHCs) from one per ward to a population-responsive distribution of two per ward, on average,
with a total of over 17,00035 nationwide; and (b) support the implementation of Basic and BEmONC and CEmONC,
including one CEmONC per Local Government Area (LGA), for a total of 774, and an equitable distribution of Tier 236
BEmONC facilities linked to each of the CEmONC facilities. The BHCPP leverages the opportunity to strengthen emergency
30 Nigeria National Adaptation Strategy and Plan of Action, 2011.
31 Updated NDC Nigeria.
32 The National Council for Climate Change. 2021. “Leading Nigeria’s Climate Change Response.”
33 file:///C:/Users/wb292592/Downloads/National%20Strategic%20Health%20Development%20Plan%20II_2018-2022_1661872868.pdf
34 National Strategic Health Development Plan II
35 BEmONC facilities constitute 30 to 40 percent of PHCs.
36 This indicates facilities that meet adaptive service readiness criteria by Nigerian Minimum Standards for Primary Healthcare including servicing a population of 10-
20,000 Nigerians having been equipped amongst other things with good infrastructure, at least two delivery rooms, an in-patient ward, maternity ward, laboratory,
and pharmacy and 4 nurses/midwives, 4 Community Health Extension Workers and 6 Junior Community Health Extension Workers.
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medical response in rural areas by addressing transportation barriers. In addition, the BHCPP includes plans for workforce
strengthening, including investments in training curricula, to address personnel gaps and improve competency and skills.
The BHCPP will leverage digital health to create an integrated ecosystem and supports the development of a digital
backbone, ensuring interoperability and data exchange.
28. The BHCPP will be managed through a SWAp that pools government financing with available funding from all
stakeholders to address fragmentation, increase alignment, and improve efficiency in health systems financing and
service delivery. The vision aims to align the government at all levels and its partners incrementally around a “one plan,
one budget, one M&E” framework, driving a single, nationally led conversation and actions aimed at achieving Nigeria’s
health sector aspirations, notably on reducing maternal and newborn mortality. The adoption of a SWAp demonstrates a
concerted effort to bolster institutional capacity in the health sector, including in the National Primary Health Care
Development Agency (NPHCDA), the National Health Insurance Authority (NHIA), and their respective state counterparts.
The BHCPP acknowledges the accountability challenges that span multiple levels—federal to state, state to LGA, and state
to provider—and are actively being addressed to ensure a robust and responsive health system under the SWAp
framework.
29. PforR Program financing will total US$570.01 million comprising of concessional financing from the International
Development Association (IDA) plus grant financing from other development partners. The GFF multi-donor trust fund
for Women, Children, and Adolescents is a country-led multistakeholder partnership housed at the World Bank that
supports investments to scale up coverage of essential health services at the community and primary care levels, enhance
service quality and resilience, and support health system redesign and innovation. The GFF grant of US$50.00 million will
be allocated to disbursement-linked indicators (DLIs) supporting primary healthcare service delivery capacity;
improvements in health policy, financing, and PFM; and increased utilization of primary healthcare services. In addition,
the GFF will also provide two grants from the Joint Financing Window in the amounts of US$10.67 million from the
Children’s Investment Fund Foundation (CFF) and US$9.35 million from the United Kingdom Foreign Commonwealth and
Development Office (UK-FCDO).
B. Theory of Change
30. The HOPE-PHC Program will support the government’s program through its focus on strengthening the primary
healthcare system to deliver good-quality essential health services and improve resilience. The HOPE-PHC Program
will focus especially on improving the quality and utilization of core RMNCAH-N services needed to substantially reduce
maternal and under-five mortality in Nigeria, building on the government’s primary healthcare reform agenda to address
a series of interrelated challenges: (a) on the supply side, poor quality of care with particular attention to weaknesses in
facility readiness, commodity availability, and supply chain management; (b) on the demand side, limited demand for
and utilization of essential services with considerable inequities, due in part to weaknesses in the community-based
health workforce; and (c) the twenty-first century threats of climate change and health emergencies as key risk
multipliers.
31. The HOPE-PHC Program is built around three key results areas: (1) improving quality of services; (2) improving
utilization of essential services; and (3) improving the resilience of the health system. Figure 2 outlines a theory of change
that connects these challenges with the HOPE-PHC Program’s results areas and activities, outputs, intermediate
outcomes, and impact. The DLIs represent key reform areas undertaken by both the federal and state governments to
drive progress toward program impact. Arrows highlight the intended synergistic impact of the HOPE-PHC Program
design, with key focus areas encompassing interventions to strengthen the supply side, including quality improvements;
measures to improve and strengthen demand for and utilization of essential services at the community, primary, and
secondary levels; and steps to strengthen resilience. The expected outcome is increased coverage of good-quality
essential health services, with the ultimate impact of substantially reducing mortality rates. Key assumptions underlying
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the theory of change include sustained political commitment, broader government and economic stability, and
continued development partner support for the SWAp modality.
Figure 2. Theory of Change
C. PforR Program Scope
32. HOPE-PHC supports key activities of all sub-components of the BHCPP spanning community-based health services,
primary healthcare delivery, vulnerable group/special intervention financing for select secondary services and medical
and public health emergency preparedness and response (EPR) systems, operationalizing a service delivery model that
mirrors the “hub-and-spoke” structure of Nigeria’s healthcare system. All results incentivized by the PforR are part of
the BHCPP. Table 1 below demonstrates the alignment between HOPE-PHC and the BHCPP. Table 2 clarifies the financing
for the HOPE-PHC Program. The HOPE-PHC Program will include: (a) primary healthcare service readiness, availability, and
quality in the NPHCDA and its counterpart State Primary Health Care Development Agencies (SHPDAs) to enable receipt
of DFF from the BHCPF; (b) strategic purchasing for maternal and child health, administered by the NHIA and the State
Social Health Insurance Agencies (SSHIAs) through general hospitals managed by the State Ministries of Health; (c) health
security functions delivered by the Nigeria Center for Disease Control and Prevention (NCDC); (d) a National Emergency
Services and Ambulance Scheme (NEMSAS); (e) digital-in-health to strengthen information systems and HRH; (f) medical
industrialization; and (g) citizen engagement.
Table 1. Scope of Government Program and PforR Program
Government’s Basic Healthcare PforR Program Reasons for Non-Alignment
Provision Program
Objective Improve population health outcomes Improve utilization of quality Improve health outcomes over the
through strengthened primary essential healthcare services and longer term, building on
healthcare systems. health system resilience.
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strengthened primary healthcare
systems.
Duration 2024–2028 2024–2028 Aligned. HOPE-PHC will support the
initial phase of implementation of
government program.
Geographic coverage National States that express interest and Aligned
meet HOPE-GOV and HOPE-PHC
eligibility criteria (EC).
Results areas Provide financing, enhance access to Results Area 1: Improving Quality This is aligned with the focus of the
essential health services, improve of Services Basic Healthcare Provision Program
quality of care, strengthen Results Area 2: Improving and the PforR’s focus on health
governance, enable a high-performing Utilization of Essential Services systems strengthening, service
health workforce, and strengthen Results Area 3: Improving readiness and improved service
institutions, partnerships, and Resilience of the Health System delivery.
community engagement.
Overall Program US$3.67 billion US$525.00 million
Financing
Investment Project US$45.01 million
Financing
US$570.01 million
Table 2. Program Financing
Source Program IPF amount % of IPF Total
Amount (US$
millions)
IDA Credit 460.51 39.47 87.67%
GFF 46.05 3.95 8.77%
GFF Nigeria Joint Financing (CIFF) 9.83 0.84 1.87%
GFF Nigeria Joint Financing 8.60 0.74 1.63%
(FCDO)
Total Program Financing 525.0 45.01 100
Results Area 1: Improving Quality of Services
(US$177.5 million, of which IDA US$155.7 million and Grant US$21.8 million)
33. This results area aims to improve service delivery by expanding the availability of PHC and CEmONC facilities that
meet minimum criteria to deliver essential primary healthcare services and secondary obstetric and infant care. The
HOPE-PHC Program interventions under this results area allow for a progressive increase in the number of well-staffed,
well-equipped, and climate-resilience BEmONC and CEmONC facilities in underserved and rural areas.
34. The CEmONC facilities will be empaneled by the NHIA, effectively accrediting them for reimbursement of eligible
services provided to the target population. This will help to ensure the availability of lifesaving commodities in required
amounts, including family planning supplies, which are essential to reduce neonatal and maternal mortality, as they
decrease the number of high-risk births, increase birth spacing, and delay first births. In addition, effective RMNCAH-N
services require the availability of other commodities, such as oxytocics, antimalarials, rapid diagnostics, nutrition
commodities, and vaccines. The HOPE-PHC Program will ensure that domestic resources are guaranteed in the budget to
allow for uninterrupted access to lifesaving commodities and will support facilities to address stockouts by measuring the
availability of tracer commodities across the priority RMNCAH-N disease areas.
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Results Area 2: Improving Utilization of Essential Services
(US$272.5 million, of which IDA US$239.0 million and Grant US$33.5 million)
35. This results area will support the NHIA to facilitate the enrollment of beneficiary populations by SSHIAs. The
government made health insurance mandatory in 2022 through the revision of the NHIA Act, but full implementation will
require significant public financing to ensure financial risk protection for targeted beneficiaries. Enrollment in the NHIA
gateway of the BHCPF has been hampered by an inability to identify the beneficiary population and by the lack of
appropriate technology to facilitate seamless enrollment. SSHIAs will be incentivized to adopt enhanced identification and
enrollment protocols and report enrollment figures to the NHIA portal. The IPF component, described in detail in Annex
7, will provide TA to enhance the operationalization of SSHIAs.
36. Global experience has highlighted the strategic role of community health workers (CHWs) in delivering health
services, especially in contexts where mistrust exists between service users and the formal health system. This results
area leverages CHWs to provide critical frontline services, such as: (a) providing micronutrient powders or small-quantity
lipid-based supplements to prevent malnutrition; (b) monitoring growth and screening for acutely malnourished children;
(c) identifying and following up with pregnant women and referring them to receive multiple micronutrient supplements
(MMS); and (d) treating childhood illnesses, such as diarrhea, rapid breathing, and fever through the use of Integrated
Community Case Management. The CHWs are also able to link beneficiaries to available emergency medical services (EMS)
in the community, allowing for quick referrals to secondary/CEmONC facilities. The HOPE-PHC Program leverages the
HOPE-GOV operation to address gaps in financing, policy, and legal frameworks for CHWs.
37. This results area will support critical interventions to address maternal and neonatal mortality by ensuring free
hospital admissions for emergency obstetric and neonatal care for pregnant women and newborns. In Nigeria, large
socioeconomic inequalities exist in RMNCAH-N services. The 2018 National Demographic and Health Survey (NDHS)
showed that only 12 percent of deliveries in the poorest wealth quintile had skilled birth attendants, compared to 87
percent in the wealthiest quintile. Moreover, fewer than 3 percent of pregnant women utilize CEmONC services for
delivery. There is a critical need to provide public financing for catastrophic but cost-effective maternal, newborn, and
child health interventions by ensuring the reimbursement of services utilized by the beneficiary population.
38. To support improvements in health outcomes, this results area aims to improve the quality and utilization of
maternal and child health services at the PHC level. It will focus on the priority interventions listed in the benefit package
agreed by the NPHCDA and NHIA in the planned revision of the BHCPF guidelines, including family planning, antenatal
care (ANC), safe delivery, postnatal care, nutrition services, treatment of pneumonia and diarrhea, and malaria treatment
for children under five.
39. Increasing the utilization of EMS among pregnant women and newborns is crucial, as delays in accessing
appropriate healthcare in the case of pregnancy complications and poorly managed deliveries have been linked to high
maternal mortality. This results area aims to enhance the utilization of quick and prompt EMS, referral, and transport of
complicated deliveries in community/BEmONC facilities requiring CEmONC care and advanced neonatal resuscitation for
newborns. It will also facilitate the scale-up of a digitally enabled ambulatory health service to improve sustainability and
dispatch times for ambulatory health services more generally.
Results Area 3: Improving Resilience of the Health System
(US$75.0 million, of which IDA US$65.8 million and Grant US$9.2 million)
40. This results area will seek to increase the equitable allocation and disbursement of the BHCPF. Given the notable
disparities in utilization of health services between urban and rural areas, with rural residents of the North-West and
North-East geopolitical zones facing the highest risk of under-five and maternal mortality, prioritizing the deployment of
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scarce resources to such areas can secure rapid improvements in health outcomes. A responsive BHCPF guideline that
incorporates this targeted approach will increase access to essential healthcare services and improve the chances of
survival for vulnerable populations. Revision of the BHCPF is a prior result under the HOPE-PHC Program.
41. Enhancing the health system’s resilience against shocks such as disease outbreaks, climate emergencies, and other
humanitarian crises is a critical part of safeguarding access to and delivery of essential health services. This results area
will further improve the containment of emergencies and shocks to the health system by ensuring that states are better
prepared to mitigate health system vulnerabilities through the development and implementation of multiyear EPR plans.
In addition, it will support the development and implementation of a costed national climate and health adaptation plan
to be adopted by subnational entities and incentivize implementation of the plan at both the national and state levels.
42. Finally, this results area will support the development of an integrated, interoperable health data ecosystem to
support evidence-based improvements in value (efficiency, quality, access, and health outcomes) for patients and
providers. Learning from other countries and customizing solutions to fit the Nigerian context, this results area aims to
lay a strong digital foundation by strengthening national standards, regulations, rules, and business processes for creating
and maintaining a national health data space through a distributed enterprise architecture approach, and to facilitate the
adoption and effective functioning of the health data ecosystem at the state level by integrating individual private, public,
and program-specific health information systems.
E. Program Development Objective (PDO) and PDO Level Results Indicators
43. The Program Development Objective (PDO) is “to improve utilization of quality essential healthcare services and
health system resilience in the Federal Republic of Nigeria.” Four PDO-level indicators align with the PDO’s emphasis on
quality and utilization of primary and priority secondary healthcare services and resilience of health systems (Table 4).
Table 3. PDO Indicators
Elements of PDO
PDO Indicator Improving utilization of Improving resilience of
quality essential services the health system
Women and children who receive tracer essential health services in the ✓
community increased (number)
PHC facilities achieving service readiness assessment criteria ✓
(percentage)
National climate and health adaptation plan developed, costed, ✓
validated, and implemented (number)
Proportion of births attended by a skilled provider (percentage) ✓
F. Disbursement-Linked Indicators and Verification Protocols
44. The HOPE-PHC Program will incentivize the achievement of DLIs in each of the three results areas. DLIs are chosen
based on key principles: (a) incentivizing a mix of DLIs across the results chain; (b) placing a heavier weighting on service
outputs and direct drivers of health outcomes; (c) reducing the complexity of results measured;(d) limiting the number of
DLIs; (e) linking to data sources and standardized measurement approaches; (f) ensuring the scalability of DLIs, where
relevant; and (g) adopting continuous rather than periodic verification cycles. The DLIs include a combination of outcomes,
intermediate results, and outputs (Annex 1). Allocations against the DLIs will allow for regular disbursement flow
throughout the HOPE-PHC Program period. Annex 1 provides more detail on each of the DLIs, including whether they are
timebound and scalable, and corresponding verification protocols.
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45. HOPE-PHC Program will disburse based on the achievement of eleven DLIs identified and pre-agreed with the
FMOH&SW and its agencies, states, and health partners. For each DLI, yearly targets (disbursement-linked results, or
DLRs) are defined, against which a “price” will be paid. Each DLI price represents a combination of strategic importance,
ambition, and feasibility of achieving the DLRs, but not the cost of achieving them. Prior results will be non-scalable. From
Year 1, most results will be scalable, and any time the results are met fully or partially, disbursement will be made in
proportion to the achievement of the DLR. A summary of DLIs proposed under the HOPE-PHC is captured in Table 4 below.
Table 4. Summary Table of DLIs Across Results Areas
DLI DLI IDA DLI Grant Recipient Scalable Time-Bound
Amount Amount DLI Unit
(US$) (US$)
Results Area 1: Improving Quality of Services
DLI 1: DLR 1.1: Improved primary 53.95 7.55 States Yes Yes
Improved healthcare facility readiness, quality,
service and climate resilience in
readiness Participating States (percentage)
DLR 1.2: Increased empanelment 50.88 7.12 States Yes Yes
and refurbishment of CEmONC
facilities that demonstrate service
readiness and climate resilience and
energy efficiency (number)
DLI 2: DLR 2.1: Federal expenditure on 21.93 3.07 Federal Yes Yes
Increased quality family planning commodities
availability of increased (percentage)
essential DLR 2.2: Frontline availability of 28.95 4.05 States Yes Yes
commodities tracer products improved in
Participating States (percentage)
Results Area 2: Improving Utilization of Essential Services
DLI 3: DLR 3.1: Financial protection for 35.09 4.91 States Yes Yes
Increased poor and vulnerable populations
enrollment of increased in Participating States
poor and (number)
vulnerable
populations
DLI 4: DLR 4.1: Women and children who 43.68 6.14 States Yes No
Enhanced receive tracer essential health
community services in the community increased
delivery of in Participating States (number)
health services
DLI 5: DLR 5.1: Secondary Facility Quality 2.19 0.31 Federal No Yes
Increased of Care for CEmONCs (Prior Result)
utilization of DLR 5.2: Women and neonates 61.40 8.60 Federal Yes No
priority receiving CEmONC and neonatal
secondary care services and/or vesico-vaginal fistula
services surgeries (number)
DLI 6: DLR 6.1: Deliveries with skilled birth 30.70 4.30 States Yes No
Increased attendant present increased in
Primary Participating States (percentage)
Healthcare DLR 6.2: Introduction of MMS for 17.54 2.46 States Yes No
utilization of pregnant women during antenatal
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priority care in Participating States
services (percentage)
DLR 6.3: Increase in Penta 3 30.70 4.30 States Yes No
coverage in Participating States
(percentage)
DLI 7: DLR 7.1: Patients with obstetric and 17.54 2.46 States Yes No
Increased neonatal complications transported
utilization of through emergency medical
emergency transport to selected facilities using
medical the digitized EMS dispatch system
services (number) in Participating States
(number)
Results Area #3: Improving Resilience of the Health System
DLI 8: DLR 8.1: Governance for improved 2.19 0.31 Federal No Yes
Improved resource allocation and
allocation and performance (Prior Result)
disbursement DLR 8.2: Participating States 8.77 1.23 States No Yes
of BHCPF funds receiving funds in compliance with
allocation formula in revised
guidelines (number)
DLI 9: DLR 9.1-9.4: System and standards 13.16 1.84 States Yes Yes
Enhanced for state EPR programs are
pandemic established (number)
preparedness
and response
(PPR) through
deployment
DLI 10: DLR 10.1-10.4: Climate and health 26.32 3.68 States Yes Yes
Improved adaptation plan developed, costed,
climate and validated (number)
resilience
DLI 11: DLR 11.1: National enterprise 2.19 0.31 Federal No Yes
Stronger digital archtecture developed, costed, and
foundation adopted (Prior Result)
DLI 11.2: Participating States 13.16 1.84 States No Yes
adopting national enterprise
architecture and integrating core
health functions (number)
TOTAL 460.53 64.47
Eligibility Criteria (EC) for States
46. The annual EC for States are intended to strengthen interdependencies between pursuit of governance actions
under HOPE-GOV, such as enhanced preparation and transparency of the basic elements of the budget cycle and
sectoral planning through the Annual Operational Plans. Participation in HOPE-PHC will be contingent upon States’
participation in HOPE-GOV demonstrated in the achievement of annual EC. HOPE-GOV EC build on EC initially introduced
by the States Fiscal Transparency, Accountability and Sustainability (SFTAS PforR; P162009) and already being practiced in
all 36 states and the Federal Capital Territory (FCT). HOPE-GOV EC include annual preparation and publication of the
budget prepared in accordance with the Chart of Accounts and approved by the State Assembly; annual preparation and
publication of audited financial statements in accordance with IPSAS; and annual publication of quarterly budget
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implementation reports on primary healthcare within 30 days of the end of the quarter. For HOPE-PHC, additional criteria
will include the preparation of sectoral Annual Operational Plans that translates the BHCPP into short-term operational
plans; maintenance of BHCPF State Oversight Committees and implementation of Funds Release Policies which strengthen
re-investment of DLI proceeds in the health sector.
Table 5. States’ Eligibility Criteria (EC) for HOPE-PHC
Year 1 – 2025 Year 2 – 2026 Year 3 - 2027 Year 4 - 2028
EC-GOV Participation in and Participation in and Participation in and Participation in and
achievement of Annual EC achievement of Annual EC achievement of Annual EC for achievement of Annual EC for
for HOPE-GOV for HOPE-GOV HOPE-GOV HOPE-GOV
EC-1 State Annual Operational State Annual Operational State Annual Operational Plan State Annual Operational Plan
Plan that aligns with the Plan that aligns with the that aligns with the goals of that aligns with the goals of
goals of the sector wide goals of the sector wide the sector wide approach as the sector wide approach as
approach as articulated in approach as articulated in articulated in the signed articulated in the signed
the signed health compact the signed health compact is health compact is approved health compact is approved
is approved by the SWAp approved by the SCO. by the SCO. by the SCO.
Coordinating Office (SCO).
EC-2 State revises the terms of State maintains composition State maintains composition State maintains composition
reference and composition and functioning of the State and functioning of the State and functioning of the State
of the BHCPF State Oversight Committee in Oversight Committee in Oversight Committee in
Oversight Committee. accordance with the revised accordance with the revised accordance with the revised
terms of reference. terms of reference. terms of reference.
EC-3 State adopts and signs
Funds Release Policy for
management of PforR
earnings.
III. PROGRAM IMPLEMENTATION
A. Institutional and Implementation Arrangements
47. The table below outlines the institutional and implementation arrangements for HOPE-PHC, including linkages to
HOPE-GOV through joint governance arrangements:
Table 6. HOPE-PHC Institutional and Implementation Arrangements
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RESPONSIBLE ENTITY COMPOSITION ROLES AND RESPONSIBILITIES ACCOUNTABILITIES
HOPE INTER-MINISTERIAL • Co-Chaired by Coordinating • Responsible for providing high- • Realization of HOPE
NATIONAL STEERING Minister of Health and Social level guidance, advice, and interdependent
COMMITTEE (NSC) Welfare (CMHSW)/Minister of strategic oversight on the series of operations
Budget and Economic HOPE interdependent series of contribution to the
“Joint inter-ministerial Planning/Minister of operations, with functions, as HCD vision of the
steering committee at the Education. further detailed in the POM. Government of
federal level (the “National • Also, include as members the • Guardian of rules for the HOPE Nigeria.
Steering Committee” or minister responsible for SOPs.
“NSC”)” finance, and any other relevant • Adoption of government wide
ministries and subnational Human Capital Development
entities, as further detailed in (HCD) policies.
the POM. • Setting and achieving of HCD
reforms agenda.
SWAp STEERING SSC shall be chaired by the • Approving policy and strategic • The investments and
COMMITTEE minister responsible for health direction for the NHSRII. other
and social welfare and includes as • Defines the health sector projects/programs
members the Minister of State priorities, convenes relevant are aligned to
“Steering committee at the for Health, the representative of entities, provides steer and national priorities
federal level (the “SWAp the Minister of Finance, the direction to all SWAp bodies on and state’s demands
Steering Committee” or Permanent Secretary for Health strategies recommended by as articulated in the
“SSC”) responsible for (PSH), relevant heads of agencies them. NHSRII.
providing strategic sectoral of the FMOH&SW, selected • Approve POM including Standard
oversight with functions, members of the Development Operating Procedures (SOPs).
composition and resources Partners Group for Health (DPG- • Administrative approval of IPF
detailed in the Program Health), and other members proposals under the project.
Operations Manual (POM)”. nominated by the CMHSW, as • The SSC will be ultimately
further detailed in the POM. responsible for achieving the
HOPE-PHC PforR PDOs through
the achievement of DLI results.
NPCU/SCO • The NPCU shall be headed by a • Day-to-day operations and • Attaining the PDO-
national coordinator. overall coordination of the level and
“Coordination unit for the • Include specialists in program project. intermediate-level
operation (the “National management, procurement, • Planning, budgeting, and indicators
Program Coordination Unit” financial management (FM), reporting.
or “NPCU”) within the SWAp environmental and social • Serving as the secretariat of the
Coordination Office, with matters, communications and SSC.
functions, composition, and such other specialist as may be • Monitoring and coordinating the
resources detailed in the specified in the POM, all with implementation of the Program
POM. qualifications, experience, and in line with guidance from the
ethics, and subject to the SSC.
terms of reference acceptable • Implementing the Project with
to the Bank, as further defined responsibilities including but not
in the POM. limited to FM, procurement,
environmental and social, M&E,
and communications, as further
defined in the POM.
STATE BHCPF OVERSIGHT • Chaired by Commissioner of • Coordination between state • Ensuring that the
COMMITTEE. Health responsible for the government and NPCU. investments conform
State health system. • Technical approval for State to national
“Based on a revised terms of • Membership includes technical Annual Operational Plans. standards.
reference and composition experts from relevant state • The BHCPF SOCs shall be • M&E of Program
of the BHCPF state oversight departments. responsible for providing indicators
committee (the “State • Includes state-based DPG- technical oversight and
Oversight Committee” or Health members. implementation monitoring to
“BHCPF SOC”) to • Meets at least quarterly ensure that critical actions are on
accommodate membership
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RESPONSIBLE ENTITY COMPOSITION ROLES AND RESPONSIBILITIES ACCOUNTABILITIES
from the State Ministry of track towards the achieving of
Finance; Budget and the DLIs in participating states as
National Planning; office of applicable, all as further specified
the state accountant in the POM.
General and any other • Day-to-day operations and
entity. overall coordination of the
project.
• Planning, budgeting, and
reporting.
B. Results Monitoring and Evaluation
48. The HOPE-PHC Program’s M&E framework will rely on multiple data sources, with an emphasis on supporting and
strengthening existing information systems. Program monitoring will take place across the federal, state, health facility,
and community levels and will be anchored by the SCO’s M&E Technical Working Group (TWG). At the federal level, the
NPCU working with FMOH&SW Department of Health, Planning, Research, and Statistics and the NPCU will be responsible
for developing and publishing the annual State of Health Report, which will include a state performance index to support
both equitable and needs-based allocation of the BHCPF and broader data-driven decision making. At the state level, M&E
will draw on administrative data from the District Health Information System 2 (DHIS-2) and other national surveys to
assess service coverage and utilization. NDHS data (and likely mini-DHS) will be used to assess skilled birth attendance;
and the Multiple Indicator Cluster Survey (MICS) and mini-MICS for immunization coverage, with the possibility of a mid-
term “mini-DHS” in 2026. Where available, surveys will be leveraged to triangulate results. Quality assessment and
supportive supervision checklists, health facility surveys, and essential medicine assessments will also be used for progress
monitoring and DLI achievement verification. Sample-based approaches will be used for facility readiness, commodity
stock, and other relevant data collection, particularly where there is risk of gaming. The performance monitoring system
will capture data on shocks (climate-related or others) that may affect service delivery. A detailed overview of the HOPE-
PHC Program’s results framework and DLIs are found in Annex 1, including detailed descriptions of verification protocols.
49. Lessons from previous PforRs in the sector suggest relying on more routine systems with data quality assurance and
verification adjustments to assess performance and make payments against results. Innovative methods to estimate
service contact coverage will therefore be explored, including service coverage estimations for high-volume services using
rigorous data quality assessment processes to derive quality-adjusted DHIS-2 estimates (following validated approaches
from the Countdown to 2030 collaboration and the GFF’s Frequent Assessments and Systems Tools for Resilience (FASTR)
initiative).
50. The HOPE-GOV NPCU will competitively recruit a third-party Independent Verification Agency (IVA), on terms of
reference acceptable to the World Bank. The IVA will verify the achievement of DLRs in accordance with the approved
verification protocol and work closely with the National Bureau of Statistics, M&E experts at the Federal Ministry of Budget
and Economic Planning (FMBEP) NPCU and FMOH&SW NPCU/SCO. Full details of the protocol will be included in the POM.
The IVA will be tasked to verify the achievement of the DLI targets based on data reported by the implementing agencies
and other information sources identified in the protocol. The IVA procurement will be an eligible expenditure under the
HOPE-PHC; however, the procurement process will be done under the HOPE-GOV within sixty days of the Program’s
effectiveness.
C. Disbursement Arrangements
51. Disbursements will be made based on the achievement of results under each DLI. The government will partly pre-
finance expenditures for the HOPE-PHC Program, using its own budget resources through the identified budget lines of
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the Program Expenditure Framework (PEF). The implementing entities will prepare technical reports to document the
achievement of DLIs, to be verified by the designated IVA. Upon verification, the NPCU/SCO will communicate the
achievement of DLIs and corresponding DLI values to the World Bank, along with supporting documents. For payments to
states, the NPCU/SCO will submit a Results Achievement Note to the World Bank, along with supporting documentation.
Once the World Bank agrees with the results achieved, it will provide a written request to the NPCU to prepare a
withdrawal application. Upon notification of acceptance of the verification report by the World Bank, the NPCU will submit
the withdrawal application to the World Bank, using its Client Connection System’s e-disbursement functionality. The
proceeds of the IDA credit and trust fund grants under the HOPE-PHC Program will be disbursed to the government’s
Special Fund Account, a subaccount of the Treasury Single Account held with the Central Bank of Nigeria (CBN) and
managed by the FMOH&SW NPCU. Disbursement to participating states will be made directly from the Special Fund
Account to a segregated HOPE-PHC Program account to be opened in each state, which will be a sub-account of the
consolidated revenue fund account of the respective states and from which disbursements will be made to the
implementing agencies according to the Funds Release Policy adopted by participating states.
52. There will be an advance equivalent up to 30 percent of the total value of DLI 1.1, 1.2 and 5.2, totaling US$55 million.
The advance is necessary for the implementation of activities to achieve DLIs in the initial years, benefitting activities with
longer lead times (such as capital investments). When the DLIs are achieved, the advance amount will be deducted
(recovered) from the amount due to be disbursed and will be available again on a rolling basis, as requested by the
government.
53. Prior results (DLIs 5.1, 8.1, and 11.1) are expected to be achieved before the HOPE-PHC Program’s legal agreements
are signed. Combined with the achievement of prior results, estimated at US$7.5 million, the total disbursement upon
effectiveness is expected to be US$62.5 million (not more than 30 percent of IDA financing), within the PforR’s allowed
threshold.
D. Capacity Building
54. Capacity building support will be critical to achieving the transformational results envisaged under the NHSRII.
Through its IPF component, the HOPE-PHC Program will support sector-wide efforts for: coordinated deployment of
needs-based and demand-driven TA and diagnostic support. The coordinated TA mechanism will be financed by
development partners and managed by the SCO. Furthermore, in recognition of pronounced geographical spatial
disparities and inequalities associated with poor health outcomes, the program will provide additional TA under the IPF
component to states with the worst health outcomes in Nigeria.
55. An IPF component (US$45.01 million) will largely finance TA designed to enhance states’ performance. The design,
procurement, and deployment of a federated digital-in-health enterprise architecture including TA on enhanced digital
capacity, including37 consultancies on defining regulatory frameworks, enterprise architecture design, and acquisition; TA
for strengthening the strategic purchasing and regulatory functions of NHIA including institutional building blocks for
provider empanelment, tariffs, claims management, medical audit, provider payment, beneficiary feedback and
engagement of third-party administrators, and support for standards adoption by SSHIAs; effective peer learning support
through the Nigeria Governor’s Forum and Association of Local Governments of Nigeria for intensive engagement with
leaders at the subnational level to maintain strong political support and commitment. The IPF component will also
enhance service delivery capacity in high-burden and climate-vulnerable states who may face institutional, financial
and/or delivery capacity constraints through innovations deployed in partnership with public or private sector actors
under the umbrella of Maternal Mortality Reduction Innovations Initiative (MaMII). The IPF component will also contribute
to the Joint Health Development TA coordination platform. See Annex 7 for IPF component details.
37 Due attention will be paid to avoiding the fragmentation of IT-enabled platforms and encourage consolidation while developing digital innovations.
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56. Retroactive Financing. The IPF component will include retroactive financing as follows: (a) regarding the credit, up to
an aggregate amount not to exceed US$877,170 may be made for payments made prior to but not more than twelve (12)
months before the Signature Date of the Financing Agreement for Eligible Expenditures specified in the Financing
Agreement; and (b) with respect to the GFF grant, up to an aggregate amount not to exceed US$122,830 may be made
for payments made prior to but not more than twelve (12) months before the Signature Date of the GFF Grant Agreement
for Eligible Expenditures specified in the GFF Grant Agreement.
57. The World Bank will provide additional TA to develop and implement an operational impact and learning agenda
linked to the PDOs and government learning priorities. This process will be led by the Development Impact (DIME) Group
at the World Bank, in collaboration with partners. DIME will support the government in using “trial-and-adopt” impact
evaluations to increase effectiveness and cost-effectiveness, working to: (a) embed existing knowledge in the design of
programs/interventions; (b) test alternative intervention designs and delivery modalities to identify what works best in
practice and iteratively optimize design; and (c) credibly document outcomes and impacts so that effective solutions can
be adopted and scaled. The focus and scope of trial-and-adopt activities will be defined jointly with the government as
part of detailed implementation planning. This approach is consistent with the World Bank’s Knowledge Compact.
58. The Nigeria DPG-Health has been actively and extensively involved in operationalization of the SWAp and co-
creation of the NHSRII. Partners are aligned with the government’s reform imperatives, including its laser focus on
strengthening health systems and primary healthcare. Most development partners are already aligning their resources
with the requirements of the NHSRII and working through the established TWGs, with membership from the FMOH&SW
and its ministries, departments, and agencies (MDAs); subnational entities; and development partners. This effort seeks
to ensure that TA resources are deployed in a transparent manner to enable lagging states to access needed support.
ASSESSMENT SUMMARY
A. Technical (including program economic evaluation)
59. The HOPE-PHC Program is designed to target strategic health outcomes that are crucial for advancing overall
development outcomes in Nigeria. Primary healthcare system strengthening, as supported by the HOPE-PHC Program, is
one of the most cost-effective approaches to improving human capital outcomes through the health sector and generates
significant economic benefits.38 Specifically, improvements in maternal and child survival are crucial if Nigeria is to improve
its HCI. Nigeria’s efforts to reduce child mortality and improve maternal health contribute to SDG 3, which aims to ensure
healthy lives and promote well-being for all.
60. The HOPE-PHC Program will enhance the capacity of primary healthcare facilities in Nigeria to deliver high-quality
health services in line with global recommendations. The investment in facility readiness encompasses efforts to improve
infrastructure, train staff, and secure necessary medical supplies and equipment, all of which are critical for delivering
quality of care. Furthermore, the HOPE-PHC Program will increase the availability of funding at the frontline to respond to
specific needs and challenges. Focusing on quality in healthcare delivery is of paramount importance, as highlighted by
the Lancet Commission on High-Quality Health Systems, which emphasizes that access to care alone is insufficient; the
quality of care is equally crucial for achieving positive health outcomes, including ensuring the availability of and
sustainable financing for high-quality drugs and commodities at facilities. Dependence on development partners for
critical commodities, such as contraceptives, risks supply chain disruptions due to the unpredictability of funding.
Increases in domestic resources for key drugs and commodities over time through the recurrent budget will align with the
38WHO. 2018. “Building the economic case for primary health care: a scoping review.” https://www.who.int/docs/default-source/primary-health-care-
conference/phc---economic-case.pdf
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aims of the SWAp. Moreover, strengthening supply chain management will not only support the provision of a basic
package of services, but also have spillover effects to help build a climate- and emergency-resilient health systems.
61. The HOPE-PHC Program’s basic package of interventions is designed to be delivered primarily at the primary
healthcare level, ensuring that foundational healthcare is accessible to all. To ensure the most effective allocation of
resources given the limited resource envelope, the HOPE-PHC Program will be guided by global and national evidence,
including Disease Control Priorities. The package will focus predominantly on RMNCAH-N, aligning with the national
commitment to reduce maternal and child mortality. The full scope of services extends beyond primary healthcare
facilities, incorporating crucial community-level interventions on health promotion, disease prevention, and simple
curative measures. In scenarios where access to health facilities is severely limited, the services provided at the community
level may be expanded beyond the core package to include essential curative care to improve health outcomes across all
segments of the population.
62. In settings where health services are underutilized, it is crucial to actively foster demand for these services. This is
particularly important for essential health services, such as family planning and ANC, which are often underutilized despite
their significance in improving health outcomes. Demand generation activities are most effective when implemented at
the community level, leveraging existing community-based service delivery mechanisms that are already trusted by the
local population. The HOPE-PHC Program will support investments to enhance the effectiveness of current community-
based service delivery platforms. To achieve this, the HOPE-PHC Program will adopt a “hub-and-spoke” model designed
to strengthen links between PHC facilities and community health actors, such as Community Health Officers, Community
Health Extension Workers (CHEWs), and auxiliary CHWs.39 The HOPE-PHC Program also places a high priority on the
professional development of community health actors, offering training opportunities to enhance their skills and ensure
that the quality of services provided at the community level meets the high standards necessary for improving health
outcomes. Through these strategic interventions, the HOPE-PHC Program aims to build a more resilient and responsive
health system at the grassroots level.
63. Ensuring that every Nigerian pregnant woman and newborn has access to lifesaving care at the CEmONC level is
necessary to reduce maternal and newborn mortality. The HOPE-PHC Program will focus on refurbishing, accrediting,
and empaneling at least one public or private CEmONC facility per LGA and will support improvements in the structural
and process quality of Tier 2 PHC facilities, in line with the revised emergency obstetric and neonatal care guidelines of
the World Health Organization (WHO), to ensure the availability of BEmONC services that can refer women and babies to
CEmONC, as needed.
64. Strengthening PHC systems is not only vital for immediate health outcomes, but also a means to create positive
spillovers for the broader resilience agenda. Strong primary healthcare systems form the backbone of effective PPR,
ensuring that communities are better equipped to handle public health emergencies. Resilient primary healthcare systems
are more adept at adapting to and addressing the emerging health needs brought about by climate change, thereby
safeguarding the well-being of populations against a spectrum of environmental challenges.
65. The HOPE-PHC Program has a strong economic rationale. Many services provided in the primary care setting have
public good or externality dimensions, including infectious disease treatment and maternal and child health services.
Moreover, primary care interventions such as family planning, ANC, immunization, and nutrition services are generally
more cost-effective (with a greater health impact per Naira spent) than secondary and tertiary care. Because of the high
value attached to better health (both intrinsically and as an investment in human capital), the benefit–cost ratio of
effective government health spending is favorable. Simulations suggest that a ratio of over 20:1 is possible. In addition,
the focus on governance and accountability, especially in the interdependent HOPE-GOV operation, can help mitigate
potential “government failure” issues that may beset healthcare delivery, helping to ensure greater impact. While BHCPP
39 CHEWs/CHOs are formally trained health workers.
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investments have recurrent budget implications for federal and state governments, Nigeria is among the world’s lowest
health spenders, such that increased (and more effective) spending is to be welcomed and can be managed. Given the
very low baseline (government spending on primary care is about 0.1 percent of GDP), even significant proportional
increases would not pose a risk to overall public finances. Moreover, increased PHC spending can be partly achieved by
reallocations away from less effective secondary and tertiary care. Finally, public primary care facilities and community
health service delivery platforms operate close to the population and thus represent the most pro-poor segment of the
government’s delivery network. These issues are discussed further in Annex 2.
Paris Alignment
66. The HOPE-PHC Program is consistent with the Paris Agreement on climate change. The HOPE-PHC Program’s service
delivery activities are anticipated to be vulnerable to storm surges, increasing temperatures, and floods, and measures to
build resilience to these shocks are embedded throughout activities to achieve the DLIs. On adaptation, through national
climate structures, execution of World Bank-financed HOPE-PHC Program, and climate-change-focused health structures,
including the FMOH&SW’s Office of Climate Change and Environmental Health and the Climate Change and Health TWG,
the Government has demonstrated capacity to execute resilience measures to achieve the HOPE-PHC Program’s results.
Climate EPR plans, including planning capacity, will be developed to respond to climate emergencies, as part of DLI 9,
which will help guide climate EPR for the HOPE-PHC Program’s activities. Health service delivery interventions under
Results Areas 1 and 2 will use climate-sensitive planning and data, for example from the climate and health vulnerability
assessment, along with CHW visits and outreach visits to ensure continuity of services during climate shocks and targeted
response to the most vulnerable communities during these periods. The CHW digitization platform, financed through DLIs
4 and 11 and IPF subcomponent 2, will include climate EPR training, job aides, and a communication platform to facilitate
the use of CHWs for service continuity. PHC and CEmONC facility rehabilitation in DLI 1 will incorporate climate resilience
measures, going beyond standard practice to reduce exposure to flooding, high heat, and storm surges. DLI 7 on increased
utilization of EMS will include resilience measures, such as climate-sensitive planning, specific climate shock operating
procedures in the standard operating procedures (SOPs) for emergency transportation and ensuring that real-time
weather information is available to dispatchers to ensure service continuity. Therefore, the risks from climate hazards
have been reduced to an acceptable level, and the project is aligned with the adaptation and resilience goals of the Paris
Agreement. On mitigation, most of the HOPE-PHC Program’s activities are universally aligned with the Paris Agreement
on Climate Change. Building rehabilitation activities will incorporate energy efficiency measures, to ensure at least a 20
percent improvement in energy efficiency in comparison to current practice including EDGE level 1 certification for
CEmONC facilities.
B. Fiduciary
67. An Integrated Fiduciary Systems Assessment (IFSA) was conducted by the World Bank, reviewing PFM,
procurement, anticorruption, and relevant laws, policies, systems, practices, and procedures at the participating MDAs.
In addition to the FMOH&SW, the IFSA assessed the NPHCDA, NHIA, and a sample of state-level counterparts. The IFSA is
deemed to be adequate, carried out in line with the World Bank’s PforR Policy and Directive. The assessment concluded
that the fiduciary systems in place for procurement, financial management (FM), governance, and anticorruption provide
reasonable assurance that financing proceeds would be used for the intended purposes, subject to implementation of the
Program Action Plan (PAP) with due attention to the principles of economy, efficiency, effectiveness, transparency, and
accountability, and will support achievement of the PDO. A detailed assessment is described in Annex 3.
68. The overall fiduciary risk (FM, procurement, and governance) is rated Substantial. Key contributing factors include:
(a) use of HOPE-PHC Program funds for purposes other than those intended, which will be mitigated by adequate
verification of results by the IVA; (b) delayed appropriated releases to implementing agencies, which will be mitigated by
introducing service standards in the release of HOPE-PHC Program funds as part of the PAP and ensuring that the terms
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of reference for external auditors and IVAs include a review of the timeliness of funds released to the agencies; (c)
implementing agencies’ limited knowledge of and lack of experience with PforR operations, which will be mitigated
through training and capacity building to be financed, as needed, under the IPF component; (d) ambiguity on the HOPE-
PHC Program’s operational procedures, which will be mitigated by preparing the HOPE-PHC POM detailing procedures for
procurement, FM, anticorruption, and environmental and social (E&S) safeguards processes; (e) low procurement
capacity, leading to inefficient and non-transparent procurement, which will be mitigated by preparing and implementing
a comprehensive Procurement Capacity Development Plan for the implementing agencies based on a needs assessment
and deployment of an experienced Procurement Officer for the PforR in each implementing agency; (f) weak controls and
inadequate compliance with Public Procurement Acts and Regulations, which will be addressed through a program
procurement performance and value for money audit to be carried out by an independent third party using terms of
reference agreed with the World Bank; and (g) multiple procurement processes throughout the year for recurring items,
leading to higher costs, delays, and stockouts, which will be addressed by using a Framework Agreement for procuring
recurring items. A fiduciary risk summary is included in Annex 3.
69. The implementing agencies have a robust budget and accounts classification system that will enable reporting on
HOPE-PHC Program expenditures. The audit of the HOPE-PHC Program will be conducted by the Office of the Auditor
General for the Federation (OAuGF) and the State Auditors General for federal and state agencies, respectively. After
receiving their audit reports, the NPCU will compile program expenditure data for the federal and state participating
MDAs, extracted from the audited financial statements. The data will be certified by the OAuGF, with an opinion expressed
based on an agreed-upon procedure. The implementing agencies will strengthen their capacity to undertake risk-based
internal audits, and the FMOH&SW and other implementing agencies will prepare and implement an internal audit plan.
70. The Nigeria Public Procurement Act 2007 and associated procurement regulations and systems are adequate for
the achievement of PDOs. Federal and state-level procurement laws are based on the United Nations Commission on
International Trade Law (UNCITRAL) model, with minor differences to cater for peculiarities at the state level. The World
Bank’s Procurement Regulations will govern procurement under the IPF component. The NPCU has prepared a
Procurement Plan for the IPF component for the first 18 months with inputs from participating states. The Procurement
Plan describes each contract to be financed under the IPF, the selection methods, estimated costs, prior review
requirements, and time frame in accordance with the procurement arrangements in the Program Procurement Strategy
for Development (PPSD) acceptable to the World Bank. The Procurement Plan will be updated at least annually, or as
required, to reflect the actual project implementation needs. All procurement transactions will be executed on the World
Bank online tool, the Systematic Tracking of Exchanges in Procurement (STEP). The Procurement Plan will be updated at
least annually, or as required, to reflect the actual project implementation needs.
71. The World Bank Guidelines on Preventing and Combating Fraud and Corruption in Program-for-Results-Financing
will apply to the HOPE-PHC Program, and grievance redress mechanisms (GRM) will be implemented across all
implementing agencies. The NPCU in the FMOH&SW will consolidate the cases of fraud and corruption received from all
implementing agencies, including procurement agencies across the states, and provide a semi-annual report to the World
Bank. The report will indicate the status and outcome of any investigations and measures taken, if any; if no allegations
or actions are reported during a period, this will be indicated. Conversely, if the World Bank uncovers evidence of
corruption, it will, in line with its policies, refer the case to the Independent Corrupt Practices Commission or other
relevant agency through the FMOH&SW and the independent integrity vice presidency of the World Bank. If the World
Bank initiates an administrative review of potential fraud and corruption related to the HOPE-PHC Program, the
Government will need to ensure full cooperation from all relevant parties, including FMBEP, FMOH&SW, NHIA, NPHCDA,
SMoH, SSHIAs, and SPHCDAs. The Economic and Financial Crimes Commission (EFCC), Independent Corrupt Practices
Commission, and Nigeria Police will handle investigations of fraud and corruption. Under the HOPE-PHC Program, the
World Bank will appraise at the earliest opportunity all allegations and complaints of fraud and corruption related to HOPE-
PHC Program.
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C. Environmental and Social
72. The World Bank has undertaken and consulted on an Environmental and Social Systems Assessment (ESSA). The
ESSA concludes that policy, institutional, and legal provisions are adequate to ensure that the HOPE-PHC Program’s social
and environmental risks are minimized and its effects positive. While gaps exist, the World Bank has agreed with the
Government on specific actions to strengthen E&S management systems and mitigate potential risks as specified in the
PAP (Annex 5).
73. Overall E&S risks have been assessed as Moderate. In line with the six core principles outlined in the World Bank’s
PforR Policy, the relevant E&S risks directly associated with HOPE-PHC Program interventions that may impact the
achievement of its intended objectives are as follows: (a) refurbishment and rehabilitation of facilities could result in
negative environmental impacts, such as the generation of solid waste, noise, and air pollution; (b) discrimination could
exist in the recruitment of healthcare workers, such as skilled birth attendants; (c) generation of e-waste could increase
due to the digitization of the health system; (d) there could be an increase in the generation of healthcare waste due to
increased spending on the provision of facilities, an expansion in the number and improved quality of healthcare facilities,
and increased expenditure for provision of health products; (e) there could be discrimination against vulnerable groups,
ethnic bias, and sexual abuse or harassment of women in the provision of health insurance under the NHIA gateway in
the revised BHCPF guideline and in the provision of essential health services by CHWs; (f) negative environmental impacts
may be associated with renewable energy, such as solar systems, especially electronic waste, old batteries and panels,
and possible clearing of land/vegetation to install solar panels; and (g) rehabilitation work could affect workers’ health
and safety. The PAP outlines comprehensive measures to manage these E&S risks (Annexes 4 and 5).
74. The E&S risks of the IPF TA component are rated Low, given its minimal scope. The Environmental and Social
Commitment Plan (ESCP), which has been prepared and publicly disclosed in-country on August 21st, 2024, and August
30th, 2024, on the Bank website40 includes activities to improve labor management procedures and continuous
stakeholder engagement throughout implementation, including grievance mechanisms for direct and indirect workers,
including IVAs. To further promote understanding of social accountability and build trust in government systems, the
HOPE-PHC Program will ensure that a GRM is in place, which will be incorporated into the Stakeholder Engagement Plan
SEP), which has been prepared and publicly disclosed (in-country on August 21st, 2024, and August 30th, 2024, on the Bank
website.41 The IPF TA component includes the deployment of a communications strategy and people’s voice survey and
will leverage civil society to help improve social accountability in the health sector. Nigeria's education, health, and
governance sectors are governed by public service rules that address issues with labor and working conditions. However,
because private entities such as the IVA and M&E consultants are not covered by public service rules, the FMOH&SW will
prepare a labor management procedure to address the risks associated with such entities. The procedure will include
information on occupational health and safety; the Code of Conduct for preventing sexual exploitation, abuse, and sexual
harassment; and grievance mechanisms. An Environmental and Social Screening Checklist will be developed to identify
other potential E&S activities.
75. Communities and individuals who believe that they are adversely affected as a result of HOPE-PHC Program
interventions, as defined by the applicable policy and procedures, may submit complaints to the existing program
Grievance Redress Mechanism (GRM) or the World Bank’s Grievance Redress Service (GRS). The GRS ensures that
complaints received are reviewed promptly to address pertinent concerns. Communities and individuals affected by the
HOPE-PHC Program and IPF may submit their complaint to the World Bank’s independent Accountability Mechanism. This
Mechanism houses the Inspection Panel, which determines whether harm occurred, or could occur, as a result of World
Bank non-compliance with its policies and procedures, and the Dispute Resolution Service, which provides communities
and borrowers with the opportunity to address complaints through dispute resolution. Complaints may be submitted at
40
https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099083124055516550/p5046931d1f9490e1adea10b19d9dc50db
41
https://documents.worldbank.org/en/publication/documents-reports/documentdetail/099082024122057708/p5046931e41e3d0d1a15f1570797c9bc69
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any time after concerns have been brought directly to the World Bank’s attention and World Bank Management has been
given an opportunity to respond. For information on how to submit complaints to the World Bank’s GRS, visit
https://www.worldbank.org/GRS. For information on how to submit complaints to the World Bank’s AM, visit
https://accountability.worldbank.org.
D. Gender
76. Nigeria has a gender gap of 63.9 percent and is among the 10 percent of countries with the highest levels of gender
discrimination. The gender gap remains a significant challenge across various dimensions, including economic
participation, educational attainment, health and survival, and political empowerment. Nigeria ranks 130 th out of 146
countries on the World Economic Forum’s Gender Gap Index for 2023. This ranking reflects the combined scores across
four subindexes—economic participation and opportunity, educational attainment, health and survival, and political
empowerment—highlighting the persistent and multifaceted nature of gender inequality in the country. Nigeria ranks
relatively better (54th) on economic participation and opportunity, but women still face considerable disparities in earnings
and job opportunities. Men earn significantly more than women for similar roles. Although women's labor force
participation has improved, they often occupy lower-paying jobs and fewer high-ranking positions, which affects their
wealth accumulation and financial independence.42 Nigeria ranks poorly on women’s educational attainment (137th).
Despite improvements in girls’ primary school enrollment, significant gaps remain at the secondary and tertiary levels.
Cultural and socioeconomic factors contribute to girls’ lower educational attainment, limiting their opportunities for
better-paying jobs and career advancement.43 Political empowerment is where Nigeria faces the most significant
challenges (142nd). Women's representation in political and legislative roles is minimal, with cultural and structural barriers
impeding their participation. Efforts to address this issue have seen limited success, and substantial reforms are necessary
to achieve meaningful progress in this area.44
77. Nigeria lags other Sub-Saharan African countries. such as Rwanda, Namibia, and South Africa, which have made
more significant strides in closing gender gaps.45 Nigeria's progress has been slow and uneven, requiring targeted policies
and initiatives to address the underlying causes of gender inequality. Addressing this requires comprehensive policies
focused on education, economic participation, healthcare access, and political representation.
78. The HOPE-PHC Program’s DLIs sufficiently outline practical measures to reduce gender gaps and improve sexual and
reproductive health. These include: (i) the number of women with deliveries attended by skilled health personnel; (ii) the
proportion of births attended by a skilled provider; (iii) the number of women and children who receive tracer essential
health services by CHWs; and (iv) disaggregation of all indicators by sex. These indicators are part of the results chain.
V. RISKS
79. Based on the Systematic Risk Rating Tool, the overall residual risk of the HOPE-PHC Program is considered High.
Political and Governance Risks (High)
The HOPE-PHC Program is based on the incentive framework provided to the state governors and, without their buy-in,
implementation could be affected. A significant change in health policy is anticipated following the recent Supreme Court
(SC) judgement on LGA financial autonomy. As primary healthcare is on the concurrent legislative list, federal, state, and
42 World Economic Forum. Global Gender Gap Report 2023. https://www.weforum.org/publications/global-gender-gap-report-2023/in-full/benchmarking-gender-
gaps-2023/; Global Gender Gap Report. https://youngafricanpolicyresearch.org/global-gender-gap-report-2023-progress-challenges-and-the-road-to-parity/
43 Khadijat Kareem. How is Nigeria’s Gender Gap Report Card? Improving but Still Poor. https://www.dataphyte.com/latest-reports/gender/how-is-nigerias-gender-gap-report-
card-improving-but-still-poor/
44 World Economic Forum. Global Gender Gap Report 2023. https://www.weforum.org/publications/global-gender-gap-report-2023/in-full/benchmarking-gender-
gaps-2023/
45 Global Gender Gap Report. https://youngafricanpolicyresearch.org/global-gender-gap-report-2023-progress-challenges-and-the-road-to-parity/
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local governments all have roles to play in ensuring its full functionality. Delivery of key services such as: immunization;
safe ANC and delivery; and early surveillance for health security, could be at risk particularly if there is lack of adequate
oversight and weak governance at LGA level. At this time, it is too early to tell if decentralization as envisaged will be
strengthened through effective grassroots governance due to the influence of state governors and state legislatures. LGA
autonomy will promote transparency and accountability but could also lead to a lack of trust between state governors
and LGA executives, leading to reduced political commitment, changes in policy stance, or delayed implementation. While
the impact of the judgement is difficult to fully mitigate, it will be lowered through continuous engagement with key
stakeholders, such as the Nigeria Governor’s Forum and Association of Local Government of Nigeria, being proven and
effective platforms for policy dialogue with states and LGAs, respectively.
Macroeconomic Risks (High)
Nigeria has recently taken important policy reforms to address restore macroeconomic stability. The CBN has unified
exchange rates to allow the rate to reflect market conditions and tightened monetary policy to reign in inflation. The
government also started to move towards market-based pricing of PMS to address the large fiscal cost of subsidized
pricing. Despite these policy improvements the macroeconomy remains fragile. Failure to maintain a tight monetary policy
until a clear dis-inflationary path is observed and any return to deficit monetization could cause inflation to worsen and
feed an inflation-depreciation spiral. Financing pressures could intensify if there was a renewed decline in oil production,
delays in ramping up non-oil revenues, and or a significant and inefficient increase in spending. Despite being resilient,
economic growth remains modest and not enough too significantly boost per capita income in the long run. With limited
local manufacturing for pharmaceutical supplies and consumables, the health sector depends heavily on imports. As a
result, severe volatility in the exchange rate and shortage of US dollar availability could affect HOPE-PHC Program
implementation and could have a serious impact on finances and timelines. The government has recently rolled out a
social protection program that may mitigate the adverse impact of reforms on the poor and most vulnerable. The
industrialization of the medical value chain, which advances pooled procurement and local manufacturing capabilities, is
part of the government’s efforts to mitigate this risk.
Sector Strategies and Policies (Moderate)
Although overall risks related to sector strategies and policies are moderate given high political commitment to the reform
program, the substantial outflow of HRH may hinder smooth implementation. Mitigation measures include preparing and
adopting state-level HRH strategy and recruitment plans under HOPE-GOV to allow states to adequately plan and finance
the recruitment and deployment of much-needed staff. Sector strategies and policies to leverage the potential of the
private health sector face a Substantial risk. Nigeria is a mixed health system with the private sector providing significant
opportunities for scaling up of service coverage, however, the private sector is heterogenous, complex, and context
specific all with varying degrees of quality and high out of pocket costs for vulnerable populations. This risk is mitigated
by ensuring poor and vulnerable women and children access services without encountering financial costs; dissemination
of empanelment and accreditation guidelines for private health providers ensures that the quality of MNCH care delivered
aligns with national standards. Greater outreach to private facilities and providers is warranted as is the inclusion of
stakeholders from the private sector in developing national policies, standards, and strategies; and strengthening case
referrals between the public and private sectors.
The sector strategies and policies to leverage the potential of the private health sector face a Substantial risk. Nigeria is a
mixed health system with the private sector providing significant opportunities for scaling up of service coverage,
however, the private sector is heterogenous, complex, and context specific all with varying degrees of quality and high
out of pocket costs for vulnerable populations. This risk is mitigated by ensuring poor and vulnerable women and children
access services without encountering financial costs; Dissemination of empanelment and accreditation guidelines for
private health providers ensures that the quality of MNCH care delivered aligns with national standards. Greater outreach
to private facilities and providers is warranted as is the inclusion of stakeholders from the private sector in developing
national policies, standards, and strategies; and strengthening case referrals between the public and private sectors.
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Institutional Capacity for Implementation and Sustainability (Substantial)
The HOPE-PHC Program supports an ambitious, expansive, and complex reform agenda, and the SWAp is a fundamentally
new approach to aligning the government’s plan with those of other stakeholders. In addition, Nigeria’s federal context
presents unique challenges with respect to the allocation of roles and responsibilities in the health sector. The
implementation capacity of the FMOH&SW and subnational entities will need to be scaled up to achieve expected
implementation progress and secure the sustained buy-in of development partners on the approach. Mitigation measures
include engaging with the Nigeria Governors’ Forum and the Association of Local Government of Nigeria, building on
existing implementation platforms such as the BHCPF, aligning the HOPE-PHC with the SWAp, and operationalizing a
coordinated learning platform in collaboration with other development partners to equitably deploy TA to subnational
entities.
There are also risks associated with Independent Verification. Lessons learnt on the use of IVAs in Nigeria are well-known.
This risk is mitigated by building on lessons such as the careful selection of data sources, independence of the IVA,
development of IVA terms of reference, procurement process, careful selection, and contract management. The risk is
mitigated by the following actions: identifying the National Bureau of Statistics (NBS) to work intricately with the IVA under
the oversight of the Ministry of Budget and Economic Planning; supporting the advanced procurement of an external firm
by the NPCU to carry out the role of the IVA for the Program with the aim of having it in place within sixty days of
effectiveness and well ahead of the first annual performance assessment; the scope and details of the IVA reports will
need to be satisfactory to the World Bank; and the verification protocol will be updated regularly throughout the Program
duration to be responsive to changes identified during implementation.
The sequencing and coordination of the HOPE interdependent series of operations also poses substantial risks. A key
innovation in the HOPE programs is how they leverage each other and generate synergies to reinforce much needed
reforms necessary for accelerating human capital development in Nigeria. There is a risk that the operations are not
adequately sequenced in a manner which allows the necessary upstream reforms to be in place in good time to allow for
the downstream actions that will lead to improvements in service delivery e.g. upstream PFM reforms allowing for
downstream contracting of private providers.
Fiduciary Risks (High)
The PEF will involve both national and state-level budget lines, introducing additional complexities and implementation
bottlenecks. The procurement profile of the HOPE-PHC Program, the federal nature of the health system, and the varied
capacities of participating states all contribute to substantial fiduciary risks. Other fiduciary risks include: (i) the use of
financing proceeds for unintended purposes; (ii) fraud and corruption; (iii) political interference in the deployment of FM
staff; (iv) the capacity of NPCU staff to produce acceptable financial reports in a timely manner; and (v) use of the fund for
expenditures that may not meet fiduciary requirements. Mitigation measures have been built into the HOPE-PHC Program
on reporting, fund flows, and audit mechanisms, as reflected in the PAP (Annex 5). The HOPE-PHC Program and IPF
component will include improved additional fiduciary assurance measures, including clarity on beneficiaries and increased
use of digital-in-health interventions.
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ANNEX 1. RESULTS FRAMEWORK MATRIX
@#&OPS~Doctype~OPS^dynamics@padpfrannexpolicyandresult#doctemplate
Program Development Objective(s)
The Program Development Objective is to improve utilization of quality essential health care services and health system resilience in the Federal Republic
of Nigeria.
PDO Indicators by Outcomes
Baseline Period 1 Period 2 Period 3 Closing Period
Resilience
Percentage of PHC facilities achieving service readiness assessment criteria (Percentage) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 25 50 75 100
National climate and health adaptation plan developed, costed, validated, and implemented (Number) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 5 20 30 37
Utilization of Quality Essential Services
Proportion of births attended by a skilled provider (Percentage) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
43 46 50 52 54
Women and children who receive tracer essential health services in the community increased (Number) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 5,000,000 10,000,000 15,000,000 20,000,000
Intermediate Indicators by Results Areas
Baseline Period 1 Period 2 Period 3 Closing Period
Improving utilization of quality essential services
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Financial protection for poor and vulnerable populations increased (Number) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
1,800.000 2,520,000 3,528,000 4,939,200 6,914,880
Increase in Penta 3 coverage (Percentage)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
53 55 57 59 61
Introduction of MMS supplementation for pregnant women during ANC visits (Percentage) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
25 28 31 34 37
Women and neonates receiving CEmONC and neonatal services and/or VVF surgeries (VVF surgeries ≤ 30% of the total share of rei mbursed services) (Number) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 50,000 150,000 250,000 350,000
People reached with digitally enabled health services (Number)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 1,000,000 3,000,000 6,000,000 10,000,000
➢People reached with digitally enabled health services - Female (Number)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 500,000 1,500,000 3,000,000 5,000,000
People who have received quality essential health, nutrition and population (HNP) services (Number)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 10,000,000 20,000,000 30,000,000 40,000,000
➢People who have received quality essential health, nutrition and population (HNP) services - Adolescent (Number)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 1,000,000 2,000,000 3,000,000 4,000,000
➢People who have received quality essential health, nutrition and population (HNP) services - Female (Number)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 5,000,000 10,000,000 15,000,000 20,000,000
➢People who have received quality essential health, nutrition and population (HNP) services - Youth (Number)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 1,000,000 2,000,000 3,000,000 4,000,000
Increase in patient experience score (Percentage)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
47.70 50 55 65 75
Received complaints resolved within defined timelines using established feedback channels (Percentage)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 80 80 80 80
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Improving resilience of the health system
People benefiting from climate resilient infrastructure (Number of people) CRI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 2,000,000 7,000,000 1,400,0000 20,000,000
➢People benefiting from climate resilient infrastructure - Female (Number of people) CRI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 1,200,000 4,000,000 8,000,000 12,000,000
➢People benefiting from climate resilient infrastructure - Youth (Number of people) CRI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 600,000 2,100,000 4,200,000 6,000,000
Federal expenditure on quality family planning commodities increased (Percentage)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 6 12 21 30
Increased empanelment and refurbishment of CEmONC facilities that demonstrate service readiness and climate resilience and energy efficiency (Number) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 100 300 500 774
Number of patients with obstetric and neonatal complications transported through Emergency Medical Transport to selected facilities using the digitized EMS dispatch system
(Number) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 10,000 50,000 100,000 240,000
Front-line availability of tracer products improved (Percentage) DLI
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 25 50 75 100
Tier 2 BEmONC facilities achieving minimum quality of care score (Percentage)
Dec/2024 Dec/2025 Dec/2026 Dec/2027 Dec/2028
0 50 60 70 80
Disbursement Linked Indicators (DLI)
Period Period Definition
Prior Results Prior Result
Period 1 CY2025
Period 2 CY2026
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Period 3 CY2027
Period 4 CY2028
Baseline Prior Results Period 1 Period 2 Period 3 Period 4
1:Number of patients with obstetric and neonatal complications transported through Emergency Medical Transport to selected facilities using the digitized EMS dispatch system
(Number )
0 10,000 50,000 100,000 240,000
0.00 0.00 500,000.00 2,500,000.00 5,000,000.00 12,000,000.00
DLI allocation 20,000,000.00 As a % of Total DLI Allocation 3.81%
2:Introduction of MMS supplementation for pregnant women during ANC visits (Percentage )
25 28 31 31 0 37
0.00 0.00 0.00 10,000,000.00 0.00 10,000,000.00
DLI allocation 20,000,000.00 As a % of Total DLI Allocation 3.81%
3:Women and neonates receiving CEmONC and neonatal services and/or VVF surgeries (VVF surgeries ≤ 30% of the total share of r eimbursed services) (Number )
0 CEMoNC Strategy 50,000 150,000 250,000 350,000
0.00 2,500,000.00 4,375,000.00 13,125,000.00 21,875,000.00 30,625,000.00
DLI allocation 72,500,000.00 As a % of Total DLI Allocation 13.81%
4:Increase in Penta 3 coverage (Number )
53 0 57 0 61
0.00 0.00 0.00 17,500,000.00 0.00 17,500,000.00
DLI allocation 35,000,000.00 As a % of Total DLI Allocation 6.67%
5:Increased empanelment and refurbishment of CEmONC facilities that demonstrate service readiness and climate resilience and energy efficiency (Number )
0 100 300 500 774
0.00 0.00 3,464,000.00 10,396,000.00 17,320,000.00 26,820,000.00
DLI allocation 58,000,000.00 As a % of Total DLI Allocation 11.05%
6:Front-line availability of tracer products improved (Percentage )
0 25 50 75 100
0.00 0.00 3,300,000.00 6,600,000.00 9,900,000.00 13,200,000.00
DLI allocation 33,000,000.00 As a % of Total DLI Allocation 6.29%
7:National climate and health adaptation plan developed, costed, validated, and implemented (Number )
0 National Plan Developed 37 37 37
0.00 0.00 1,000,000.00 5,700,000.00 7,750,000.00 15,550,000.00
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DLI allocation 30,000,000.00 As a % of Total DLI Allocation 5.71%
8:Financial protection for poor and vulnerable populations increased (Number )
1,800.000 2,520,000 3,528,000 4,939,200 6,914,880
0.00 0.00 5,630,631.00 7,882,883.00 11,036,036.00 15,450,450.00
DLI allocation 40,000,000.00 As a % of Total DLI Allocation 7.62%
9:Percentage of PHC facilities achieving service readiness assessment criteria (Percentage )
0 25 50 75 100
0.00 0.00 6,150,000.00 12,300,000.00 18,450,000.00 24,600,000.00
DLI allocation 61,500,000.00 As a % of Total DLI Allocation 11.71%
10:Federal expenditure on quality family planning commodities increased (Percentage )
0 6 12 21 30
0.00 0.00 5,000,000.00 5,000,000.00 7,500,000.00 7,500,000.00
DLI allocation 25,000,000.00 As a % of Total DLI Allocation 4.76%
11:States receiving funds in compliance with allocation formula in revised guidelines (Number )
0 Guidelines Developed 37 37 37 37
0.00 2,500,000.00 2,500,000.00 2,500,000.00 2,500,000.00 2,500,000.00
DLI allocation 12,500,000.00 As a % of Total DLI Allocation 2.38%
12:System and standards for state EPR programs are established. (Number )
0 National Standards 37 37 37
Developed
0.00 0.00 1,000,000.00 2,750,000.00 3,750,000.00 7,500,000.00
DLI allocation 15,000,000.00 As a % of Total DLI Allocation 2.86%
13:States adopting National enterprise architecture and integrate core health functions (Number )
0 National Health Enterprise 37 37 37 37
Architecture
0.00 2,500,000.00 3,750,000.00 3,750,000.00 3,750,000.00 3,750,000.00
DLI allocation 17,500,000.00 As a % of Total DLI Allocation 3.33%
14:Proportion of births attended by a skilled provider (Percentage )
43 50 54
0.00 0.00 0.00 17,500,000.00 0.00 17,500,000.00
DLI allocation 35,000,000.00 As a % of Total DLI Allocation 6.67%
15:Women and children who receive tracer essential health services in the community increased (Number )
0 5,000,000 10,000,000 15,000,000 20,000,000
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0.00 0.00 5,000,000.00 10,000,000.00 15,000,000.00 20,000,000.00
DLI allocation 50,000,000.00 As a % of Total DLI Allocation 9.52%
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Disbursement Linked Indicators Verification Protocol
Results Area 1: Improving Quality of Services Scalability
DLI 1 Improved service readiness.
DLI 1.1 Improved primary healthcare facility readiness, quality, and climate resilience in Participating States (Percentage)
Percentage of BHCPF-supported Tier 2 (BEmONC PHC) facilities that maintain a score of 75 percent on the health
Definition facility readiness assessment that includes measures of structural and process quality, solar power, and climate Yes
resilience
To be accredited to receive DFF by NPHCDA, Tier 2 PHC facilities -- i.e., those that offer PHC services plus
BEmONC services -- will need to meet a score of 75 percent on the health facility readiness assessment that will
be developed by NPHCDA before project effectiveness. The assessment tool will have components around
structural quality (water source, toilets, blueprint for bed numbers and layout, commodities, medicines,
equipment, health information system and human resources); Accredited facilities will have to be assessed
biannually for re-accreditation.
Description
Refurbishment to be financed through the DLI will include financing for (i) solar power; (ii) minor rehabilitation of
facilities; (iii) climate resilient measures for all health facilities in climate vulnerable areas and facilities that are
identified as at risk of climate shocks; (iv) Water, Sanitation and Hygiene (WASH) improvements at facilities; and
(v) energy efficiency measures at high power use facilities. The assessment tool will include content on each of
these areas.
Data Source NPHCDA Reports (linked to DHIS-2)
Verification Entity Independent Verification Agent
The IVA will visit 25 percent of all accredited BEmONC facilities in the first year and inspect the premises for
compliance against the NPHCDA checklist. Facilities must meet the 75 percent score to remain accredited. In
subsequent years, the IVA will visit 5 percent or more of previously accredited BEmONC facilities in each state
Procedure and 25 percent of newly accredited BEmONC facilities to inspect for compliance to the checklist. Furthermore,
facilities that fell below the 75 percent mark on verification will have 90 days to take remedial action and request
a re-verification. A disbursement of US$12,300 per facility meeting the BHCPF tier 2 standard per ward would be
received.
Increased empanelment and refurbishment of CEmONC facilities that demonstrate service readiness and climate resilience and
DLI 1.2
energy efficiency (Number)
Number of EDGE level 1 certified CEmONC facilities that are empaneled according to the NHIA guidelines and
Definition Yes
maintain the empanelment requirements and have implemented climate resilience measures.
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CEmONC facilities will be refurbished by the SCO and inspected and empaneled by NHIA according to the
accreditation guidelines developed under the related Prior Result. Refurbishment will include key structural
elements of quality (water source, toilets, mother-newborn intensive care units, surgical theatres, bed numbers,
Description
visibly posted schedule of free services, equipment, commodities and medicines, human resources, health
information system) reaching EDGE level 1 certification and implementing climate resilience measures.
Empanelment will be renewed on an annual basis.
Data Source NHIA empanelment records (linked to DHIS-2)
Verification Entity Independent Verification Agent
The IVA will go to 25 percent of all CEmONC facilities reported by NHIA to have been empaneled in the first year
and use the checklist of criteria developed as a prior result to ensure that the requirements for structural
readiness, and climate resilience have been met, and EDGE level 1 certification has been achieved. In subsequent
years, the IVA will go to 25 percent additional facilities reported by NHIA to have been empaneled and check for
compliance against the checklist; AND visit or verify by phone a random sample of 10 percent or more of all
previously empaneled facilities in each state to ensure that they are still in compliance with previously
Procedure
empaneled facilities. A selection of empanelment criteria will be checked. Facilities must meet 100 percent of
the assessed criteria to be verified as newly empaneled and to be verified as continuingly complaint if previously
empaneled.
US$34,647.55 per facility per LGA meeting the NHIA CEmONC standards to be shared by allocating 97.5 percent
reward to SSHIAs of participating states and 2.5 percent reward to NHIA.
DLI 2 Increased availability of essential commodities.
DLI 2.1 Federal expenditure on quality family planning commodities increased (Percentage)
Annual increases in domestic spending on contraceptive commodities to reach 15 percent of forecasted total
Definition Yes
need by the end of the Program
The Government of Nigeria will match donor and IDA contributions of US$25 million over the life of the Program
Description
with US$12.5 million of domestic spending on contraceptive commodities from a baseline of US$0.
Data Source Budget Implementation Reports (BIR) from Accountant General
Verification Entity Independent Verification Agent
The designated IVA will review expenditure data of the state and national level budget execution reports
annually to verify achievement of domestic spending on contraceptive commodities. If expenditures fall below
the targeted amount for any year, the DLI disbursement will be prorated against spending level after a minimum
increase of 20 percent of target increase is met. Irrespective of target achievements each year, the target for the
Procedure
subsequent year remains fixed. For example, if an increase of US$1 million is the target, a minimum of
US$200,000 in domestic spending must be in evidence to scale disbursement proportional to actual
achievement.
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The amount received per percentage point increase in federal expenditure varies annually increasing annually
from US$0.4 million per percentage point annual increase in year 1 to US$0.28 million per percentage point
annual increase and US$0.32 million per percentage point annual increase.
DLI 2.2 Frontline availability of tracer products improved in Participating States (Percentage)
Percentage of BHCPF-supported Tier 2 (BEmONC PHCs) facilities that have a minimum of five of six commodities
Definition Yes
available.
A tracer basket of commodities and medicines will be assessed for availability of a minimum stock position at Tier
2 facilities and reported by the SPHCDAs. The tracer commodities include oxytocin, MMS, Artemisinin-based
Combination Therapy (ACTs), Human Immunodeficiency Virus (HIV) rapid test kits, Pentavalent vaccine, and a
Description
minimum of three modern contraceptive methods including at least one long-acting reversible contraceptive
(LARC). A minimum stock position by commodity or threshold and the essential medicines score will be defined
in the HOPE-PHC Program POM.
Data Source Annual Health Facility Readiness Assessment and DHIS-2
Verification Entity Independent Verification Agent
States are expected to achieve different percentage point increase annually on the proportion of the 2,000
BHCPF-supported Tier 2 (BEmONC PHCs) facilities NHSRII-service ready facilities that have a minimum of five of
six commodities above the defined minimum stock position. US$5,600 per BHCPF supported facilities per ward.
Several data sources will be used to verify reported achievement of this indicator. The IVA will first review
procurement and delivery data by state for the tracer commodities. The IVA will note stock positions at federal
and state central medical stores, as well as reported stocks at facility level. The facility level stock positions will
Procedure
be triangulated with the respective services delivered reported in the annual facility readiness survey and DHIS2
to ensure coherence. The IVA may opt to do spot checks of facilities that do not report rational stock positions;
and will visit 5 percent of Tier 1 PHC facilities that have reported adequate stock per state. Facility visits that
result in discordant verification from reported data will be labeled as High Risk. All High-Risk facilities will have
repeat visits within 6 months of first visit; this will not be part of the 5 percent pool. Facilities that meet the
requirement for minimum threshold will qualify as successfully verified and will be labeled as Low Risk. Low Risk
facilities will be randomly selected in the 5 percent pool the following year.
Results Area 2: Improving Utilization of Essential Services
DLI 3 Increased enrollment of poor and vulnerable populations.
DLI 3.1 Financial protection for poor and vulnerable populations increased (Number) in Participating States
This DLI will reflect progress in the number of poor and vulnerable persons covered by health insurance under
Definition Yes
the NHIA gateway in the revised Basic Healthcare Provision Fund guideline.
This is the number of eligible population (poor and vulnerable) enrolled in the NHIA gateway of the BHCPF by the
Description
SSHIAs.
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Data Source NHIA portal
Verification Entity Independent Verification Agent
1. The achievement report provided by the NHIA should provide a breakdown of the total number of
enrollees per state in each period. This data would be from the NHIA portal. The IVA should cross-check
these figures against the SSHIA portal, in consultation with the NPCU.
2. The IVA will also apply a stratified random sampling method to verify at least one percent of all
enrollees listed in each report, via field visits/telephonic surveys – to ensure the figure reported in the
NHIA portal for the selected SSHIAs and selected period corresponds to what is seen from the NHIA
records (and the IVA should cross-check the various records with unique identification number ~ NIN to
ensure accurate reporting).
Procedure
3. The strata will be: (i) state; and (ii) whether in urban or rural.
4. Each 1 percentage point discordance above 5 percent as detected by the IVA will be deducted from the
total maximum eligible disbursement. (e.g., 7 percent discordance will result in (7-5) = 2 percent
deduction of the total eligible disbursement)
5. US$8 per eligible health insurance enrollment to be shared by allocating 97.5 percent reward to SSHIAs
of participating states and 2.5 percent reward to NHIA.
6. The maximum earning for this DLI per State will be US$1.08 million and overall maximum of US$40
million.
DLI 4 Enhanced community delivery of health services.
DLI 4.1 Women and children who receive tracer essential health services in the community increased in Participating States (Numbe r)
Definition This DLI will disburse when the tracer essential health services are delivered by health workers in the community. Yes
The DLI will incentivize the number of household visits made by CHWs to deliver key services including provision
of micronutrient powders or small-quantity lipid-based supplements for prevention of malnutrition, growth
monitoring and screening for acutely malnourished children, identification/follow up of pregnant women and
Description referral to receive MMS, treatment of any childhood illness (Integrated Community Case Management – for
diarrhea, fast breathing, fever) as measured by (i) Number of Children with Growth Monitoring Cards/(ii) Children
(6-59 months) who received micronutrient powders and (ii) Number of pregnant women attending ANC revisited
by a community health workers/Pregnant women identified for ANC (new).
Data Source CHMIS or independent MIS data feed to DHIS-2
Verification Entity Independent Verification Agent
1. The baseline is established using the Community Health Management Information System (CHMIS)-2 or MIS
for the CHW program.
Procedure
2. The annual aggregate number of pregnant women who were visited by a community health worker at home
and total number of children who have a growth monitoring card (or MCH handbook).
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3. FASTR will confirm the validity of CHMIS. Each 1 percentage point discordance above 10 percent as detected
by the IVA will be deducted from the total maximum eligible disbursement. (e.g., 15 percent discordance will
result in (15-10) =5 percent deduction of the total eligible disbursement)
4. Validation through small-scale survey done using household visits and telephone verification methods based
on primary records. Wards/LGAs with anomalous data trends will automatically be included in the household
verification sample.
5. Anomalies could include out of age range beneficiaries, out of ward beneficiaries,
6. US$1 per CHW-client contact in the communities verified from the CHMIS or other nationally agreed MIS.
7. Earnings will be allocated at 97.5 percent reward to SPHCDAs of participating states and 2.5 percent reward to
NPHCDA.
DLI 5 Increased utilization of priority secondary care services.
DLI 5.1 Secondary Facility Quality of Care for CEmONCs (Prior Result)
Definition This DLI will disburse against the design and approval of a CEmONC empanelment and reimbursement strategy. No
NHIA will develop operational documents that detail
(1) definition of empanelment criteria for CEmONC facilities by the NHIA,
(2) baseline assessment of secondary facilities in participating states,
the package list of CEmONC services eligible for reimbursement,
Description
(2) the tariff schedule corresponding to each eligible package,
(3) SOPs for claim submission, review and payment,
(4) identification of key entities and development of MOUs involved (NHIA, TPAs, etc.), and
(5) the key performance indicators for claims management.
Data Source NHIA
Verification Entity Independent Verification Agent
This is a Yes/No prior result. NHIA will share the relevant document(s) for review. Disbursement will depend on
validation against confirmation that the document includes the above elements. One-time payment of US$2.5
Procedure
million following the achievement of the DLI to be shared by allocating 97.5 percent reward to SSHIAs of
participating states and 2.5 percent reward to NHIA.
DLI 5.2 Women and neonates receiving CEmONC and neonatal services and/or vesico-vaginal fistula surgeries (Number)
This DLI will disburse against the number of women and neonates availing CEmONC services from NHIA- Yes
Definition
empaneled public or private health facilities.
NHIA is developing a benefit package of eligible CEmONC services for reimbursement. This will include both
Description obstetric and neonatal care packages, plus VVF surgeries. The DLI is a count of these reimbursed services (paid
claims, not submitted claims). To ensure a relatively equitable share of service coverage, no individual state can
account for more than 1.25 times its share of the annual births (that is, any reimbursement above 1.25 times that
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state annual births forecast will not be eligible to count towards DLI disbursement). Estimates will be based on
the 2006 population census data.
Data Source NHIA portal
Verification Entity IVA
1. NHIA will share anonymized individual claim data that includes (1) date of patient admission; (2) empaneled
facility where admitted; (3) CEmONC/VVF service package provided; (4) date of payment. The IVA will confirm
that the facility is on the empaneled list, the service provided is on the eligible list, and that the date of payment
occurred during the relevant period.
2. The IVA apply a stratified random sampling method to verify at least one percent of all claims listed in each
report, via field visits/telephonic surveys – to ensure the figure reported in the NHIA portal and selected period
corresponds to what is seen from the NHIA records (and the IVA should cross-check the various records with
Procedure unique identification number ~ NIN to ensure accurate reporting).
3. Each 1 percentage point discordance above 5 percent as detected by the IVA will be deducted from the total
maximum eligible disbursement. (e.g., 7 percent discordance will result in (7-5) = 2 percent deduction of the total
eligible disbursement).
4. US$87.5 per woman or neonate is reimbursed to the NHIA for CEMONC services in an accredited CEmONC
facility of which, at least 50 percent of the target met on a year-on year basis should be for CEmONC services
(deliveries and neonates); not more than 30 percent to be VVF surgeries; the balance being under five child
admissions.
DLI 6 Increased primary healthcare utilization of priority services
DLI 6.1 Deliveries with skilled birth attendant present increased in Participating States (Percentage)
This DLI will disburse against the increase in the proportion of deliveries with skilled birth attendant present (i.e.,
Definition Yes
Skilled Birth Attendance -SBA)
Description Proportion of pregnant women whose births were attended by a skilled provider
Data Source NDHS/mini-DHS
Verification Entity Independent Verification Agent
1. The baseline is established using the NDHS 2023.
2. Annual performance will be measured in 2025 and 2027 by two mini-DHS surveys conducted by the
Government of Nigeria
Procedure 3. US$118,243 will be paid out per percentage point annual increase per State, over and above the previous
year’s results.
4. Earnings will be allocated at 97.5 percent reward to SPHCDAs of participating states and 2.5 percent reward to
NPHCDA.
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Introduction of MMS for pregnant women during antenatal care visits (Percentage) in Participating States Introduction of MMS
DLI 6.2
for pregnant women during antenatal care visits in Participating States (Percentage)
Definition Percentage of women receiving MMS during antenatal visits Yes
This maternal nutrition service is the distribution of at least 180 MMS (MMS) (one bottle) for pregnant women
Description
aged 15-49 years at least once during any ANC service or contact with health worker at community level.
Data Source NDHS/mini-DHS
Verification Entity Independent Verification Agent
1. The baseline is established using the NDHS 2023.
2. Annual performance will be measured in 2025 and 2027 by two mini-DHS surveys conducted by the
Government of Nigeria
Procedure 3. US$45,045 will be paid out per percentage point annual increase per State, over and above the previous year’s
results.
4. Earnings will be allocated at 97.5 percent reward to SPHCDAs of participating states and 2.5 percent reward to
NPHCDA.
DLI 6.3 Increase in Penta 3 coverage in Participating States (Percentage)
Definition Percentage of children immunized with Penta-3 vaccination Yes
Description This is the proportion of children aged 12-23 months who received DPT-HepB-Hib vaccination (3 doses)
Data Source DHIS-2
Verification Entity Independent Verification Agent
1. The baseline is established using the NDHS 2023.
2. Annual performance will be measured in 2025 and 2027 by two mini-DHS surveys conducted by the
Government of Nigeria
Procedure 3. US$118,243 will be paid out per percentage point annual increase per State, over and above the previous
year’s results.
4. Earnings will be allocated at 97.5 percent reward to SPHCDAs of participating states and 2.5 percent reward to
NPHCDA.
DLI 7 Increased utilization of EMS
Patients with obstetric and neonatal complications transported through emergency medical transport to selected facilities using
DLI 7.1
the digitized EMS dispatch system in Participating States (Number)
This DLI will disburse when patients with obstetric and neonatal complications are transported to Tier 2 (PHC
Definition Yes
BEmONC) facility or empaneled CEmONC facilities using the digitized EMS dispatch system
This DLI will incentivize the scale-up of digital dispatch platform on the national emergency transport gateway of
Description
the BHCPF encompassing both use of community transport and the formal transport system. The DLI will target
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pregnant women and children and track the number of these targets from Community to BEmONC/CEmONC
centers.
Data Source NEMSAS Electronic Dispatch Database
Verification Entity Independent Verification Agent
1. The IVA will verify from NEMSAS digital platform database the number of pregnant women and children
that were transported on the digital platform.
2. There is a year-on-year increase in the target set for the number of pregnant women and children
expected to be transported on the digital platform.
2. The IVA will conduct call backs and visit states to confirm a randomized sample of 1 percent of digital
Procedure
EMS dispatch records provided by NEMSAS for reimbursement to confirm the dispatch entries.
3. The IVA will recommend for disbursement upon satisfactory verification of presented record from
NEMSAS.
3. US$50 per obstetric and neonatal patient transported to be shared by allocating 97.5 percent reward to
SEMSAS of participating states and 2.5 percent reward to NEMSAS
Results Area 3: Improving Resilience of the Health System
DLI 8 Improved allocation and disbursement of BHCPF funds
DLI 8.1 Governance for improved resource allocation and performance (Prior Result)
This prior result will disburse against revised and approved BHCPF 2.0 guidelines reflecting equity and climate
Definition No
resilience
This prior result will reimburse the government upon revision and approval of BHCPF guidelines by the BHCPF-
MOC. The revised guidelines will identify the allocation formula whereby BHCPF funds are disbursed to states.
Description
The formula will give due consideration to state variation in (1) RMNCAH-N burden, (2) poverty headcount and
(3) climate vulnerability, among other relevant factors as determined by BHCPF MOC.
Data Source BHCPF MOC
Verification Entity IVA
This is a Yes/No prior result. BHCPF MOC will share the relevant document(s) for review. Disbursement will
depend on validation against confirmation that the document includes the above 3 elements.
Procedure One-time payment of US$2.5 million following the achievement of the DLI to be shared by allocating 20 percent
reward to BHCPF MOC, 20 percent to NPHCDA, 20 percent to NHIS, 20 percent to NEMSAS, and 20 percent to
NCDC
DLI 8.2 Participating States receiving funds in compliance with allocation formula in revised guidelines (Number) No
This DLI will disburse against the adherence to the allocation formula contained in the revised BHCPF guidelines
Definition
reflecting RMNCAH+N burden, poverty headcount and climate vulnerability
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This DLI will disburse based on a review of BHCPF MOC documents that will determine/confirm the adherence to
Description
the allocation formula contained in the revised BHCPF guidelines prevailing at the time of verification.
Data Source BHCPF MOC
Verification Entity Independent Verification Agent
The IVA will review the minutes of quarterly MOC meetings to confirm adherence to the revised, prevailing
guidelines with respect to state-wise allocations.
Procedure Yearly payment of US$2.5 million following the achievement of the DLI to be shared by allocating 20 percent
reward to BHCPF MOC, 20 percent to NPHCDA, 20 percent to NHIS, 20 percent to NEMSAS, and 20 percent to
NCDC
DLI 9 Enhanced PPR through deployment
DLI 9.1-9.4 System and standards for state EPR programs are established (Number)
This DLI will disburse when states develop and implement a multi-year EPR plan encompassing disease
Definition Yes
outbreaks, climate shocks, natural disasters, and other humanitarian emergencies.
The DLI will incentivize the strengthening of subnational EPR by encouraging states to develop peacetime plans
to improve emergency response and health security. The plans will address use of seasonal, multi-hazard risk
calendars to support responsive risk response, risk profiling, responsibility chains for shock response, shock
response simulations, commodity stockpiling and quantification of pharmaceuticals to respond to shocks,
Description preparations for health service delivery during shocks. The NCDC will play a role in providing TA to states in
developing a multi-year EPR plan which meets specified standards as determined by the NCDC following risk
profiling and multi-hazard assessment of states including disease outbreaks, climate shocks, natural disasters,
and other emergency emergencies. Following these plans’ development, the NCDC will also provide technical
support and guidance to states for the implementation of the state specific EPR plans.
Data Source NCDC subnational assessments
Verification Entity Independent Verification Agent
1. 1. The IVA will verify from the NCDC states that they have prepared and validated an EPR plan that meets
the predetermined standards set by the NCDC for the development of subnational EPR plans and include
disease outbreaks, climate shocks, natural disasters, and other humanitarian emergencies.
2. The IVA will recommend for disbursement when states prepare and validate their multi-year EPR plans
Procedure with the NCDC.
3. The NCDC will monitor states on the implementation of validated multi-year EPR plans and provide to
the IVA; states that have reached 50 percent and 100 percent implementation of the validated multi-
year EPR plan.
4. The IVA will visit a randomized sample of states (not less than 25 percent) to confirm the NCDC report
the status of implementation of the multi-year state EPR plans.
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5. Each 1 percentage point discordance above 5 percent as detected by the IVA will be deducted from the
total maximum eligible disbursement. (e.g., 7 percent discordance will result in (7-5) =2 percent
deduction of the total eligible disbursement)
6. The IVA will recommend for disbursement upon satisfactory confirmation that states meet the
implementation milestones for 50 percent and 100 percent respectively.
7. One-time payment of maximum of US$1.0 million to NCDC on achievement of DLI in year 1.
8. Subsequently, an incremental annual amount allocated is per 36+1 state per costed EPR Plan developed.
a) From Year 2, the amount of US$74,324 for each state that delivers a plan in adherence with the national
standard.
b) For Year 3, the amounts of US$101,351 will be disbursed to each State that achieves 50 percent
implementation of the plan.
c) For Year 4, US$202,703 will be disbursed to each State that achieves 80 percent implementation of the
plan.
DLI 10 Improved Climate Resilience
DLI 10.1-10.4 National climate and health adaptation plan developed, costed, and validated (Number)
This DLI will disburse with the development of the National climate and health adaptation plan which will include
Definition Yes
costs followed by implementation
This DLI will disburse with the development of the National Climate and Health Adaptation Plan including its
Description costing in the first year, followed by development of implementation plans in the second year, and
implementation in the third and fourth years.
The country, led by the FMOH&SW, has developed a National Climate and Health Adaptation Plan, outlining
timebound actions throughout the health system that are aimed at addressing climate change and health
vulnerabilities identified in the National Climate and Health Vulnerability Assessment. The plan has been costed,
Data Source
linked to available resources, and validated. Implementation plans have been developed at the state and national
levels, and implementation has commenced. Implementation plans are developed by states and the national
level in the second year and the plans are implemented in the third and fourth year.
Verification Entity Independent Verification Agent
Year 1: A.) NCCC verifies National Climate and Health Adaptation plan for (i) completeness of plan; (ii) costing;
(iii) linking plan to available resources; and (iv) inclusion of a template and guidelines for national and state
implementation plans; and B.) verifies TWG meeting minutes for validation of the plan through a participatory
process. Year 1 will be paid based on the completeness of all elements defined here. Any incomplete elements
Procedure will not result in payment. The amount of US$1 million will be disbursed for the national plan.
One-time payment of US$1.0 million following the achievement of the DLI to be shared by allocating 33 percent
reward to BHCPF FMOH, 33 percent to NPHCDA, and 33 percent to NCDC.
Year 2: NCCC verifies State and National level implementation plans for consistency, completeness, and
adherence to the template and guidelines as developed in the NCHAP. Each state will be paid on a fully
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developed plan. A partially complete plan will not result in payment. Each state will be paid based on their own
plan, not contingent on the progress of other states. The amount of US$154,054 will be disbursed to each State
that develops their plan in adherence to national standard.
Years 3 and 4: IVA verifies State and federal documents to confirm implementation of plans and spot checks
implementation through in-person or phone verification (i.e., confirming trainings conducted; renovations done,
etc.). States and the Federal Level will be paid once they have achieved at least 50 percent of activities in year 3
and at least 80 percent of activities in year four. Subsequent years, an amount will be paid per 36+1 state per
state climate and health adaptation developed; 97.5 percent Reward to states; 2.5 percent Reward to be shared
by FMOH, NPHCDA and NCDC. In year 3he amount of US$209,459 will be disbursed to each State that achieves
50 percent implementation of its plan, and in Year 4, US$420,270 for each State that achieves 80 percent
implementation of its plan.
DLI 11 Stronger Digital Foundation
DLI 11.1 National enterprise architecture developed, costed, and adopted (Prior Result)
This DLI will support the development of an integrated, interoperable health data ecosystem to support
evidence-based improvements in value (efficiency, quality, access, and health outcomes) for patients and
Definition No
providers. The Program shall support the FMOH&SW and its agencies to lay the foundations for an interoperable
platform to systematically exchange data to enhance systems functions.
This subcomponent will finance the architecture, costing and adoption of three digital
interventions.(1)Development and adoption of a digital health services platform for frontline CHW to strengthen
the frontline CHW system (2)Development of the digital infrastructure for the emergency transportation
Description
platform (3) A federated digital-in-health enterprise architecture platform which will enable the switch from a
paper-based to digital platform and support digital interoperability between health information systems to
reduce data hyper- fragmentation and duplication.
Data Source Committee on Digital in Health Initiative
Verification Entity Independent Verification Agent
Year 1 Define a national set of standards, regulations, rules, and business processes for creating and maintaining
a national health data space through a distributed enterprise architecture approach.
Year 2 -Definition of regulatory frameworks, enterprise architecture design, and acquisition.
Procedure Year 3 and 4. A federated digital-in-health enterprise architecture platform which will enable the switch from a
paper-based to digital platform and support digital interoperability between health information systems to
reduce data hyper- fragmentation and duplication.
One-time payment of US$2.5 million following the achievement of the DLI to the MOH in year 1.
DLI 11.2 Participating States adopting national enterprise architecture and integrating core health functions (Number)
This DLI will facilitate the adoption and effective functioning of the health data ecosystem at the state level by
Definition Yes
integrating individual private, public, and program-specific health information systems.
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States will prioritize 4 core health functions from the list of functions (electronic health records, emergency
response management (SORMAS), ambulatory services dispatch and management system, supportive
supervision, QOC management, HRH/HRIS, CHW Service management, claims management, health insurance
Description
enrollment management, essential drugs and stock logistics management, and DHIS-2) and have these functions
interoperable and feed into the national health data ecosystem at the federal level integrating individual private,
public, and program-specific health information systems.
Data Source SMoH, SPHCDA and SSHIA and all public and private hospitals at the state
Verification Entity Independent Verification Agent
1. To follow the implementation plan laid out by the committee on digital in health initiative
2. The IVA will verify before disbursement to states that they are fully plugged in on the digital in health
Procedure initiatives across the SMOH, SPHCDA, SSHIA, and the public hospitals in the state.
3. Payment of US$101,351 per state following the achievement of the DLI reward is to be shared 97.5 percent to
the state and 2.5 percent to the MOH
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ANNEX 2. TECHNICAL ASSESSMENT
1. Improving health outcomes is crucial for bolstering Nigeria's human capital—a determinant of economic prosperity
and inclusive economic growth. Healthy and well-nourished children achieve greater cognitive development and better
educational outcomes, which are essential for their future productivity and success. Healthier populations are more
productive, which can stimulate faster economic growth and foster more equitable development. Moreover, investments
in health are pivotal for poverty alleviation, a matter of great urgency for Nigeria, which harbors 13 percent of the global
poor and has the second-largest number of individuals living in extreme poverty. Such investments can break the cycle of
poverty by closing the gap in learning outcomes and enhancing the opportunities of poor communities to effectively
contribute to the economy.
2. Accelerating progress toward UHC in Nigeria will require deliberate and transformative action . In recent decades,
Nigeria has seen the development of various strategies that aim to expand healthcare access, such as the National
Strategic Health Development Plan 2018–2022, the National Health Act 2014, the SOML 2015, and the NHIA 2022 to
introduce mandatory insurance coverage. Further, the Vulnerable Group Fund (VGF) was established to provide additional
funding to cover poor and vulnerable Nigerians. The implementation of these strategies has been inadequate, however,
due primarily to low government investment and a fragmented health system that struggles with coordination and
efficient resource allocation. Given the scale of the challenge and the limited resources available, transforming Nigeria’s
health system will require embracing a “business unusual” approach. This means fostering innovations in healthcare
delivery and financing and ensuring robust coordination among all health sector players. Only through such concerted
efforts can Nigeria make significant strides toward UHC for all its citizens.
3. There is a palpable window of opportunity for Nigeria to embark on a transformative journey toward UHC . This
opportunity is underscored by the emergence of new leadership that brings a clear and focused vision for health sector
reform. There is a growing consensus among stakeholders that revitalizing the health system hinges on injecting dynamism
into primary healthcare—the cornerstone of effective and equitable health service delivery. This revitalization is seen as
the most impactful approach to strengthen the health system from its foundation. Furthermore, there is robust support
from the development partner community, which is ready to back these reforms with resources, expertise, and advocacy.
This confluence of favorable conditions creates an unprecedented chance to implement meaningful changes that can
significantly improve health outcomes for Nigeria's population.
4. The government is striving to accelerate progress toward UHC through an ambitious strategy known as the NHSRII .
This strategy encompasses two key components: the BHCPP and the Nigeria Industrialization Fund. The BHCPP represents
an expansion of the BHCPF to also cover services delivered at the community level. The BHCPF already provides DFF to
over 8,000 primary healthcare facilities and includes the VGF to subsidize care for vulnerable populations, targeted
secondary care services facilitated by the NHIA, and a Medical and Public Health Emergency Fund. The Nigeria
Industrialization Fund focuses on tertiary and quaternary care, in addition to a medical industrialization plan that aims to
encourage the production of medical commodities in the local market. Integral to the BHCPP are the health security
agenda and community engagement activities, which are crucial for generating demand for health services.
5. The strategic partnership between the government and the World Bank is set to play a pivotal role in the
implementation of these health sector reforms. Strengthening primary healthcare is not only about enhancing service
delivery, but also about instituting significant changes in the governance of the health sector. Recognizing this dual need,
the government has requested the World Bank to prepare interdependent operations. The first operation, with a focus
on governance (HOPE-GOV), aims to contribute to the improvement of resource allocation, encompassing both financial
and human resources. This is a critical step toward ensuring the sustainability of all health programs. The second
operation, focusing on service delivery (the HOPE-PHC Program), is designed to contribute to the reorganization of primary
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healthcare and the prioritization of cost-effective interventions. This will be instrumental in improving access to good-
quality, essential health services, thereby laying a solid foundation for a more robust and resilient health system in Nigeria.
6. The FMOH&SW in Nigeria has laid the foundation for collaboration by establishing a SWAp. The aspiration to unify
all relevant stakeholders in the health sector under a shared framework has been crystallized with the signing of the
compact by both state and federal actors. The HOPE-PHC Program is poised to become a central platform for coordinated
support to the government's health sector reform agenda. Through its various TWGs, the SWAp will be instrumental in
setting key sectoral priorities. These priorities will be financed through a strategic blend of pooled resources, including
both domestic and external sources, which will be funneled through the HOPE-PHC Program, and parallel financing
provided by selected development partners. This approach ensures that the collective efforts of the government and its
partners are harmonized and aligned, thereby maximizing the impact of the resources invested in Nigeria's health system
transformation.
7. The HOPE-PHC Program’s relevance is thus derived from its high potential to achieve transformational impact. The
HOPE-PHC Program offers a significant opportunity to enhance the quality of health service delivery in Nigeria, a move
that is essential for the betterment of the country's (and global) health outcomes. Moreover, the HOPE-PHC Program's
relevance is echoed by the widespread endorsement from the wider health community, as evidenced by the signing of
the compact, signaling a collective vision to revitalize Nigeria's healthcare system.
8. The HOPE-PHC Program is informed by lessons from previous World Bank operations and analytical work:
a. The Nigeria State Health Investment Project (NSHIP) made notable strides in enhancing the use of good-quality
health services across various states.46 This success can be attributed to several key strategies. First, health facilities
received direct funding into their accounts, which they could use with considerable discretion. The involvement of
local ward development committees in managing these facilities also played an important role. Accessibility and use
of health services were further improved by subsidizing vital RMNCAH-N services and waiving fees for at-risk
populations. Quality enhancements47 were due primarily to swift upgrades in structural quality, consistent supportive
oversight with a detailed quality checklist, and training for healthcare workers in maternal and newborn care, drug
management, and hygiene practices. Moreover, the verification of data and the implementation of stronger
governance and accountability measures were instrumental in delivering concrete outcomes amidst challenging
political and emergency situations.
b. The SOML Program represented Nigeria's inaugural PforR, heralding the potential for profound transformation.
It emphasized the use of government systems, the mobilization of increased domestic health funding, and the pursuit
of systemic reforms. The HOPE-PHC Program also introduced performance incentives to drive these outcomes. The
execution of a realistic M&E plan is crucial, however. The frequency of survey data collection fell short of the annual
target, hampering the project’s overall success.
c. Programmatic support and TA are vital to bolster the effectiveness of incentives and outcome measurement in
a federal system like Nigeria’s. A combined approach of PforR and IPF TA can bridge critical implementation gaps and
mitigate risks, encompassing areas such as program support, M&E execution, IVA performance, and the advancement
of health system strengthening through private sector engagement and innovation. The phased implementation
strategy, as evidenced by the SOML Program, is another crucial lesson, demonstrating its importance in managing
large-scale programs.
46
Project data shows that the proportion of skilled births deliveries increased from a baseline of 20 percent to 47.2 percent, the proportion of sick children who
attended government health facilities increased from 27 percent to 69.1 percent and Penta 3 coverage increased from 27 percent to 68.6 percent by June 30, 2020
(SMART survey). In addition, the project had a significant positive impact on immunization coverage and net usage by under-five children, improving curative care for
under-five children and antenatal care utilization.
47 Based on the health facility Quality of Care survey, the NE states improved quality of care from a baseline of 38.8 percent in 2016 to 59.4 percent by June 30, 2020.
This was higher than the national average of 51.7 percent in 2019.
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d. The Huwe project (BHCPF; P163969) has illustrated that, with meticulous planning, federal funds can be
directed to shape the expenditure of social programs at the subnational level. The operationalization of the BHCPF
has enabled the federal government to prioritize and secure additional public financing, creating a system that holds
subnational entities accountable for the judicious use of public and other funds, with the goal of enhancing the
standard and quality of healthcare services. This reform presented a significant opportunity to fortify FM, ensure
accountability for performance, and promote value-for-money within the health system. In addition, the Huwe project
took advantage of other FM reforms by the government, such as the Treasury Single Account used by government
institutions, to streamline the flow of funds from the central government to frontline health facilities. The blending of
government and World Bank project resources, with the same fiduciary protections as foreign grants and loans, has
improved transparency and accountability in financing and ensured coordination among development partners. This
blending has also set the stage for the SWAp that the government is currently implementing, with several
development partners having signed an agreement to implement a single national financing program under the
NHSRII.
e. Nigeria’s RMNCAH-N Investment Case, spanning from 2017 to 2030, was formulated in line with the RMNCAH-
N strategy through a collaborative process. It received the endorsement of Nigeria's health sector leadership, under
the guidance of the health minister, in March 2018. This initiative was bolstered by a US$50 million grant to aid in its
execution. The government, in partnership with the GFF and other stakeholders, facilitated the prioritization of
Investment Case interventions, employing transformative, geographical, and programmatic methods within three
World Bank projects: NSHIP, Huwe, and ANRIN. The midterm review delved into the FMOH&SW’s strategy formulation
process and examined the interplay between the National Health Sector Development Plan and specific plans like the
RMNCAH-N strategy. Six years into its implementation, there have been encouraging signs of improvement in health
indicators, although a definitive assessment awaits the release of the 2023 Demographic and Health Survey report.
9. Lessons learned from the midterm review emphasize the significance of ongoing advocacy, particularly through
changes in leadership, and the necessity of comprehensive monitoring and mapping of outcomes to ensure adherence
to strategy implementation. The development of policies and strategic plans alone did not ensure their faithful execution
or the attainment of intended results; rigorous M&E across health sector strategies are essential. The activation of DFF in
the BHCPF was transformative in the three project states, serving as an advocacy mechanism that demonstrated the
alignment of external resources with national initiatives, essential for fostering synergistic efforts toward positive
outcomes. Other lessons include the identified lack of coordination among MDAs at the federal level, underscoring the
need for interagency collaboration for effective implementation and mutual accountability. In addition, there is no clear
evidence of how the government, at both national and subnational levels, prioritized and preferentially implemented
essential RMNCAH-N interventions beyond donor-driven projects.
10. Primary healthcare is widely recognized as the most appropriate and efficient48 means of delivering health services
to reduce maternal and child mortality rates. Evidence from various studies49 highlights that primary healthcare promotes
equity by ensuring that healthcare services are accessible to all segments of the population, particularly underserved and
rural communities. This equitable distribution of health services is crucial in reaching vulnerable groups and providing
them with the care needed to improve health outcomes. In addition, primary healthcare is often lauded for its cost-
effectiveness. By focusing on prevention, early detection, and treatment of common conditions, primary healthcare helps
to reduce the need for more expensive specialized care, thereby saving costs for both the healthcare system and patients.
11. The HOPE-PHC Program will bolster the capabilities of primary healthcare facilities in Nigeria, ensuring that they
provide top-tier health services. This commitment to enhancing facility readiness includes upgrades to infrastructure,
48https://www.afro.who.int/countries/nigeria/news/who-harp-efficient-investment-primary-healthcare-backbone-resilient-health-system
49Starfield, B. (2009) Primary Care and Equity in Health: The Importance to Effectiveness and Equity of Responsiveness to Peoples' Needs; Hanson, K. et al. (2022) The
Lancet Global Health Commission on financing primary health care: putting people at the center. The Lancet Global Health Commissions.
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professional development for staff, and the procurement of essential medical supplies and equipment. Additionally, the
HOPE-PHC Program will boost the accessibility of funds at the grassroots level, allowing for tailored responses to unique
local needs and obstacles. The pursuit of quality in healthcare is of utmost importance, as underscored by the Lancet
Commission on High-Quality Health Systems. The Commission asserts that having access to healthcare is not enough; the
caliber of the care provided is equally vital to secure favorable health outcomes. Strengthening primary healthcare systems
not only is vital for immediate health outcomes, but also offers positive spillovers for the broader resilience agenda.
12. The HOPE-PHC Program will provide universal access to a basic package of health services . This basic package of
interventions is designed to be delivered primarily at the primary healthcare level, ensuring that a foundational level of
healthcare is accessible to all. As part of the BHCPP, the basic package of health services extends beyond the primary
healthcare level, incorporating crucial interventions at the community level, which center mostly around health
promotion, disease prevention, and simple curative measures. In addition, targeted secondary-level interventions are
earmarked specifically for maternal and newborn health, recognizing the specialized care required in these areas at higher
levels of care.
13. In areas where essential health services are not fully utilized, it is vital to focus on both enhancing the availability
of these services and actively encouraging their use. To effectively stimulate demand, initiatives should be rooted in the
community, utilizing established community service delivery systems that have the community’s confidence.
14. In addressing Nigeria’s health challenges, it is crucial to recognize that poor outcomes are not confined to the most
impoverished segments of society. For instance, even when considering the second-richest quintile of the Nigerian
population in isolation, it would stand among the ten nations in the world with the highest rates of under-five mortality.
This stark reality underscores the necessity for the HOPE-PHC Program to adopt a universal approach in its interventions.
Universality, in this context, means committing to the provision of a simple package of good-quality essential health
services that is accessible to all Nigerians. As additional resources become available, the scope of these services can be
broadened based on their cost-effectiveness, but the foundational principle remains that good-quality essential health
services must be accessible to all.
Results Areas
15. The HOPE-PHC Program is poised to be at the heart of the SWAp, an approach that has demonstrated success in
various settings and brings forth significant benefits. By adopting a SWAp, there is a concerted effort to bolster
institutional capacity in the health sector, including the capacity of the NPHCDA and the NHIA, along with their respective
state counterparts. Concurrently, the initiative acknowledges the existing accountability challenges that span multiple
levels—federal to state, state to LGA, and state to provider. These challenges are recognized and actively being addressed
to ensure a robust and responsive health system under the SWAp framework.
16. The HOPE-PHC Program is set to significantly strengthen all health financing functions. On the mobilization side, it
aims to raise substantial resources, including contributions from the HOPE-PHC Program, HOPE-GOV, and through the
reprogramming of resources under the IMPACT initiative. The establishment of the SWAp is a pivotal step toward pooling
funds, moving toward the harmonization of domestic and external funding, which includes the strategic pooling of
investments. On the strategic purchasing side, the HOPE-PHC Program’s alignment of funding with key sectoral priorities
promises to improve the efficiency of health spending, ensuring that financial resources are used effectively to support
the health sector’s most critical needs. Furthermore, the HOPE-PHC Program will play a crucial role in scaling up DFF, a
strategy whose effectiveness has been affirmed by an impact evaluation in Nigeria. In addition, HOPE-GOV is committed
to tackling PFM challenges that pose significant bottlenecks in ensuring the flow of funds to the frontlines.
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17. Through investments in the governance of the health system, the HOPE-PHC Program will enhance the service
delivery environment by emphasizing critical enablers such as digital health. By providing foundational support for a
high-performing digital health ecosystem, the HOPE-PHC Program will aid in the establishment of national health data
standards and the reinforcement of the regulatory landscape. These steps are crucial for encouraging the adoption of
digital health tools by the private sector. Moreover, the introduction of unique patient identifiers will be instrumental in
promoting the interoperability of digital health tools, ensuring a more connected and efficient healthcare system. In
addition to these technological advancements, the HOPE-PHC Program will focus (under Results Area 3) on strengthening
community platforms to foster community engagement, thereby ensuring a holistic approach to service delivery
enhancement.
Results Area 1: Improving Quality of Services
18. The HOPE-PHC Program is set to facilitate the operationalization of a service delivery model that mirrors the “hub
and spoke” structure. This model will underpin the BHCPP’s support for investments aimed at fortifying community-based
service delivery, enhancing the capacity of primary healthcare facilities to dispense an essential package of health services,
and ensuring the availability of good-quality BEmONC and CEmONC services across every LGA. Achievement of these goals
will be pursued through a suite of investments, which include broadening universal primary healthcare by way of equity-
focused DFF, reimbursements for CEmONC, an Incentive-based Quality of Care Program that prioritizes the process and
content of care, and an overhauled community-based health services system strengthened by robust FHWs. Climate
change resilience and energy efficiency measures will be embedded in health facility upgrades.
19. Access to family planning is a critical component of reproductive health services, playing a significant role in
reducing fertility rates by minimizing the incidence of unwanted pregnancies. This, in turn, can lead to more sustainable
population growth and better allocation of household resources. Ensuring that adolescents have access to family planning
commodities is particularly crucial, as early childbearing can have detrimental effects on maternal and child health
outcomes. Early pregnancies can increase the risks of maternal mortality and morbidity and can adversely affect the child's
health and future socioeconomic potential. Addressing this challenge will necessitate substantial efforts to generate
demand for family planning services, especially considering that only 36 percent of married women aged 15-49 have
expressed a desire to access these services, more than half of whom face an unmet need for family planning.50
Results Area 2: Improving Utilization of Services
20. The demand for health services in Nigeria remains notably low, which can be attributed in part to the subpar quality
of care offered by public health facilities. Merely enhancing the quality of these services is not sufficient to guarantee an
uptick in their utilization. It is crucial, therefore, to pair quality improvements with initiatives that aim to stimulate
demand. To address this, the HOPE-PHC Program is committed to financing investments designed to bolster community-
based service delivery, recognizing that a multifaceted approach is essential for expanding access to and coverage of
health services across the nation. To further create demand for health services, strategies such as conducting home visits,
encouraging care-seeking at primary healthcare centers, and mobilizing communities for outreach programs and health
campaigns will be implemented. These will be informed by stakeholder consultations and a patient voice/perception
survey. In parallel, primary healthcare facilities will be strengthened to manage increases in demand for services. In
addition, social behavior change communication will be employed to enhance interpersonal communication, community
outreach, and counseling, particularly on maternal and child health, ANC attendance, improved dietary practices,
vaccination for children under five, NCD counseling, and birth spacing.
50 National Population Commission (2018) Demographic Health Survey 2018.
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21. The HOPE-PHC Program is set to play a salient role in the implementation of the Nigeria NHIS, which is operated by
the NHIA. The HOPE-PHC Program will address one of the main challenges faced by the NHIA, the low rate of enrollment.
It will leverage revised BHCPF guidelines to support states’ health insurance agencies to boost enrollment rates among
poor and vulnerable populations. All mothers supported through the CEmONC intervention will also be automatically
enrolled. This effort will be supported through the national scale-up of the newly developed digital Civil Registration and
Vital Statistics (CRVS) system (VITAL REG), and the HOPE-PHC Program will facilitate the automatic enrollment of every
newborn registered in VITAL REG and pregnant women with a NIN into the NHIA system. This strategic approach is
anticipated to significantly boost enrollment, with the goal of adding more beneficiaries to the NHIA by the end of the
project, thereby expanding access to healthcare services and enhancing overall health outcomes in the country.
22. Community-based service delivery has proven to be an effective model in various countries, bringing healthcare
closer to the people, especially in underserved and climate-vulnerable areas. This approach is designed to complement
facility-based services, with a phased and targeted strategy to enhance demand creation, as well as promotive, preventive,
and simple curative services at the community level. Key to this model is the retraining of all existing FHWs such as
midwives, CHEWs, and auxiliary CHWs. In addition, the recruitment of additional FHWs, including CHEWs and auxiliary
CHWs, is essential to bolster the workforce. The regularization and upskilling of FHWs, particularly auxiliary CHW agents,
is crucial, ensuring that they serve as a complement to, and not a substitute for, other FHWs. This involves rationalizing,
standardizing, and certifying competencies, as well as improving remuneration and supervision and expanding their scope
of work to effectively complement other facility based CHWs. Furthermore, absorbing unemployed CHWs and partnering
with the private sector through contracting out and other collaborative models can significantly enhance the reach and
quality of community-based health services.
23. A functional “hub and spoke” model will require substantial investments to improve Nigeria’s low supply -side
readiness to deliver essential quality health services. In Nigeria, various studies51 have highlighted a concerning trend:
health facilities, particularly in rural areas, score significantly low in their readiness to provide good-quality services. This
encompasses a range of issues, including inadequate infrastructure, a lack of medical equipment and critical commodities,
and a shortage of trained medical personnel. These deficits are more pronounced in rural settings, exacerbating the
urban–rural divide in healthcare quality. Studies have also revealed the low readiness of health facilities in Nigeria to
deliver BEmONC services,52 which are essential in preventing maternal and neonatal mortality. The HOPE-PHC Program
will play a significant role in supporting the implementation of the NHSRII by placing a critical emphasis on improving
primary healthcare readiness, including for the provision of BEmONC, and meticulously tracking advancements using
quality scorecards. In addition, the integration of solar energy systems in health facilities is a key component of the climate
agenda. The HOPE-PHC Program is committed to supporting investments that will increase health facilities’ access to solar
energy, thereby contributing to the resilience of healthcare services while simultaneously addressing environmental
concerns.
24. The HOPE-PHC Program will contribute to the prioritization of essential RMNCAH-N services through the “hub and
spoke” model. This support is key to hastening progress toward Nigeria’s key development goals and the main objectives
of the NHSRII, which focuses on the reduction of maternal and child mortality. By enhancing the availability and quality of
RMNCAH-N services, the HOPE-PHC Program is expected to play a significant role in advancing the health outcomes of
mothers and children in Nigeria, thereby contributing to the success of the NHSRII’s ambitious health targets. The
prioritized benefit package has been thoughtfully designed to integrate considerations of the impact of climate change on
the health system and health outcomes, including factors such as the effects of extreme heat, the heightened risks of
51 WHO (2016) National Health Facility Survey; Oyekale, A.S. (2017) Assessment of primary health care facilities’ service readiness in Nigeria; Oluwale, E.O. et al.
(2022) Maternal and child health service readiness among primary health care facilities in Ekiti, Nigeria; Ekenna, A. et al (2020) How ready is the system to deliver
primary healthcare? Results of a primary health facility assessment in Enugu State, Nigeria.
52 Ibadin, S.H. (2020) Facility readiness for basic emergency obstetric and neonatal care at PHC centers in Nigeria.
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malnutrition, and the potential for increased prevalence of malaria and other vector borne as well as waterborne diseases.
The essential package will include, among other services:
a. Basic immunization. Universal immunization coverage is a cornerstone of public health, vital for preventing the
spread of infectious diseases. High population coverage is essential for immunization efforts to be effective, as it
ensures herd immunity and protects those who are unable to be vaccinated. Immunization stands out as one of the
most cost-effective health interventions, offering significant returns on investment through reduced healthcare costs
and the prevention of disease outbreaks. On the other hand, zero-dose coverage, where individuals have not received
any vaccinations, signaled deep-seated deprivation, and reflected an inequitable health system. As of 2020, Nigeria
had the largest number of zero-dose children in the world,53 as estimates of the number of zero- or missed-dose
children increased to 3.1 million (from 3.0 million in 2019). Prioritizing the availability of vaccines and achieving high
vaccination coverage rates is fundamental for any health system. The HOPE-PHC Program’s commitment to supporting
Nigeria in this endeavor is crucial, as it strives to ensure that every individual, especially the most vulnerable, has access
to life-saving vaccines.
b. Maternal nutrition, antenatal care, and deliveries. With a staggering 37 percent of children under the age of five
experiencing stunting, Nigeria faces a significant challenge in improving the nutritional status of the youngest segments
of its population. Strengthening the health system is imperative, linked with multisectoral interventions to prevent
more children from becoming stunted. The HOPE-PHC Program is set to bolster community platforms to enhance
maternal nutrition services at the primary healthcare level and to ensure nutrition counselling at the community level.
Special focus will be given to the nutritional and birth outcomes of pregnant women, recognizing their vulnerability
and the impact of a mother’s nutritional status on her newborn’s nutrition outcomes, as well as the critical impact of
nutrition on early development.
c. CEmONC services. Improving maternal mortality rates is contingent upon a robust secondary healthcare level that
is fully equipped and prepared to provide quality CEmONC services. In the face of stringent financial limitations, the
BHCPP is unable to extend its coverage to a broad spectrum of secondary-level services. However, for Nigeria to realize
its ambitious objectives of drastically diminishing maternal and child mortality rates, it is imperative to guarantee that
pregnant women have effective access to CEmONC services. While investments under Results Area 2 are poised to
mitigate some of the geographic and financial hurdles, it is the support provided by Results Area 1 that will be pivotal
in ensuring that at least one facility in every LGA, reaching a total of 774, is primed to deliver good-quality CEmONC
services.
25. Another critical element of the health system is the provision of transportation for referrals and emergency care,
which is vital for timely access to medical services . The HOPE-PHC Program recognizes this need and will support the
New Rural EMS Program Arrangement, which introduces three innovative service models to address urgent medical
emergencies. Utilizing 112 or mobile-cellular technology and call center capabilities, the program connects local EMS
operators with community members who serve as first responders. Private sector operators will be equipped with Basic
Life Support tricycles, staffed by trained professionals, to provide emergency care en route to LGA hospitals. In addition,
designated community members and commercial drivers will receive training in basic first aid and be skilled to offer
specialized transport for maternity-related services, ensuring that pregnant women have access to the care they need
during critical times.
Results Area 3: Improving Resilience of Health System
26. DLI 8 supports the implementation of and adherence to an enhanced allocation formula for BHCPF resources, to be
stipulated in revised guidelines. A revised allocation formula will consider, inter alia, state-by-state variations in the
disease burden (especially maternal and under-five mortality), poverty headcount, and climate vulnerability. The impact
53 WHO / UNICEF Estimate of National Immunization Coverage (WUENIC)
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of BHCPF can be improved by taking these factors into account in resource allocation decisions. Adherence to the revised
guidelines will also ensure transparency and integrity in Program implementation.
27. EPR is a critical pillar of the NHSRII, given the health security challenges faced by Nigeria and the world beyond. The
country developed a National Action Plan for Health Security, which was partially funded and partially implemented. The
Joint External Evaluation, which aimed to assess the core capacities of International Health Regulations (IHR) 2005,
revealed low scores in its first assessment (39 percent), with marginal improvements in the second round (54 percent).
Given the low level of preparedness at the subnational level, the BHCPP will, alongside other national health protection
efforts under the NHSRII, incentivize subnational governments to strengthen state-level systems to adequately prevent,
detect, and respond to public health threats of disease outbreaks, including both epidemic and pandemic risks, climate
shocks, natural disasters, and other humanitarian emergencies. These incentives will sharpen subnational focus on
planning, systems capacity development, and financing of emergency preparedness efforts.
28. Proactive measures to adapt to the impact of climate change on health and health system outcomes, embedded
throughout the health system, are needed to minimize the health effects of climate change. To facilitate a national
approach to climate change adaptation, integrated into the health system, the HOPE-PHC Program will finance the
development of a costed national climate and health adaptation plan. To initiate and support implementation of the plan,
the HOPE-PHC Program will finance: (a) a financing strategy and monitoring framework for the plan; (b) development of
state- and national-level implementation plans; and (c) implementation of the national- and state-level implementation
plans. Implementation will be coordinated closely with FCDO, which will provide TA for the development of the plans in
conjunction with the World Bank.
29. The HOPE-PHC Program is set to bolster investments aimed at enhancing Nigeria’s health management information
system. The PforR component presents an additional avenue to scale the use of digital-in-health initiatives in Nigeria’s
health sector. Furthermore, the governance of data, as well as its collection, analysis, and application, will receive a
significant boost from the support directed toward the digital health agenda, ensuring a more robust and data-driven
approach to health system management.
Economic Justification
30. The HOPE-PHC Program has a strong economic rationale. Many services provided in the primary care setting have
public good or externality dimensions, including infectious disease treatment and maternal and child health services.
Moreover, primary care interventions such as family planning, ANC, immunization, and nutrition services are generally
more cost-effective (with a greater health impact per naira spent) than secondary and tertiary care. Because of the high
value attached to better health (both intrinsically and as an investment in human capital), the benefit–cost ratio of
effective government health spending is favorable. Simulations suggest that a ratio of over 20:1 is possible. In addition,
the focus on governance and accountability, especially in the interdependent HOPE-GOV operation, can help mitigate
potential “government failure” issues that may beset healthcare delivery, helping to ensure greater impact. While BHCPP
investments have recurrent budget implications for federal and state governments, Nigeria is among the world’s lowest
health spenders, such that increased (and more effective) spending is to be welcomed and can be managed. Given the
very low baseline (government spending on primary care is about 0.1 percent of GDP), even significant proportional
increases would not pose a risk to overall public finances. Moreover, increased PHC spending can be partly achieved by
reallocations away from less effective secondary and tertiary care. Finally, public primary care facilities and community
health service delivery platforms operate close to the population and thus represent the most pro-poor segment of the
government’s delivery network.
31. Nigeria is facing a challenging macro-fiscal outlook, but the incremental recurrent costs implied by the HOPE-PHC
Program are sustainable. First, it is noteworthy in this context that government health spending in Nigeria is currently the
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lowest in the world as a share of GDP, implying that increased spending is to be welcomed. This is due in part to low
prioritization of health within both the federal and state budgets. At the federal level, BHCPF funding is derived from the
1 percent earmark from the Consolidated Revenue Fund, which is expected to grow in part due to revenue generation
reforms supported under a new World Bank project. At the state level, there is scope to boost primary healthcare spending
in part through reallocations, for example from secondary care to primary care or from “extra” primary healthcare facilities
to those supported under BHCPF (which account for about 17,000 out of the 30,000 nationally). Ultimately, Nigeria’s
health system performance will require additional government resources.
32. The priority services to be supported under the HOPE-PHC Program are closely aligned with principles of cost-
effectiveness to ensure value for money. By incorporating insights from the third phase of the Disease Control Priorities
Project (DCP-3), the HOPE-PHC Program is committed to making the most judicious use of available funds. DCP-3 provides
a comprehensive review of the most effective interventions in health, offering guidance on how to achieve the best health
outcome per naira spent. By aligning the benefits package with DCP-3 recommendations, the HOPE-PHC Program aims to
optimize the health impact of its investment, focusing on interventions that deliver the greatest benefits to the population
at the lowest possible cost. This approach is crucial in a context where resources are limited, and health needs are
significant.
33. The HOPE-PHC Program’s focus on improving the quality of care is an important aspect of ensuring efficiency. As
highlighted in the Lancet Global Health Commission on High-quality Health Systems in the SDG Era, poor quality of care is
a major barrier to reducing mortality—of equal or greater importance than access barriers in many settings. Quality of
care is thus expected to become an even larger driver of population health as utilization of health systems increases.
Strengthening the quality of the primary care system in Nigeria will help the government make better use of scarce
resources. In addition, the SWAp model offers efficiency gains by reducing transaction costs and duplicated efforts that
have been common in a fragmented approach.
34. Prioritizing primary healthcare and community services is a cornerstone of the HOPE-PHC Program's strategy to
enhance health outcomes for Nigeria’s poor and vulnerable populations. There are several pro-poor features in the
program’s design. First, the focus on primary care and community service delivery models ensures that care is offered as
close as possible to the population, favoring those without the resources to travel long distances. Second, and related, the
benefit package covers RMNCAH-N services that are more prevalent among lower socioeconomic groups, as per evidence
from the Nigeria DHS 2018. Third, the revision of BHCPF guidelines will incorporate equity considerations in its allocation
formula, including decisions around where to locate additional facilities during the expansion from 8,800 to 17,600
facilities. Fourth, expanded coverage of CEmONC services through a reimbursement model will help protect the poor and
vulnerable from the catastrophic costs of emergency obstetric care in a hospital setting. Fifth, the climate focus of the
HOPE-PHC Program promises to disproportionately help poorer, climate-vulnerable communities.
35. An illustrative cost-benefit analysis was undertaken assuming that coverage rates for critical RMNCAH-N services
would rise by 20 percentage points over 2025–2028. This progressive scale-up was assumed to be achieved through
annual increments of 5 percentage points versus intervention-specific baselines for Nigeria incorporated in the Lives Saved
Tool (https://www.livessavedtool.org/). This reflects a commitment to substantial improvements in the delivery and
uptake of essential RMNCAH-N interventions over the specified period.
36. This rate of service coverage expansion is projected to avert an estimated 825,000 deaths . This figure includes
783,000 children under the age of five and 42,000 pregnant women. The anticipated reduction in mortality among children
under five is attributed to a wide range of interventions, including safe deliveries, neonatal care, nutrition
supplementation, and better case management of malaria, pneumonia, and diarrhea. For pregnant women, the
combination of expanded periconceptual services and CEmONC availability are the main drivers.
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37. The high value of mortality reduction at this scale implies a highly favorable benefit-to-cost ratio. Mortality
reduction can be valued using either a human capital approach (wherein foregone income is the key metric) or a “value
of statistical life” (VSL) concept, which aims to capture the intrinsic value of better health and longevity. At Nigeria’s
income level, estimates of VSL fall between US$75,000 and US$350,000, depending on the methodology.54 Even at the
lower end of this range, the implied benefit-to-cost ratio of averting over 800,000 deaths with a program cost of US$3.8
billion is over 16:1. This does not include the value of morbidity reduction. The human capital approach, which equates
the value of life to income earned, would be less than this but still offers high returns.
Program Expenditure Framework
38. Program Expenditure Framework (PEF). The IDA contribution to the HOPE-PHC PforR (2025-2028) will be US$570
million, for an expenditure framework estimated at US$3.6 billion for the HOPE-PHC government program (IDA accounts
for 15.6 percent).
Table 2.1: Financing Framework (US$, millions)
Financing Source 2025 2026 2027 2028 Total
Borrower/Recipient 610 742 850 894 3,084
IDA 60.04 138.70 135 235.70 525.00
Total program financing 670.04 880.7 985 1129.7 3,665.44
Notes: 1. IDA funding equally divided into 4 years, but year-year allocation may vary. Total program financing includes government’s own funding as well as IDA funding
for both PforR and IPF components. Figures for 2025 were estimated assuming a 21 percent increase from the approved budget of 2024, subsequent year-on-year
increases are assumed to be 20 percent, 16 percent and 14 percent respectively. 2. An estimated US$100m projected to be disbursed against 2028 expenditures will
be disbursed in 2029 as reflected in the datasheet.
39. Critical aspects of the government program, the BHCPP, are described in the National Health Act 2014 and the NHIA
Act of 2022 and include: (a) primary healthcare service readiness, service availability, and quality in the National and State
Primary Healthcare Development Agencies; (b) strategic purchasing for maternal and child health, administered by the
National and State Health Insurance Agencies through general hospitals managed by the State Ministries of Health; (c)
health security functions delivered by the Nigeria Centre for Disease Control; (d) a NEMSAS; (e) Digital-in-Health for
information systems strengthening and HRH by the Department of Health, Planning, Research, and Statistics of the
FMOH&SW and State Ministries of Health; (f) medical industrialization; and (g) citizen engagement.
40. The government will support the expenditure framework through annual budgets aligned with key pillars of the
government program. These expenditures will cover several entities of the government including Federal and State
Ministries of Health, Federal and State Primary Healthcare Development Agencies, National and State Health Insurance
Agencies, State Drug Management Agencies, State Hospitals Management Boards (HMB) spanning 36 + 1 states and the
National Annual Operational Plans of the government. The expenditure categories and economic codes to be considered
include: (a) the BHCPF for fiscal transfers to 36 + 1 states by the FMOH&SW; (b) general services and utilities; (c) consulting
services; (d) acquisition of fixed assets including medicines, basic equipment and other commodities; (e) acquisition of
non-tangible assets; (f) provision and repair of general fixed assets; (g) training; and (h) preservation of the environment.
These expenditures are directed towards the following activities: (a) strategic purchasing through the NHIA; (b) investment
in primary healthcare rehabilitation; (c) essential commodities; (d) emergency and ambulance services; and (e) data and
information systems. The HOPE-PHC Program boundaries will exclude high-value equipment procurement, extensive civil
works and construction, and land acquisition. A portion of salaried recurrent line items will be covered under HOPE-GOV.
Non-salary recurrent line items including the cost of administration, supervision, and minor inputs will not be prioritized
for funding within this HOPE-PHC Program.
54 Robinson, L., J. Hammitt and L. O’Keeffe (2018). Valuing Mortality Reductions in Global Benefit-Cost Analysis. https://sites.sph.harvard.edu/bcaguidelines/
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41. The Program Expenditure Framework (PEF) is assessed as fiscally sustainable. The government’s medium-term
trajectory is sound. The overall cost of the PforR Program over the next four years is US$3.67 billion, out of which
US$500.00 million in IDA financing; US$50.00 million from GFF and US$70.01 million expected from other Development
Partners. The PEF aligns with the results areas. Table 2.2 provides details of the overall Program financing.
Table 2.2: PEF Summary (HOPE-PHC)
Budget Code Yearly Projections of program expenditures (US$55)
2024 2025 2026 2027 2028 Total
(A) FGN MDAs
(A1) BHCPF
Personnel Cost
210101 Salaries & Wages 92,725,825 112,198,248 134,637,898 156,179,962 178,045,156 673,787,089
Total - BHCPF 92,725,825 112,198,248 134,637,898 156,179,962 178,045,156 673,787,089
(A2) FMoH
Other Recurrent Costs
220201 Travel & Transport- General 47,669 57,679 69,215 80,290 91,530 346,384
220202 Utilities- General 16,741 20,257 24,308 28,197 32,145 121,648
220203 Materials & Supplies- General 26,228 31,736 38,083 44,176 50,361 190,584
220204 Maintenance Services- General 19,944 24,132 28,959 33,592 38,295 144,922
220206 Other Services- General 27,609 33,407 40,088 46,502 53,013 200,619
220208 Fuel & Lubricants- General 42,724 51,696 62,035 71,961 82,035 310,452
220209 Financial Charges- General 6,245 7,556 9,068 10,519 11,991 45,379
220210 Miscellaneous 86,924 105,178 126,214 146,408 166,905 631,628
Capital Expenditures
230101 Purchase of Fixed Assets- General 22,018,348 26,642,201 31,790,641 37,085,944 42,277,976 159,995,110
230201 Construction/Provision of Fixed Assets- 5,310 6,425 7,710 8,944 10,196 38,585
General
230301 Rehabilitation/Repairs of Fixed Assets- 1,475 1,785 2,142 2,484 2,832 10,718
General
230401 Preservation of the Environment- - - - - - -
General
230501 Acquisition of Non-Tangible Assets 46,899,618 56,748,538 68,098,245 78,993,965 90,053,120 340,793,485
Total - FMoH 69,198,835 83,730,590 100,476,708 116,552,982 132,870,399 500,837,898
(A3) NHIS
Capital Expenditures
230101 Purchase of Fixed Assets- General - - - - - -
230201 Construction/Provision of Fixed Assets- - - - - - -
General
230301 Rehabilitation/Repairs of Fixed Assets- - - - - - -
General
230401 Preservation of the Environment- - - - - - -
General
230501 Acquisition of Non-Tangible Assets 422,339 511,030 613,236 711,354 810,944 3,068,903
Total - NHIS 422,339 511,030 613,236 711,354 810,944 3,068,903
(A4) NPHCDA
Other Recurrent Costs
220201 Travel & Transport- General 16,522 19,992 23,990 27,828 31,724 120,056
220202 Utilities- General 21,976 26,591 31,909 37,015 42,197 159,687
220203 Materials & Supplies- General 19,230 23,268 27,922 32,389 36,924 139,734
220204 Maintenance Services- General 8,038 9,762 11,671 13,539 15,434 58,408
220206 Other Services- General 66,336 80,267 96,320 111,731 127,373 482,027
220208 Fuel & Lubricants- General 23,776 28,769 34,523 40,046 45,653 172,767
220209 Financial Charges- General - - - - - -
220210 Miscellaneous 34,929 42,264 50,717 58,832 67,068 253,810
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Exchange rate as of 30th April 2024; US$1 – NGN1,356.01.
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Budget Code Yearly Projections of program expenditures (US$55)
2024 2025 2026 2027 2028 Total
Capital Expenditures
230101 Purchase of Fixed Assets- General 27,622,411 33,423,117 40,107,741 46,524,979 53,038,476 200,716,725
230201 Construction/Provision of Fixed Assets- 1,174,479 1,421,120 1,705,344 1,978,198 2,255,146 8,534,287
General
230301 Rehabilitation/Repairs of Fixed Assets- 16,167,064 19,562,147 23,474,577 27,230,509 31,042,781 117,477,078
General
230401 Preservation of the Environment- - - - - - -
General
230501 Acquisition of Non-Tangible Assets 1,751,415 2,119,212 2,543,055 2,949,943 3,362,935 12,726,560
Total – NPHCDA 46,906,176 56,756,473 68,107,768 79,005,010 3,729,309 340,841,139
Budget Code Yearly Projections of program expenditures (US$)
2024 2025 2026 2027 2028 Total
B) 36 States, excluding FGN56
Other Recurrent Costs
220201 Travel & Transport- General 1,707,965 2,066,638 2,479,965 2,876,760 3,279,506 12,410,833
220202 Utilities- General 429,354 519,518 623,422 723,170 824,413 3,199,877
220203 Materials & Supplies- General 5,573,248 6,743,630 8,092,356 9,387,133 10,701,332 40,497,699
220204 Maintenance Services- General 2,477,827 2,961,871 3,554,245 4,122,924 4,700,133 17,787,000
220206 Other Services- General 5,212,855 6,307,555 7,569,065 8,780,116 10,009,332 37,878,923
220208 Fuel & Lubricants- General 876,997 1,061,166 1.273,400 1,477,144 1,683,944 6,372,650
220209 Financial Charges- General 791,112 957,246 1,148,695 1,332,486 1,519,034 5,748,572
220210 Miscellaneous 11,934,713 14,441,003 17,329,203 20,101,876 22,916,138 86,722,933
220400 Grants and Contribution General 1,971,498 2,835,513 2,862,615 3,320,634 3,785,522 14,325,781
220700 Transfers-Payments 806,334 975,664 1,170,797 1,358,124 1,548,262 5,859,182
Capital Expenditures
230101 Purchase of Fixed Assets- General 84,698,039 102,484,627 122,981,553 142,658,601 162,630,805 615,453,625
230201 Construction/Provision of Fixed Assets- 93,869,969 113,582,662 136,299,195 158,107,066 180,242,055 682,100,948
General
230301 Rehabilitation/Repairs of Fixed Assets- 33,803,894 40,902,712 49,083,254 56,936,575 64,907,695 245,634,130
General
230401 Preservation of the Environment- 224,795 272,002 326,402 378,627 431,634 1,633,460
General
230501 Acquisition of Non-Tangible Assets 51,086,533 61,814,705 74,177,646 86,046,069 98.092,519 371,217,472
Total – 36 States 295,435,133 357,476,511 428,971,813 497,607,303 567,272,326 2,146,763,086
Source: 2024 Appropriation published by the BoF (FGN MDAs), and the websites of each of the 36 states, and WB staff calculations.
Yearly Projections of program expenditures (US$)
FGN + 36 States
2024 2025 2026 2027 2028 Total
Total – PEF 504,706,308 610,672,852 742,807,423 850,056,611 882,728,134 3,665,298,115
• Note 1: BHCPF: 100 percent of 2024 Budget. Budgeted by the FGN under personnel cost, salaries & wages.
• Note 2: FMoH: 40 percent of 2024 Budget, excluding Personnel Costs. The same applies to the States, MoH.
• Note 3: NHIS: 50 percent of 2024 Budget, excluding Personnel Costs. The same applies to the States, SHIS.
• Note 4: NPHCDA: 100 percent of 2024 Budget, excluding Personnel Costs. The same applies to the States, SPHCDB.
• Note 5: States HMB: 20 percent of 2024 Budget, excluding Personnel Costs.
Note 6: States DMA: 60 percent of 2024 Budget, excluding Personnel Costs.
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Figures only relate to States Ministries of Health, States Health Insurance Agencies, States Primary Health Care Development Board, and States Hospital
Management Board.
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ANNEX 3. SUMMARY FIDUCIARY SYSTEMS ASSESSMENT
1. An FSA was carried out to review the systems, practices, and procedures at the participating MDAs. These include
the FMOH&SW, NPHCDA, and NHIA, including state-level counterparts across a sample of four representative states:
Enugu, Nasarawa, Ondo, and Oyo. Capacity and performance with respect to procurement, FM, and anticorruption
systems are adequate to provide reasonable assurance that financing proceeds will be used for the intended purposes of
the HOPE-PHC Program.
2. A summary of key fiduciary risk and mitigation measures identified by the assessment are listed in the PAP (Annex
5). This includes both FM and procurement.
3. Program Budget and Audits. The implementing agencies have a robust budget and accounts classification system
that will enable reporting of Program expenditures. The HOPE-PHC Program audit will be conducted by the OAuGF and
the State Auditors General for federal and state agencies, respectively. The PCU will, after receiving the audit reports
from the OAuGF and SOAuGs, compile the data on Program expenditures for the federal and state participating MDAs
extracted from the audited financial statements. The data will be certified by the OAuGF with an opinion expressed based
on agreed upon procedure. The implementing agencies will strengthen their capacity to undertake risk-based internal
audit. The FMOH&SW and other implementing agencies will prepare and implement an internal audit plan under the
HOPE-PHC Program.
4. In respect of Procurement, the HOPE-PHC Program will use the government’s public procurement management
mechanism which is considered adequate and saw reform with the enactment of the Public Procurement Act 2007 and
related states legislation which guide the procurement of goods, works, and services. Both the Federal and states
procurement laws are based on the UNCITRAL model with minor differences to cater for peculiar domestications at the
State level. The World Bank Procurement Regulations will govern procurement under the IPF component of the HOPE-
PHC Program. The Nigeria Public Procurement Act 2007 and associated procurement regulations and systems meet the
requirements of the PforR policies and procedures - and are adequate for the achievement of the HOPE-PHC Program
objectives. The government has created a procurement cadre in the public service. The MDAs use the Public Procurement
Act and apply procurement approaches and procedures that are based on the Procurement Regulations developed by the
Bureau of Public Procurement.
5. The World Bank ‘Guidelines on Preventing and Combating Fraud and Corruption in PforR-Financing’ will apply to
the HOPE-PHC Program and Grievance Redress Mechanisms will be implemented across all the implementing agencies.
The HOPE-PHC Program governance and anti-corruption arrangements will rely on the country’s national level governance
and anti-corruption arrangements with additional Program-specific reporting and agreed protocol.
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Figure 3.1 Disbursement Arrangements
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ANNEX 4. SUMMARY ENVIRONMENTAL AND SOCIAL SYSTEMS ASSESSMENT
1. The ESSA examines the extent to which the existing E&S management systems of Nigeria’s federal and state
governments operate within an adequate legal and regulatory framework to guide E&S impact assessments, mitigation,
management, and monitoring at the HOPE-PHC Program level. It assesses their consistency with the six “core principles”
of the PforR Policy and recommends actions to address the gaps and to enhance performance during Program
implementation. This ESSA incorporates recognized elements of good practice in E&S assessment and management,
defines measures to strengthen the system, and recommends measures that will be integrated into the overall HOPE-PHC
Program. The ESSA is undertaken to ensure consistency with six core principles and key planning elements of the PforR
ESSA.57
2. The World Bank prepared the ESSA through a combination of detailed reviews of existing program materials and
available technical literature. This literature includes policies, regulations, guidelines and examples of due diligence and
design documents, interviews and extensive consultations with government staff, nongovernmental organizations,
regulatory agencies, private sector organizations, and sector experts associated with the health sector in Nigeria.
3. In line with the six core principles, the relevant risks associated with the HOPE-PHC Program, and within the
proposed Results Areas that cover E&S issues, include:
(a) The refurbishment and rehabilitation of facilities to achieve a 75 percent score on the health facility readiness
assessment could result in negative E&S impacts, such as the generation of solid waste, noise, and air pollution.
(b) Discrimination could exist in the recruitment of healthcare workers, such as skilled birth attendants, to meet the
readiness assessment criteria.
(c) Generation of e-waste may increase due to the digitization of the health system for digital health enterprises in
health architecture.
(d) There could be a potential increase in the generation of healthcare waste due to increased spending on the
provision of facilities, an expansion in the number and improved quality of healthcare facilities, and increased
expenditure for provision of health products.
(e) There could be potential discrimination against vulnerable groups, ethnic bias, and sexual abuse or harassment
of women in the provision of health insurance under the NHIA gateway in the revised BHCPF guideline, and in
the provision of essential health services by CHWs.
(f) The rehabilitation of facilities with climate resilience and energy efficiency features under the National Climate
and Health Implementation Plan could lead to negative E&S impacts associated with rehabilitation, such as the
generation of solid waste, noise, and air pollution. In addition, there are negative environmental impacts
associated with renewable energy, such as solar systems, especially electronic waste, old batteries and panels,
and possible clearing of land/vegetation to install solar panels.
(g) Rehabilitation work can also impact workers’ health and safety.
4. The overall E&S risks have been assessed as moderate. Although the HOPE-PHC Program does not involve
construction works, and Program activities are not likely to require significant changes to the government’s overall
environmental systems, the HOPE-PHC Program was generally assessed as moderate because there are some
rehabilitation works on facilities to strengthen the health system.
5. The ESSA process includes stakeholder consultations and disclosure of the ESSA Report, in accordance with the
World Bank Policy and Directive for Program for-Results Financing and Access to Information Policy. At present, the
ESSA consultation process is embedded in the HOPE-PHC Program consultation process.
57 https://ead.gov.ng/public-disclosure-of-the-escp-sep-essa-for-hope-p-for-r-by-federal-ministry-of-health/
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6. Some analysis was carried out to determine the range of E&S risks and benefits that are associated with the HOPE-
Health Program based on each of the DLIs. The HOPE-PHC Program will generate some E&S risks and benefits.
7. The HOPE-PHC Program will generate some E&S benefits and risks. The environmental risks will result from the
rehabilitation and refurbishment of infrastructure, digital health enterprise in health architecture, and traffic risks due to
increased patient emergency transport. On the other hand, the environmental benefits are minimal and limited to
facilitating climate resilience measures for primary healthcare centers and BEmONC facilities and the climate benefits
from the implementation of the National Climate and Health Adaptation Plan.
8. The HOPE-PHC Program will deliver some direct and indirect environmental benefits. Direct environmental benefits
will accrue from achieving DLI 1.1, which focuses on the percentage of BHCPF-supported Tier 2 (PHC+BEmONC) facilities
that maintain a score of 75 percent on the health facility readiness assessment and includes measures of structural and
process quality, solar power, and climate resilience, and DLI 1.2, which aims for an increase in refurbished and empaneled
CEmONC facilities that demonstrate service readiness, climate resilience, and energy efficiency. The installation of solar
power and efforts to strengthen energy efficiency and climate resilience in health facilities will help reduce emissions and
facilitate the achievement of Nigeria’s 2060 zero emission target.
9. Activities to achieve DLI 9, which strengthens EPR at the subnational level, will also yield environmental benefits.
Achieving this DLI will improve Nigeria’s ability to handle climate shocks, natural disasters, and other humanitarian
emergencies and generate some climate co-benefits. In addition, the development and implementation of a national
climate and health adaptation strategy in DLI 10, which will help address climate change and vulnerabilities, will generate
some climate co-benefits.
10. The HOPE-PHC Program includes some activities that are expected to have an environmental impact. Rehabilitation
and refurbishment activities would be conducted to achieve a score of 75 percent on the health facility readiness
assessment in DLI 1.1 and to ensure that CEmONC facilities demonstrate service readiness, climate resilience, energy
efficiency in DLI 1.2. Implementation could involve the rehabilitation of facilities—for example, WASH facilities—that may
be exposed to natural disasters, such as floods. Environmental risks associated with rehabilitation, such as solid waste,
noise, and air pollution, as well as occupational health and safety risks, would negatively impact the environment.
11. Generation of waste from electrical and electronic equipment, often referred to as e-waste, is expected. This is due
to the increased use of information and communications technology to facilitate digital health transformation in DLI 11.1
and states’ adoption of digital health infrastructure to achieve DLI 11.2.
12. The emergency medical transport system in DLI 7 will increase the number of vehicles transporting patients during
emergencies and the number of patients transported to primary or secondary healthcare facilities. This will result in
increased consumption of fossil fuels, which will lead to increased CO2 emissions and air pollution from transportation.
Moreover, the digitized system that will be employed in emergency transportation could, in the long run, result in e-waste.
13. The HOPE-PHC Program will result in many social benefits from achieving the DLIs. These benefits include enhanced
health outcomes, reduced infant and maternal mortality rates, increased life expectancy, enhanced economic
development, and poverty reduction, given that more people will be healthy enough to work and contribute to economic
development.
14. The refurbishment and staffing of primary healthcare facilities to meet readiness in the assessment tool and
application of the tool (DLI 1.1) and the refurbishment and empaneling of CEmONC facilities that demonstrate service
readiness, climate resilience, and energy efficiency (DLI 1.2) will facilitate the availability of water sources, toilets,
mother–newborn intensive care units, surgical theatres, and equipment. This will help to enhance health outcomes,
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reduce infant and maternal mortality rates, and increase life expectancy. Improving the quality of healthcare services in
Nigeria’s healthcare facilities will help to ensure equity in access to healthcare, which will facilitate the realization of some
health-related SDGs.
15. Moreover, the rehabilitation of health facilities will lead to increased employment for locals who may be engaged
in menial jobs. The rehabilitation may lead to an influx of workers into communities, enhancing the local economy. Health
workers will also be recruited for primary healthcare facilities, thus creating employment opportunities for unemployed
health workers, and enhancing their income and well-being.
16. In addition, activities under DLI 2 will facilitate the provision of contraceptives, tracer commodities, and medicines
to women and children. Tracer commodities include oxytocin, MMS, ACTs, HIV rapid test kits, Pentavalent vaccine, and a
minimum of three modern contraceptive methods, including at least one LARC. Provision of these commodities will reduce
the incidence of malaria, especially during pregnancy; reduce mother-to-child transmission of HIV; enhance the health of
mothers and children; reduce infant and maternal mortality rates; and enhance life expectancy.
17. Increased insurance coverage through linkages with the NHIA gateway (DLI 3) will increase child enrollment in the
NHIA. Increased insurance coverage will help ensure access to health services, especially among the poor, as it will protect
them from increased healthcare costs. This will help to ensure improved health outcomes and quality of life.58 In addition,
the provision of tracer health services (DLI4) through CHWs, including micronutrient powders or small-quantity lipid-based
supplements for prevention of malnutrition, growth monitoring and screening for acutely malnourished children,
identification of and follow-up with pregnant women and referral to receive MMS, and treatment of childhood illnesses,
among others, will enhance the health of women and children, reduce infant and maternal mortality rates, and enhance
life expectancy.
18. Skilled birth attendance during delivery in primary healthcare centers (DLI 6.1) will help to ensure that women can
deliver babies in the presence of skilled professionals, thus reducing infant and maternal mortality rates. Moreover,
because children under five and pregnant and lactating women are particularly vulnerable to micronutrient deficiencies,
providing MMS for pregnant women in DLI 6.2 will help prevent micronutrient deficiency in pregnant mothers and their
babies and increase the changes of delivering healthy babies with high immunity against diseases that threaten the lives
of infants. Provision of MMS will also help to ensure the normal functioning and growth of babies and the health of their
mothers. In addition, the provision of Penta-3 vaccination in DLI 6.3 will help to ensure that children aged 12 to 23 months
are maximally protected against diphtheria, tetanus, pertussis (whooping cough), polio, hepatitis B and Haemophilus
influenzae type b (Hib), thereby substantially reducing infant mortality rates.
19. Digitizing the health system in DLI 11 (digital-in-health enterprise in health architecture) offers many benefits to
primary healthcare and general healthcare. For example, it would help policymakers make informed decisions about
resource allocation and thus reduce healthcare costs and free up resources for other important healthcare services. It
would also help doctors and nurses prioritize individual treatment plans and thus enhance better health outcomes. A
study in Ethiopia found that implementing a 20-month data-informed digital platform for health management resulted in
strengthened health management through better use of data and appraisal practices, enhanced stakeholder engagement,
and systemized problem analysis to follow up on action points.59
20. The HOPE-PHC Program is associated with some social risks. The refurbishment and rehabilitation of medical facilities
under DLI 1 could potentially affect the health and safety of workers involved in the rehabilitation works. The workers may
58 Institute of Medicine (US) Committee on the Consequences of Uninsurance. Coverage Matters: Insurance and Health Care. Washington (DC): National Academies
Press (US); 2001. 1, Why Health Insurance Matters. Available from: https://www.ncbi.nlm.nih.gov/books/NBK223643/
59 Avan BI, Dubale M, Taye G, Marchant T, Persson LÅ, Schellenberg J. Data-driven decision-making for district health management: a cluster-randomised study in 24
districts of Ethiopia. BMJ Glob Health. 2024 Feb 29;9(2):e014140. doi: 10.1136/bmjgh-2023-014140. PMID: 38423549; PMCID: PMC10910485.
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be exposed to pollution caused by dust and noise at the work site. There could also be an influx of workers into the
communities where rehabilitation work will occur, and there could be cases of sexual abuse, drug abuse, and other social
problems.
21. There is the potential for discrimination against women and other vulnerable groups, ethnic considerations, and
sexual abuse or harassment of women. This discrimination could occur in the provision of tracer essential health services
by CHWs (DLI 4), provision of health insurance under the NHIA gateway (DLI 3), provision of CEmONC, neonatal and under-
five services and/or VVF surgeries (DLI 5.2), distribution of MMS supplementation for pregnant women during ANC visits
(DLI 6.2), and provision of emergency medical transportation for patients with obstetric and neonatal complications (DLI7).
In addition, although social conflict as envisaged by the ESSA—especially regarding armed conflict—is not applicable,
discrimination along the lines of ethnicity and religion in medical staff recruitment under DLI 1, provision of tracer
essential health services and provision of emergency transportation for patients with neonatal complications, and
distribution of MMS supplementation for pregnant women can result in complaints, grievances, social unrest, and
demonstrations among communities that feel left out or cheated.
22. Following the identification of E&S risks, the E&S management system in place to manage the identified risks was
assessed. The assessment was conducted using the following criteria: the strengths of the system, or where it functions
effectively and efficiently and is consistent with the World Bank Policy and Directive for PforR Financing; inconsistencies
and gaps between the principles espoused in the World Bank Policy and Directive for PforR Financing and capacity
constraints; and actions to strengthen the existing system. Information from this analysis, including the identification of
gaps and opportunities/actions, was used to inform the recommendations and PAP as detailed in Annex 5.
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ANNEX 5. PROGRAM ACTION PLAN
@#&OPS~Doctype~OPS^dynamics@padpfrannexprogramactionplan#doctemplate
Completion
Action Description Source DLI# Responsibility Timing Measurement
Develop and Other NA NPCU/SCO Other At Finalized
publish on effectiveness. Program
Ministry website, Operations
Program Manual
Operations developed in
Manual (POM) agreement with
the World Bank
and published.
Develop Code of Environmental NA NPCU/NEMSAS Other Within one year Finalized Code of
Conduct, Traffic and Social of effectiveness Conduct and
Management and Systems Occupational
Occupational Health and
Health and Safety Safety Plans
Plans for reports.
managing traffic
related risks from
increased
emergency
patients transport.
Develop referral Environmental NA NPCU/FMOWA Other Within one year Referral
pathways and and Social of effectiveness pathways
communication on Systems developed and
GBV prevention integration of
and management GBV prevention
to be integrated and
into retraining management in
curricula for front
curricula.
line workers.
Undertake Environmental NA Federal Other Prior to Environmental
environmental and Social Ministry of commencement screening
screening of Systems Health and of rehabilitation checklist
designs for the NPCO/SCO works satisfactory to
rehabilitation of the World Bank
facilities to ensure developed for
that the use before
rehabilitation
rehabilitation
activities filter out
works
substantial or
high-risk civil
works and
proposed actions
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Develop e-waste Environmental NA NPCU Other Within one year Health care e-
and health care and Social of effectiveness waste
waste Systems management
management plan developed
strategies for and
managing e-waste disseminated to
and healthcare health care
waste result from
facilities.
the program.
Deployment of key Fiduciary NA NPCU Other At effectiveness Terms of
financial Systems Reference,
management, Curriculum Vitae
procurement and and
safeguards Appointment
personnel, with Letter for each
TOR acceptable to designated
the Association
officer
Prepare and Fiduciary NA NPCU Other Within 90 days Capacity
implement a Systems of effectiveness development
comprehensive plan developed
Procurement
Capacity
Development Plan
for the
Implementing
Agencies based on
a need
assessment.
Conduct clinics to Fiduciary NA NPCU Other Throughout Annual training
strengthen Systems Program reports
procurement implementation
institutions and
systems through
capacity building.
Ensure that Fiduciary NA NPCU Other Throughout Annual reports
individuals or Systems Program
firms debarred or implementation TOR for
suspended by the audit firms will
Bank are not include the
awarded a requirement to
contract by assess on
verifying the same random basis
prior to award whether any
under the contract has
Program. been awarded to
a suspended or
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debarred firm
and no parties
debarred or
suspended by
the Bank shall
benefit from the
program funds.
Development and Fiduciary NA NPCU Other Within six Standard
adoption of Systems months from Framework
standardized effectiveness. Agreement and
framework procurement
agreements for package
procurement of templates
recurring items.
Carry out program Fiduciary NA NPCU Other Once at mid- Value for Money
procurement Systems term review audit report
performance and (MTR) and once
value for money at program
audit by an closure.
Independent
Agency/Consultant
(Third Party) using
the terms of
reference agreed
by the World
Bank.
Establish service Fiduciary NA NPCU Other At effectiveness Fund Release
standards with Systems Policy
implementing
agencies to ensure
timely for the
release of Program
funds.
Engagement of Fiduciary NA PCU Other 2 months after Engagement of
IVA with technical Systems Program IVA by
and audit skill to effectiveness. implementing
review the agencies.
achievement of
DLIs and release of
funds to the
implementing
agencies by the
Government in
conjunction with
HOPE-GOV PCU
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Submit report on Fiduciary NA NPCU Other Bi-annually Bi-annual report
fraud and Systems /implementing after
corruption agencies effectiveness
allegations. Where
there are no such
allegations or
complaints, a
statement to that
effect shall be
included in the
submission.
Strengthening of Fiduciary NA NPCU Other Throughout Semi-annual
ICPC’s Anti- Systems Program summary
Corruption and implementation reports
Transparency Unit
(ACTU) at FMOH
and strengthening
reporting linkages
to the Economic
and Financial
Crimes
Commission
(EFCC).
Submit PEF based Fiduciary NA NPCU Other Throughout Annual report
Program financial Systems Program and updated
and IPF interim implementation expenditure
financial reports. framework
Focused training Fiduciary NA NPCU Other Within 90 days FM Training
to fiduciary staff in Systems /implementing of effectiveness Report package
implementing agencies that includes
agencies to agenda, training
strengthen manual
financial
management and
reporting.
Capacity training Fiduciary NA NPCU Other Within 18 Annual report
on risk based Systems /implementing months of
internal audit for agencies effectiveness
internal auditors.
Government shall Technical NA NPCU/DFH- Other Throughout Annual PDSR
strengthen FMOH Program Assessment /
Maternal and implementation Report
Perinatal Deaths
Surveillance and
Response (MPDSR)
system
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ANNEX 6. IMPLEMENTATION SUPPORT PLAN
1. The Implementation Support Plan is designed based on the residual risks identified in the SORT assessment, in
addition to other technical, fiduciary, environmental, and social gaps noted by the World Bank team. Implementation
support will cover all facets of the HOPE-PHC Program (Table 6.1), and World Bank team roles and inputs are proposed in
Table 6.2. Advisory and TA activities that are critical for the achievement of DLIs, identified in the PAP (Annex 5), will be
implemented with the support of the World Bank team.
2. The World Bank will partner with the NSC and development partners under the SWAp TWGs to provide
implementation support to national and subnational entities in the implementation of the HOPE-PHC Program. The SCO
has recently established seven TWGs to coordinate development partner TA under the SWAp. The TWGs are responsible
for acting on sector-wide priorities (for example, the M&E TWG is tasked with creating sector-wide indicators and
collecting inputs from relevant sub-groups, such as NHIA, NPHCDA, and Family Health). All SWAp TWGs report their
findings to the NSC, chaired by the CMHSW, and have specific mechanisms through the SCO to hold them accountable, as
described in Section III(A) – Program Implementation. The technical and fiduciary support provided through enhanced
development partner coordination aims to facilitate coordination, monitor progress and outcomes, help identify and
resolve roadblocks, strengthen performance management, improve equity, and enhance overall administrative efficiency.
Table 6.3 lists the development partners that are currently providing financial and technical support for the NHSRII.
3. To ensure successful Program/Project implementation, the World Bank team will be comprised of members with
different skills and required experience. Table 6.2 outlines the expected staff, staff time, and travel needed to ensure
sufficient resources to implement planned program actions and schedules.
Table 6.1: Focus of Implementation Support
Time Focus Skills Needed from Task Team Resource Partner role
Estimate (US$)
First 12 • Project readiness and preparation in • M&E 1,500,000
months advance of project effectiveness • Data management
• Procurement preparation pre-award • Technical
• Capacity building
• Design and implementation of surveys,
including quality assurance.
• Development of the State of Health
Report
• Design and implementation of public
health fellows’ program.
• Advice to results teams on development
of workplans and implementation start;
determination of whether advisory
support is needed to achieve the DLIs.
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Time Focus Skills Needed from Task Team Resource Partner role
Estimate (US$)
12–48 • Review of progress in tender process • Technical 1,500,000
months and construction • Fiduciary
• Timely implementation of action plan • Social and environmental
and surveys
• Prompt disbursement against DLI
achievements.
• Monitoring of procurement, FM, E&S,
and fraud and anticorruption action
plans
• M&E, E&S, and FM
• Capacity building
• In-depth midterm review
Table 6.2: Task Team Skills Mix Requirements for Implementation Support
Skills Needed Number of Number of Trips Comments
Staff Weeks per Year
Task Team Leaders (TTLs) 88 TTL and co-TTL based in Abuja
M&E specialists 24–30 3–4 One based in Abuja/HQ
Procurement specialists 10–15 nan Based in Abuja
FM specialist 6 n.a. Based in Abuja
Environmental/social specialists 5–6 n.a. Based in Abuja
Operational support 5–10 2 One based in Abuja/HQ
Specialized technical experts 5–10 3
Administrative support 5-10 n.a. Based in Abuja
Table 6.3: Role of Partners in Program Implementation
NAME ROLE
Bill and Melinda Gates Foundation (BMGF) TA
CIFF Cofinancing /TA
GLOBAL AFFAIRS CANADA TA
FCDO Cofinancing/TA
GAVI TA
GLOBAL FUND TA
GIZ TA
UNICEF/UNFPA/WHO TA
US Center for Disease Control (CDC) TA
USAID NDHS/State of Health Report/TA
Japan International Cooperation Agency (JICA) TA for EPR
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ANNEX 7. INVESTMENT PROJECT FINANCING COMPONENT
1. Implementation arrangements for the HOPE-PHC Program will be fully streamlined into existing government
structures at the federal and state government levels. The government launched the NHSRII in December 2023, supported
by a SWAp. A compact outlining the roles and responsibilities of key stakeholders in the SWAp framework was signed by
the federal and state governments and most development partners in Nigeria, and its implementation is supported by a
SCO in the office of the CMHSW. To ensure alignment of the SCO’s activities with the objectives of the HOPE-PHC Program,
the SCO will also serve as the NPCU for the HOPE-PHC Program. Oversight of state-level implementation will be through
the BHCPF SOCs. This implementation arrangement reflects the recommendations and outcomes of various consultations
and assessments carried out as part of Program preparation.
2. The main features of the institutional, implementation, and coordination arrangements for the HOPE-PHC Program
include: (a) alignment with the SWAp; (b) establishment of an NSC, which comprises development partners and civil society;
and (c) expansion of the functions of the BHCPF SOCs. Within this framework, the HOPE-PHC Program leverages key
implementation models, processes, and tools from the existing organizational structure of the FMOH&SW and subnational
entities to ensure the sustainability of investments and improve service delivery.
3. The HOPE-PHC Program’s governance structure comprises NSC and the NPCU/SCO. First, the HOPE-PHC NSC will be
chaired by the Honorable CMHSW and will comprise Honorable Minister of State for Health (HMSH), PSH, relevant heads
of agencies of the FMOH&SW, selected members of the DPG-Health, and other members nominated by the CMHSW. The
key responsibility of the NSC is to provide oversight and policy guidance to the SWAp Program in pursuit of the achievement
of the HOPE-PHC PforR PDOs and Program development indicators. The terms of reference for setting up the NSC will be
prepared by the NPCU/SCO and will be cleared by the World Bank. These TORs are expected to adequately reflect that the
NSC provides important strategic oversight for the overall SWAp Program and for the IPF project, and it will define the
future direction and sustainability of the HOPE-PHC Program. This will include broader investments mobilized under the
SWAp, including deployment of additional CEmONC facilities, implementation of the public health fellows’ program, and
expansion of midwifery and nursing training capabilities. The NSC will be expected to have periodic interface with the
broader HOPE Program at the national level to further strengthen engagement with the FMBNP and Federal Ministry of
Education. The NPCU/SCO will function as the core task team, reporting to the CMHSW and serving as the secretariat for
the Steering Committees. This hierarchical structure draws on experience with other successful PforR operations
implemented in Nigeria and facilitates efficient communication, oversight, and resolution of implementation challenges at
various levels.
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Figure 7.1. HOPE-PHC NPCU Organigram
4. Federal-level project management, coordination, and implementation arrangements. The NPCU/SCO, headed by a
National Program Manager recruited from either the public or private sector and reporting to the CMHSW/PSH, will meet
weekly to steer day-to-day Program activities. The head of the SCO will double as the National Program Manager based in
the Office of the coordinating minister and will serve as a secretariat for the NSC and as the World Bank’s counterpart. The
head of the NPCU/SCO will work under the overall supervision and guidance of the CMHSW, HMSH, and PSH. The
NPCU/SCO will manage and coordinate implementation of the HOPE-PHC Program. While the actual implementation of the
HOPE-PHC Program will be the responsibility of states, relevant entities such as NHIA, NPHCDA, NEMSAS, NCDC, BHCPF
MOC will provide general oversight, technical support, supervision, M&E, and resource management, as required for states’
engagement. The NPCU/SCO for the HOPE-PHC Program will oversee day-to-day implementation and will be responsible
for coordinating HOPE-PHC Program activities in the FMOH&SW. The NPCU will have specific responsibilities, including: (a)
coordinating and facilitating FMOH&SW activities related to the HOPE-PHC Program; (b) ensuring the timely collection of
high-quality data and publication of the State of Health Report; (c) implementing and overseeing disbursements to states
and participating entities under the various DLIs; (d) communicating and working with the states, including developing and
implementing a communications plan; (e) serving as the NSC secretariat; (vi) facilitating the timely disbursement of funds
to the states; (f) coordinating knowledge management and learning; (g) serving as a focal point for FMOH&SW activities
within the broader HOPE Program; and (h) making sure that covenants are complied with and that the PAP is implemented.
The head of the NPCU/SCO will be supported by a full-time, technically competent staff, either seconded from the
FMOH&SW or competitively recruited from the private sector. The NPCU will be supported by a procurement specialist, an
E&S specialist, and a communications specialist, in addition to the FM staff deployed to the PCU by the Accountant General.
The ToRs for the staff to be deployed to the unit will be reviewed and agreed with the World Bank. The NPCU/SCO will have
lean and efficient staffing, and its organizational structure will be reviewed by the NSC. The NSC will also review the
performance of the SCO/NPCU after six months and then annually. The POM will include a clear delineation of the roles
and responsibilities of relevant entities.
5. BHCPF SOC. The BHCPF SOCs will provide oversight and policy guidance for the HOPE-PHC Program at the state level.
Each BHCPF SOC is chaired by the Commissioner of Health, and the current membership of the BHCPF SOC will be expanded
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to include the Commissioner (or equivalent) responsible for planning and budget in the state. The ToRs for this expanded
BHCPF SOC will be prepared in consultation with the Nigeria Governors’ Forum and will be cleared by the World Bank. The
BHCPF SOCs will provide important strategic oversight for the HOPE-PHC Program at the state level and will serve as the
secretariat for state-level BHCPF implementation and the HOPE-PHC Program. The rationale for aligning the BHCPF and the
HOPE-PHC Program is to help ensure the sustainability of the HOPE-PHC Program and allow for the holistic inclusion of all
resources deployed at the state level to be considered as part of broader SWAp implementation. The BHCPF SOCs will be
expected to meet on a quarterly basis and will periodically interface with the various State Executive Councils to further
strengthen program engagement at the state level. The BHCPF SOCs will approve Annual Operational Plans required to
support states in implementing activities and interventions required to access disbursements under the various DLIs and
will assist key stakeholders in analyzing data and adjusting workplans to allow the achievement of DLIs.
6. State-level project implementation and coordination arrangements. The BHCPF SOCs are established in all 36 states
and the FCT and will perform functions like that of NSC, at the state level. The NPCU/SCO will provide guidance to the state-
level implementation bodies to ensure the speedy implementation of activities, with the aim of fostering and building
strong state-level institutions under the BHCPF. The secretaries of the BHCPF SOCs will, in addition to this role, serve as the
focal points for the HOPE-PHC Program in the 36 states and the FCT. There are no Project/Program Implementation Units
at the state level, as there are no IPF procurement or FM functions. This approach focuses subnational entities on achieving
results and not on process. This way, the states can organize themselves in ways that is most effective in their context.
7. The IPF component of the HOPE-PHC (US$45.01 million equivalent) will provide targeted financing in key areas. The
IPF component for TA has two components: (1) Strengthening Systems and Capacities; and (2) Strengthening Program
Coordination and Verification of Results. The IPF will be delivered by selected national-level institutions that are critical for
supporting state governments to achieve program results, as well as to strengthen state government capacities in a
sustainable manner. The first component will be the largest, focusing on establishing platforms for service delivery and
supporting all participating state governments to strengthen their systems and capacities to enable them to achieve the
HOPE-PHC Program results (the DLRs). The second component will focus on program management, IVA functions, and the
learning agenda. Activities under the IPF include the establishment of a MaMII initiative; the design, procurement, and
deployment of a federated digital-in-health enterprise architecture; joint TA coordination platform; operationalization of
the public health fellows' program; hiring of an IVA; and critical TA and capacity building activities.
8. The first IPF component will provide support to strengthen systems and build capacities.
(a) Operationalization of the Maternal Mortality Reduction Innovation Initiative (MaMII). MAMII innovation initiative
“investments” focus primarily on strengthening primary healthcare in high-burden, lagging, and climate-vulnerable states,
allowing them to address legacy issues and “prime the pump.” These types of service delivery innovations would aim to
expand the coverage or quality of services at the population level, with an emphasis on underserved rural populations. The
MAMII initiative will be designed to support public and private sector innovations aimed at increasing the utilization and
quality of maternal and child health Interventions. The establishment and operation of the MAMII initiative will support
not only private sector innovations aimed at increasing utilization and quality of maternal and child health interventions,
but also partnerships with the public sector to test new approaches or scale up services to improve the delivery of RMNCAH-
N services. The initiative will support interventions critical to ending preventable maternal, newborn, and infant deaths,
including midwifery, emergency obstetric and newborn care, maternal and perinatal death surveillance and response,
obstetric fistula and other obstetric morbidities, and digital capabilities and technologies. The MAMII initiative will be
managed through a competitive process, to be established by the NPCU. The process will be cleared by the World Bank
before its operationalization. Given the link between climate change and maternal, neonatal, and child health conditions
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in Nigeria, the initiative will prioritize proposals focused specifically on climate-vulnerable areas with measures to address
the additional burden of disease from climate change.
(b) Design, procurement, and deployment of a federated digital-in-health enterprise architecture. The NHSRII reforms
include plans to bring about a digital transformation in the health sector by digitizing most information systems, including
the electronic human resource management information system, the electronic national health insurance system, and the
electronic health records systems. The TA will support enhanced digital capacity, including TA60 and consultancies for the
definition of regulatory frameworks and acquisition of hardware and software. The HOPE-PHC Program will support the
FMOH&SW and its agencies to achieve an interoperable platform to systematically exchange data. In addition, the National
Digital Transformation Office shall be supported to undertake feasibility study and to establish requirements for an
enterprise data-sharing protocol, and a system for interoperability and data governance will be financed. Furthermore, any
professional and consulting charges required to finance the design, building, and implementation of the data-sharing
architecture will be financed by the HOPE-PHC Program, including consultancies to support platforms to undertake: (a)
improved management of medicine stocks and supply chains; (b) introduction of advanced digital learning tools to upskill
CHWs; (c) digital platforms for the management of emergency transportation for pregnant women and vulnerable patients;
(d) expansion of the existing information technology (IT) application for Application Programme Interface; (e) strengthening
of the health sector digitalization strategy; and (f) an increase birth registration using e-CRVS systems, with National
Identification Number issued, and children enrolled in national health insurance.
(c) Platform for coordinated TA to support implementation. Supported activities will include the deployment of needs-
based and demand-driven TA, as well as TA for climate activities.
(d) Strengthening strategic purchasing and regulatory functions of NHIA. The IPF will be used to provide TA on establishing
a stronger strategic purchasing platform for the NHIA. Many key institutional building blocks and operational documents
are in need of updating or development at the NHIA, including: (a) provider empanelment guidelines; (b) a tariff schedule
based on a costing exercise; (c) a claims management manual; (d) a medical audit manual; (e) a fraud control manual; (f) a
grievance redress manual; (g) a functional call center for beneficiary feedback; (h) beneficiary communication guidelines;
and (i) contract templates for providers and third-party administrators. These building blocks are best developed at the
NHIA as “public goods” for operationalization by SSHIAs, rather than each SSHIA attempting to develop its own approach,
which would result in inefficiency and fragmentation.
(e)Platform to support implementation of Public Health Fellows' Program. The NHSRII reforms includes the establishment
of the National Health Fellows’ Program,61 with young Nigerian fellows engaged across all 774 LGAs. The fellows will serve
as fiduciary and performance management agents, strengthening health facilities’ capacity for effective planning and
resource management and equipped with appropriate tools to track the performance of BHCPF-supported health facilities
across the nation.
9. The second IPF component will support program management, measurement, results, and the learning agenda.
(f) Hiring of an IVA for Independent Verification of Program Results. The IPF will be used to procure the consultancy
services of an IVA responsible for the implementation of the verification protocol and reporting to the NPCU/SCO on the
HOPE-PHC Program results. The IVA will be engaged by the FMBEP. The role of the IVA is to provide an independent,
credible, and coherent analysis of state and federal government performance and earnings under the HOPE-PHC Program
using agreed-upon data sources and earnings calculations as specified in this PAD.
(g) Program Monitoring and Evaluation and Learning, including Data Quality Assessments and publication of the annual
State of Health Reports and Performance Ranking. The NPCU/SCO will put in place a robust program M&E system to select
60 Due attention will be paid to avoiding the fragmentation of IT-enabled platforms and encourage consolidation while developing digital innovations.
61 https://statehouse.gov.ng/news/president-tinubu-approves-establishment-of-national-health-fellows-programme/
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the right tools to monitor program activities and ensure comprehensive data collection on all results and DLIs and DLRs,
including through internal checks and balances to ensure continuous availability of credible data sources for verification.
An M&E Specialist in the NPCU/SCO will assist the HOPE-PHC Program Manager to implement and coordinate these
activities. The IPF component will cover the costs of consultancy services to implement the annual State of Health Report.
Furthermore, the HOPE-PHC Program incorporates a strong emphasis on the learning agenda to support the HOPE-PHC
Program in adapting and enable peer learning and knowledge dissemination. The NPCU, through the IPF, will implement a
program of peer learning and knowledge dissemination to support the PforR. Thus, the knowledge and learning agenda
provides support for state peer learning forums and periodic exchanges among state health commissioners, with a view to
tapping into the tacit knowledge that exists within state governments and facilitating peer learning among states. In
addition, the learning agenda will support South-South learning through exchange visits to countries with long experience
with the SWAp, such as Bangladesh, and countries with experience using intergovernmental fiscal transfers as part of fiscal
federalism.
(h) Support SCO as the PCU for program communications, stakeholder engagement, and SWAp coordination. The
NNPCU/SCO will receive support in providing effective coordination of stakeholders across the three tiers of government,
as well as stakeholder management and aid coordination in the context of the SWAp. The PCU will collect and analyze
relevant data, coordinate with national and state entities to make sure that results are on track, solve problems early and
rigorously and, when necessary, escalate issues for corrective action to achieve the program’s aspirations, reporting
regularly to the CMHSW/NSC. The NPCU/SCO will work to coordinate the strategic communications activities to be
implemented by relevant agencies, including the NHIA, NPHCDA, NCDC, and NEMSAS. The HOPE-PHC Program will
implement activities with all stakeholders to enable regular dialogue and information sharing throughout its lifecycle. The
communication strategy aims to reinforce the accountability framework underpinning the HOPE-PHC Program. The HOPE-
PHC Program’s stakeholder engagement and program communication will support activities such as a people’s voice
survey, advocacy for the State of Health Report, and communicating and working with states on the HOPE-PHC Program
communications plan. The results of the people’s voice survey62 will be used to directly inform the following: improvements
in the delivery of services under the program; performance in the health system more broadly; and to develop and
implement a communications strategy to bolster service delivery morale, strengthen public awareness of the health
system, and support the advocacy campaign for the State of Health Report. Specialists will be hired within the NPCU/SCO,
in addition to seconded FMOH&SW staff, on specific areas of program management.
Procurement Arrangements
10. Procurement under the IPF component of the operation will be carried out in accordance with the World Bank
procedures, as follows: Procurement for goods, non-consulting and consulting services for the project will be carried out
in accordance with the procedures specified in the ‘Procurement Regulations for IPF Borrowers” (Procurement Regulations)
dated September 2023 and the Guidelines on Preventing and Combating Fraud and Corruption in Projects Financed by IBRD
Loans and IDA Credits and Grants of July 1, 2016, as well as the provisions stipulated in the Financing Agreement.
11. Procurement will be carried out by the NPCU/SCO at the FMOH&SW: The categories of procurement consist
mainly of procurement of goods, non-consulting services and consulting services. Procurement of works is not envisaged
under the IPF component. The consulting services will include the engagement of consulting services to deploy the
federated digital in health architecture, selection of IVA firm by the FMBEP for the HOPE-PHC Program. The IVA
procurement will be an eligible expenditure under the HOPE-PHC; however, the procurement process will be done under
the HOPE-GOV. High performing consultants will be hired to strengthen the NPCU/SCO/SCO as needed. In addition, for
specific technical aspects of the TA to help states achieve specific DLRs, the NPCU/SCO may engage consultants or firms.
62Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. Lancet Glob Health 2018; 6:
e1196–252.
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12. The NPCU has prepared a Program Procurement Strategy for Development (PPSD) acceptable to the World Bank.
The Procurement Plan will be updated annually and as necessary and in agreement with the World Bank to reflect the
project’s actual implementation needs and improvements in institutional capacity. Advance procurement of key TA
activities will be critical.
Operating Costs
13. Operating costs for the NPCU/SCO, and the implementing agencies for the capacity building will include the
following: staff’s travel expenditures and other travel-related allowances with prior clearance from the World Bank;
equipment rental and maintenance; vehicle operation, maintenance, and repair; office rental and maintenance; supply of
office consumables; utilities and communication expenses; and bank charges. The operating costs financed by the project
will be procured using the government administrative procedures that are acceptable to the World Bank. The operating
expenses will be subject to a statement of expenditure (SOE) review by the World Bank.
14. Operating costs for the NPCU/SCO and the implementing agencies for the capacity building will be based on annual
work plan and budget and will include the following: staff travel expenditures and other travel-related allowances with
prior clearance from the World Bank; equipment rental and maintenance; vehicle operation, maintenance, and repair;
office rental and maintenance; supply of office consumables; utilities and communication expenses; and bank charges. The
operating costs financed by the Project will be procured using the government administrative procedures that are
acceptable to the World Bank. The operating expenses will be subject to a statement of SOE review by the World Bank.
Operating costs exclude the salaries of government civil servants.
Training, Capacity Building, and Workshops
15. The NPCU/SCO and other implementing agencies (through the NPCU/SCO) will submit their annual training plans,
including capacity building activities for the states and training for their own staff, to the World Bank for clearance. The
plans will include, but not be limited to, the names of the officers to be trained, training institutions and/or facilitators,
contents, justification for the training, and estimated cost.
16. The IPF component will include training targeted at improving the capacity of the NPCU/SCO on E&S compliance.
This training will be delivered by the hired E&S officers/consultants.
Financial Management
17. Implementation of the IPF component will be managed by the NPCU/SCO in the FMOH&SW. The Federal Project
Financial Management Department (FPFMD), established in the Office of the Accountant General of the Federation (OAGF),
will be responsible for managing the financial affairs of the project, along with the NPCU/SCO. The FPFMD has been
assessed and found to be acceptable for the implementation of World Bank-assisted projects. A Project Accountant and a
Project Internal Auditor will be assigned to the NPCU/SCO by the FPFMD, and they will be subject to clearance by the
World Bank. Given the NPCU/SCO’s larger role regarding FM on the PforR component, an FM consultant may be hired, if
needed. The consultant will be funded from the TA and will be hired under terms of reference acceptable to the World
Bank.
18. Budgeting. Budget preparation will follow the Federal Government’s procedures, as appropriate. The NPCU/SCO will
prepare the annual project budget based on the TA work plan. The annual work plan and budget will be submitted by the
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NPCU/SCO to the World Bank for approval at least two months prior to the start of the fiscal year. There are adequate
procedures in place for planning and budgeting.
19. Accounting and Financial Reporting. The TA funds will be accounted for by the NPCU/SCO using its computerized
accounting system. The annual financial statements for the IPF component will be prepared in accordance with the relevant
IPSAS. The biannual Interim Unaudited Financial Reports (IFRs) and annual project financial statements will be generated
from the accounting system. Quarterly IFRs will be prepared and submitted to the World Bank by the NPCU/SCO within 45
days of the end of each calendar quarter.
20. Internal Controls, including Internal Audit. The internal control mechanism is considered adequate and acceptable for
the purpose of this project. Staffing is adequate, and there is proper segregation of functions. A Project Internal Auditor
will be assigned to the NPCU/SCO by FPFMD. The internal auditor will carry out project internal audits on a quarterly basis
and prepare corresponding reports. The project internal audit should focus specifically on controls over soft expenditures
under the TA (including travel, workshops, and study tours). The quarterly internal audit reports will be shared with the
World Bank within 45 days from the end of the quarter.
21. External Audit. The NPCU/SCO will prepare annual project financial statements and will be responsible for having them
audited by the OAGF. The audit reports will be due within six months of the end of the fiscal year. The cost of such audits
will be funded under the project.
22. FM Supervision. FM supervision and implementation support will follow a risk-based approach. Supervision will be
carried out at least twice a year, and onsite review will be carried out at least once a year covering all aspects, including
transaction review of TA expenditures. The review will include staffing, IFRs, and annual audit reports, along with
management letters, internal audit reports, internal controls, and follow-up on any previously identified issues. Training
and capacity building will be provided by the World Bank on a periodic basis, as needed.
23. Funds Flow and Disbursements. The World Bank will disburse advances into an US$ Designated Account to be opened
at the CBN and managed by the NPCU/SCO/FPFMD. A Naira drawdown account will also be set up, into which transfers can
be made from the US$ Designated Account based on need and from which payments will be made for eligible expenditures.
A flexible advance ceiling will be applicable for the Designated Account and will be determined based on a six-month
forecast of expenditures. The quarterly IFR, apart from reporting expenditures of the relevant quarter, will provide a
forecast for the subsequent six months.
24. Disbursement. After initial advance to the Designated Account, replenishment will be made against withdrawal
applications supported by Statements of Expenditures. Authorized account signatories for the NPCU will consist of panels
(A and B), as in Table 7.1 One signatory from each panel will jointly sign the project financial documents/instruments.
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Table 7.1: Authorized Account Signatories for the Federal and State Project FM
Panel A Panel B
Main National Program Manager Project Accountant
Alternate PS FMOH&SW Director FPFMD (Federal)
Environment and Social
25. The NPCU/SCO will assign a focal person prior to effectiveness to ensure E&S compliance. A full-time environmental
consultant and a social consultant will be hired by the NPCU/SCO within three months of effectiveness to provide technical
support to the NPCU/SCO on ensuring E&S compliance of the IPF component. The consultants/officers will help the
NPCU/SCO to prepare a half-yearly monitoring report. Both the E&S officer/consultant will be maintained throughout the
operation’s implementation period. Both consultants will provide regular training to the NPCU/SCO staff, project/program-
related state-level staff, and participating private sectors players on the requirements of the proposed ESSA for the PforR
and Environmental and Social Framework for the IPF to effectively manage E&S risks. The requirement of the IPF
component has been clarified in the ESCP.
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