Executive Summary

This case study examines the efforts led by Minister George Werner to create fiscal space in Liberia’s education sector through a teacher vetting and testing project. By February 2018, a third-party audit confirmed that Liberia’s education ministry had removed 83% of 2,046 ghost teachers; generated US$2.3 million in annual savings; and hired 1,371 new and qualified teachers. In addition to sharing the details of this implementation success story, this case study shares reflections from key actors, highlights unique political and funding relationships, and looks ahead to what remains to be done to improve education outcomes in Liberia.

Introduction

In 2013, all 25,000 high school graduates in Liberia who applied to the University of Liberia failed the entrance exam.¹ This wasn’t entirely surprising given that the average high school classroom in Liberia had 158 students; the estimated qualified teacher-to-pupil ratio ranged from 33:1 to 90:1;² and Liberia ranked 177th out of 199 countries on the UNDP education index.³ Furthermore, more than 90% of Liberian teachers did not have a university degree and 36% were untrained and unqualified.⁴ So when President Ellen Johnson Sirleaf appointed George K. Werner as Liberia’s Minister of Education in 2015, he knew there was work to be done.

Werner came to the Ministry of Education with experience in the education sector. He had studied education and social work, taught at the university level, and more recently served as the head of the Liberian Civil Service Agency where he worked to clean up government payroll. In his new role, Werner knew that education outcomes were poor and that Liberia was not seeing any progress despite the amount of aid that was being received. Starting his term in the shadow of the Ebola crisis, he was primarily charged with reopening schools, setting the school calendar, and making sure teachers and students were prepared to go back to school. However, from his time at the Civil Service Agency, he knew that education was the largest and most troubled government sector and that it comprised 40% to 45% of employees on government payroll in Liberia. Looking ahead, he saw the impending likelihood of donor fatigue and realized that in order to make any significant long-term progress in improving education outcomes, he would also have to address fiscal space for education domestically.

Problem: From listening to legacy

As a trained social worker, one of Werner’s first acts as minister was to conduct a listening tour around the country. In his words, “To know a problem, you first have to assess it.” Notebook and pen in hand, Werner traveled from community to community around the country, shadowed by some staff and members of the media, to meet with parents, students, teachers, school administrators, and more. In this capacity, Werner got a first hand account of the challenges in the education system in Liberia. He learned about the day-to-day problems of different stakeholders; he learned that ‘free education’ was not really free because of uniforms and learning materials; he saw the involvement of volunteer teachers who cared more for community than their salaries; he saw what schools looked like after months of abandonment during the Ebola crisis; and more. Most importantly, however, he got a sense of what children wanted for themselves.

With this knowledge in hand, Werner put together a list of 15 priorities he wanted to accomplish during his time as minister. The top five were 1) quality learning outcomes, 2) teacher training, 3) school infrastructure, 4) free early childhood education, and 5) increasing girls enrolment and completion rates. The cost of implementing his priorities was US$100 million. At the time, Liberia’s national annual budget was US$500 million, of which US$40 to $44 million was allocated to the Ministry of Education and approximately 92% of that was budgeted for payroll expenses. Werner had no funds to put behind his priorities. The education ministry applied for a US$11 million grant from the Global Partnership for Education (GPE) to support its work over four years but GPE required that the Liberia’s domestic financing for education show progress towards reaching 20% of government budget. Werner needed to show that Liberia was taking steps in that direction.

Funding: It takes money to get money

When Werner came in to office, a pilot project (funded by USAID and implemented by FHI 360) to identify “ghost workers” and unqualified teachers was already in place. Ghost workers were defined as “teachers who never showed up for their jobs but still received pay, or who were fraudulently included on the payroll.”⁵ Their presence in the education system used up government budget, affected education outcomes, and affected the government’s ability to implement other programs. The pilot was being conducted in three of Liberia’s 15 counties as part of the Liberia Teacher Training Program and President Sirleaf wanted Werner to complete the removal of ghost workers across the country. This was well-aligned with a 2014 government-wide pay-reform strategy that Werner had led as part of the Civil Service Agency but also an opportunity for Werner to free up domestic funds that could be leveraged to generate more external funds and used to implement his priorities.

Werner knew that the ghost worker removal strategy would eventually free up domestic funds but it would require significant initial funds to be implemented. As such, he decided to share Liberia’s story internationally and from that a series of fortunate meetings ensued. In September 2015 at the annual United Nations General Assembly in New York City, Werner shared his plan to remove ghost workers to free up personnel costs and implement his education sector priorities with Robin D’Alessandro, CEO of Vitol Foundation. A few months later in November 2015, D’Alessandro invited Werner to speak at a conference in London. Jamie Cooper, Chair & President of Big Win Philanthropy and Dr. Muhammad Pate, CEO, were at that same conference. Cooper and Pate were intrigued by Werner’s goals. After sending a delegation to visit the education ministry in January 2016 for a feasibility assessment, Big Win approved a US$1 million grant for the ghost worker removal program as well as mandatory competency testing for all teachers. This grant was made directly to the education ministry on the condition that the Liberian government committed to reinvesting any recouped funds back into the education sector. To verify Liberia’s commitment and efficient use of Big Win’s grant, President Sirleaf authored a letter to Big Win confirming reinvestment, PricewaterhouseCoopers was brought on board as a third-party auditor, and arrangements were made to release funds on a quarterly basis (based on achieving implementation targets). This grant from Big Win was critical as the ministry leveraged it to generate additional funds to support vetting and testing across the country.

Context: The challenge of finding ghosts

In Liberia, the Ministry of Education is responsible for supervising the education sector; the Civil Service Agency is the human resources arm of the government that sets policy for pay and benefits of all government employees and informs the Ministry of Finance of personnel costs; and the Ministry of Finance makes funds available for pay and benefits. The challenge of identifying and removing ghost workers was particularly challenging because of this joint governance structure and the presence of three payrolls.

Despite the fact that Liberia’s civil war had ended more than a decade prior, its effects lingered. During the war, thousands of teaching posts were abandoned as people lost their lives or fled and often community members who stayed behind filled in. To compensate these substitute and often under qualified teachers, the government instituted a “supplementary” payroll in addition to its “regular” payroll for qualified teachers and its “general” payroll for non-teaching government employees who worked at schools.

All three payrolls were managed by the Civil Service Agency and funds were disbursed by the Ministry of Finance. The Civil Service Agency crosschecked payroll numbers with the education ministry’s formal personnel listings, however the ministry’s listings were often incorrect because the ministry had neither the capacity nor resources to verify the teacher lists it received from district and county education officers.

By the time Werner came into office, the personnel listings had not been spot checked in years, the payrolls had not been integrated, and the distinctions between the different cadres of workers were not as clear. Anecdotally, it was well known that many teachers abandoned their posts or had intermittent attendance but continued to collect paychecks. It was also not uncommon for lower level decentralized staff within the ministry to add their family or friends to personnel listings. These acts of dishonesty were magnified by flawed policies. New teachers that were hired to replace old teachers automatically took their spot on whichever payroll, regardless of qualifications or experience. This replacement policy combined with the government’s inability to check qualifications meant that unqualified teachers could get hired on the higher paying regular payroll and qualified teachers could get hired on the lower paying supplementary payroll. Furthermore, the Civil Service Agency often took months to add new names to payroll so some new teachers chose to receive their salary in the name of the teacher they were replacing to avoid any lag in payment. And to top it all off, an additional cadre of unpaid volunteer teachers had emerged.

Ultimately, the three payrolls contained duplicate names and payroll numbers, incorrect names, and missing names. All of this exacerbated the ministry’s lack of control and potential for corruption. As of November 2016, the ministry of education had 13,403 teachers on the regular payroll, 6,024 teachers on the supplementary payroll, and 7,299 unpaid teachers.⁶

Implementation: From planning to action

With funding in hand, the teacher vetting and testing project was officially launched in July 2016. The deadline for the project was August 2017, two months ahead of the October 2017 presidential election when President Sirleaf’s term was due to expire. Political support for this project under a new administration was not guaranteed and thus time was of the essence.

To focus exclusively on this project, a project implementation unit was created within the ministry consisting of a project manager, financial manager, field operations manager, and an administrative assistant. This unit was additionally supported by staff from the education ministry’s human resources and teacher education departments.

Appendix A outlines the specific implementation steps of the teacher vetting and testing project.

Results: Changing the status quo

The teacher vetting and testing project is the most comprehensive assessment Liberia has ever done of its education workforce. It has communicated to teachers, principals, and staff that the ministry is making an effort to keep track and hold people accountable and that abandoning one’s post will result in removal.

By February 2018, a third-party audit confirmed that almost all of Liberia’s 19,500 teachers had their qualifications vetted and 73% of them wrote the competency test. Through this process, 2,046 ghost teachers were identified, 83% were removed, and US$2.3 million in annual savings were recouped. The outstanding 17% of ghost teachers were identified in the last six months of the program and will be removed shortly leading to an additional US$800 thousand of annual savings. Gbilia noted that while reaching higher levels of domestic financing can trigger other financing options, an added benefit is a changed mindset within the ministry that they can achieve things domestically over time going forward.

As a result of the fiscal space created within the ministry’s budget and the physical spots available for hire, the ministry of education was able to hire 1,371 new and qualified teachers who were recent graduates of Liberia’s teacher training institutes that provided ministry certification. Furthermore, at least 2,000 qualified teachers who were previously on the supplementary payrolls were transitioned to the higher paying regular payroll, reducing the supplementary payroll from approximately 6,000 to 3,762 teachers. Looking ahead, the data collected has allowed the ministry to estimate that it needs to hire an additional 10,782 principals and teachers to ensure that across the country every classroom has an appropriately paid and qualified teacher. However, despite these significant successes, the last field visits conducted by the ministry found that 15-20% of teachers that had been vetted were not present. It is evident that spot checks will be necessary going forward and norms need to be eroded to communicate to staff that showing up is mandatory and that monitoring is ongoing. Essentially, teacher vetting is important but it must be accompanied by a strategic plan for robust accountability and monitoring with district and county education officers going forward.

The teacher testing component of the project yielded jarring results. Only 6% of teachers passed with a combined score on the math and English papers above 70%. Forty-five percent received a conditional pass between 40% to 69% and 49% failed with less than 40%. While these results make the challenge ahead of improving education outcomes apparent, the data will be a valuable tool for the ministry to design customized training programs to better meet their needs. Werner notes that having this evidence base within the ministry means that they are owning their own data, rather than relying on donors, and that there is intrinsic pride in this. Sheeler adds that data had always been perceived as “for donors” but ministry ownership of data has changed the way the ministry views its role in collaborating with donors. In fact, the new administration now plans to use the results of the test assessment to design its first teacher training and implement it during the next school break for teachers.

As the data continues to be analyzed, it is now becoming apparent that missteps did occur with regards to data management. The project implementation unit prioritized data consolidation but in many cases inconsistencies in data collection and formatting meant that efforts are still being made to reconcile data to create the final consolidated personnel listings. This was likely magnified because of the change in management between the pilot study by USAID and FHI 360 and the remainder of the project by the education ministry.

The results above refer to public school teachers on the regular payroll but analysis to confirm the number of ghost teachers on the supplementary payroll is ongoing. The Civil Service Agency implemented a policy that ghost workers removed from the regular payroll could be replaced but that ghost workers removed from the supplementary payroll had to be deleted. The ministry still needs to analyze how many supplementary deletions occurred so that they can reallocate those funds to hire new teachers to the regular payroll. They estimate that for every two to four supplementary ghost workers deleted they can hire one new teacher on the regular payroll, and ultimately they aim to use the data to migrate all qualified supplementary teachers to the regular payroll.

Reflections: Blinded by the urgency of the moment

Based on conversations with a number of key stakeholders with various levels of involvement in the teacher vetting and testing project, some key reflections on political risk, funding relationships, and transformational leadership emerged.

Looking back as Werner reflects on his feelings at the conclusion of his listening tour, he says, “I was blinded by the urgency of the moment. What I saw in the field pains me and blinded me to the degree that I really wanted to solve problems in the here and now.” Perhaps this naiveté was a blessing as the political risk associated with undertaking the project was much higher than the technical risk. Jamie Cooper, President and Chair of Big Win Philanthropy, comments that “George may not have appreciated the potential political risk…but the upside of that is that he was focused on changing the system and not about protecting himself.” She also notes that Werner’s relationship with President Sirleaf and his efforts to nurture it were critical to her willingness to provide political cover when needed.

The funding relationship upon which this project was built is particularly unique. Toby Eccles, Cofounder and Development Director of Social Finance, reflects that, “In a place with as few resources as Liberia, room to use imagination is extremely limited because there are only incremental changes you can make to the budget.” However, distrust of government, especially those with a history of corruption, is a common sentiment in the international philanthropic space. While the story of Liberia’s project may be appealing to other countries, a key challenge to replicating this experience within a ministry is identifying funders who are willing to give funds directly to government. One of Werner’s clear successes was his ability to attract and develop a relationship with a funder that was open to such an arrangement. While a series of fortunate events led to their meeting, Werner’s plan to campaign externally for funding; President Sirleaf’s willingness to commit in writing to reinvesting funds; and the amenability of both the Liberian government and the Big Win Philanthropy team to negotiate terms of a target-based, incremental funding deal with a third-party auditor in place are all intentional factors that contributed to this unique funding arrangement. Government efforts to recreate some of these elements may be a foundational step to generating trust and allowing such funding relationships to occur more commonly in other settings.

One critical element associated with the aforementioned funding relationship that may not be as easily replicable is the need for a transformational leader. When asked about what attracted her to Werner’s mission, Cooper immediately noted his earnest commitment. She said, “What’s more unique about George than almost any minister I’ve met is his ability to think outside the box, to try something that is really different but can have a tremendous upside.” While his leadership and public speaking skills are well admired, Werner admits that he didn’t prioritize communication domestically as much as he could have. In hindsight he would have had a better communications architecture in place and made use of ‘palava,’ traditional Liberian peace huts, to increase communication with teachers, settle disputes, and promote inclusiveness. Despite the successes, the opportunities for improvement, and the work ahead, Cooper’s final reflection on Werner is that “he resonates with integrity” – and that basic quality may be the key to why the teacher vetting and testing project worked.

Appendix A: Detailed Implementation

The following sections outlining the specific implementation steps of the teacher vetting and testing project were obtained from “Managing the Business of Education: Liberia Cleans up its Teacher Payroll, 2015-2017,” an in-depth case study by Princeton University’s Innovations for Successful Societies.⁷

Winning Support

The implementation team’s first challenge was to work with Gbovadeh Gbilia, Deputy Minister of Education, to secure buy-in from two crucial stakeholders: the Civil Service Agency and the National Teachers’ Association. A lack of coordination between the education ministry and Civil Service Agency was a longstanding problem, and Werner hoped his past role as head of the agency would pave the way for better collaboration.

The Civil Service Agency initially did not see the vetting project as part of its responsibility, arguing that it was up to individual ministries to ensure that personnel listings were accurate. However, because the agency had to sign off on any changes to the listing, the education ministry felt it was vital for agency officials to see the vetting process was legitimate. “In response to the initial lack of cooperation, Werner’s ministry elevated [its lobbying efforts] to another level by going directly to the finance ministry,” said David Baysah, a sociologist and education planning strategist hired to lead the vetting project’s implementation unit.

By explaining that the vetting and testing exercise could save up to US$7.5 million per year—reducing the annual amount spent by the education ministry on salaries from US$34 million to US$26.5 million—the project team secured support from the finance ministry. The team also relayed to the agency and the finance ministry that President Sirleaf had agreed up front that the funds recovered would be earmarked for reinvestment in education, and would not be put into the government’s general coffers.

Convinced by the outreach effort, officials from the Civil Service Agency agreed to have their officials accompany the vetting team as they traveled around the country. The ministry also agreed to pay additional per diems to enable staff from the Civil Service Agency who became part of the team that traveled throughout the country.

In another step to address the disjuncture between the Civil Service Agency and other government departments, the finance minister worked with the agency to introduce a policy amendment in the cabinet. Whereas the agency previously had overarching responsibility for—and substantial control over—ministry payrolls, there was now “a policy, endorsed by the cabinet, that ministries will handle their own payroll and be held accountable for it,” Baysah said. In addition to smoothing the path for the project’s implementation, the finance ministry’s creation of the draft policy promised to give greater power to individual ministries to maintain their own payrolls.

Next, the education ministry turned to the teachers’ association. In negotiations with Werner and senior officials, the association’s main concerns were that no teacher should be fired summarily based on the outcome of the competency testing, that those who failed but held at least a high school qualification should receive training, and that the government should pay adequate severance to any teachers who lost their jobs because they were determined to be “untrainable” for various reasons.

The ministry used an existing forum to open a dialogue with the teachers. Under the teacher training program that ended in 2015, the ministry had established a committee that brought together the teachers’ association, senior education officials, donor partners, and nongovernmental organizations as well as civil society groups. In response to resistance that had emerged among some teachers during the USAID pilot, the ministry framed the new project as one that would remove cheaters and improve payroll management, leading to better salaries. The team presented its plan to the committee in the hope of winning the association’s support.

Despite initial resistance, the teachers’ association’s long-serving president, Ellen Varfley, ultimately agreed to the planned vetting and testing, and the ministry agreed to provide future training opportunities to all teachers deemed trainable, and severance packages to others. In addition to being the teachers’ association president, Varfley also worked in the ministry’s teacher-training division, a position that allowed her to be involved in drafting the test.

In championing the project, Varfley said she hoped that the competency testing in particular would lead to further gains. “After doing the test, we would know if people need content or pedagogical training, which would allow us to design better training” plans, she said. “… We knew that one size does not fit all. Teachers would [ultimately] benefit by receiving better training.”

Managing Data

Before the team could begin collecting data, they needed a way to manage it. They decided to use a common software product, Microsoft Access, to create a database of information that would allow users to see the big picture as well as to focus on specific schools, districts, and counties. Data would enter the system both electronically and manually. After a teacher’s fingerprints were digitally scanned, a computer would generate a unique enrollment number. Using the same number, the team would manually upload information—including digital copies of the teacher’s qualification documents, photo, and ID materials—to the corresponding file in a database, which the team named the Payroll Data Access Tracking System.

When all the information on any particular person was in the system, “you can see the person’s face as well as all their bio data, their current status, their salary history, their health information and also all their academic credentials,” Baysah said. “It’s a one-stop shop.” The cost of setting up the system was minimal because the human resource team was able to use the ministry’s existing computer systems and worked with the ministry’s in-house IT specialist to design the platform.

Once completed, the database was a valuable management tool. In addition to forming the backbone of an integrated future payroll system, the ministry could use it for professional development and to track replacements and transfers between schools. Further, the ministry could use the database to predict how many teachers were set to retire in coming years, enabling the ministry to anticipate future costs and recruitment needs.

Gbilia’s team recognized that keeping the database up to date was crucial to its long-term effectiveness. After completion of the countrywide vetting and testing, education officers in each of the 15 counties would gain access to the database. The plan required the education officers to update the system whenever a teacher was hired, transferred, or otherwise changed status in their region. The national human resources department in Monrovia would then audit the central database every calendar quarter. The ministry’s hope was that, over time, the Access Tracking System managed by Gbilia “would not just be a data management system but also a planning system,” Baysah said.

Getting the Word Out

The team’s next task was to inform teachers about the planned project. In a nation where roads were poor and comparatively few people, particularly in isolated or densely forested rural areas, had access to television and less than half the population had cell phones,⁸ radio was the go-to communications medium. Aware of the need to assuage potential fears among teachers and to inform parents and the general public, the education ministry produced a series of radio spots that played on some of the more than 60 FM radio stations across the country. (Radio jingles and other productions were often used as tools to make public service announcements in Liberia). The education ministry’s radio spots aimed to head off any knee-jerk opposition among teachers by emphasizing that the vetting and testing would not lead to any arbitrary firings. At the same time, the messages reached the wider community, potentially galvanizing public support.

Prior to kicking off the vetting process in any specific county, the field team also distributed flyers at schools and engaged with community leaders and county authorities during town hall meetings. Their aim was not only to encourage public and parental support for the vetting project but to help teachers understand that they ultimately stood to benefit because the cleanup would free up more money for salaries.

“The communication was very clear that the process will lead to results and consequences: At the end of this process, teachers will have better salaries and access to training opportunities. But also, those that cannot be trained will be removed from the system,” Baysah said. “But no one will be just kicked out. … There will be severance packages.”

Public sentiment was on the side of the project team. Many parents were deeply concerned about the quality of education. Afrobarometer research network survey showed that half of all respondents felt the Liberian government handled education “very badly” or “fairly badly.”⁹ “When the teachers heard [the president saying that] if you want to boycott the vetting exercise or test you will be removed, protests stopped immediately,” Gbilia recalled.

The team also worked closely with local district education officers and their county-level supervisors. The local officers, who were well known in their communities, provided additional information to teachers in other areas of their counties. Before they traveled, the project unit and local education officers jointly decided on a feasible schedule and locations across a county (usually in public spaces like schools or town halls) to conduct the vetting and testing.

Vetting and Testing

Teachers from each school received assignments telling them when and where their vetting and testing would take place. While teachers were responsible for their own travel expenses, the ministry paid accommodation and food costs, as needed. The project team divided the teachers—usually about 150—into two groups. One group took the competency test in the morning, while the other group went through the vetting process. In the afternoon, the tasks were reversed. Baysah pointed out that bona fide teachers who happened to be sick on their assigned days were “provided a window for them to come to one of the other vetting venues in the county, or they would have to travel to Monrovia.”

On the assigned day, the vetting process began when school principals submitted personnel lists to the project team. The team then compared each principal’s list to lists submitted separately by district and county education officers, who monitored all schools in their areas. If principals and local officials could not explain why a name appeared on one list and not on the other, the name moved to the “ghost worker” category. This step would enable the ministry, working with the Civil Service Agency, “to get rid of some ghosts,” Baysah said. “It was the first filter.”

The competency test, designed by the education ministry’s teacher training division, contained two papers, one on mathematics and the other on English. Both tests included questions on teaching methods. The test incorporated a combination of different types of questions, including multiple choice, short one-paragraph answers, as well as one longer essay or sample lesson plan based on a prompt. Kammi Sheeler, an economist from the Overseas Development Institute (an independent London-based think tank) who worked with the education ministry on data management, noted that the ministry eventually created four different versions of the test in order to prevent cheating.

While the tests were mandatory only for salaried teachers, the ministry encouraged volunteer teachers to participate. The ministry recommended that volunteers who did well on the test but lacked formal qualifications should attend a teacher training institute and then apply for formal positions. Volunteers who scored well and held teaching qualifications would be in line to replace ghost workers on the payroll. After teachers completed the tests, the team sent the papers to Monrovia, where 25 staff members from Varfley’s teacher training division graded them. The team then uploaded the results to the digital Access Tracking System.

During the vetting part of the day, teachers formed lines behind their principals (all principals and vice principals also had their identities and qualifications reviewed as part of the project). Teachers submitted their credentials to the vetting team, including their national identity cards as well as any documents proving high school and other educational qualifications. Because some Liberians, especially in rural areas, did not have national ID documents, the vetting team also accepted voting ID cards, birth certificates, passports or driver’s licenses. “Almost everyone had at least a voting ID card, but we accepted any of these documents,” explained field supervisor Veekie Wilson.

It was particularly important to confirm dates of birth and the exact spellings of names in order to stop the practice where some teachers received salaries made out in someone else’s name. If the team identified a fake document, they seized the document, and placed the offending teacher’s name on the same list as personnel who did not show up for the vetting process. Just as was the case for teachers who missed the exercise, those who submitted fake documents were given up to two months to provide the proper documentation before their names were submitted to the Civil Service Agency for removal from the payroll.

Similarly, when the team identified a ghost worker, they submitted the name to the Civil Service Agency for removal from the payroll. The agency then sent a letter to the school where the person supposedly worked, calling on the teacher to present his or her credentials to the national education ministry. If the person in question failed to do so during a specified period, the name was removed from the payroll.

The team also regularly encountered qualified teachers who were older than the mandatory retirement age of 65. In some counties, over 10% of the teachers were eligible for pension. When a teacher was older than 65, the team issued the teacher a pensioner’s ID card from the Civil Service Agency, and the Agency official that accompanied the field team recorded that the teacher was eligible for pension. But due to a lack of funding, it often took the Civil Service Agency a long time to issue pensions and remove pensionable teachers from the payroll. In the meantime, many kept teaching to continue earning an income. (The government calculated pension benefits based on length of tenure. For example, a 65-year-old teacher with 30 years of service and a monthly salary of US$100 would get a monthly pension of about US$60).¹⁰

Project staff next made copies of all supporting documents and uploaded digital scans to the Access Tracking System. At the end of the process, teachers who submitted all of the required documents had their fingerprints scanned and were issued special biometric ID cards. (The cards were issued only to qualified teachers who also took the competency test.)

The process was not foolproof. Despite the team’s efforts to work with district and county education officers, local officials still might collude with school principals to get ghost names added to the payroll. For example, if a district and county officer, as well as a local principal, agreed to add a person’s name to their personnel listing, that person could theoretically show up and undergo vetting and testing. In an effort to curb fraud, the team carried out follow-up spot checks a few weeks after completing the vetting process, in order to identify any ghost workers who slipped through the net.

In addition, the biometric system fell short of expectations. The USAID pilot had planned to install biometric card readers at all public schools. Teachers who had been vetted could then use their biometric cards to clock in and out of work every day, reducing the opportunities available for ghosts, tracking absenteeism, and generating useful data. When the project team took over, they found that about 400 card scanners had already been purchased by the education ministry as part of the Liberia Teacher Training Program. “But we have around 3,000 public schools, so that was not enough. Many of the machines were already quite old, so we didn’t know how many still worked,” Baysah said. Another problem was that “every year you would have to pay a license fee of US$20,000 to continue using the software, but that did not include maintenance costs.”

The field team also experienced problems with the machines used to capture biometric IDs, which meant that some fingerprints were not recorded. The project team also decided not to install the 400 scanners. For those teachers who did receive IDs, the cards were still useful in proving their identities. But the money spent on the scanners was effectively wasted, and the technical problems with some data-capturing machines meant that not all teachers had their biometric information captured.

Refrences

1. David Smith, “All 25,000 candidates fail the Liberian university entrance exam,” The Guardian, August 27, 2013; https://www.theguardian.com/world/2013/aug/27/all-candidates-fail-liberia-university-test
2. Ministry of Education, Liberia education statistics report 2015-16; http://moe.gov.lr/documents/
3. United Nations Development Program, Human Development Data: Education Index (2015 ranking); http://hdr.undp.org/en/data
4. Ministry of Education and UNESCO, Assessment of teacher education and development needs to ensure education for all, June 12, 2014; http://unesdoc.unesco.org/images/0023/002330/233080E.pdf
5. Leon Schreiber, Blaykyi Kenyah, “Managing the business of education: Liberia cleans up its teacher payroll, 2015-2017,” 2018, Innovations for Successful Societies, Princeton University; https://successfulsocieties.princeton.edu/sites/successfulsocieties/files/LS_Liberia_Payroll_FORMATTED_27_Feb_18_LS-2%20TDedit2Apr17.pdf
6. Ministry of Education, Liberia Education Sector Analysis, November 2016.
7. Leon Schreiber, Blaykyi Kenyah, “Managing the business of education: Liberia cleans up its teacher payroll, 2015-2017,” 2018, Innovations for Successful Societies, Princeton University; https://successfulsocieties.princeton.edu/sites/successfulsocieties/files/LS_Liberia_Payroll_FORMATTED_27_Feb_18_LS-2%20TDedit2Apr17.pdf
8. The Mobile Economy 2014, GSMA Intelligence; http://www.gsmamobileeconomyafrica.com/GSMA_ME_SubSaharanAfrica_Web_Singles.pdf
9. Afrobarometer, Handling addressing educational needs, Round 6 2014/2015; http://afrobarometer.org/online-data-analysis/analyse-online
10. Civil Service Agency, Guide to Civil Servants’ Pension, October 2013; http://csa.gov.lr/public/doc/Pension%20Brochure_CSA_Oct3.pdf

Executive Summary

A high-quality health system should support the physical, mental, and social wellbeing of the people it serves and a high-quality education system should help students reach their full potential as productive members of society. The likelihood of achieving improvements in the health, education, and economic development of a population hinges on the quality of the underlying and interrelated health and education delivery systems.

This policy brief provides an overview of three key areas in health and education: human resource motivation and performance; procurement, supply delivery and management; and data for decision-making. It reviews challenges and potential policy options to guide quality improvement efforts in those areas. A summary table is included in Annex 1.

Human resource motivation and performance are fundamental to equitable service provision and effective achievement of health and education outcomes. Key challenges include absenteeism; professional attrition (either to urban areas or high-income countries); and low technical competence. Root causes of these challenges include inadequate professional training; stressful working conditions; scarcity of essential supplies and materials; heavy and increasing workloads; low and unreliable remuneration; and lack of opportunities for growth and professional development.

Policy options to tackle these challenges could include reforming remuneration schemes to create a stronger link between payment and performance indicators. Changes could also be made to the recruitment and deployment strategies for health and education workforces, including setting higher admissions standards into the profession, diversifying the workforce and putting in place measures to attract and retain staff in underserved areas. Policies could also include enhanced professional development programs, either in-service or using technology to facilitate remote learning and supervision. Finally, technology could also be integrated into monitoring and service delivery systems to make them more accountable and responsive.

Procurement, supply delivery, and management systems critically affect efficient resource utilization and effective achievement of health and education outcomes. In education, the provision of textbooks is a challenging area for supply chain and procurement, but one which yields excellent returns on investment. Across both the health and education sectors, weaknesses in national procurement and supply chain systems are leading to stockouts and waste of essential supplies, inflated prices, and poor quality of products (including counterfeit or ineffective medicines). The causes of these issues range from high production and import costs, difficulties with making accurate forecasting and requisition estimates, inadequate storage and transportation conditions (which can lead to theft or damage), as well as diffused responsibility in the underlying accountability structure and unpredictable financing.

Effective policies to strengthen these systems should be carefully adapted to the local context and capacity but could include seeking procurement agreements with national or regional producers, the private sector, or through a pooled funding arrangement. Policies could also aim to centralize procurement or streamline the distribution of essential goods, while also potentially reducing the number of wholesalers and intermediaries to drive down costs. Distribution processes could be improved through investments in strengthening the stock-management and requisition systems at local levels (potentially enabled by technology), shortening the lag between replenishment cycles, and integrating systems for improved product traceability and efficient transportation. Finally, focusing on developing and retaining a qualified procurement and supply chain workforce is an important area to consider.

Data-driven decision making is a fundamental delivery tool that impacts the equity, efficiency, resilience, and effectiveness of a delivery system. The availability of quality data is often inadequate in many low- and middle-income countries (LMICs) as well as underutilized when available. Data from health and education systems are often managed in a fragmented system with little capacity for rapid and digestible analysis and dissemination. At the root of this situation is a history of underfunding national statistics offices, an over-emphasis on donor-driven aggregated surveys for cross-national comparisons over disaggregated and actionable national-level data, as well as weak demand for data from users (from government decision makers to citizens).

To enact the “data revolution” called for by the UN, initiatives should be put into place to improve the quality of data, through financing more robust national statistical offices, performing enhanced data audits and better aligning donor and local data streams. The key indicators for each sector should be chosen to reflect the desired outcomes (quality) and not just quantity and should include regularly administered internationally recognized standard measures. Policies should also be enacted to create a culture of “demand for data” at every level, as well as working with data producers to create user-friendly products that meet the needs and are easily actionable for decision makers.

Introduction

There has been increased attention in recent years on moving beyond accessing services to focusing on the quality of service delivery across health and education. High-quality delivery systems are effective at achieving outcomes, efficient at utilizing resources, equitable at providing services, and resilient in the face of challenges. Thus, a high-quality health system should support physical, mental, and social wellbeing of the people it serves and a high-quality education system should help students reach their full potential as productive members of society. The likelihood of achieving improvements in the health, education, and economic development of a population hinges on the quality of the underlying and interrelated health and education delivery systems.

Strategies to improve quality must include policies to improve resource utilization and service delivery in three key areas: human resource motivation and performance; procurement, supply delivery and management; and data for decision-making. This brief will seek to provide context, as well as possible policy options and combinations, to guide quality improvement efforts.

Quality in health systems

A recent Lancet Global Health Commission on High Quality Health Systems in the SDG Era¹ has called for “a revolution” in health care quality. Despite gains in health outcomes globally, the commission points to the often poor quality of care provided across LMIC, which leads to nearly eight million avoidable deaths each year. As countries strive to provide universal health coverage (UHC), an integral part of achieving SDG 3 “Good health and well-being,”² they must also make improving quality a core component of these efforts, together with expanded coverage and financial protection. The Commission’s report includes among the foundational elements of high-quality health systems: workforce numbers and skills, tools and resources from drugs to data, as well as the capacity to analyze and learn from data.¹

Quality in education

Since 2000, there has been enormous progress around the world toward achieving Millennium Development Goal (MDG) 2: universal primary education. Total enrollment rates reached 91% in 2015 in developing regions, and the number of children out of school was halved.³ However, these efforts have often eclipsed concerns around the quality of education, a concept which encompasses the learners’ cognitive development and the “promotion of values and attitudes of responsible citizenship and in nurturing creative and emotional development.”⁴ The 2018 World Development Report has called the current situation a “learning crisis,” with hundreds of millions of children worldwide failing to learn basic arithmetic and reading skills. To address this, SDG 4 is concerned explicitly with “quality education.”

Within UNESCO’s framework for understanding education quality,⁴ “enabling inputs for quality education” include teaching and learning materials, physical infrastructure and facilities, human resources (teachers, principals, inspectors, supervisors, and administrators), as well as school governance.

Human Resource Motivation and Performance Overview

Worker performance is highly linked to worker motivation due to the labor-intensive and interpersonal nature of the services being provided. The performance of health professionals (though relevant to education professionals as well) has been defined as being available – retained and present – competent, productive, and responsive.⁵ A WHO framework for health worker performance and its link to motivation is in Annex 2.

Motivation has been defined as “an individual’s degree of willingness to exert and maintain an effort towards organizational goals.”⁶ This definition also frames motivation as being composed of two components: “the extent to which workers adopt organizational goals (‘will do’) and the extent to which workers effectively mobilize their personal resources to achieve joint goals (‘can do’).”

Herzberg⁷ provides a theoretical foundation for the determinants of motivation that is grounded in two types of factors:

While financial incentive levels and schemes may be important determinants of worker motivation, they alone have been found to be insufficient to keep health professionals motivated. A motivated worker must also have the right competencies, work environment, and resources to be high performing.⁵

Challenges in Human Resource Motivation and Performance

The challenges relating to human resource motivation and performance in health and education systems are considerable.

• Absenteeism: Many countries have epidemic levels of teacher and health worker absenteeism, particularly in rural and remote areas. A study in six developing countries found an average of 19% of teachers and 35% of health workers were absent during regular working hours.⁸ In India, more than 23% of teachers were absent during unannounced school visits, which was associated with an annual cost of $1.5 billion for services that were not delivered.⁹
• Professional attrition and “brain drain”: Teacher attrition rates in sub-Saharan Africa are variable but high—between 5-30%,¹⁰ and yet demand for teachers in low-resource countries is expected to grow dramatically in the years ahead, nearly doubling by 2030.¹¹ Similarly, for health professionals in LMICs, migration to urban areas or higher-resource countries is mostly unplanned, leading to a “brain drain” of talented professionals and exacerbating shortages in resources in health. Despite efforts by the WHO to curb this trend, physician density is still declining in the majority of African countries and physician migration is on the rise.¹²
• Low technical competences in teaching and care: A study of nine sub-Saharan African countries using Service Delivery Indicators (SDI) found very weak rates of adherence to clinical guidelines. Less than a third of providers adhered to guidelines for neonatal and maternal health complications, and 35.9% adhered to guidelines for diarrhea, pneumonia, and malaria, with a diagnostic accuracy for these conditions of only 50%. Similarly poor guideline adherence was found in studies in health centers in India.¹³ Concerns also exist with the quality of teaching. The Learning Barometer survey of student performance, carried out in 28 African countries with primary school-age learners (Grades 4 and 5), identifies the proportion of children who meet a minimum learning threshold. It found that over a third of students—23 million children—fell below the minimum learning threshold, meaning most will be “unable to read or write with any fluency, or to successfully complete basic numeracy tasks.”¹⁴

Root Causes of These Challenges

Several of the root causes of the aforementioned challenges are described below.

• Inadequate initial professional training: Many teachers graduate from their training lacking information on what their pupils are supposed to learn and basic teaching and curricular management skills.¹⁴ Training programs for health care professions also suffer from chronic under-investment.¹⁵ A survey of medical schools across Africa found “ubiquitous faculty shortages in basic and clinical sciences, weak physical infrastructure, and little use of external accreditation.”¹⁶
• Difficult working conditions, including insufficient physical and supportive infrastructure: Schools and health centers, particularly in rural areas, can lack the very basics such as running water, consistent electricity, and adequate sanitation facilities.^17,18 Access to decent housing and family-centered services (schools, daycare) outside of urban areas is also a major challenge for many professionals in education¹⁹ and health,²⁰ particularly for women.
• Lack of work materials and essential supplies: (discussed in the following section)
• Increasing workloads: Pupil to Teacher Ratios (PTR) have increased dramatically following the roll-out of Universal Primary Education policies. This has meant overcrowded classrooms, more teaching periods, and more non-teaching activities.¹⁷ The global needs-based shortage of health-care workers is projected to be 14 million by 2010. When taking into account population size, the most severe challenges are in sub-Saharan Africa, where ratios of health professionals to patients are predicted to worsen between 2013 and 2030.¹⁵
• Low and unreliable remuneration: In many countries, teachers and health care providers do not earn enough to live above the poverty line, requiring many to turn to other part-time work to supplement their income.^5,19 They may also experience delays in receiving their salary and be required to travel long distances to receive it.¹⁷
• Lack of constructive supervision, professional recognition or professional development opportunities: Education systems in many countries report having infrequent or ineffective supervisory visits. Teachers also generally receive very little feedback, support, or advice from more senior teachers or school administrators on how to improve.¹⁴ Similarly, health professionals have often limited access to professional development opportunities, which tend to be unevenly distributed despite high demand.¹⁷

Policy Options to Improve the Motivation and Performance of Human Resources

Below is an overview of policy options that could be considered to improve the motivation and performance of health and education professionals.

It must be noted that worker motivation is sensitive to system-wide or facility reform processes which can affect organizational dynamics, reporting, accountability and incentive structures. These changes may elicit a range of responses from professionals as they often require the development of new workforce capabilities and can affect different health system cadres differently.⁶ The involvement of health workers in the design and implementation of reforms has been found to be an effective way to manage these concerns.⁵

Policies to improve motivation and performance can be undertaken at the macro-system level or at the micro-facility level and can be designed to address performance issues by tackling “can do” or the “will do” gaps. They can also address the living conditions of health workers in ways that are adapted to the context, including rural location, age and gender considerations.⁵

Option 1. Changes to Payment and Reward Systems

Creating stronger linkages between payment and performance indicators can be an important way to improve the quality of professional work. The implementation of reforms to payment schemes requires careful consideration of bureaucratic and political economy considerations, such as resistance from unions, and the required data collection infrastructure.²¹

• Health worker performance-based financing (PBF or P4P) schemes: PBF is a contracting mechanism designed to increase the performance and quality of service providers by offering financial incentives to health facilities for the provision of a defined set of services, with adjustments based on measures of quality. These vary considerably in their format (payment structure, target services, etc.) and effect on employee performance and health outcomes.²² In the past decades, PBF schemes have generated substantial interest among policy-makers, donors and international organizations; as of 2015 a dedicated trust fund at the World Bank alone supported 36 PBF programs.²³ Conditional cash transfers, modified by quality measurements, were found to be particularly effective in Rwanda – where P4P was found to have a positive effect on health care utilization, quality of care and outcomes, as well as on lowering worker absenteeism.^24-27
• Teacher performance pay schemes: Numerous schemes exist to reward teachers based on specific measures of performance and outputs. Studies in Tanzania, India and China generally found these approaches to be effective when combined with providing resources such as unconditional grants or textbooks.^25,28,29 However, several other evaluations showed either no or marginally positive gains from such measures, especially for low-performing schools. It was also found that rewards may have detrimental effects, such as diminishing peer collaboration, narrowing the curriculum, and over-emphasis of teaching to the test. Generally, these schemes remain relatively rare at scale – a review found that only 17 of 101 education systems used test scores to formally sanction or reward schools or educators.³⁰
  • Benchmarking: Payments are based on the number of students that reach specific proficiency levels. This was found to be easier to communicate and implement,³¹ but difficult to sustain.³²
  • Pay for Percentile: Payments are based on students’ test scores relative to other students at the same starting level or similar students in other schools. This is harder to implement but incentivizes teachers to improve learning across the entire student distribution.³³
  • Special awards for teaching quality: Particularly when recognizing collaborative work among teachers, as research has found that monetary incentives are more effective when awarded to teaching teams compared to individual teachers.³⁴

Option 2. Changes to Recruitment and Deployment

Macro-level policies can aim to improve education and health workforces by targeting who is recruited into key professions, how they are trained, and where they are deployed to work.

• Higher standards for recruitment: Setting higher minimum qualifications to enter the teaching or nursing profession, such as an undergraduate degree, could be an effective way to improve the status of the profession as well as to attract high-performing individuals. A merit-based appointment system, such as one implemented in Pakistan for teacher recruitment, included a test administered by a third-party National Testing Service to protect the system from political influence.³⁵
• Measures to attract and retain professionals in understaffed rural areas: Several initiatives have been found to be effective for health care workers, including providing preferential admissions to students from rural areas, designing a “rurally oriented curricula” with a focus on rural health issues, imposing compulsory training rotations in rural settings, as well as providing scholarships, financial incentives, professional advancement, support networks, and help with setting up medical practices in rural areas.²⁰ In education, other non-monetary incentives have been used, such as offering bicycles, housing, and preferential access to resources and training. “In the short term, the provision of good quality housing with running water and electricity for teachers is probably the most cost-effective way of attracting and retaining teachers at hard-to-staff rural schools.”¹⁹
• Diversification of the health and education workforce: To minimize the time spent by teachers on non-teaching activities, it is possible to include pedagogic assistants, health practitioners, and administrative support.¹¹ Similarly in health care, shifting tasks between health care workers (“task sharing”) and expanding the clinical team, particularly to include community health workers, can relieve short-term human resource limitations.¹⁸

Option 3. Enhanced Professional Development Programs

Opportunities to improve existing or develop new technical skills are often a major source of motivation for professionals in health and education, and they also directly address the “can do” gap that inhibits performance.

• In-service or facility-based skills-development programs: Training is best when done close to practice where learners can immediately apply concepts and receive feedback. Meta-analyses show that successful in-service teacher training, coupled with ongoing monitoring, mentoring, and coaching, is a proven way to improve primary school teachers’ instructional practice in LMICs.^36,37 Such approaches are generally more expensive but preferable to external continuing education programs or training-of-trainers cascade models, which have the disadvantage of being expended on a small minority of professionals who are withdrawn from their work.³⁸
• Training and skills-building programs specific to management professionals: In addition to frontline workers, initiatives to develop the skills of managers are an important part of improving overall system quality. Health facility management training and supervision were found to be effective at improving organizational practices and health outcomes but needed to be ongoing.³⁹ Training programs for headmasters in school management and leadership were also found to be effective across 13 countries at improving teacher motivation and performance.^19,34
• Technology-enabled training and support: Some initiatives, such as technology-assisted professional development and text-message support, have been used to effectively reach teachers in remote areas.^40,41

Option 4. Integration of Technology into the Classroom or the Clinic

Technological innovations, from apps to integrated teaching and learning systems, are multiplying in health and education spaces. These present great opportunities for improved performance, but also require significant investments and infrastructure. Across many developing countries, the rate of internet connectivity in schools is less than 10%. There is some concern that uneven access to these resources could exacerbate existing learning inequalities between rural/urban or affluent/resource-constrained areas.¹¹ Nevertheless, technological innovations have been deployed to achieve a number of goals.

• “Blended-learning classrooms”: This format combines learning using technology with face-to-face teaching and was found to be effective in several case studies.⁴¹
• Technology for improved attendance monitoring: Different approaches have been tried to reduce absenteeism, including using sophisticated surveillance technology or simple mobile phone text systems. Biometric attendance monitors in primary health centers or cameras in schools in India were only found to be effective when attendance was linked to rewards or penalties and there was sufficient buy-in from the stakeholders involved in these processes.⁴² Other simple phone-based platforms to send daily data on teacher attendance were found to be effective in the Gambia and Zimbabwe.⁴³

Procurement, Supply Delivery and Management Overview

Functioning procurement, supply delivery, and management systems are essential for quality health and education service delivery. A supply chain encompasses an “ecosystem of interlinked organizations, people, technology, activities, information, and resources” that is required to get products from manufacturers to users in the most cost-effective way possible. This includes inventory management, storage, distribution, and inventory control, and requires a large, competent, and properly trained workforce. Supply chains do more than simply delivering products, they also produce critical information related to the need, demand, and consumption to national and regional level planners.⁴⁴

Procurement and Supply Chains in Health

The structure of supply chains for health varies greatly depending on national health system characteristics, such as the different sources of financing, risk pooling and purchasing, as well as national pharmaceutical regulations and treatment-seeking behaviors of patients. Supply chains play a role in many dimensions of health system performance: payment, organization, regulation, and also behavioral aspects of the health system.⁴⁴ In the coming decades, as many global health initiatives such as GAVI, the Global Fund, and PEPFAR roll back their support, many LMICs will need to play a larger role in the procurement of health products.⁴⁵

Procurement and Supply Chains in Education

Access to appropriate learning materials is listed as a key strategy for achieving SDG4 – particularly the dimension related to providing inclusive and effective learning environments for all.³ Textbooks are a particularly important input for improving learning outcomes in contexts with large class sizes, under-qualified teachers, and shortened instructional time. They have been found to be, when they are in the appropriate language and level of difficulty, a particularly cost-effective input with high returns in student achievement.³⁰ A multi-country study of 22 sub-Saharan African countries found that providing one textbook to every student in a classroom increased literacy scores by 5–20%.⁴⁶

Challenges in Procurement, Supply Delivery and Management

Supply chains can significantly affect the availability, price, and quality of strategic inputs. However, many national procurement and supply chain systems remain ineffective and poorly managed.

• Lack of availability of working materials and supplies: Key health system inputs, such as medicines, are not consistently available in many low-resource settings. According to an analysis of WHO data, the average availability of generic medicines in the public sector ranges between 29% to 54% across WHO regions.⁴⁷ Interruptions in the access of medications are an important threat to public health, as they interfere with treatment initiation or continuity and increase the likelihood of ill health and antimicrobial resistance.⁴⁵ Similarly, the procurement and supply of essential learning materials, particularly quality textbooks, remains a challenge in many LMICs. Between 2000 and 2007, rapid enrollment increases were experienced across several LMICs; however, textbook availability could not keep up. For example, in Malawi, “the percentage of students who either had no textbook or had to share with at least two other pupils increased from 28% in 2000 to 63% in 2007.”⁴⁶ Gaps in essential school supplies are even more pronounced in rural or underserved areas.
• Inflated prices: Across LMICs, the prices of many vital inputs for health and education systems can be variable and disproportionately high. According to an analysis of WHO data, median government procurement prices for 15 generic medicines are 1-11 times international reference prices, and procurement prices that were low did not always translate to lower patient prices. This created a situation in which “treatments for acute and chronic illness were largely unaffordable in many countries.”⁴⁷ The cost of textbooks varies greatly by country and region. In sub-Saharan Africa, the unit cost of a primary school textbook is between US$2 and US$4 compared to Vietnam, which produces books domestically, where the cost is between US$0.33 and US$0.66.⁴⁶
• Poor quality of products delivered to end-users: Dysfunctional health product procurement and supply chain systems are associated with an increased risk of substandard quality or counterfeit drugs, which can lead to poisoning, ineffective treatments, and anti-microbial resistance.⁴⁸ It is estimated that 1 in 10 medical products in low- and middle-income countries is substandard or falsified.⁴⁵ In education, some national regulatory bodies lack a reliable process to evaluate the quality of textbooks, resulting in the use of substandard materials and production and errors in the content.⁴⁹ The provision of quality textbooks in the correct language should be prioritized in early grades as this is when they have the largest impact on learning. However, in Chad, a 2010 survey found that only 20% of students had a textbook in the correct language of instruction (French) in grade two, and 40% of students in grade five.⁴⁶

Root Causes of These Challenges

Weaknesses in national supply chain and procurement systems in health and education have several root causes.

• High production and import costs: The reasons for variations in the cost of textbooks across country and region include “fluctuating prices for raw materials, manufacturing, procurement, publishing overheads, distribution and storage, importation, and shipping.”⁴⁶ In the health systems of many countries, depending on the size of the market and regulatory environment, importers and wholesalers of health products are numerous and fragmented, which significantly drives up prices. For example, there are 292 licensed medicine importers in Nigeria and 166 national wholesalers in Ghana.⁴⁴
• Inability to correctly predict needs: The capacity to effectively forecast procurement or requisition materials is often deficient, particularly at decentralized levels. Accurate data estimating needs and consumption rates are fundamental to the effective management of procurement and distribution processes, and yet they are often unavailable or unreliable, resulting in stock-outs or waste.^44,46 In most national health systems in LMICs “there are no processes by which information about consumption is systematically captured” – with many systems relying instead on “ad hoc surveys.”⁴⁴
• Poor storage conditions and theft: Inappropriate distribution, storage, and usage conditions have been found in some cases to lead to an annual loss rate of 50% for textbooks. Moreover, poor security during transport and storage allows school supplies, particularly books, to be stolen and resold in the black market. A 2010 survey in Ghana found that 29% of English textbooks went missing during this process.⁴⁶ Similarly, product diversion is a major driver of drug stock-outs in LMICs. The complexity of drug distribution systems can create many opportunities for diversion; in Kenya, for example, “medicines can change hands ‘five to seven times’ before reaching local clinics.”⁴⁵
• Inefficient transportation: The lack of a well-functioning and managed government transportation fleet is a major barrier to effective supply chains in health. Vehicles for medication distribution are often unavailable due to lack of appropriate planning, poor maintenance, and inappropriate use.⁴⁴
• Underlying weakness of the accountability structure: These weaknesses may be a result of fragmented responsibility and governance at different levels. Furthermore, the enforcement of supply chain and distribution regulations may be hampered by underfunding and limited human resource and organizational capacity, as well as inadequate supervision and corruption.⁴⁴
• Unpredictable financing: The predictability of financing for the procurement of textbooks is very important because their development, production, procurement, and distribution is a long process. However, this is the case in only a few LMICs.⁴⁶ In health systems, delays in the disbursement of funds from national finance bodies or international donor agencies often result in disruptions that ripple down the supply chain.⁴⁴

Policy Options for Improved Supply Chain and Procurement

There is no ‘one-size-fits-all’ approach to improving the performance of procurement and supply chain systems. There are only a few well-designed randomized or quasi-randomized studies that demonstrate effective reforms to improve health system supply chain performance. The external validity of what evidence exists is reduced by the context-specific and complex features of national supply chain systems across countries.⁵⁰ Nevertheless, some promising policy avenues exist and are described below.

Option 1. Procurement from Different Actors

Working with different actors for the procurement of key inputs in health and education systems may provide opportunities to improve the performance of procurement and supply chain systems. In health systems, however, the flexibility to work across different producers may be more limited.

• Regional or national production: Depending on the context and the product being procured, these may provide cost savings compared to international producers in relation to competition, taxes, import duties, and transportation. In Viet Nam, for example, the unit price for books is much lower than in many sub-Saharan African countries because it prints books domestically and fosters competition among publishers to drive down prices.⁴⁶
• Procurement from the private sector: Turning to the private sector for textbook procurement is something some countries have done to try to drive down costs. For example, in 2002 Uganda began working with a private publisher through a competitive process and “saw the cost of textbooks fall by two-thirds and their quality increase.”⁴⁶ However, other studies in Ghana, Tanzania, and Kenya suggest that there is little effect on the inefficiency, corruption, and lack of transparency from changing from state-controlled to private sector textbook provision.⁵¹
• Pooled funding mechanisms for improved predictability: These kinds of systems could provide more and predictable funding for textbooks; however, the current pooled funding mechanism for education, the Global Partnership for Education (GPE), has not had the same success as pooled funds in other sectors, such as GAVI health, in attracting more and predictable funding.⁴⁶

Option 2. Re-Design the Procurement and Supply Systems

There are several potential ways to restructure these processes to make the best possible use of limited resources.

• Centralized procurement and tendering processes: This can help to create economies of scale and improved purchasing power. Such reforms were found to produce cost savings in a number of case studies from different regions, including the Middle East, Brazil, Mexico, and several countries in Asia and Africa.⁵⁰
• Streamlined tiers of the supply chain system: Some countries have sought to decentralize procurement and supply processes to lower levels of the system, to provide additional flexibility, autonomy, and speed for purchasing at local facilities. However, in some cases, this has led to worse outcomes.⁴⁴ In contrast, a quasi-randomized study in Zambia resulted in large improvements in medical product availability by cutting out the regional distribution step. Multiple modeling studies have also confirmed the benefits of reducing tiers in the supply chains for vaccines and immunization supplies.⁵² The decentralization of the supply of textbooks has also had mixed success with some countries, like Uganda, preferring instead to centralize procurement to combat corruption and mismanagement at the school and district levels.³⁰
• Reduced number of wholesalers or middle-men: A smaller number of wholesalers is generally preferable for optimal supply chain performance, since fewer larger wholesalers gain economies of scale in their distribution efficiency and have improved access to capital for infrastructural investments. The creation and enforcement of regulations around quality standards and distribution practices can lead to the consolidation of smaller players, although the resistance from smaller actors who stand to lose from this type of reform may be prohibitive.⁴⁴ The cost of distributing textbooks can contribute to high variations in price, as seen when comparing Kenya and Rwanda. Although both countries use a commercial distribution system to deliver books, the unit textbook cost in Kenya is nearly double that of Rwanda, partly because Kenya delivers books through a bookseller middleman rather than having publishers deliver directly to schools.⁴⁶
• Public-private partnerships: Several effective partnerships have been established, particularly those which involve the contracting of private operators for the last-mile delivery of products. Large multinational companies partnering to improve the effectiveness and efficiency of supply chains in LMICs include Coca-Cola and the UPS Foundation.^49,53

Option 3. Improved Distribution Processes

At different points in the supply chain process, improvements can be made to improve forecasting capacity, replenishment systems, as well as product transportation and traceability.

• Improved stock-management and procurement request practices: Simple technology and software can be used to track consumption and demand—to know when stocks are running short and to update them faster. If such systems are not able to be put in place, particularly in areas with poor technology infrastructure or IT connectivity to carry out stock requisitioning, it is possible to combine information collection with product distribution. Such systems were found to be effective in Zimbabwe and Mozambique.⁴⁴
• Reduced lead-times from suppliers and increased frequency of replenishment: Increasing replenishment frequency “increases the speed and velocity of the supply chain and decreases the reliance on long-term forecasts,” approaching actual levels of demand. However, this can lead to higher transport costs, and therefore statistical modeling should be used to determine the best balance between transport costs and benefits from forecast improvement.⁴⁴
• Digital technologies that help “track and trace” the movement of products: In addition to improved security throughout the storage and transportation process, unique serial numbers at the package level can be a good defense against theft during the distribution chain.⁴⁸ “Track and trace initiatives allow actors on a supply chain to determine where a product is at any given time (tracking) and where it came from (tracing). The approach starts with the process of serialization, in which a manufacturer assigns a unique identifier to each product that it ships using a two-dimensional (2-D) barcode that other supply chain actors can scan to obtain information about the product and record when it changes hands.” This creates a digital trail of information linking each package along its path through the supply chain for increased accountability.⁴⁵
• New or outsourced delivery methods: “Depending on the geography, overall economic situation, maturity of the transport market and structuring of the price and service level contracts, a third-party logistics provider can offer better service at rates comparable to the fully loaded cost of owning and operating a government fleet.” In the case of Kenya, this approach helped to address problems with transport planning, vehicle maintenance, and inappropriate use.⁴⁴ Leapfrogging using novel delivery technology is also possible, such as using drone delivery for emergency supplies or deliveries in hard-to-reach areas in Rwanda.⁵⁴

Option 4. Invest in Human Resources and Management Tools

Recruiting talented supply chain experts into the public sector is important for high levels of financial and operational performance. Management and leadership roles in this sector should not only be restricted to civil servants but also include individuals with strong commercial sector experience.

• Professional development for procurement and supply chain professionals: Several countries have successfully implemented comprehensive short-term training programs aimed at procurement practitioners, members of tender committees, tender review boards, and oversight institutions. As procurement and supply chain processes become increasingly technology-driven, it is equally important for practitioners to also expand their expertise in business engineering and design and information technology.⁵⁵ Other effective quality improvement interventions focused on improving teamwork and the human elements of supply chain management.⁵⁰
• Benchmarking tools to improve performance: These tools can also help to standardize supply chain performance metrics such as Data Envelopment Analysis (DEA).

Data for Decision Making Overview

Data is a fundamental part of strategic, goal-oriented, and effective systems. “Data-informed decision making” is a process that is proactive and interactive, and that “consider[s] data during program monitoring, review, planning, and improvement; advocacy; and policy development and review.”⁵⁶

For data to be used for decision making, it should be accurate, timely, disaggregated, and widely available, as well as made actionable through analysis.⁵⁷ Given the ambitious vision of the SDGs—with 17 goals, 169 targets, and 232 indicators to be achieved by 2030—there is a great need for quality data for monitoring and measuring progress.⁵⁸

Challenges with Using Data for Decision Making

There have been gains in the frequency and quality of censuses and household surveys, however, many of the “building blocks” of national statistical systems remain weak. Importantly, this gap includes data that is central to estimating “almost any major economic or social welfare indicator—[such as] data on births and deaths; growth and poverty; taxes and trade; sickness, schooling, and safety; and land and the environment.”⁵⁷ The inadequacy and unreliability of official statistics in many Sub-Saharan African countries have led to the U.N. High-Level Panel on post-2015 development goals calling for a “data revolution” to improve tracking of economic and social indicators across the developing world.⁵⁹

Data in Education

Behind the learning crisis in much of the developing world is a huge data gap. Only a few middle-income developing countries have the political incentives and technical capacity to develop and sustain national data systems for education. Countries in the developing world rarely have the infrastructure of data collection in place, nor the capacity to analyze and feed information back to educators, parents, and communities. International assessments and regional initiatives cover relatively few developing countries; the majority of school children in the developing world are not tested at all. Moreover, while there is a range of data sources on education systems, services, and outcomes, these are not always translated into user-friendly formats for decision making.⁶⁰

School-level enrollment statistics are necessary to make efficient staffing decisions, however, in some countries, like Kenya, this information is only available from the country’s Education Management Information System (EMIS) three times a year.⁵⁹

Data in Health

Quality and timely data from health information systems are the foundation of the health system and inform decision making in each of the other five building blocks of the health system. Recent years have witnessed significant commitments to and investments in the strengthening of information systems.⁵⁶ However, data quality and the availability and demand for timely analysis for decision making remain problematic.

• Poor quality data: Many LMICs continue to face challenges related to the poor quality of routinely collected data. Comparing administrative and survey data of primary school enrollment in 46 surveys across 21 African countries found a bias toward over-reporting enrollment growth in administrative data—with an average change in enrollment nearly one-third higher in administrative data. “Many countries’ health management information systems (HMIS) databases rely on self-reported information from clinic and hospital staff, which aggregated up by district and regional health officers, each with potentially perverse incentives.”⁵⁹
• Under-resourced and under-staffed national statistical agencies: The high turnover of qualified EMIS staff, particularly in Ministries of Health, is a recurring challenge in LMICs, largely due to the low and relatively unattractive salaries.⁵⁸ These agencies have also failed to improve significantly over time due to a lack of functional independence, as well as being reliant on volatile donor funding.⁵⁹
• Fragmented and inadequate information systems: Electronic Medical Information Systems (EMIS) in many sub-Saharan African countries are “chronically weak,” with problematic or at times absent key functions such as data entry control, import-export, data consolidation, consistency checks, and data extraction, estimation and imputations, projections, or archiving facilities.⁵⁸
• Limited capacity for analysis and use of data at local levels: All too often, data remains unutilized, sitting in reports, on shelves, or in databases and not being used in program development, quality improvement, policymaking, or strategic planning.⁵⁶ In a survey of several tiers of Ethiopian government officials, only about 12% of officials stated that they used national information management systems as their primary source of information, preferring instead “formal field visits” (63%) or informal informational interactions such as discussions with frontline colleagues (51%) or colleagues in their organization (45%). Reliance on these more informal information sources was found to lead to only a minority of officials being able to make “relatively accurate claims about their constituents.”⁶¹

Root Causes of These Challenges

Challenges related to data for decision making are not merely technical but rather the result of implicit and explicit incentives and systemic challenges, including a lack of stable funding for national statistical systems and minimal checks and balances to ensure that the data are accurate and timely.⁵⁷

• Dominance of donor data priorities over national priorities: “The different needs of donors and government present trade-offs between the comparability, size, scope, and frequency of data collection. Given that donors finance a large share of spending on statistics, these differing needs can imply that national statistical systems aren’t built to produce accurate data disaggregated for use by domestic policymakers and citizens.” An example of this is the DHS in Tanzania, which reported results for seven aggregate zones that did not correspond to any practical local unit of measure or political accountability.⁵⁹
• Weak demand for data from users: Data are not consistently utilized by senior officials and policymakers within ministries of health and education for a number of reasons. This can be due to a lack of capacity to make data available or “because senior ministerial staff choose not to use data that contradict official views or out of fear it will damage their credibility or subject them to heavy pressure from the executive branch of government.”⁵⁸

Policy Options for Data-Driven Decision Making

Option 1. Improve the Quality of Data

This can be achieved a number of ways, including through stronger systems, better monitoring, and by reducing the incentives to misrepresent data.

• Better funding national data collection systems: Improving the funding levels and structure of national statistical systems and organizations could help to improve their performance. Also consider increasing domestic funding allocation for National Statistical Offices, mobilizing more donor funding through government–donor compacts, and experimenting with pay-for-performance agreements.⁵⁷
• Improved data collection and reporting accuracy through enhanced data audits: Facility-level technology can be used to support more frequent quality audits of routinely collected data. Regular data audits by an independent third-party verifier are a central part of PBF systems to attempt to overcome asymmetric information between the providers and payers, create accountability, and minimize gaming. Effectively targeting these verification activities can help to balance the costs and benefits of having a large enough sample to carry out effective verification activities.²³
• Integrating different data streams: Redesigning data systems for improved accountability could also be achieved by getting administrative and survey data to “speak to each other,” whereby household surveys can be used to provide regular checks on administrative data at different levels.⁵⁹

Option 2. Strategically Selecting Data to Collect

The effort to generate data for international goals should not displace the focus from building the capacity of national statistical agencies.

• Diversifying and prioritizing indicators: Health and education systems should identify and prioritize key indicators for tracking progress toward SDG targets as well as answering questions of national relevance.^62,63 For measurement to promote accountability and quality improvement, it must capture the processes and outcomes that are most important to people. In many cases, data systems produce metrics that yield inadequate insight at a substantial cost both in terms of finances and front-line workers’ time. For example, a frequently used indicator is the proportion of births with skilled attendants, however, this does not adequately reflect the quality of care during childbirth and therefore may deceptively represent progress in maternal and newborn health.¹
• Introduce internationally recognized standard measures: Currently, few countries in the sub-Saharan African region perform international learning assessments of their students,¹ and most collect learning data in a “fairly haphazard fashion.”^14,60 Most school children should be able to take a test that can be compared year over year or globally benchmarked. Policymakers and citizens need a basis to assess the quality of schooling.

Option 3. Improve Demand for Data from Decision Makers

To improve the use of data at all levels, data systems and tools can be put into place.

• Develop decision-maker facing data dashboards: To complement smaller initiatives to present data to decision makers, other larger dashboards or toolkits have been introduced, including the World Bank’s multidimensional Global Education Policy Dashboard and the “Data4SDGs Toolbox,” which seeks to help countries “create and implement their own holistic data roadmaps for sustainable development.”⁶⁴
• Data briefs or review meetings: For data to be understood and digestible by potential users, they must be synthesized and disseminated in formats that are specific and adapted to users. Different targeted information products, focusing on “need to know” information, could include standardized reports and presentation templates for regular dissemination and feedback to decision makers.⁵⁶ “External briefings” were found to significantly reduce errors made by officials, particularly in contexts where organizational incentives for data use were in place.⁶¹
• Targeted capacity building for data utilization: These efforts can include ministries, national institutes, academia, and other stakeholders. Better linking the data producers with data users, who may otherwise be working at different levels of the health system and have an incomplete understanding of each other’s needs and roles. By addressing barriers to data use together, producers and users of data can also identify programmatic priorities and make data available to work on them.^56,59

¹ International assessments and regional initiatives such as LLECE in Latin America (Latin American Laboratory for Assessment of the Quality of Education) or PASEC (Program for the Analysis of CONFEMEN Education Systems) and SACMEQ (Southern and Eastern Africa Consortium for Monitoring Educational Quality) in Africa, cover relatively few developing countries (Source: Birdsall, 2016).

Annexes

Annex 1: Summary Table of Challenges and Policy Options

Annex 2: Framework for Analysis of Motivation

Source: Adapted from “Improving health worker performance: in search of promising practices” by Marjolein Dieleman and Jan Willem Harnmeijer (WHO, 2006)⁵

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Background

Over several decades, Nigeria has confronted major health crises characterized by a double burden of disease — preventable infectious diseases and a rising prevalence of non-communicable diseases (Li et al., 2022). Vaccine-preventable diseases, in particular, have contributed to the country’s high child and maternal mortality rates (Ophori et al., 2014).

Minister Muhammad Ali Pate was appointed Nigeria’s Minister of State for Health in June 2011. Before he was appointed Minister of Health, he served as the Chief Executive Officer of the National Primary Healthcare Development Agency (NPHCDA) for three years, made significant progress in improving Nigeria’s primary healthcare system, and initiated crucial health sector reforms during his tenure.

President Goodluck Jonathan appointed Dr. Pate Minister of Health to continue his previous work at NPHCDA. His mandate included improving efforts to eradicate polio and enhancing routine immunization. Initially focusing on polio, his goal as Minister of Health expanded to encompass child and maternal health through the Saving One Million Lives campaign. The Saving One Million Lives campaign by Minister Pate was developed to ensure that efforts to improve health in Nigeria also addressed other urgent health issues such as measles and malaria.

This case study explores how Minister Pate was able to navigate the fraught politics of Nigeria and win the support of the President, key Cabinet allies, and 36 state governors for a country-wide transformative health initiative.

Building a Guiding Coalition

When Minister Pate took office, there were rumblings of discontent regarding Nigeria’s health system, but health issues were not high on the national political agenda. Plus, given the decentralized nature of the health system, the Minister had limited control over how each of the 36 states spent their federal budget allocation. Although a significant part of the state budget came through federal allocations by a constitutionally determined formula, the fiscally decentralized federal system of government allowed states fiscal autonomy. The result was limited federal oversight or accountability regarding how much states allocated to health and how such resources were allocated. National Health Account data showed that most health resources were spent on politically popular curative facilities. These were often geared to the health needs of wealthy citizens. Even though the federal government had conceptually sound health policies, execution and enforcement at the state level were difficult.

Developing a Legacy Goal

Soon after taking office, Minister Pate assembled a core leadership team, led by a long-time trusted colleague, Dr. Kelechi Ohiri. With the support of his core team, Minister Pate reflected on the healthcare landscape in Nigeria to determine what he wanted to accomplish during his limited term of a maximum of four years. He said:

“I built a very strong team, including some I had mentored before, like Dr. Kelechi Ohiri. I chose people who were not only competent but had the right mindset and character attributes to help me deliver on our goals. As a Minister, very early on, you need to know what you want to accomplish. Build a good team, mobilize resources, and ensure everyone is accountable, including yourself. Focus on execution, or you will not achieve much.”

Minister Pate wanted to focus his agenda on something that would help Nigeria achieve something tangible, particularly given the multiplicity of problems within his main portfolio of primary healthcare. As he reflected, he realized that all around him was a culture of input-based thinking. Healthcare policy was made based on what else could be put ‘in’ to the health system. He wanted to shift the conversation to what was coming ‘out’ of the system, i.e., an outcomes-based approach. To drive this mindset, Minister Pate asked his ministry:

“What are we here for?”

When they thought about primary healthcare, saving lives was the most concrete outcome. The next step was to define ‘saving lives’ in a way that was easy to communicate. From this discussion, Minister Pate’s signature program, “Saving One Million Lives (SOML),” was born.

SOML was an aspirational target that was big enough but also tangible enough to focus people on the outcomes that matter and to work backward toward the inputs. SOML aimed to strengthen primary healthcare and prioritize interventions that could save lives, such as improving maternal and child health, eliminating mother-to-child transmission of HIV, strengthening immunization, scaling up access to essential medicines, controlling malaria, and improving child nutrition.

SOML built on existing policies outlined by the National Strategic Health Development Plan and the President’s Transformation Agenda rather than introducing new ones by way of strengthening existing delivery channels.

Minister Pate also used the Lives Saved (LiST) tool to prioritize the critical intervention areas that would contribute the most to lives saved. Based on this analysis, the six key priorities of SOML were improving maternal and newborn child health, eliminating mother-to-child transmission of HIV, strengthening routine immunization and achieving polio eradication, scaling up access to essential medicines, malaria control, and improving child nutrition. The underlying idea was that to save one million lives; the primary healthcare system would have to be strengthened by increasing health personnel, introducing performance management systems to increase health worker productivity, improving quality of care, and using information and communication technology for the supply chain management. By linking health systems strengthening to concrete outcomes, Minister Pate hoped that beyond saving one million lives, the benefits of these systemic changes would continue. Nonetheless, Dr. Pate realized that SOML’s success depended on the political will that supported it. This began with the President.

Working with the President

According to Minister Pate:

“When I started in 2008 as CEO of the Primary Healthcare Development Agency, it was polio that led the previous President to appoint me. To deal with polio and immunization, I had to build a primary healthcare system. By 2011, when the new President was elected, he asked me to join his government to build on the work I had started.”

Soon after his appointment as Minister of Health, Dr. Pate made sure to meet with President Goodluck Jonathan to thank him for the honor of appointing him to serve. In that meeting, he promised to serve the President with his very best and asked him for one thing in return:

“If I make any mistakes or if I am not doing something you really want, I want you to call me directly. And if I have a similar issue with you, I want to be able to come to you directly.”

This conversation formed the foundation for an effective working relationship and proved useful for the duration of Pate’s term.

To communicate SOML to the President, Minister Pate recollected what he knew about the President. Two key factors proved important. Firstly, President Jonathan had lost several siblings to preventable diseases at a very young age. Secondly, President Goodluck’s term had begun with a deeply unpopular move – the cancellation of longstanding subsidies to Nigerians on oil and petroleum gas.

Saving children from death and disease was something the President had a connection to, and the public was concerned about it, so it made for a compelling goal.

After the President’s support for the SOML campaign, Minister Pate provided monthly written updates to the President to regularly reinvigorate his political will and to maintain their connection. The President wanted to say that he had eradicated polio and ‘saved one million lives’ as part of his Transformation Agenda. His and Minister Pate’s legacies were aligned. Minister Pate said:

“Polio and immunization were embedded within the context of primary healthcare revitalization. We reframed the polio fight to include vaccines and saving the lives of children and mothers, rather than isolating it as a separate issue.”

Minister Pate gained this high-level backing by aligning SOML with the President’s personal experiences and the public’s needs.

Finance Minister

After the President, Minister Pate set his sights on bringing the Minister of Finance, Ngozi Okonjo-Iweala, on board with SOML. He knew Minister Okonjo-Iweala as a senior colleague from their time together at the World Bank, where she remained until her cabinet appointment. He had built on this pre-existing relationship with her by visiting her in Washington, DC, after her appointment but before her taking office. He also knew that during her previous tenure as Minister of Finance, she had been frustrated with the health sector because she did not have a clear sense of what had been accomplished with the funds she had allocated.

To get Okonjo-Iweala on board, Minister Pate had to stress the outcomes-based approach to SOML. Okonjo-Iweala was swayed by SOML’s clear definition of goals and deliverables because she could easily see and understand it as Minister of Finance. Thus, she was willing to support it. She asked Minister Pate to serve on the Economic Management Team and the Economic Management Implementation Team – two intersectoral working groups housed within her ministry. This was the first time the health sector was fully represented in such a body.

As part of the Minister of Finance’s Economic Management Team, Minister Pate gained a higher-level understanding of government priorities and connected with his colleagues on the team – including the Minister of Planning, the Director General of the Budget Office, and the Chief Economic Advisor to the President. He made SOML one of the key deliverables of the Economic Management Team, which further solidified their buy-in to its success.

Consequently, Minister Pate convinced both the President and the Minister of Finance to invest part of the money recouped from the cancellation of oil subsidies in maternal and child health to deliver results for the public. In September 2011, with President Jonathan’s and Minister Okonjo-Iweala’s support, Dr. Pate made a public announcement about defining his term with the goal of Saving One Million Lives in Nigeria.

Managing Stakeholders with Influence

With the support of the President, the Minister of Finance, and high-level officials from the Ministry of Health, Minister Pate moved to identify other key stakeholders that needed to be managed. Later in his career, he would learn more about using stakeholder analysis to explicitly map supporters and opponents against their level of influence. Still, at this time, he took a more intuitive approach. He maintained an internal inventory of the relationships he had cultivated and leveraged his social networks to forge connections with those who were truly influential, regardless of their positional authority.

Within his own ministry, Minister Pate had traditional authority by virtue of his position as Minister of State for Health, but this was supplemented by good relationships with the Federal Minister of Health (whose primary focus was on tertiary care and health insurance, among other areas), the Permanent Secretary, key directors, and the Primary Health Care Agency.

Nonetheless, within his own health ministry, Minister Pate sensed a feeling of “passive resistance.” The Health Ministry had traditionally taken responsibility only for the allocation of the federal health budget to states without monitoring the use of the state health budgets, with minimal state accountability and little regard for impact. At the outset, senior officials in the health ministry thought they could ignore Minister Pate’s SOML initiatives and “let it die on its own.” Nonetheless, Minister Pate persisted onwards with the higher-level health officials who formed his guiding coalition to prove to these opponents that SOML was not going away.

As SOML gained traction in the form of support from the President, the Finance Minister, and more state entities, and by raising substantial funds, the naysayers not only came on board but also began to be champions of the initiative.

As Minister Pate continued to work to achieve his mandate, he had a secret weapon on his side: the initiative’s name – “Saving One Million Lives.” By framing the program this way, opposing stakeholders, particularly those in the political sphere, had a challenging time voicing their opposition to “Saving One Million Lives.”

Engaging Governors and Community Leaders

Minister Pate leveraged his previous relationships with governors and community leaders to understand the importance of state-level cooperation, especially when it came to vaccinating citizens. He organized forums and secured commitments from state governors to support primary healthcare improvements. Additionally, he established the Northern Traditional Leaders Committee on Primary Healthcare to engage trusted community leaders in vaccination and health campaigns. He explained:

“When it came to vaccination hesitancy, we worked to earn the trust of communities and community leaders. We created the Northern Traditional Leaders Committee on Primary Healthcare, which engaged religious and community leaders across Northern Nigeria. This network became crucial in planning and implementing vaccination campaigns. To select the Northern Traditional Leaders, we went to the Sultan and asked him to convene a group of representatives from each of the 19 states in the North. The Sultan and a committee selected leaders who were relatively younger, stronger, respected, and trusted. We then organized them into a committee and enabled them to act effectively. To engage communities, we provided them with information and involved them in planning, which built legitimacy in the eyes of the people.”

As he had anticipated, Nigeria’s 36 state governors were key stakeholders whose support Minister Pate needed to save one million lives. Fortunately, Minister Pate had existing relationships with several governors and with the Director General of Nigeria’s Governors’ Forum. The Governors’ Forum had preexisting goals to eradicate polio and implement effective routine immunization programs as part of Nigeria’s 2009 Abuja Commitments to Polio Eradication. Minister Pate said:

“When I became Minister, it was easier for me to build on the relationships I had already established with the governors. As CEO of the Primary Healthcare Development Agency, I had worked closely with the Governor’s Forum, helping to organize their secretariat and getting them to sign the Abuja Commitment Declaration in 2009. This previous work allowed me to leverage those relationships when I became Minister.”

While this was helpful in aligning them with SOML, convincing them to relinquish their budget autonomy was still a challenge. Ultimately, the President had to play a significant role in bringing the governors on board.

The President asked the Governors to be accountable for progress in their states. Minister Pate’s team provided each state with a ‘Countdown to 2015’ one-page document summarizing how many lives the state could save by expanding specific services relevant to its context. This provided each state with its own baseline and endline target.

Once the states had pledged their commitment to their targets, Minister Pate’s team set up a scorecard system tracking progress state-by-state. The data comparing state performance was presented at the quarterly meeting of the Presidential Task Force on polio eradication, with the governors in attendance, presided over by the President, and quickly became a major incentive for the states to improve performance. Initially, some governors were uncomfortable with the pressure to be accountable and pushed back. However, according to Minister Pate, the measurement of performance became:

“An inflection point shifting the dialogue to focus on the data to its use in decision-making and results.”

Furthermore, the scorecards on state performance were published in newspapers. This decision was made to ensure that data collected from the public was ‘given back’ to the public and to further motivate state progress.

Finally, there were donors. Minister Pate needed donor support to generate more innovative ideas for technical assistance and strategy for the maternal and child health programs associated with SOML. Traditional and particularly non-traditional donors were eager to fund the initiative, and he was able to work with philanthropic foundations with flexible sources of funding to recruit world-class experts to help with ideation and design. He explained:

“As Minister, I was very active in mobilizing resources. I leveraged traditional domestic financing, multinational financing, and other sources to move the agenda quickly. We raised resources through innovative financing, which helped draw states in the direction we wanted.”

Implementing Strategically

As he worked to bring stakeholders on board, Minister Pate was invited to attend the Harvard Ministerial Leadership Forum in June 2012. This gave him the opportunity to learn about tactics for effective policy implementation and organization. In his own words:

“I was internally strengthening my hand while externally learning and strengthening relationships to succeed.”

The President officially launched SOML in Nigeria on October 16, 2012. The idea behind this campaign was a national rallying cry to end preventable infectious diseases and curtail infant and early childhood mortality. SOML had a strong brand identity (including a logo) and a deliberate communications strategy.

Minister Pate created a culture of collaboration and a sense of obligation amongst public and private sectors to do their part by positioning the campaign as a collective social movement across the nation. The communications strategy allowed key actors to pledge how many lives they would save – the private sector initially pledged to save 30,000, which later increased. Finally, and perhaps most importantly, SOML’s multichannel messaging plan created a sense of accountability to the people. This made it more difficult for state governments to allocate resources away from the program’s initiatives.

Once launched, Dr. Pate had to ensure implementation success. He needed some control over state-level health spending to ensure compliance with the national goals.

To this end, he introduced three key nationally managed elements to the program. The first was developing a robust data management system to monitor and evaluate performance. Historically, data had been collected independently at the state level, but in order to improve its reliability and comparability across states, he implemented a centralized data management system to enable the tracking of outcomes for the nationally outlined priorities. Furthermore, this data would be used for decision-making purposes regarding future state health budget allocations.

The second element was stewardship and stakeholder engagement. It involved introducing a steering committee housed within his ministry comprising representatives from federal and state government, professional associations, civil society associations, and donor groups. The goal of this committee was to enhance coordination through increased transparency and mutual accountability for the outcomes determined by the data collection. Pate chaired meetings with the steering committee every three months to review progress and ensure stakeholder alignment.

The final element introduced by Minister Pate was a program delivery unit, jointly accountable to the health and finance ministries, to support execution and ensure effective, high-quality delivery. This was led by competent professionals with a focus on results.

After Strategic Implementation

Minister Pate resigned in July 2013, confident that SOML was institutionally secure and embraced by his successors. By 2018, one million lives had been saved, and SOML had raised over US$1 billion in investments. The initiative had survived three Ministers of Health and fundamentally shifted the mindset towards primary healthcare. SOML’s principles were further institutionalized through a partnership with the World Bank, rewarding federal and state governments based on performance.

Looking back, Minister Pate was gratified by the adoption of outcomes-based thinking within the ministry and state governments. However, he reflects on areas for improvement, such as spending more time with state governors, consolidating information management systems, focusing on public sector supply chains, and integrating health insurance into SOML plans. His final reflection underscores the importance of strategic decision-making in complex systems:

“In a complex system, you cannot always fight in all directions. You have to choose which battles to fight and when.”

In 2020, “Nigeria was declared free of wild polio in 2020” (The WHO, 2023).

2023 Reappointment

In 2023, Minister Pate was again appointed Coordinating Minister of Health & Social Welfare, Federal Republic of Nigeria. He said:

“I’m refreshing and learning from every experience I have had. When I enter a new role, I treat it as a fresh start and apply the lessons learned from previous experiences, ensuring we build strong teams, mobilize resources, and maintain a clear focus on execution. In my current role, I quickly did a stock take together with my colleague the Honorable Minister of State, engaged with the ministry bureaucracy and agencies, and developed an agenda and blueprint. We are focused on saving lives, reducing pain, and producing health for all Nigerians. I brought in capable hands, the best I could find, to ensure we could deliver on our objectives.”

References

Li, Z., Shi, J., Li, N., Wang, M., Jin, Y., & Zheng, Z. (2022). Temporal trends in the burden of non-communicable diseases in countries with the highest malaria burden, 1990–2019: Evaluating the double burden of non-communicable and communicable diseases in epidemiological transition. Globalization and Health, 18(1). https://doi.org/10.1186/s12992-022-00882-w

Ophori, E. A., Tula, M. Y., Azih, A. V., Okojie, R., & Ikpo, P. E. (2014). Current Trends of Immunization in Nigeria: Prospect and Challenges. Tropical Medicine and Health, 42(2), 67–75. https://doi.org/10.2149/tmh.2013-13

The WHO. (2023, August 24). Protecting every child in Nigeria from poliovirus. WHO | Regional Office for Africa. https://www.afro.who.int/countries/nigeria/news/protecting-every-child-nigeria-poliovirus#:~:text=Nigeria%20was%20declared%20free%20of