UHC Optimization Linkages to the Uptake of the Basic Minimum Package of Health Services by Eligible Population Through Decentralized Facility Financing in Kogi State, Nigeria (2022 To 2025)

Abstract

Uptake of the Basic Minimum Package of Health Services (BMPHS) in Kogi State has been limited by supply‑side constraints, demand‑side barriers, and place‑based vulnerabilities concentrated in riverine and rural LGAs. The IMPACT rollout (2022–2025) combined Decentralized Facility Financing (DFF) with bundled Continuous Quality Improvement (CQI) supports to strengthen facility responsiveness, stabilize commodities, and expand outreach.
We used a quasi‑experimental, mixed‑methods design on a facility‑month DHIS2 panel (2019–2025; n = 96 PHCs). Quantitative inference triangulated three counterfactual generators: augmented two‑way fixed‑effects Difference‑in‑Differences (DiD) for average effects, Interrupted Time Series (ITS) segmented regression to decompose immediate (level) and sustained (slope) impacts, and facility‑level counterfactuals via synthetic control and matrix completion for robustness. Multilevel mixed‑effects models estimated heterogeneity; causal mediation (bootstrap, 5,000 sims) quantified pathways (cold‑chain uptime, outreach frequency, commodity availability). Qualitative interviews and supervision records explained fidelity and contextual moderators. Costing used activity‑based methods with probabilistic sensitivity analysis.
DFF plus CQI produced both rapid operational gains and durable system strengthening. Primary policy‑relevant estimates: DiD DPT3 +6.2 percentage points, ITS immediate level change α₂ = +3.7pp, and ITS slope α₃ = +0.12 pp/month. Mediation attributed ~41% of the DPT3 gain to improved cold‑chain uptime; outreach and commodity availability explained large shares of ANC1 and IPTp3 gains. Results are robust across lagged‑outcome DiD, matrix completion, generalized synthetic control, event‑study checks, and autocorrelation corrections. Cost‑effectiveness benchmarks show program‑level ICERs consistent with high probability of value for money for composite BMPHS gains.
To maximize equitable BMPHS gains, prioritize cold‑chain resilience, predictable and timely disbursements, and earmarked outreach financing for high‑environmental‑risk LGAs. Embed both the ITS level (α₂) and slope (α₃) as complementary KPIs in routine dashboards: α₂ signals rapid operational fixes; α₃ signals durable system strengthening. Scale‑up should pair DFF with CQI, protected commodity lines, and context‑sensitive outreach modalities to sustain and equitably distribute gains.