Peer-reviewed article

Using performance-based grants to subnational governments to improve health outcomes: a repeated cross-sectional evaluation of the Saving One Million Lives Programme in Nigeria.

Adewole IF, Filani O, Kana I, Bello YO, Morhason-Bello IO et al. · 30 Jan 2026

Abstract

Background Performance-based grants (PBGs) to subnational governments have been used in other sectors to improve the delivery of government services, but have rarely been used in the health sector. This study aimed to assess changes in maternal, newborn and child health (MNCH) outcomes and quality of care associated with the implementation of PBGs under the Saving One Million Lives Programme for Results (SOML-PforR) in Nigeria. Methods This study employed a repeated cross-sectional observational design. Trends in MNCH service coverage indicators and quality-of-care domains were analysed using nationally representative household and facility surveys conducted in 2016 (baseline) and 2021 (endline). Changes in incentivised and non-incentivised indicators across Nigeria's six geopolitical zones were used to assess coverage and equity. Coverage indicators were reported as percentages, while changes were presented as percentage points. Simple and multivariable linear regression analyses were performed to determine the effect of baseline coverage in 2016 on the percentage point change in coverage for MNCH indicators, with female literacy included as a covariate. Statistical significance was set at p<0.05. Results Between 2016 and 2021, significant improvements were observed in Penta3 vaccination coverage (23.3% points), skilled birth attendance (7.7% points), vitamin A supplementation (26.4% points) and contraceptive prevalence (7.4% points). However, coverage of insecticide-treated nets declined nationally (-7.9% points). The quality of care in health facilities also improved, particularly in the availability of essential drugs and functional equipment (20.5% points). The data quality and financial transparency domains showed the least progress (7.3% points). Equity improved across the five SOML indicators and was statistically significant for Vitamin A supplementation (p<0.001), Pentavalent 3 vaccination (p<0.001), and ITN use (p=0.038). Conclusion SOML-PforR contributed to significant improvements in MNCH coverage, equity between states and quality of care in Nigeria.