© 2019 - International Centre for Investigative Reporting
Chaotic Maternal Health Policies Hurt Nigerian Women
An estimated 145 women continue to die daily in Nigeria of pregnancy and childbearing-related causes due to ineffective interventions in maternal health and poor policy implementation by government.
By Chikezie Omeje
Deborah James felt a slight pain in her lower abdomen and became worried because she was in advance stage of her pregnancy.
This pain came around 10:30 am on Friday, February 10 when her husband had gone to work and she was at home with her two-year-old son.
James decided to visit the Kuchigoro Primary Health Centre, PHC, along the Airport Road in Abuja where she registered for antenatal care.
Without wasting time, she strolled to the PHC, holding her son’s right hand as they walked about 10 minutes from their house to the health centre.
In less than 30 minutes of getting to the PHC, a nurse attended to her, scanning her stomach and determining that there was no problem. The nurse assured the expectant mother that she was okay and sent her on her way. James was already outside the gate of Kuchigoro PHC, going back home with her son when our reporter met her.
She revealed that she delivered her son in the PHC about two years ago and she had been coming to the health centre for her health care needs.
Although, her husband made her to also register for antenatal care in Wuse General Hospital, she prefers Kuchigoro PHC because it is closer to her and the health workers have been taking good care of her.
“I like this place,” James said. “Them dey try”.
A month before James and her son visited, Kuchigoro PHC had received unusual visitors.
On January 10, President Muhammadu Buhari and a retinue of government officials were at the Kuchigoro PHC to launch an ambitious agenda to revitalise 10,000 PHCs, at least one functional PHC in every political ward in the country.
Due to paucity of funds, the federal government decided to use a phased approach, starting with the revitalisation of a PHC in every senatorial zone. This will culminate into 109 PHCs in this first phase of revitalisation.
The Kuchigoro PHC is the first and a model of the government’s current revitalisation effort for the remaining 108 centres.
Among other laudable health outcomes in this federal government’s revitalisation of PHCs, Buhari specifically said that by this initiative, “women will no more be dying needlessly during childbirth.”
The federal government claimed that it “revitalised and made fully functional” the Kuchigoro PHC.
Investigations by the icirnigeria.org, however show that the claim is false and that the government might have misinformed Nigerians, including the President.
Checks by this website revealed that Kuchigoro PHC had been one of the few functional PHCs in the Federal Capital Territory, FCT, and the centre had been offering 24-hour services prior to the purported intervention of federal government.
“The only thing is that this launching by President Buhari brought publicity to this place. We have always been a functional PHC,” a staff of the Kuchigoro PHC who pleaded anonymity because she is not permitted to talk to journalists said.
The staff wondered why the federal government did not go to one of the numerous non-functional PHCs in FCT to revitalise instead of claiming to have revitalised and made fully functional the best PHC in Abuja.
Kuchigoro PHC’s record showed that the health centre took deliveries of an average of 70 live births in a month in 2016 and this figure has not changed since the revitalisation by federal government.
The federal government’s claim to revitalising the Kuchigoro PHC lies only in the renovated buildings, new overhead water, power generator and ambulance to facilitate emergency referral.
Before the intervention, Kuchigoro PHC already boasted of essential functional medical care infrastructure such as laboratory and basic equipment like scan, monitor, phototherapy and resuscitation equipment.
The PHC also got a 42-inch television in the waiting room and desktop computers branded with Sterling Bank. The PHC revitalisation was a collaboration of federal government and FCT Administration and partners like Sterling Bank, General Electric and the University of Abuja.
These additions to the PHC came at a cost of about N10 million to federal government as revealed by the officials of Federal Ministry of Health, FMH.
Meanwhile, the federal government’s intervention in Kuchigoro did not address the critical challenges of the centre which have to do with inadequate staff and sustainable financing for the day to day operations of the PHC.
Kuchigoro PHC has 19 members of staff, which is below the required minimum of 24 staff as recommended in the minimum standards for PHC by the National Primary Health Care Development Agency, NPHCDA.
“Two problems we are facing in health care system is funding and human resource,” the Executive Secretary of FCT Primary Health Care Development Board, Rilwanu Mohammed confirmed in an interview with our reporter.
The FCT has a total of 233 PHCs in its six area councils but only 1,008 staff. The staff shortage is more than three quarters below the minimum staff requirement to consider the PHCs functional.
The acute shortage of staff has resulted in a situation where only 28 out of the 233 PHCs are running 24-hour services.
Even then, it was discovered that many of the 28 PHCs that offer 24-hour services in the FCT do not have doctors, contrary to the standard set by NPHCDA that every PHC should have one.
“Kuchigoro PHC was selected based on federal government criteria and they selected a 24-hour facility, trying to make sure there was a number of health personnel in place, particularly doctors,” Mohammed told our reporter.
Needless to say, the goal of revitalising PHCs without addressing the critical component of staffing and funding will fail like similar interventions by the federal government in the past.
A previous story by the icirnigeria.org revealed how the federal government wasted N2 billion between 2012 and 2014 in constructing new primary health centres in some states that were later abandoned. The states and local governments were unable to take charge of the new PHCs in providing staff and essential drugs.
Video clip showing a deserted Primary Health Centre in Ebonyi State
This year, the federal government has appropriated over N3 billion for the PHCs’ revitalisation without any comprehensive plan for the staffing and other critical funding needs.
Women at receiving end of non-functional PHCs
According to the United Nations Children’s Fund, UNICEF, a woman’s chance of dying from pregnancy and childbirth in Nigeria is 1 in 13.
The organisation noted that these deaths are preventable but the coverage and quality of healthcare services in Nigeria continue to fail women.
UNICEF also added that less than 20 per cent of health facilities offer emergency obstetric care and only 35 per cent of deliveries are attended by skilled birth attendants.
The World Health Organization, WHO, in a report in 2015, estimated that 830 women in the world die each day due to pregnancy-related causes while an estimated 145 of those women die in Nigeria every day.
The Nigerian Demographic and Health Survey (NDHS 2013) estimated that more than a quarter of all deaths among women of reproductive age (15 – 49 years) in Nigeria is caused by pregnancy.
Maternal mortality is often measured at the ratio of 100,000 live births.
The NDHS 2013 estimated that maternal mortality is 576 per 100,000 live births. This means that out of 100,000 women who give births in Nigeria, 576 of them will die.
However, WHO, UNICEF, UNFPA, World Bank Group, and United Nations Population Division’s estimates of trends in maternal mortality from 1990 to 2015 put maternal mortality in Nigeria at the ratio of 814 to 100,000 live births in 2015.
Using the World Bank’s figure, icirnigeria.org estimates that about 1.5 million women in Nigeria have died of pregnancy-related causes in 25 years from 1990 to 2015 with an average of 57,900 deaths a year.
Nigeria failed to achieve the Millennium Development Goals, MDGs, goal 5 which set out to reduce maternal mortality by three-quarters, that is 75 per cent, in 2015 from what it was in 1990.
The MDGs were set at the United Nations Summit in the year 2000 to accelerate global progress in development.
Maternal mortality in Nigeria in 1990 was at the ratio of 1,350 to 100,000 live births. This means that if Nigeria had achieved MGDs 5, maternal deaths would have been reduced to 338 per 100,000 live births in 2015.
In terms of the rate of women who die due to pregnancy-related causes, Nigeria has one of the worst maternal health outcomes, being in the same status with countries like Chad, Central Africa Republic, Sierra Leone, Somalia, and South Sudan.
Afghanistan was almost at par with Nigeria in 1990 with a maternal mortality ratio of 1,340 per 100,000 live births but had made tremendous progress of getting to 396 per 100,000 live births by 2015.
Maternal mortality ratio is as low as 3 in Finland, 4 in Austria, 6 in Australia, 6 in Germany, 7 in Canada and 8 in France per 100,000 live births.
Why intervention in maternal health by government fails
The Executive Director, Centre for Social Justice, Eze Onyekpere believes that the problem is the skewed federal system and the missing link is the lack of federal government’s collaboration with state and local governments in providing maternal health care.
Nigeria operates three tiers of government, including the federal, 36 states and the FCT and 774 local government areas.
Under the Nigerian laws, PHCs are under the purview of the local governments while the states provide the secondary and tertiary health facilities.
In addition to providing the overall policy framework and certain interventions on health, the federal government handles tertiary health facilities.
Health experts estimate that over 70 per cent of disease burden in the country occurs at the PHC levels and functional healthcare delivery at that level would solve the problem of maternal deaths.
From time to time, especially after Nigeria committed to the MDGs, the federal government has carried out several interventions on maternal health at the PHCs, many of which have not yielded desired results.
Onyekpere said the previous interventions failed because they did not address the fundamental challenges of staffing and sustainable funding for PHCs as local governments have not been able to maintain the PHCs.
The first practical attempt by the federal government to address the acute shortage staff in PHCs was in 2009 when the Midwives Service Scheme, MSS, was introduced.
The MSS was an interventional programme to demonstrate to the states and local governments that appropriate midwives in PHCs would reduce maternal mortality drastically.
Under the MSS arrangement, the federal government paid half of the salary of the midwives while the balance was supposed to be paid by the states and local government on N30, 000 and 20,000 respectively.
The states and local governments were supposed to employ and take full charge of paying these midwives after four years but all the states and local governments failed to take up the programme and it failed.
Another effort by federal government to intervene in providing staff to PHCs was the Subsidy Reinvestment and Empowerment Programme, Popularly called SURE-P.
The SURE-P was a social investment programme, following the partial removal of petroleum subsidy in 2012 and part of the money was used in recruiting health workers to PHCs.
Also under SURE-P, pregnant women who attended antenatal and delivered in a health facility got a financial reward of about N4, 000. SURE-P supplied drugs and consumables to PHCs as well as renovated and constructed new PHCs.
President Buhari suspended the programme after taking over power in 2015.
Until their suspensions, MSS provided 105 midwives to PHCs in the FCT and SURE-P also contributed 97 staff.
Project Director of Community Health Research Initiative, Aminu Magashi noted in an interview with our reporter that frequent change of policies and programmes makes it difficult to have maximum impact on federal government’s intervention on maternal health.
All processes, no result
By icirnigeria.org estimation, the three tiers of government have spent more than N10 trillion on healthcare since the year 2000 without corresponding result in health outcomes, especially maternal health.
The three tiers of government all have separate budgets for health. The combined budgets for health by federal government and states this year alone is about N600 billion.
Much of the inability to achieve result stems from the failure of policy makers in Abuja to plan effectively and implement policies.
Chairman of Health Sector Reform Coalition, Ben Anyene, in an interview with our reporter, observed that the love for procurement as an avenue to loot public funds is why government does not do long term planning.
“That is why everything is procurement. Sometimes even procure what is not needed,” he said.
Icirnigeria.org counted about 25 policies, strategies, and programmes to promote maternal health since the year 2000 as every new government or minister of health or executive secretary of NPHCDA tried to develop new policies and strategies without recourse to what had been done in the past.
Following the MDGs in 2000, billions of dollars have poured in from international donors into the healthcare delivery in Nigeria, especially on maternal health but like Nigerian government’s expenditure on health, the impact had been less desirable.
Much of the problem is poor coordination of foreign donations and grants by the federal government, resulting in a situation where implementing partners of foreign grants carry out their activities without any plan on the national needs by the federal government.
Michel Arrion, Head Of European Union Delegation to Nigeria And ECOWAS told our reporter that it was not the responsibility of the Federal Ministry of Health, FMH, to plan and coordinate foreign grants but that the Ministry of Budget and National Planning, stressing that the country must have a plan and take ownership.
Arrion also called for more transparency in the states on how public finances are managed.
Revitalisation Without Plan
Investigations by icirnigeria.org showed that the current revitalisation of PHCs by federal government is not backed by any comprehensive plan.
On inquiries to see the plan, our reporter was referred to NPHCDA by the Director, Media and Public Relations in the FMH, Boade Akinola who said NPHCDA is the implementing agency.
Our reporter was however redirected to the ministry by officials of NPHCDA, insisting that the revitalisation was the initiative of the minister.
The Public and Private Development Centre, PPDC, a non governmental organisation, NGO, that works in the area of open contracting and procurements, had earlier applied to get the plan under the Freedom of Information Act.
The PPDC’s Executive Director, Seember Nyager told our reporter that she had not gotten any response after more than three weeks that her organisation applied to see the plan.
Under the Freedom of Information Act, an organisation is supposed to respond to information request within seven days of receiving such request.
A staff of FMH confided in our reporter that the ministry has no detailed plan on the PHCs revitalisation.
Checks by this website showed that the closest thing to a plan for the current PHC revitalisation is the “Minimum Standards for PHC” published in 2014 by the NPHCDA and the “Expert Report on Revitalisation of PHC” in 2015.
The Minimum Standards for PHC recommends one PHC in every political ward in the country. A local government area is made of an average of 10 wards and Nigeria has 774 local government areas. It is expected that each PHC will cater for a population of between 10, 000 to 20,000.
Meanwhile, the Minister of Health, Isaac Adewole insisted that the federal government has a plan for the PHCs revitalisation, stressing that the government was quite convinced that “If we have a strong health system, maternal mortality will be a thing of the past”.
Responding to a question by our reporter on how similar interventions by federal government in the past had failed, Adewale said, “If things are not done in a structured manner, if things are not done with sustainability in view, we will have a problem and that is why we are doing things differently.”
Asked what exactly the government was doing differently regarding staffing and provision of drugs, Adewale said: “in terms of staffing and drugs, we are doing things differently.”
“If we look at the National Health Act, there is a provision for infrastructure and there is a provision for the commodity. This time around, things will be done differently and we are also partnering with the states”.
When told that government has refused to implement the National Health Act, the minister said things would take time.
“The Health Act is a journey. It is not a destination. If you said it has not been implemented, that is not right. We have constituted the committees. In fact today, we are inaugurating some of the committees. So we are on and we are also going to pilot test the basic health care provision fund”.
National Health Act
The National Health Act, NHAct, was signed into law on December 9, 2014, by Former President Goodluck Jonathan. The Act was expected to bring sanity into the Nigerian health system and improve the health outcomes in the country, especially maternal health.
More than two years after the law was passed, the federal government has failed to implement it.
A key provision in the Act that will improve maternal health is the Basic Health Care Provision Fund, BHCPF, to provide a basic package of care for all Nigerians.
The Act provides that BHCPF will be financed through yearly release from the federal government of not less than one per cent of the Consolidated Revenue Fund. Other means of funding could come from international donors. States and local governments are also expected to contribute 25 per cent counterpart funding for PHCs projects.
If Nigeria had implemented BHCPF, about N48 billion would have been available for PHCs this year alone from the consolidated revenue. This estimate is based on about N96 billion statutory transfers to the Universal Basic Education Commission, UBEC, which receives 2 per cent of the Consolidated Revenue Fund.
As provided in the Act, half of this money will be used to provide a basic package of care for all Nigerians through the National Health Insurance Scheme, NHIS; 45 per cent of the fund will be disbursed by the NPHCDA for essential drugs, maintenance of PHC facilities and strengthening of human resource capacity, while the remaining five per cent will be used by the FMH to respond to health emergencies and epidemics.
Another key provision in the Act is that within two years of enacting the law, all health facilities, both public and private, must obtain a certificate of standard. The penalty for operating without this certificate of standard is a shut down.
However, more than two years after the law came into effect, no health facility in Nigeria has been issued the certificate of standard.
The Centre for Social Justice, a civil society group, has filed a court case to compel federal government to implement the NHAct and the matter is currently being determined in the court.
Chairman of Health Sector Reform Coalition, Ben Anyene, who took part in drafting the Act said the law was an intervention that could help to correct some of the anomalies in the health care and he was worried that the government has refused to implement it.
The government has just set up fresh committees in February, after pressure from civil society groups, to come up with modalities of implementing the Act. Similar committees were set up in 2015 without any tangible outcome.
“Right now, they have corrupted the whole thing,” Anyene said. “They don’t want to implement the Act. It is wrong for a country to make a law and refuse to implement. They go into all kinds of conventions and refused to implement”.
Similar to MDGs, the United Nations has set another target for maternal health in the Sustainable Development Goals, SDGs.
Under SDGs 3, the first target is to “reduce the global maternal mortality ratio to less than 70 per 100,000 live births” by 2030.
The big question is will Nigeria fail women and the world again?