I am deeply concerned by the recent findings that Nigeria has overtaken India as the world capital for under-five deaths, according to the UNICEF report ‘Levels and Trends in Child Mortality,’ particularly as we had previously seen significant improvements in Nigeria between 1990 and 2015. This distressing news comes just as we congregate virtually this year for the United Nations General Assembly.
The report compiles data spanning three decades from 1990 to 2019, and it reveals that 49% of all under-five deaths in 2019 occurred in just five countries: Nigeria, India, Pakistan, the Democratic Republic of Congo and Ethiopia. It finds that Nigeria and India alone account for almost a third of the deaths, and what is evermore worrying is that it is clear that there is a strong potential of a continued mortality crisis in 2020 with the additional strain of the coronavirus pandemic.
Our primary health care services must be supported beyond bricks and mortar to encompass the full range of quality affordable health care provided by a well equipped, well skilled and adequately remunerated health workforce, who are motivated to deliver respectful maternity and child health care and advice. We must intensify our efforts to engender, enable, empower, replenish and reinforce the capacities of the most appropriate and qualified health professionals to stand with women and their families as a central core focus which will be validated, vindicated and reinforced throughout this Year And Decade of the Midwife and Nurse. We must build resilience within our healthcare system.
In my opinion the significant 35% aggregated gains and improvement in maternal and child survival measured between 2010 and 2015 across Nigeria, which is now gravely threatened, was catalysed by the roll-out of the simple yet revolutionary Midwives Service Scheme (MSS), launched in 2009 by the National Primary Health Care Development Agency (NPHCDA), in 2009 during the administration of late President Umaru Yar Adua. It aimed to address the challenge of Nigeria’s very poor record regarding maternal and child health outcomes. An estimated 53,000 women and 250,000 newborns were dying annually mostly as a result of preventable causes.
The NPHCDA was tasked with establishing the MSS as a public sector initiative and a collaborative effort between the three tiers of government in Nigeria. A memorandum of understanding between the Federal, State and Local governments set out clearly defined shared roles and responsibilities, which were supported by the Wellbeing Foundation Africa and other strategic partners. The MOU was signed by all 36 states of Nigeria and was designed to mobilise newly qualified, unemployed and retired midwives for deployment to selected primary health care facilities in rural communities and facilitate an increase in the coverage of Skilled Birth Attendance (SBA) to reduce maternal, newborn and child mortality.
The MSS Technical Working Group (TWG) met regularly to receive updates, review progress and advice in order to provide strategic direction, support and guidance for the implementation of the MSS. The secretariat of the MSS was responsible for day-to-day management, whilst state focal persons served as contact people for the midwives in the MSS.
The MSS was based on a cluster model in which four selected primary healthcare facilities with the facility to provide Basic Essential Obstetric Care (BEOC) were clustered around a General Hospital with capacity to provide Comprehensive Emergency Obstetric Care (CEOC). Qualified professional midwives were deployed to each selected PHC, ensuring 24 hour provision of MNCH services and access to skilled attendance at all births to reduce maternal, newborn and child mortality and morbidity. The MSS pilot then covered 163 clusters, which had 652 PHCs and 163 general hospitals. The MSS strengthened the PHC system by distributing basic equipment (midwifery kits, BP apparatus etc, and a comprehensive civil registrations and vital statistics data capture system including partographs, to all facilities, in the form of the IMNCH Personal Health Records and Home-Based Records, developed by the Wellbeing Foundation Africa) to 652 facilities through the vaccine logistics system. The MSS was successful in establishing and reactivating ward development committees WDC’s at all MSS PHCs to ensure community participation and ownership in its implementation.
The outcomes were impressive and immediately impactful: 2,488 midwives were successful in applying to the MSS and were deployed to PHC facilities. The midwives from all over Nigeria were then given an orientation which I was pleased to host, as a member of the Critical Core Committee of the FMOH to upskill and familiarise them with the scheme. As of July 2010, 2,622 midwives had been deployed to PHC facilities in rural areas. MSS provided capacity building by the creation of a training framework, which was aimed at improving the skills and proficiency of midwives in provision of quality maternal and child health services. The midwives then underwent competency training through Principals of Schools of Midwifery. The MSS planned to implement information and communications technologies support to improve communication and articulated a monitoring and evaluation framework for the scheme.
Partners, including the Wellbeing Foundation Africa, committed to initiating and implementing a two-pronged approach to programme communication: it focused on political leaders and decision makers, as well as clients, through radio, TV, billboards, community outreach, and health centre branding to ignite social and behavioural change and demand creation for health-seeking and health providing orientation.
The MSS faced (and still faces) five key challenges, namely: 1) implementation of the Memorandum of Understanding, 2) availability of qualified midwives, 3) retention of midwives, 4) capacity building of midwifes and 5) sustenance of linkages. There needs to be more support and commitment from officers in relevant government departments, which can be achieved by ensuring clarity on the objectives and aim of the MSS.
Over the years, several initiatives and programmes had been introduced to reduce mortality among mothers and children in Nigeria. Despite these efforts, poor maternal and child health indices had continued to be one of the most serious development challenges facing the country. Significant progress was accomplished in the implementation of the MSS initiative however and the best practices identified under scheme need to be reactivated and consolidated nationally, with a view to overcome challenges.
Despite the dire recent national indices, which were not entirely unexpected given the stoppage of the original MSS and its replacement with an eponymous but less focused model, I remain encouraged to redouble my institutional efforts for maternal and child survival. I am encouraged by the fact that Kwara and Lagos States, where my Wellbeing Foundation Africa has achieved and maintains significant programmatic scale, are now consistently recorded as having the two lowest preventable mortality rates in Nigeria respectively, while Kaduna State and the FCT Abuja where we also work have shown significant improvements. These gains highlight the importance of the WBFA’s midwifery-led direct frontline action models which deliver our MamaCare Maternity Education, EmONC Healthworker Training, WASH for Wellbeing and Hygiene in Health Facilities, Child and Adolescent PSHE WASH In Schools, and Alive&Thrive Maternal Infant and Young Child Feeding and Nutrition programs. In tandem, we support strong accountability frameworks that can hold governments to account on their health commitments to drive a policy continuum of health for all.
Mindful of the fact that we have only ten years to accelerate actions towards our 2030 Sustainable Development Goals, the Wellbeing Foundation Africa is energised by the WHO and multi-lateral agencies’ commitments to pursuing stronger collaborations for better health. In addition, we commit to strengthening deliberate sexual and reproductive health and gender programming and women’s leadership, with the simple premise that stronger collaborations contribute to better health. This Global Action Plan for healthy lives and wellbeing for all, will promote, engage, accelerate, align and account for purposeful, systematic, transparent and accountable primary health care. It will create sustainable financing for health, community and civil society engagement, improve determinants of health, invest in innovative programming in fragile and vulnerable settings and for disease outbreak responses as well as research and development, innovation and access, data and digital health.
In promoting better leadership at global, regional and country levels, stronger collaboration is the path, but better health is the destination.
If the nation cares to ensure women can give birth safely to babies that survive from the cradle to age, we MUST strengthen frontline health care services, immunisations, nutrition and WASH – I hope that the community of best practice we have developed and implemented towards healthy lives and wellbeing for all, from birth to age may cascade its impact across my nation Nigeria, Africa, and the world.