Author: Xinyu Chen
Mentor: Dr. Allyn Taylor
Poor maternal and child health in Nigeria is a chronic issue. In 2022, Nigeria had a maternal mortality rate of 512 deaths per 100000 live births, among the highest in the world, accounting for over 34% of global maternal deaths (MATERNAL MORTALITY IN NIGERIA – THISDAYLIVE; Adejoro). In response, the government of Nigeria initiated the Maternal, Newborn, and Child Health Week (MNCHW), amongst other programs. This essay seeks to evaluate the strengths and limitations of the design and implementation of the Nigerian MNCHW and provide recommendations to strengthen the campaign.
I will first introduce the methodology used to write the paper. Then, I will provide background information regarding the Nigerian MNCHW, followed by an overview and analysis of the program’s outcomes. Finally, I will provide recommendations for strengthening the campaign. The analysis explains how the Nigerian MNCHW suffers from issues also faced by other public policies in Nigeria. Thus, the analysis and suggestions can also be used to strengthen overall public health programming in Nigeria.
II. Methodology: Literature Review
The primary methodology used is literature review. A range of sources, including secondary evaluations, journals, and news articles, were evaluated to gain a thorough understanding of the design and implementation of the MNCHW.
The primary sources used are the evaluative reports by the Nigeria Country Office of UNICEF, the Center for Maternal and Newborn Health of the Liverpool School of Tropical Medicine, and the OR Researcher Team (Dr. E Ferguson, Dr. J Webster, Dr. C Yohanna-Dzingina, Prof. I Akinyele and Dr. O Adeyemi). These reports present quantitative and qualitative data gathered from different states of Nigeria, allowing for insights into the design and implementation of the MNCHW from the data they offer and their conclusions. Both the UNICEF and LSTM reports evaluate the Nigerian MNCHW’s impact on the implemented interventions through Contribution Analysis, which helps managers, researchers, and policymakers determine the Nigerian MNCHW’s impact on Nigeria’s maternal and child health status (Contribution Analysis | Better Evaluation).
Though the three evaluative reports are the most comprehensive sources, the evaluations’ time periods are dated, and the geographical scope is limited. The research and analysis of the MNCHW program could be enhanced by a deeper and more current literature pool. Further data collection and research are recommended for future studies on the Nigerian MNCHW.
Nigeria suffers from some of the highest maternal mortality rates in the world. The leading causes of maternal deaths include infection, obstructed labor, unsafe abortion, and malaria, mainly caused by the lack of access to knowledge about pregnancy complications and health services (National Population Commission).
In response to the acute maternal and child health issues plaguing Nigeria and the health objectives of the Sustainable Development Goals, the National Primary Health Care Development Agency (NPHCDA), along with the State Primary Health Care Development Agency (SPHCDA) and the State Ministries of Health initiated various programs, including the MNCHW in Nigeria in 2009 (Securing Greater Funding for Nutrition, Maternal Newborn and Child Healthcare Interventions in Nigeria – THISDAYLIVE). At the time, Nigeria had a high maternal mortality rate of 1099 per 100000 live births and an infant mortality rate of 89 per 1000 live births (“World Bank Open Data”; Nigeria Infant Mortality Rate 1950-2023).
The MNCHW started as Child Health Days (CHD), initiated by the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) in 1999. It was implemented in other countries such as Ethiopia and Sierra Leone (UNICEF Nigeria Country Office).
In Nigeria, the NPHCDA aimed to significantly increase the coverage of existing interventions to improve maternal and child health through implementing the MNCHW (Maternal, Newborn and Child Health Week (MNCHW) | Interventions | Maternal Figures – Nigeria’s Maternal Health in Focus). The beneficiaries of the Nigerian MNCHW include mothers and children aged 0 to 59 months from all states of Nigeria. The Week occurs twice a year and aims to reduce maternal and child mortality and improve maternal and child health by providing a comprehensive set of interventions (The OR Researcher Team).
The NPHCDA recommended 19 sets of interventions. However, the state governments have the authority to modify the interventions to fit local needs. Examples of interventions for pregnant women include ante-natal care, tetanus toxoid, and HIV Counselling and Testing (HCT). Nursing women received counseling regarding family planning and Prevention of Mother-to-Child Transmission. Interventions such as newborn care, immunization, and Long Lasting Insecticidal Treated Nets are provided to children aged 0-5 months. Children 6-59 years old received Vitamin A supplementation, deworming, nutrition screening, etc. (UNICEF Nigeria Country Office). In addition, the week educated women on family planning, sanitation, and feeding.
The constitutional structure, and in particular the authority of the federal and state governments of Nigeria, is central to understanding the organization and implementation of nationwide public health programs, including the MNCHW. Nigeria’s federal system consists of the federal government, 36 states, and one territory (The Federal Capital Territory). In turn, the states and the Federal Capital Territory comprise 774 Local Government Areas. The federal system is highly decentralized, and the Nigerian Constitution doesn’t specify the functions and responsibilities of each tier of government in public health services. Though the National Health Policy prescribes primary health (PHC) care under the control of local governments, other levels of government are also involved in the management of PHC, resulting in poor coordination and the lack of a clearly defined accountability framework (Eboreime et al.).
Compounding the challenges of implementing public health policies in Nigeria’s federal system, the Nigerian MNCHW also has a complex and unclearly defined management system with duplicated roles and responsibilities for different levels of government. As the dictated leaders of the implementation of the Nigerian MNCHW, the NPHCDA is primarily responsible for national planning and coordination of the MNCHW, with the Federal Ministry of Health providing assistance. However, the State Ministries of Health (SMOH) and State Primary Health Care Development Agencies (SPHCDA) have significant authority in the implementation at the state and local levels. For example, though the NPHCDA sets the implementation dates, the states have the power to adjust the dates. The state ministries and agencies are also responsible for funding the procurement of commodities and training healthcare workers. UNICEF and other international organizations, including Save the Children, Vitamin Angels, Helen Keller International, and Micronutrient Initiative, are also involved in the implementation system. They mainly provide material supplies and technical support. However, some organizations are also involved in the responsibilities of the national and state government. As a result, some functions, such as training of health workers, social mobilization, and monitoring, are shared among different tiers of government and international and non-governmental organizations. For example, the Federal Ministry of Health, NPHCDA, SPHCDA, and Helen Keller International are all involved in training healthcare providers.
IV. Outcome of the Nigerian MNCHW
While the Nigerian MNCHW has made some impact, it needs to be strengthened to become more effective. Evaluative studies evidence that from 2010 to 2015, the Nigerian MNCHW partly achieved two expected outcomes. First, it made a substantial contribution to the improved coverage of Vitamin A supplementation, deworming, insecticide-treated bed nets, and measles vaccine, according to Palmer et al. (UNICEF Nigeria Country Office). Another significant expected outcome of the MNCHW is that its health education led to changes in the recipients’ behaviors and an increase in the utilization of family planning. During Focus Group Discussions, participants of the MNCHW reflected that the program boosted their awareness of the importance of health issues and that the services provided were helpful (Liverpool School of Tropical Medicine).
However, the Nigerian MNCHW has yet to significantly contribute to the increase in coverage of all maternal and child health interventions. According to a study on the 2012 MNCHW, at Rivers State, out of the 15 interventions investigated, only the coverage rate of Vitamin A supplementation reached 43.41%; the coverage rates of the remaining ones were all below 20% (Ordinioha). Moreover, the UNICEF evaluative report acknowledges insufficient proof that the MNCHW has improved the overall health outcomes for mothers, newborns, and kids in Nigeria.
As a general matter, it is well-established that implementing public policy programs in Nigeria is fundamentally challenging due to the lack of government commitment, human and material resources shortages, and ineffective collaboration between health ministries (Nigeria). According to Atakpa et al., public policy implementation in Nigeria has the following problems (Atakpa et al.):
- Ineffective administration,
- Lack of coordination and communication,
- Disconnection between policymakers and beneficiaries,
- Over-reliance on international institutions,
- Bureaucracy, and
As described below, the Nigerian MNCHW also suffered some of the problems widely recognized in public policy programs in Nigeria.
A. Ineffective administration
Ineffective administration is the major cause of the poor implementation of the Nigerian MNCHW at the state and local levels. First and foremost, implementation was not well supported by the local governments. In Rivers State, for example, the implementation committees complained about the lack of support from the Local Government Councils (Ordinioha). The lack of political will depleted the commitment of the health workers. Secondly, the administrative ministries failed to recruit enough healthcare providers with sufficient health knowledge, which directly worsened the quality of health services and education provided by the campaign. For example, the desired percentage of healthcare providers with adequate knowledge of normal labor and delivery care in urban regions of Osun State is 60%, but the actual percentage is only 9.5% (Performance Needs Assessment of Maternal and Newborn Health Service Delivery in Urban and Rural Areas of Osun State, South-West, Nigeria).
Ineffective administration also plagued action at the federal level. The poor administration led to flawed fund delivery, causing some states not to receive sufficient budgeted funding. Funds received by the implementation committee in Rivers State were only 10% of the budgeted amount and arrived late (Ordinioha). Insufficient funding led to the poor social mobilization of the campaign in Rivers State as the committees couldn’t fund promotions through posters and flyers (Ordinioha). As a further example, in Benue State, only 40% of the surveyed facilities had an associated town announcer to promote the campaign (Korenromp et al.).
B. Lack of coordination and communication
Another public policy problem common in Nigeria that the MNCHW experienced was the lack of coordination and communication in program implementation.
First, there was a lack of coordination among health workers at the health centers. For example, health centers in Rivers State were not uniformly staffed with health workers, so there were also local nurses and doctors in the health centers. However, the leaders of the healthcare centers had no authority over the nurses and doctors. As a result, they didn’t work together well, which led to less desirable implementation quality (Ordinioha).
Poor coordination and communication also led to shortages of commodities and health service equipment in some states. Equipment and material supplies were not consistently available in all states due to the mixed delivery of supplies from national and state levels and the delayed delivery of commodities (UNICEF Nigeria Country Office). In Rivers State, for example, most commodities were unavailable or insufficient (Ordinioha). In the urban regions of Osun State, only 42.9% of health facilities had essential drugs and consumables (Performance Needs Assessment of Maternal and Newborn Health Service Delivery in Urban and Rural Areas of Osun State, South-West, Nigeria). In Benue State, most facilities had no or insufficient behavioral change communication materials, and activities were delayed due to the late delivery of materials (Korenromp et al.). Since most beneficiaries had to travel long distances to the health facilities, some of them quit attending the MNCHW after being sent back due to commodity shortages. Commodity shortages and delayed activities disappointed the beneficiaries and led to low participation, depleting the effectiveness of the program, including the trust of beneficiaries in the government’s program.
C. Disconnection between policymakers and beneficiaries
The Nigerian government’s top-down operation alienates the people from policy design and implementation (Atakpa et al.). Most community leaders are not involved in decision-making, only receiving executing instructions. Consequently, the policymakers were unable to address various challenges, including, most notably, the barriers to women’s attendance and participation in the MNCHW, which led to low participation in most states. Due to the lack of evidence and the limitation of research data, it is unclear how widely spread this problem is. However, it is known that this issue is acute in the Muslim communities, which constitute a significant proportion of Nigerian society. According to available data, only 27.8% of the respondents to the LSTM’s survey attended the MNCHW in 2015 (Liverpool School of Tropical Medicine). Lack of support from spouses (permission, money, transportation, encouragement), mistrust regarding free government services, worries about the wife mingling with other men, or religious convictions was among the causes of non-attendance (The OR Researcher Team). Travel distance, supply shortages, and negative experiences at healthcare institutions also hindered attendance (The OR Researcher Team).
The ineffective social mobilization led to a lack of awareness of the campaign among beneficiaries. On the state level, only 28.57% of participants in the interviews conducted by the Department of Community Medicine of the University of Port Harcourt Teaching Hospital at Rivers State in 2012 were aware of the campaign (Ordinioha). Amongst 5389 households interviewed by the LSTM research team, over half of them were not aware of the existence of the MNCHW, and only 12% of mothers in Jigawa and Zamfara States were aware of the campaign, suggesting that the MNCHW lacked overall awareness amongst Nigerians and awareness among the target population (Liverpool School of Tropical Medicine; The OR Researcher Team). The ineffective promotion is attributed to the lack of funding, which is caused by the poor administration at the federal level, demonstrating that Nigeria has compounding policy failures.
D. Other challenges
Apart from the above problems, the implementation of the Nigerian MNCHW was also affected by external factors. Service delivery was interrupted by heavy rains, and attacks by local militia occurred during the implementation of the campaign in Benue State (Ordinioha; Korenromp et al.). Heath facilities were vandalized, and three local government areas were burnt down (Korenromp et al.).
The Nigerian MNCHW could have avoided heavy rains by scheduling the MNCHW during the dry seasons. However, the militia attacks were hard to predict and avert. The unstable political situation in Nigeria and other low-income countries challenges the implementation of public health programs.
It is widely recognized that good governance requires equity, transparency, participation, responsiveness, accountability, and the rule of law. These aspects are crucial for human development and implementing effective public health programs since ineffective institutions usually result in the greatest harm to those who are poor and vulnerable.
This paper is going to focus exclusively on accountability in governance and how, in particular, boosting accountability could strengthen the Nigerian MNCHW. This paper has shown how accountability is crucial. The MNCHW’s unclear accountability mechanisms have caused ineffective administration and poor coordination. Additionally, the sheer lack of data produced in this program has hindered effective evaluation. The NPHCDA should create an accountability framework in collaboration with state governments and stakeholders at both the central and state levels to enhance coordination and track advancement. This framework will make effective oversight of inputs, actions, and outcomes possible, which will help to improve implementation quality and enhance the public’s trust in the government (Kisiangani et al.). Suggestions for increasing financial, performance, and political accountability are provided below.
A. Financial accountability
Financial accountability pertains to the tracking and reporting of the allocation and utilization of financial resources (Accountability and Health Systems: Toward Conceptual Clarity and Policy Relevance | Health Policy and Planning | Oxford Academic). The Nigerian MNCHW has weak financial accountability as it doesn’t even have a comprehensive budgeting process and effective tracking system (UNICEF Nigeria Country Office).
To enhance financial accountability, the establishment of a transparent funding framework that records and allows efficient tracking of the allocation and utilization of funding is crucial. In addition, hearings and investigations on spending should be frequently held to bolster and monitor the following of the financial accountability framework.
The policymakers could also reach out to other partners, such as NGOs and funding agencies, to expand funding and resources. However, the NPHSDA should strictly regulate and constrain the supporting bodies’ political involvement in the program to avoid the risk of chaotic and sluggish administration.
B. Performance accountability
Performance accountability concerns whether the services and outputs of public health agencies and programs meet the agreed-upon expectations (Accountability and Health Systems: Toward Conceptual Clarity and Policy Relevance | Health Policy and Planning | Oxford Academic). The Nigerian MNCHW could better fulfill the expectations and needs of the beneficiaries by enhancing performance accountability in the following two ways.
First, the campaign should be community-based. Each community should have at least one health facility to provide the MNCHW services, and the leading health workers should communicate with the community leaders to learn each community’s specific needs and social norms and adjust ways to provide the services accordingly. This strategy enhances performance accountability by better understanding and meeting the beneficiaries’ needs and increasing the people’s participation in decision-making. Increased performance accountability enhances people’s trust in the governmental public health program and thus could boost participation. Community-based service could also increase participation by reducing the travel distance to the health centers, which is one of the barriers to attendance to the MNCHW.
Second, the NPHCDA and State Primary Health Care Development Agencies (SPHCDA) should design context-specific MNCH weeks. The maternal and child health status and coverages of different interventions vary across different states in Nigeria. Based on a state’s specific situation, interventions that best address that state’s maternal and child health issues should be implemented intensively. Moreover, extra interventions and outreach programs should be used in addition to the core set of interventions that can be conducted consistently (National Population Commission). This strategy increases performance accountability by utilizing the resources more effectively and better meeting the needs of the people. The Kaduna State Case Study supports the suggestion as it is a successful case, and the State focused on interventions with low coverage rather than all 17 interventions (Liverpool School of Tropical Medicine).
C. Political accountability
Political accountability refers to the government fulfilling the public trust, representing the public’s interests, and responding to societal needs and concerns (Accountability and Health Systems: Toward Conceptual Clarity and Policy Relevance | Health Policy and Planning | Oxford Academic). Thus, improving the political accountability of the Nigerian MNCHW could enhance the public’s trust and thus increase participation.
To respond and fulfill public trust, the NPHCDA should accurately introduce the MNCHW interventions and explain their related health benefits through social mobilization channels to all the beneficiaries and their relatives (The OR Researcher Team). This strategy encourages participation and thus also boosts the coverage of maternal and child health interventions.
The government should also regularly update the implementation status of the program to continually promote the campaign and prove to the Nigerian people that the government is making actual improvements.
The previously mentioned suggestion of allowing community leaders to get involved in the planning and implementation of the MNCHW at the local level could also increase political accountability. Engaging the community leaders in decision-making ensures that the implementation of the campaign conforms to each community’s values and cultures. The beneficiaries would be more willing to accept the services provided when their values are respected.
The MNCHW was initiated by the NPHCDA in Nigeria in response to the Sustainable Development Goals and the acute maternal and child health issues in Nigeria.
Evaluation of the Nigerian MNCHW is hindered by the lack of a wide range of current data. Access to a pool of robust and current data regarding the implementation of the MNCHW at all states of Nigeria enables researchers to produce more accurate, comprehensive, and steadfast evaluations. The Nigerian government needs to undertake an effective and continuous monitoring mechanism to boost the data pool.
Available data shows that the MNCHW has made some impact but is considered inadequate overall due to the lack of awareness and participation, limited contribution to the increase in maternal and child health intervention coverage, and poor quality of services provided. The main causes of the undesirable outcomes of the Nigerian MNCHW are issues common in the implementation of public policy in Nigeria, including ineffective administration, poor coordination and communication, and disconnection between policymakers and beneficiaries. These issues are attributed to the absence of a clearly defined accountability framework.
Governance of the Nigerian MNCHW could be improved from various aspects. This paper mainly recommends that the NPHCDA improve the Nigerian MNCHW design and implementation by establishing an accountability framework and enhancing financial, performance, and political accountability accordingly.
Overall, the accountability framework could potentially strengthen not only the MNCHW, but also other health policy programs in Nigeria as they face similar challenges. Ineffective public policy programs is a tragic issue in Nigeria. Problems of the system undermine the ability of the government to deliver crucial services to the most vulnerable. Strengthening data collection, accountability and other dimensions of policy development and implementation could have a profound impact of delivering crucial services to the most vulnerable populations.
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