By Chioma Blessing Kanu
As part of the efforts to achieve greater government and medical service provider accountability for maternal health in Nigeria, MacArthur Foundation’s Population and Reproductive Health area made grants in 2013 in multiple aspects of maternal health accountability to seven Nigerian civil society organizations working at Federal, State, and local government levels including Civil Society Legislative Advocacy Centre (CISLAC).
Recently, the Foundation presented to relevant stakeholders, report from series of evaluative activities across 13 States over the next three years to assess the extent to which the portfolio of grants is achieving results through the established four accountability strategies—policy advocacy, budget analysis, maternal death reviews, and legal strategies.
Accessing the passion of civil society organisations for maternal and reproductive health across seven States, the report holds that CSO respondents cited passion for, and commitment to, maternal and reproductive health, and reducing maternal mortality as the enabling factor.
According to the report, competition and funding were most cited by respondents as hindering effective collaboration on maternal health, fueled by funding and suspicion. “The competition was attributed to several factors including too many CSOs with preference to work independently, lack of synergy between old and new CSOs. Some remarked that the lack of trust or unity was driven by disparate and fragmented values, and organizational specialization in maternal and reproductive health areas,” it lamented.
In Kaduna State, the study identifies the existence of networks and partnerships in response to the question on how CSOs are collaborating and coordinating around maternal health accountability. This includes improved collaboration between maternal and child health CSOs to form the Maternal Child Health Partnership. The Partnership involves in the Medium Term Sector Strategy processes to ensure that the government continues to fund maternal and child health, with special attention to budget allocation.
Similarly, the report described the partnership in Enugu State as a pressure group to ensure the government provides free maternal and child health services, and reduce maternal and infant mortality rates by focusing on three advocacy channels—interest in maternal and child health, health project bodies and medical associations, and representatives of the Ministry of Health. The partnership includes a free maternal and child health steering committee (policy support, broad oversight) and free maternal and child health implementation committee (operational issues) with high level and influential subjects in government to help steer the program and ensure political will is retained, and attracted to the program.
In Bauchi State, the study reveals the role of Bauchi State Network of Civil Societies as a common platform for CSOs working to get a Maternal and Child Health Bill passed. They mobilizes human and material resource to strengthen the health care system, advocacy, capacity building, and government commitment.
On the formation and functioning of Maternal Death Review (MDR) committees by government commitment to reducing maternal deaths, the report discloses that Lagos State government’s commitment to reduce the number of maternal deaths, and create budgetary allocations for MDRs has supported MDR committee formation and functioning including training and capacity building capacity to carry out successful MDRs, including proper use of the forms. However, MDR committee members in the State lamented lack of clarification in some MDR directives, leading to confusion; as the committee’s recommendations are not being implemented because government and facilities are unsure of how to implement them.
Across the nine States, while the study bemoans infrequent media coverage of maternal health, programs and reports that do occur are primarily driven by international organizations or projects. Although health stories may be as frequent as weekly, the report noted that maternal health is often overshadowed by other diseases such as HIV and polio. Maternal health stories are viewed as mostly limited to specific times of the year, such as during United Nations-specific maternal health days.
Media reports were seen to focus on lack of government commitment to fund maternal health, and the role that instability plays in limiting access to services. In Bauchi, Enugu, Jigawa, Kano, and Lagos States, the study questions the general low quality of media coverage on maternal health, and the majority inaccurate and distorted reports by most media. Enablers of effective maternal health coverage were seen as a passion for reporting on maternal health, availability of accurate information, a supportive media house, the Freedom of Information Act, and collaboration with others.
The study states that Federal allocations for health and maternal health line items have declined over the last 3 years, and increased budget allocations to maternal health need prioritization. It notes the delay associating with release of funds allocated, which are sometimes less than the sum allocated; and specifically highlights the overall reduction in allocation for implementing the Integrated Maternal Newborn and Child strategy between 2012 and 2014. “In 2012, 100% of the funds allocated were spent, yet expenditures reduced by almost half in 2013. 2014 allocations are less than half the 2012 allocations. For instance, since 2012, allocations to the National Obstetric Fistula Center, Abakaliki have reduced, and 2012 and 2013 expenditures are approximately half of the allocations. 2012 and 2013 data show Nursing and Midwifery Council expenditures below allocations.
“In 2013, various line item expenditures focused on nursing and midwifery services, such as support for midwifery training schools. A review of 2014 allocations indicated reduced support to these services at the Federal level, and in Bayelsa, Eboyi, Enugu, and Yobe States. Some of these reductions might be appropriate. For example, in Enugu State expenditures were to construct training schools so the zero allocation in 2014 could be because construction was completed.
Similarly, the report divulges inadequate budgetary allocation to maternal health as evident in FCT, Enugu, Gombe, Kano, and Niger States. Reasons cited include lack of commitment by leaders to devote resources to maternal health, and a lack of revenue to accommodate need.
On maternal health litigation related cases, in Enugu, Kaduna, and Lagos States poor awareness of women’s right to seek redress in court for grievances, and fear of victimization resulting from pursuing legal redress for maternal health-related cases, fear of families being the subject of gossip, and the prevailing perception that women should not air grievances in public were observed. These are connected with lack of confidence in authorities to pursue the matter, and medical staff’s reluctance to appear in court because they do not want to give evidence against a colleague or be the cause of potential financial implications a successful case might have on the facility.
Indications from Bauchi, Enugu, Kaduna, Kano, and Lagos States pointed out the need to prioritize implementation of existing State and Federal maternal health policies, and better government coordination to move from paper to actual implementation, stressing the importance of signing various governments’ pronouncements or verbal policies into law.
The report emphasizes the need for CSOs collaboration to minimize duplication and increase joint advocacy for maternal health that will, in turn, strengthen demands for government accountability and quality maternal health services. It opines that for MDRs to be effective, perceptions of accountability need to change, and should move away from blame-placing towards an emphasis on making a difference and contributing to results, including anonymity in conducting MDRs at the local level, where it may be hard to maintain.
It recommends that journalists, lawyers, and government officials as key boundary partners in the portfolio theory of change, must be able to draw on accurate and timely information for meaningful reporting, litigation, and policy development, improvement, and implementation. “Meaningful information on maternal health involves accurate data, awareness that the data exists, access to the data, and requisite skills to use the data,” it urged.
The report further sees the need for monitoring of government expenditures—budget tracking and analysis involves monitoring against actual Federal, State, and local government expenditures for evidence based advocacy to improve budget performance for maternal health policy and program implementation.