The midwives service scheme and private sector involvement

Nigeria is the largest country in Sub-Saharan Africa. It is home to 2% of the world’s population and 47% of West Africa’s. The UN further projects it to become the 3rd most populous nation in the world with more than 300 million people by 2050. Interestingly, by GDP, it has the largest economy in Africa at 510 billion dollars. These impressive socio-economic indicators have not translated into improved human development for its teeming population.

One area where this plays out is in its maternal, newborn and child mortality rates. While the estimates vary based on different data generation techniques employed in the field research, they all paint a grim scenario. While one report by the UNFPA states that 36,000 women and 250, 000 women die annually from largely unavoidable causes such as post-partum hemorrhage, infections, unsafe abortions and others, another by the RAND Corporation pegs it at 50, 000 women and 250, 000 children.  Of this, only 39% of women were attended to by skilled birth attendants. Unfortunately, this is within the context of a weak health system as Nigeria carries 10% of the global disease burden.

The RAND Corporation report goes further to state that these high rates of mortality have been attributed in part to low rates of use of maternal and child health services. This border on access to healthcare amply corroborated by a SURE-P blog which stated that regarding Ante Natal Care, 58% of women receive some antenatal care from a skilled provider, with 45%  recording four or more ante-natal care visits, but only 16% of women had had an ANC visit by the end of the fourth month, as recommended.

In other words, the root cause of the dismal figures is due to poor access to and uptake of known, successful interventions in both supply (low rate of skilled birth attendants) and demand (low presentation rates for 4 or more ante-natal visits).

As a result of the former reason i.e. low rate of skilled birth attendants, the Federal Government introduced the Midwives Service Scheme (MSS) in 2009 to stem the ugly situation. This was to be a public sector initiative to be implemented by the nation’s Primary Healthcare Development Agency (NPHCDA) at the rural and semi-urban areas. Being a public sector initiative, the three different tiers of government in Nigeria signed a memorandum of understanding with defined responsibilities and roles.

With the aim of facilitating an increase in the coverage of Skilled Birth Attendance (SBA), it sought to mobilize midwives, including newly qualified, unemployed, and retired midwives for onward deployment to selected primary health care facilities in rural communities. Based on a cluster model in which 4 primary health centres (PHCs) with the capacity to provide Basic Essential Obstetric Care (BEOC) are clustered around one General Hospital able to provide Comprehensive Essential Obstetric Care (CEOC), it has covered 163 clusters. This translates to 163 General Hospitals and 652 PHCs. In the process, about 7,000 midwives have successfully applied and had been deployed to primary care facilities nationwide. In addition, each midwife was armed with a mama kit for the discharge of their duties.

However, this beautiful idea is not free of its own challenges. For one, the memorandum of understanding that defines the roles and responsibilities of each tier of government is yet to be implemented. This is played out in the non-payment of salaries of midwives in the scheme and non-participation of states and local governments, especially in the payment of their part of the allowances. The latter is all the more devastating because the states were supposed to take ownership of the program two years after the program kick-off. As of now, that remains something to hope for.

It has also been bogged down with challenges related to the retention and recruitment of midwives as a result of poor welfare system and the attendant brain drain. This is exacerbated by the absence of an accommodation system and the absence of a friendly environment characterized by stable power and water supply that would aid the professionals in the discharge of their duties to the mothers.

The inability of the MSS to achieve its goal of improving maternal and child mortality should not be surprising to those familiar with every public sector-led development initiative in Nigeria. The best examples here are the National Development Plans.  While the nation has had many development templates notably the rolling Development Plans, none has been meticulously implemented for various reasons when in actual fact; other nations such as India have attained considerable development using the same methods.

One of the lessons to be learnt in tackling social problems, as the Avahan in India shows, is to apply private sector business and management principles into solving public health problems that seem intractable.

There were four principles at the core of the Avahan strategy. The first was clarity on what the purpose was and effective communication of this purpose to every partner or stakeholder involved in the program. The second was a consistent but flexible implementation of the program based on a periodic review. This was to ensure that the execution of the program at any given time was still in sync with the founding objectives. Third, is the use of data for decision making based on doubly-relevant market information questions such as the location of the target group (s), what quantity and quality of services they require, amongst others. The fourth is a willingness to admit mistakes and correct them. For instance, in the Avahan program, the managers of the program did not count it failure to go back to the drawing board with a grantee. Rather, it was harnessed for the overall success of the program.

What is at stake with the introduction of the Midwives Service Scheme (MSS) is the fate of 50,000 women and the 250,000 children that die every year as a result of a lack of skilled birth attendant. The private sector in health has been identified as a veritable partner in achieving a strong health system, and is the focus of some advocacy groups such as the Healthcare Federation of Nigeria (HFN). What this means, is that the power of the private sector in health can be galvanized to drive public health programs for improved health outcomes.

Billy Hamilton, a professor, at the University of Texas’ LBJ School of Government once said, “it doesn’t matter how sound the policy or how well-intentioned the program is. If an organization doesn’t pay close attention to management details – and how it will work on the ground – the result will be program failure. Successful programs need a little luck, but they need a lot of attention to management details”. As far as these management details are concerned, the private sector might well be the next place to look in the delivery of public health programs in Nigeria.

Opeyemi Ogunsola with wired reports