The inaugural Summit on Accountability for Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) organised by the Federal Ministry of Health and co-sponsored by Champions for Change and other partners has come and gone but the echoes from the summit would reverberate for a long time.
A key outcome of the Summit which has as its theme: Accountability Now’, Advancing RMNCAH in Nigeria’, was a call by participants on governments at all levels to declare maternal and neonatal deaths a national priority emergency and as such design an emergency action plan to address them.
Government was also advised to immediately ensure the full implementation of the National Health Act and the Violence against Persons Proibition Act (VAPP) and include budget lines in the 2016 budget for the Health Act while all states are to domesticate the VAPP Act.
One of the key players at the Summit is the Chair of the Country’s Maternal, Newborn and Adolescent Reproductive Health Accountability Mechanism, Committee responsible for ensuring the dividends of reproductive healthcare reaches the last mile and users, Dr Ejike Oji also, former Country Director, Ipas Nigeria.
Oji in an interview session with some journalists shortly after the Summit was declared closed explained why the Summit has to hold, why it was different from previous meetings on Reproductive Healthcare and on how best to make use of the outcome of the RMNCAH Summit to ensure mothers and children get the best care.
Why Summit on RMNCAH was different:
So far, this last Summit holds a different concept in that Accountability was its key focus. We have had some other RH meeting in the past but its communique was never implemented.
This particular edition is focussing on ‘Accountability’ as its mainstay and if you look at the major sub-themes, one is to get everybody who is working on this field to come together as a team; the second one is looking at how else can we do what we are doing if not, let us have an agenda on how we are going to do things and the other one is to share best practices that have been seen across the nation-that is why two to three states have come to share their best practice and finally, to see how we do things to lead to the new Sustainable Development Goals (SDGs). We are done with the Millennium Development Goals which ended in 2015 and the new SDGs which is about seventeen is what everybody is focussing on and this summit is also linked to it.
But like I said, what is new is that we are now bringing in Accountability to the table and why I am so involved in it is that I happened to be the Chair of Maternal, Newborn and Adolescent Reproductive Health Accountability Mechanism (of the country) which is part of a world accountability mechanism that is put in place and have mandated each country government to go and develop national accountability mechanism.
Whatever that happens at this conference, our group or committee would now take it to scale. The Group is a coalition of local Non-Governmental Organisations (NGOs) and International Partners.
We have already started in terms of the accountability mechanisms in that we have begun to ask: how do we start if we want services to get to the women and children?
The first thing is how do we slice the money that we have? Have we prioritised, making sure the people that are supposed to intervene on their behalf have the resources to do the work?
Like the presentation I made before the Senate recently, I reminded them that all countries came together in 2001 to make the Abuja declaration that 15% of the National Budget would go to health, but that has never happened. The highest we have actually got was 9% and that was during the Late President Yar’adua era and it has been coming down gradually to what we now have, 4.2%.
Even though the aggregate amount of our national budget has increased by almost two Trillion in this fiscal year, the amount that went to the healthcare sector is still lower than what we got in 2015 and that is where the Accountability comes in. There must be a philosophy guiding how we use our resources.
We must make sure we direct our resources to priority areas and health happens to be one of the key priority areas in life. It is only a healthy person that can work and it is only a healthy nation that can grow.
Now this summit is about Maternal and Child health, when we go down to the Reproductive health line item in the Ministry of Health, you won’t see the appropriate allocation.
Now, one of the reasons why we went before the Senate was because the Midwifery Service Scheme (MSS) which was on stream a few years ago actually reduced Maternal Mortality Ratio (MMR) by more than 40%. As at the time that was conceptualised, we suggested that an average of N5bn should be spent for five years to follow the Marshal plan after the 2nd World War; to enable us reduce MMR to single digit rate. Within the five years, we would have looked for sustainable mechanisms to fund Reproductive Healthcare and the important thing is that there would be evidence that it can be done.
But sadly or unfortunately, we only spent about a billion Naira ever year and the one that really got to us is that in this fiscal year, in the 2016 budget, there was no money allocated to the MSS and no money was also allocated to Family Planning too.
During President Jonathan Administration, we were able to get $3m to be put into counterpart funding for commodities. It is sad that all these years those who have been paying for our commodities are international partners and multilaterals.
So, the $3m was supposed to be the starting point and we were to graduate from there to ease the foreign donors, then take over from there as our responsibilities.
At the London Family Planning 2020 conference, our government made an additional pledge of $8.3m to go into Reproductive Health commodities because the real cost of Family Planning Commodities in Nigeria is about $21m. You can see its largely Donor driven.
What we were supposed to be spending annually therefore would have amounted to $11.3m on Family Planning and reproductive health commodities but sadly, in 2016, nothing was allocated to Family Planning till we protested and we believe some allocation is now being made likewise to the midwifery service scheme. We do want to pre-empt how much till the budget is out.
Who should responsibly be held accountable and by whom?
As an aside, in this fiscal year, the Federal Government through the Federal Ministry of Health has said it would revamp about 10, 000 PHCs existing and this is very commendable, we’ve been pushing for that.
We also do know that the Health Act, up till now, we do not know where the money is that is the one percent of our consolidated National Revenue. The Act sliced into two, fifty percent of that money is supposed to go to PHC and further sliced, about fifteen percent is to go to medicament another fifteen percent to training and re-training of healthcare workers at that level and we are talking of Midwives, Nurses, CHEWS and in some cases in some states, we have doctors at that level too.
We do believe that Health Act, if the money is properly provided for, would be used to intervene at that level of care-the Primary level.
However, what we have seen over the years, is that if we compare what the Federal Government is doing to what the States are doing or the local government, the Federal Government is a Saint. It has shown a lot of leadership in that regard even though we are saying they are not doing enough. The States and Local Governments are not doing much.
For example, in the Midwifery Service scheme, N75, 000 was proposed as the salary to be paid to the midwives. The FG says, it can’t pay more than N30, 000; so they signed an MOU with the States and Local Governments for the States to pay N25, 000 and the Local Government to pay N20, 000.
The MSS survived so far because the FG consistently and regularly paid their N30, 000 while only two or three states were able to pay their counterpart; fo the LG, almost all were not able to do anything except a few which tried to pay as much as N10, 000 and then stopped paying.
When you go to the States, you will see some secondary health facilities are non-functional. In some states if there are say ten r twenty, maybe only two or three are functional. The way the facilities are shared, the FG is supposed to take care of the tertiary care, research institutes while the states are in charge of the secondary facilities and the LG are for the PHC, but what we have is the FG still supporting the local government by putting infrastructure and equipment in PHCs. The LGs are actually doing nothing. If we look at this fact and find the SG and LG doing their bits, we would not have the problems that we do have right now.
People say Nigerians are trooping abroad, those trooping abroad are not those supposed to go to the Primary and State Hospitals. They are those supposed to be taken care of by the Tertiary level of medical system in the country. The reason why they go abroad is that their problems have been seen not to be handled by the Primary or Secondary levels and when they go to the Tertiary, this level has been so abused that they are no longer centres of excellence or supernumerary or centres of research. They cannot be that way because they are inundated with patients who have no business coming there in the first place.
The sheer numbers of the patients at this level of care makes it impossible for the hospitals impossible to give the specialised care they are supposed to give. That is the distortion.
This summit is just trying to re-focus attention on the priorities. If you say we are releasing just 4.2%, we want to follow the money. That is why the media, the Journalist is key here. The media has the power to enter any cranny or crevices in this country to seek information. By the profession, nobody can say, why are you here?
This Accountability we are talking about is about follow up, let’s make sure the money is released which we’ve been doing but then, if it is released, let’s make sure it get to the last mile and that last mile is when our women and children get the services that they deserve.
Doing Things Differently:
First and foremost, we all must have to believe this is our country and we have no other place to go and we all must be nation builders whether in government, civil society or as ordinary citizen. If we all are in agreement that this is our country that is a commonality of purpose. That would be a re-orientation. The reason for a re-orientation is that as a member of the Assembly before slicing the budget would have touched base with his Constituency and knows their needs and would be empathetic to the issues that concerns the constituency and when all are gathered, one can easily see the commonality of needs- women are dying everywhere. And that tells the Representative he needs to look for money to put in that area and the civil servants would feel the need to monitor what is on ground and do supportive supervision rather than culture of impunity or tyranny of the few and absolute lack of civility and respect for fellow Nigerians.
When it comes to the budgeting process, because it is all about resource, the executive arm of government needs to involve the people- these are the representatives in CSOs and the Media. The Executive need to invite them to make input in terms of community dialogue and the Senate has assured that in 2017, it would open up the space for such interactive dialogue.
The FG should also open the space for the CSOs to get into the MDAs as ways to make things get better. If the Federal Ministry of Health had involved the CSOs in the MSS for example, the issue of it not been funded wouldn’t have happened in the first place.
Areas we haven’t done so well:
One of such areas is funding. We haven’t adequately funded Family Planning. Secondly, we have not allocated enough to the people who would make the change to happen. Finally, we have also not released the money where allocated, timely.
In 2012, only $1m was released, in 2013, about $2m was released, in 2014, there is assurance anything was released and so there are deficits even in the small
money the government has agreed to release, it wasn’t completely released.
And then, one of the biggest problems we have also is logistics. The FG is paying for the commodities but the states are supposed to provide money for logistics and consumables, this is never done.
When the federal government provides the commodities, the logistics to move from the federal warehouse t the state and to individual hospitals is supposed to be provided by the state, but it’s always a problem. Then at the service delivery level, no money is budgeted for consumables and supplies.
For example if it is commodity like the condom, there isn’t much problem because this is just handed over to the consumer and its done. But if it is an injectable, you’ll need syringe, self-sterile pouch, spirit and sterile gloves as consumables to make sure the commodity gets to the woman who needs it.
Now the implication is that the commodity might just be sitting in the warehouse or even in the store of the hospital and is not getting to the woman-that is what is called the last mile.
And in some places, some midwives in their wisdom have decided to start a small trade within the hospital where they raise money to buy the consumables and when the women come make them pay a token to get the services. Some of us in the civil society would frown at such and call it corruption.
Implications on mothers, children and adolescents
The implication is that these commodities are not getting to the women and that means they do not have it. What this means is that, the family planning services they deserve, they do not get and so are now unable to manage their fertility.
Now if you look at the reasons why women die in Nigeria or elsewhere, there are five main reasons: haemorrhage, unsafe abortion, obstructed labour, eclampsia and infection.
Now let’s take unsafe abortion; for you to have unsafe abortion means you have an unintended pregnancy that led to an unwanted pregnancy and when you have an unwanted pregnancy, you either have a safe abortion or unsafe abortion, an unsafe procedure which later leads to all sorts of complications.
Meanwhile, if there was adequate family planning services, the woman or girl can only get pregnant when she wants to keep the baby.
Let’s look at why women die from all of these reasons I mentioned. If any girl starts becoming pregnant before age of 18, the chances of dying from that pregnancy ids very high because the reproductive system of the body ae not well developed. She could develop obstructed labour leading to fistula and young prima also have high degree of developing eclampsia.
If you move from that to the number of children women have, too frequently less than two years apart, the woman is also at the risk of dying and the only thing that can make her space is family planning.
Now, when a woman already has four children and is going to the fifth one, the fifth can even be more dangerous than the other four put together. The only way she can stop herself from having that fifth baby is through family planning. The repeated assault on the uterus makes it dangerous.
Remember we are not talking about absolute here but a process and a mechanism. I think what we should be looking at is, what did we do to make people accountable in what they were supposed to do for the women and children of Nigeria and did we play our own part and if we played our part, did it have any impact?
The only way we can say we had impact is if we look at the baseline that we have now and in one year’s time ask, has there been any shift? And that shift, we need to interrogate why it happened because when you talk about research, it has to be evidence based. One cannot say because we had a meeting this year, next year if the contraceptive prevalence rate of women shoots up by ten percent you cannot link it to the meeting. We would need a better accountability mechanism for that as it could be result of other factors. So, it is an evidence based outcome that has to be properly done.
But for me, so far we can use process indicators by asking, how many times did the accountability and mechanism coalition meet? How many times did they sit and discuss issues of maternal and child health with the authorities that are responsible for it? How much monitoring has been done? Was money released? If it was released, was it used for the purpose meant for? Those are the kind of questions I’ll like when we come next year we would be asking.
By 2017, we’ll like to see a robust conversation before the budget is passed between the civil society and the National Assembly on one hand and between the civil society and the executive arm on the other. All these are the process indicators. The outcomes would be that if these things are put in place in two three years down the line.
That Nigeria has put money into family planning is just a process indicator of doing the right thing; the real outcome of the indicator would be seeing a rise in our contraceptive prevalence rate (CPR) that is, the number of women using modern method of family planning to space their children.
If you look at the Nigerian space, the CPR is 10% but the unmet need is very high at 16%. So, there is a disconnect somewhere and that 16% means these are the women who wants family planning by all means but are not getting it.