Editor's note: Nigeria has the highest maternal death rate in the world second only to India in fatality rate according to the 2015 World Health Organisation report.
In this report, Olajide Adelana examines the depressing statistics of maternal deaths, the role of traditional birth attendants and how failure of National Primary Health Care Development Agency fuel maternal deaths in Nigeria.
Yetunde Yinusa was set for the day’s work when she noticed blood flowing uncontrollably from her thighs. She dashed to somewhere hidden and checked herself but still couldn’t figure out what was wrong.
Several minutes later, the blood flow hadn’t stopped. Yinusa’ pregnancy was almost 36 weeks old and she began to panic as thoughts of possible losing her child grew. She had to run to Olushade Adeitan who gave her local herbs to stabilize and stop the bleeding.
Adeitan, whose name has been changed to protect her privacy, is a Traditional Birth Attendant (TBA) whose popularity in Ibeshe, Lagos state, has been on the rise for over 10 years.
The story of Yinusa is one among several others in which she takes delight in telling people who care to listen. According to Adeitan, she is one of the few credible TBAs in Agaja Kekere in Ibeshe community dedicated to saving women from dying during their pre and post pregnancy stages.
“I gave her Abiwere and Idaje and watched her for a while. I then told her to go for a confirmatory test at a nearby clinic to show that my work is good. They told her it was Placenta Previa. This year alone, I have attended to and taken delivery of nothing less than 20 pregnant women,” Adeitan said as she rearranged the dusty shelf that houses her concoctions.
Ibeshe is an Island community with a Primary Health Centre (PHC) catering for thousands of residents from Ilase, Ibasa, Ibeshe-Beach, Imore, Igbo-Osun, Igbo-Eseyere, Okun-Ilashe, Ibeshe-Beach and other riverine communities within the axis.
In Nigeria, TBAs and herbalists serve as an invaluable bridge between rural communities and formal health system. According to a report by the Partnership for Transformation Health System II (PATHS2), 342 TBAs in Lagos helped birth 14,536 in 2015.
However, with limited training and supervision by government agencies, TBAs and herbalists have hounded orthodox medicine across Nigeria causing significant havoc to the health of mother and child.
But why would Yinusa prefer to seek help from a TBA rather than visit a health facility?
Farouk Jega is a prominent advocate of family planning in Northern Nigeria and also the Nigerian country director for Pathfinder International.
He believes that the two main reasons for the persistent high maternal mortality in Nigeria are poor health seeking behaviour of most Nigerians and the dysfunctional health system with poor emergency obstetric care capability.
“Hospital delivery with a skilled attendant in Nigeria is only about 30 percent. So women mainly deliver at home, thinking childbirth is essentially a ‘normal or natural’ phenomenon, and only come late to the hospital when complications occur, to meet a health system that is ill-equipped to take care of the emergency.”
Just as Jega observed, the Ibeshe PHC which is a 10 minute walk from Adeitan’s house has been reduced to a landmark as it has become under-equipped and under-staffed in the last 10 years, residents said. This was also corroborated by the only official at the facility who identified herself as Ms. Alabi.
“I have spent over 5 years at this PHC and had never taken delivery before. All we do here is treat small cases like malaria if we have the drug. We also give immunization,” she said.
Nigerians especially its religious faithful’s see childbirth as a thing of joy but for many women like Yinusa who live in rural and riverine areas, it is a gamble with death, a moment of pain and struggle with the unknown.
In Nigeria, one in every 13 pregnant women you encounter will not survive pregnancy and childbirth. It is estimated that Nigeria loses on a daily basis 2,300 children under the age of five and 145 women of child bearing age thus accounting for the second largest number of maternal and child deaths in the world.
Many of these deaths are due to complications which can be prevented if quality health care services were available and accessible to pregnant women.
To stem this death trend and other health related issues, the National Primary Health Care Development Agency (NPHCDA) was created in 1992 to perform oversight roles on PHC implementation at the state and local government levels and bring health care closer to the grassroots.
But years later, the story remains disheartening and recent ranking of Nigeria’s health system as 187th amongst 200 countries by World Health Organization is no small indication of the current detrimental state of the nation’s health sector, experts say.
Experts believe that the major problem with PHC implementation is chiefly political and constitutional. Nigeria operates a largely decentralized health system which merely requires the cooperation of state and local governments.
More importantly, the local governments are made to run primary health care since they are the closest to the people but are not obliged by law to be accountable to the federal government for monies spent.
Prof. Shima Gyoh, renowned surgeon and former Permanent Secretary of the Federal Ministry of Health, x-rayed the challenges in an email conversation.
“There is no clear policy articulation on who implements PHC. Although the Constitution does not state it, our National Health Policy and the nature of PHC suggests it should be implemented by Local Governments (LGs).
However, the LGs are presently the weakest tier of government, often undemocratically run and highly politicised. The fate of PHC is tied to that of LGs unless the country comes out with a decisive policy.
Sorting this out is a huge problem. Does the NPHCDA just disburse funds as provided for in the National Health Act, or does it take a more active part in PHC implementation?” he queried.
Missing and not found!
But then the issues Gyoh describes mean the door to effective PHC implementation is left open to misinterpretations and provides an avenue for corruption to thrive.
For instance, NPHCDA said the federal government awarded 89 contracts worth 2.6 billion naira for the construction of PHCs in 2014 but two years later when most of these contracts should have been concluded, they are yet to meaningfully contribute to improved access to healthcare in the communities where they are located, a 2016 report by Public and Private Development Centre (PPDC) on its procurement data monitoring website, Budeshi.ng says.
Nyanger Sember is the Executive Director of PPDC, a non-governmental organization focused on ensuring accountability and transparency in government processes.
Nyanger highlighted the findings of its procurement monitors at the presentation of its report on the performance of health related contracts.
“In some cases, PHCs were not constructed or untraceable against the data provided by NPHCDA. In the north central state of Benue, it was discovered that four out of the six PHC construction contracts awarded in 2014 were completed in 2015 but have remained non-functional till date.
"A similar trend was noticed in Abuja and Kano where PHCs are open but unable to provide any medical service due to lack of medical facilities or personnel.”
PPDC also discovered and alerted the authorities to a ₦21 million contract awarded to Barking Consults Limited in 2014 for the construction of a PHC in Burutu Local Government, Delta state to which no work was done by the contractor.
Efforts to get comments from NPHCDA were futile as at the time of filling this report. The Agency’s spokesperson, Mr. Salahu Saadu promised to get back to our correspondent on the issue but failed to do so.
Despite laudable initiatives, Nigeria is still sleeping at the wheels
Although Nigeria has launched commendable initiatives and made important policy pronouncements geared towards ensuring that issues of access and affordability to health care are properly addressed, but experts believe that these efforts would only culminate into appreciable success if government can summon the political courage to provide adequate funding, ensure accountability and transparency in the leadership and management of its health system.
Unless government fixes the “problem of poor funding and even improper management of health institutions” the full benefits of PHC implementation across the nation might come at a delayed pace, said Jega Farouk.
“What is needed is the political will to make the right commitments in terms of funding for the health system. Funding will take care of scaling up innovations, fixing infrastructure and human resource gaps, and improving demand for services.”
Gyoh, who is keen on seeing policy declarations translate into action and observable results in the country, posited that an increase in demand for services and wider PHC coverage and access can best be achieved by “keeping the level of user fees within the range of the income of members of the public”.
It is beyond funding and awarding contracts to build PHCs, says Seember Nyager in a phone call. She opined that the “award of health related contracts be based on the prevalent needs in a certain constituency”.
“Whenever the Federal Government is supporting states and local governments to provide primary health, it must speak to the most critical needs in that community; be it drug or whatever else. But building with no real integrated plan on how it would be maintained is a waste of resources.
“It would take much more than construction contracts to improve primary health care access. Primary health care access would require adequate planning, coordination across government tiers and sectors and a system that enables public accountability.”
But then Nigeria’s corruption rating isn’t admirable. According to Transparency International’s 2016 Corruption Perceptions Index (CPI), Nigeria is the 136 least corrupt nation out of 175 countries.
Seember believes that rigorous procurement monitoring could help solve this problem. She is of the opinion that the NPHCDA would continue to sleep at the wheels regardless of whatever initiatives, and funding it gets unless it embraces transparency by using Open Contracting data standards to make health related projects traceable, verifiable and drive accountability.
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“Furthermore, NPHCDA should provide its procurement data based on the Open Contracting data standards for several reasons; first, it enables us link contracts from their conception to the contract implementation and eventual service delivery outcome.
"That way, they can better measure value for money, know specific areas along the procurement value chain that require intervention, provide an incentive for contractors to compete and be innovative and offer the best.
“This enables anyone to look out for the service that have been provided and weigh it with the specifications of the contract. Beyond that, having standardized information enables us sifts through related problems that may not be procurement problems so that we can address those and make data driven decisions.”
Meanwhile, NAIJ.com had previously examined the depressing statistics of maternal deaths, the role of traditional birth attendants and how corruption and poor health care system fuel maternal deaths in Nigeria.
Watch what Nigerians say upon finding out that the budget for each citizen's health is N1,500: