How do you get women in rural areas to discard harmful traditional maternal health practices and adopt the practice of going to health facilities for antenatal care and delivery? One approach is to give them the opportunity to understand the problems posed by the harmful practices and supporting them to come up with the solutions themselves. Using this type of approach has been shown to make it easier to break the cycle of poor health indices especially in the area of maternal, new born and child health (MNCH).
Preventable deaths of women and children continue to be a major challenge for many government agencies and partner organisations working in Nigeria’s health space. Various initiatives have been put in place to change the narrative and drastically reduce Nigeria’s contribution to the global burden of maternal mortality, which currently stands at nearly 20%. Some of the interventions applied include: training and commissioning community mobilisers to lead immunisation efforts in conflict zones to reduce the number of children dying from vaccine preventable diseases and; providing tuition free midwifery education for young girls selected to serve their communities in northern Nigeria.
These two solutions share a common premise-the empowerment of members of the community to actively participate in addressing the challenges they face, instead of bringing in external experts with limited knowledge of the local context. In Gombe State, a project developed along these lines, but with some interesting innovations, appears to be contributing effectively to improving maternal health. This project provides insights which may be worth replicating in states where MNCH continues to be a challenge.
A project with an innovative twist
The Gombe MNCH project started in 2009, co-funded by the Bill and Melinda Gates Foundation (BMGF) and the Gombe State Government. With a record $50 million invested in the MNCH project, Gombe is the first state to receive support from BMGF in Nigeria. Society for Family Health (SFH) Nigeria played a key role in the design and execution of one of the elements of the project — The Village Health Worker (VHW) initiative.
Managing Director at SFH, Dr Omokhudu Idogho, said the project had many proofs of concept built into it to determine what would significantly reduce the high number of women dying while giving birth. “10 years after, a lot of progress has been made in terms of massive reduction in the number of mothers who were dying during childbirth and also children who are living,” he added.
What excites him the most, however, is the way in which the state government has demonstrated ownership of the project. He highlights that while a large proportion of the funds came from the BMGF, a significant component came from the government, via the Gombe State Primary Healthcare Development Agency (GSPHCDA), to support monthly stipends for the VHW scheme. They contributed 50% payment of N6000 monthly to the 1200 VHWs in 2017 and have taken 100% responsibility since 2018.
The scheme kicked off in 2017 as part of the main project that commenced in 2009 after several strategies had been tested to determine best practice. Other strategies involved working with Traditional Birth Attendants (TBAs) and the Federation of Muslim Women’s Associations in Nigeria (FOMWAN) in strictly community-based efforts. The refined scheme tackled the demand and supply sides, involves other partners with Gombe State government taking lead.
Partnering for Progress
In addition to BMGF and SFH, other partners joined in to deliver different aspects of the project, all aimed at improving MNCH outcomes in the state. This was a notable departure from the norm of working in silos to solve the same problem.
How did organisations that had never worked together, overcome the many challenges of partnership working? Dr Idogho says they were able to work together more seamlessly by focusing on the bigger picture of improving health outcomes for women and children, with each partner playing specific roles in delivering the project.
Beyond providing stipends for the village health workers, GSPHCDA led the coordination of the project. This means that the state drove the project and actively participated in the design and execution of intervention strategies. The GSPHCDA played a key role here by ensuring that adequate human resources were available at health facilities to absorb the increasing demand generated for MNCH services.
PACT, a nonprofit international development organisation, led the State Accountability for Quality Improvement Project element (SAQIP). The SAQIP Project Director, Dr Bala Bello Abubakar, said they trained staff of GSPHCDA to lead the project and supported SFH in the formation of women groups. They formed 1800 women groups across the 57 intervention wards with each group having over 25 members. Over 45,000 women of child bearing age formed these groups and contributed a total of NGN 157,742,478 between 2015 and 2019 to help each other and provide soft loans to start up or expand their businesses, Abubakar said. This increased the ability of women to pay for MNCH services.
Mamaye’s Evidence for Action worked to improve accountability and performance management for the state primary healthcare system by establishing the State’s Accountability Mechanism for MNCH, a system of tracking health outcomes against investment and set targets. They also supported the State to produce scorecards to rate performance.
The Informed Decisions for Actions in maternal and newborn health project IDEAS led data generation and analysis to support decision making, measurement and learning. They conducted periodic household and health facility surveys to track progress of MNCH interventions.
Tackling various aspects of maternal health challenges, these partners all worked together to achieve the same goal, the reduction of maternal mortality in Gombe State.
Getting to the point where citizens desire and demand quality health care is the hallmark of success of any health intervention as Melinda Gates states in this eight year old TED Talk.
The VHW scheme led by SFH is a major highlight of the Gombe MNCH project. It shows the importance of using community women, who volunteer to take a leadership role, to increase health seeking behaviours and women’s desire for quality health. These women understand the local context, are trusted by their community members and have a certain literacy level to help them benefit maximally from their training.
After training, they are deployed into their communities where they go from house to house seeking out pregnant women, providing simple services and life-saving commodities. They also assist in health promotion, encouraging women to visit hospitals for antenatal care and delivery.
Beyond their stipends, the knowledge they acquire is a source of pride to them. Mary Bitrus, who has been a village health worker since 2017, said “I like the work because of the benefits. There are so many things I know now that I didn’t know before, so I go around to share this knowledge with others”.
To complement the women’s efforts, some members of the National Union of Road Transport Workers (NURTW) volunteer as Emergency Transport Service (ETS) providers to help carry pregnant women to facilities. With implementation in 50% of the 114 wards in Gombe by project end in 2019, 1200 VHWs received training in 2016 before the project commenced in 2017 and 400 community transport workers volunteered their time. Data from the project shows increased births in health facilities from 21% in 2016 to 48% in 2018. The percentage of women with knowledge of at least two pregnancy danger signs also increased from 50% to 85% between 2012 and 2018. 67.7% of women visited by VHWs eventually delivered in health facilities with the ETS volunteers transporting 11%.
Hajara Abdullahi, a fura seller from Rugga village in Funakaye LGA of the state already had six children before encountering a village health worker from her community during her seventh pregnancy. She said the birth of her son, 16-month-old Muhammed Abdullahi, cannot be compared to his siblings whom she gave birth to at home. She said she especially liked how the hospital handled post-partum bleeding: “When I gave birth at home, there was blood everywhere but delivering at the hospital, they give me something that stopped the bleeding…”. Mohammed Suleiman, one of the ETS drivers, said the opportunity to contribute to safe deliveries was fulfilling because, “life is important and cannot be bought no matter how much you are willing to pay”.
The Society for Family Health and other partners have organised dissemination events to share learning from the project. The partners shared various outcomes from the project. Challenges encountered included low literacy of some VHWs, inadequate staffing in health facilities to meet generated demand, the influence of men on their wives’ health seeking behaviour and poor road networks.
There is also the danger of focusing only on data generated from the project to measure progress, when this is not a representation of the entire story of the state. This could make stakeholders relax when there is still more work to be done. Abimbola Olaniran, Research Fellow at IDEAS explained the possible data disparities between preliminary findings from the 2018 Nigeria Demographic and Health Survey (NDHS) and project. The DHS shows 28% for facility births while the endline project data is 61%. Olaniran said this is because the project’s data collection focused on the 57 intervention wards and therefore a subset of the more elaborate DHS which covered the entire state.
Sustainability is another potential concern. Ensuring that the state government actively drove the process from the beginning was one way of mitigating this challenge says the Project Lead, Bolanle Oyebola. Also, securing the commitment of the Speaker of the State House of Assembly to work with his colleagues in supporting the Executive through proactive legislation, was another key strategy.
But beyond legislative commitments to support the project, perhaps the VHW scheme should be institutionalised by formally adopting it as a cadre of the state’s health workforce. Alternatively, it could be transitioned into the national Community Health Influencers and Promoters (CHIPS) program of the National Primary Healthcare Development Agency (NPHCDA). It would be a shame if after all the hard work, the initiative is allowed to fizzle away like most projects do when external funding ends. As Dr Caroline Jehu-Appiah, Deputy Director, Health, Nutrition and Eradication at BMGF rightly put it, “marginal change will not improve health outcomes,” there is need to scale initiatives with proven impact. To achieve this, perhaps it will be good practice for organisations to have a clear-cut plan for scaleup developed when designing health interventions.
The VHW is very similar to the community health worker program that transformed Ethiopia’s health system. So, it’s not a question of if the VHW scheme will work, but of how far we are willing to leverage on it to transform primary health care, improve maternal and child health and achieve Universal Health Coverage for every Nigerian.