Maternal mortality continues to critically impact women of reproductive age across Africa. In Nigeria, research shows that maternal and infant mortality rates are highest in the northeast and northwest zones and lowest in the southeast and southwest. Kano State has the highest maternal mortality rate, with 377.8 per 100,000 live births, which exceeds the national target of 288 per 100,000 national target.
Between May to June 2024, Nigeria Health Watch conducted a community-based perception survey in Kano State to assess communities' perception of the accessibility and quality of primary health care available to them. Some of the key findings highlighted a significant shortage of human resources to enable level 2 Primary Healthcare Centres (PHCs) to function optimally. The survey also revealed disparities in healthcare access, with rural areas such as Ghari (Kunchi) and Kura wards facing limited access to healthcare services compared to urban areas.
In line with this, Nigeria Health Watch organised a policy dialogue in Kano State themed "Strengthening PHC Accountability for Improved Maternal and Child Health: Bridging Gaps in Service Delivery." The dialogue, which took place on October 3, 2024, discussed the need to identify and address gaps in PHC service deliver with a view to improve maternal and child health outcomes in the state. In his remarks, Alhaji Shehu Sani, Permanent Secretary of the Kano State Ministry of Health, highlighted the progress made in strengthening primary healthcare (PHC) in Kano. Key achievements include the, implementation of emergency ambulance services for hard-to-reach areas, ensuring transported patients receive up to 78 hours of free care.
Additionally, since 2018, the state has consistently met the Abuja Declaration, allocating at least 15% of its budget to health. However, challenges persist, which include limited coverage of services and insufficient human resources. "Based on the Minimum Service Package, every ten thousand population [in Kano] must have access to a PHC. We know there are a lot of gaps in that area", noted Dr Nasiru Mahmoud, Director General, Kano State Primary Healthcare Management Board (KSPHCMB). Similarly, Dr Abubakar Labaran Yusuf, the State's Commissioner for Health, emphasised the importance of PHCs in improving the state's maternal and child health outcomes. "Primary healthcare is the bedrock of healthcare development," he noted, commending the Federal Government's Sector-wide Approach Initiative (SWAp) and its potential benefits to health service delivery in the country.
Addressing PHC inequities: Digitalisation is a key enabler
Discussions at the policy dialogue focused on bridging healthcare access disparities to achieve equitable, affordable, and quality care for all patients. These discussions aligned with the 2023-2026 health sector blueprint, specifically the 'Efficient, Equitable and Quality Health System' pillar. Digital health innovations have been indispensable in bridging inequities in healthcare access. Thelma Oriade, Program Manager for the For M(om) project, highlighted the role of health records digitisation in addressing delays in maternal health. "We're digitising health facility records so that records are properly sorted out..reducing the waiting time for women who visit these health facilities". The For M(om) project has been successfully piloted in Kano state, though currently only in private facilities. There is a need to expand to public facilities through partnerships with the kano state government. Similarly, Dr Rahia Aliyu Muktar, Executive Secretary of Kano State Contributary Health Care Management Agency, spoke about the digitisation of enrolment processes at the Agency to increase enrolee rates, with provisions for offline capturing to ensure penetration in remote areas. According to her, enrolees captured offline are later uploaded to the enrolee database. Digitisation of enrolee records in rural areas will contribute towards balancing out the disparities in enrolee rates across urban and rural areas.
Improving the availability and retention of human resources for health in PHCs
Moreso, the KSPHCMB has deployed some strategies to ensure equitable resource distribution to improve access to essential services. These strategies include the establishment of a 10-year strategic plan for Human Resources for Health (HRH), the adoption of policies like the minimum service package, the redistribution guide for human resources for health, and the absenteeism reduction plan. Dr Musa Ali Kachako, member, Committee on Health, Kano State House of Assembly, highlighted the relevance of policies to strengthen PHC in Kano and the role of lawmakers in ensuring these policies are legal and binding in the state.
However, a notable recurring challenge to the equitable distribution of HRH in the state has been that staff initially deployed to rural areas often redeploy to urban centres, leveraging their relationships. According to Dr Bashir Sanusi, Director, Human Resources, KSPHCMB, "most of the time we deploy our staff to the various hard-to-reach and rural facilities, but later in time they request to be (sent) back to the cities, so the ratio of our staff; urban and rural is almost 60:40". Nevertheless, he indicated that the redistribution guide is being leveraged to ensure equitable distribution of HRH within the state. Panellists also advised against preferential treatment by the KSPHCMB in deploying HRH to rural communities.
Strengthening PHC through community engagement and accountability
Ward Development Committees (WDCs) are instrumental in empowering communities to take charge of their health, ensuring collective ownership of primary healthcare services. Their scope includes health promotion, maternal and child health, nutrition, disease prevention, and sexual and reproductive health, fostering a cohesive community health system. Mr Sani Abdullahi Ungogo, Director of Environmental and Public Health at the KSPHCMB, explained that WDCs create awareness, ownership and participation of the community towards healthcare access. He noted that WDCs are integral to the monitoring and evaluation of accountability frameworks and the supervision of community-based initiatives.
Research further highlights the roles of men as advocates to realign other men towards proactive involvement in ensuring the health of their partners. Monsura Yahaya, the State's Maternal, Neonatal and Child Health Coordinator, corroborated this, emphasising the roles men can play within WDCs. She also added that incorporating male voices in maternal health advocacy is an invaluable strategy for advancing the uptake of maternal health services by women, especially in a conservative society like Kano State.
However, while WDCs are integral in PHC strengthening and accountability, it is essential to foster equity within these groups, ensuring that women voices are also captured within these committees, as male-dominated WDCs often tend to drown out female voices and perspectives. Habiba Mijinyawa, State Amira of Federation Of Muslim Womens Association Of Nigeria (FOMWAN), noted, "..Yes, we have WDCs but what we want now is the women to have voices in WDCs".
Additionally, Kano State is implementing community-based Maternal and Perinatal amd Child Death Surveillance and Response (MPCDSR), an approach that can significantly strengthen primary healthcare. By systematically tracking and reviewing maternal and perinatal deaths at the community level, MPCDSR helps identify preventable causes and factors contributing to these losses. This process enables health authorities to develop targeted interventions, allocate resources more effectively, and address specific gaps in maternal and newborn care. Furthermore, MPCDSR fosters community engagement and accountability, as local insights and feedback become integral to shaping responsive, quality healthcare services, ultimately improving health outcomes for mothers and newborns across the state.
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Key policy and practice recommendations
Key recommendations from the policy dialogue are to:
1. Strengthen community oversight, ensure regular performance audits, increase citizen participation in healthcare decisions, and expand community engagement efforts by strengthening community outreach programs to enhance ownership, accountability and transparency in PHC governance frameworks.
2. Digitise healthcare records at health facilities to ensure proper and effective patient management, which will address the three delays in maternal health.
3. Implement a robust capacity-building initiative for healthcare workers and leverage policies like the redistribution guide for the human resources for health, to address the issue of inequitable distribution of HRH within the state.
4. Guard against bias and preferential treatments in assigning HRH to rural areas KSPHCMB.
5. WDCs, village development committees, and religious and traditional leaders should actively engage and mobilise in community engagement.
Strengthening PHC accountability is vital for improving Nigeria's maternal and child health outcomes. By fostering transparency, ensuring efficient resource allocation, and promoting community participation in decision-making, a more responsive and effective healthcare system can be developed.
