International Journal of Gynecology and Obstetrics 127 (2014) 113–116
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
EVIDENCE FOR ACTION
The Nigeria Independent Accountability Mechanism for maternal, newborn, and child health Aminu Magashi Garba a, Sarah Bandali b,⁎ a b
Evidence for Action, Abuja, Nigeria Evidence for Action, Options Consultancy Services, London, UK
a r t i c l e
i n f o
Keywords: Accountability Evidence for Action (E4A) Maternal, newborn, and child health Nigeria Transparency
a b s t r a c t Since the 2010 launch of the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, worldwide political energy coalesced around improving the health of women and children. Nigeria acted on a key recommendation emerging from the Global Strategy and became one of the first countries to establish an independent group known as the Nigeria Independent Accountability Mechanism (NIAM). NIAM aims to track efforts on progress related to Nigeria’s roadmap for the health of women and children. It includes eminent people from outside government to ensure independence, and is recognized within government to analyze and report on progress. The concept of NIAM received approval at various national and international forums, as well as from the Nigeria Federal Ministry of Health. This experience provides an example of connecting expertise and groups with the government to influence and accelerate progress in maternal, newborn, and child health. Engagement between government and civil society should become the norm rather than the exception to achieve national goals. © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Background Since the launch of the UN Secretary-General’s Global Strategy for Women’s and Children’s Health in 2010, worldwide political energy coalesced around improving the health of women and children through several initiatives, including A Promise Renewed [1], Family Planning 2020 [2], and the Commission on Life-Saving Commodities [3]. Simultaneously, accountability and transparency came to the forefront of the discourse on maternal and newborn health in 2011, with the work of the Commission on Information and Accountability (CoIA) for Women’s and Children’s Health [4]. The emergence of new commitments and resources cemented the need to ensure transparency of results and accountability regarding the use of resources to improve outcomes for women and children. Often, however, translating this discourse into practical action is a challenge. The case of Nigeria has some experience to offer. Nigeria is one of the countries in Sub-Saharan African with a high maternal mortality ratio (MMR). Although the MMR decreased between 1990 and 2013, from 1200 to 560 per 100 000 live births [5], Nigeria will not reach its Millennium Development Goal (MDG) target
⁎ Corresponding author at: Evidence for Action, Options Consultancy Services, Devon House, 58 St Katharine’s Way, London, E1W 1LB, UK. Tel.: +44 20 7430 5158; fax: +44 20 7430 5191. E-mail address: [email protected] (S. Bandali).
of 275 by 2015. Coverage of key maternal, newborn, and child health (MNCH) interventions is abysmally low: met family planning need is at 29%; four prenatal care visits is at 45%; and skilled attendance at delivery is at 39% [6]. Child mortality decreased between 1990 and 2010, from 213 to 143 per 1000 live births, but the MDG target of 71 is far from sight [6]. Nigeria endorsed the Global Strategy for Women’s and Children’s Health and is implementing related interventions through its national and state health sector plans and strategies. It pledged to have government funding for the health sector at 15% in line with the 2001 Abuja Declaration, and has promised to allocate not less than 1% of its consolidated revenue fund under the National Health Bill to primary health care [7]. Despite these promises, the current average government budget allocation to health is 5% (compared with the 15% Abuja target) and the National Health Bill—passed by the Senate and House of Representatives—is awaiting assent by the President (as of June 2014). Concerted action to improve resource allocation and use for MNCH outcomes in accordance with commitments is needed. A specific CoIA recommendation was “all countries to have established national accountability mechanisms that are transparent, that are inclusive of all stakeholders, and that recommend remedial action” by 2012 [8]. For global oversight, CoIA also recommended setting up an independent Expert Review Group (iERG) that would report regularly on results and resources related to the Global Strategy and on progress in implementing CoIA’s recommendations.
http://dx.doi.org/10.1016/j.ijgo.2014.07.004 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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A.M. Garba, S. Bandali / International Journal of Gynecology and Obstetrics 127 (2014) 113–116
Nigeria acted on these recommendations and became one of the first countries to establish an independent group known as the Nigeria Independent Accountability Mechanism (NIAM). As one of 75 countries facing high maternal and newborn mortality, Nigeria participated in a multicountry workshop in Harare, Zimbabwe, in October 2012, to find solutions to the crisis. In subsequent discussions in Abuja, Nigeria, this led to the development of a roadmap to advance progress on women’s and children’s health [9]. NIAM emerged as the accountability mechanism—an iERG equivalent at national level—to monitor the implementation status of the roadmap developed for Nigeria. The present paper describes how NIAM was established and its envisioned role in strengthening national level accountability in maternal, newborn, and child health. 2. Establishing accountability in Nigeria The Nigerian government has taken steps to address the challenges in MNCH. The National Strategic Health Development Plan (NSHDP) for 2010–2015 is a guiding document for health interventions that includes a costed framework for action, as well as an essential package of care for reproductive, maternal, and infant health [10]. In 2007, the country also adopted the Integrated Maternal, Newborn, and Child Health (IMNCH) strategy with assistance from UNICEF [11]. The strategy takes an integrated approach across all levels of government, strengthens the continuum of care for women and children and includes an essential childhood medicines scale-up plan. Nigeria’s Midwives Service Scheme (MSS) is one example of a national policy that reflects a relatively high level of harmonization among tiers of government, including clear roles and responsibilities for federal, state, and local authorities. The National Health Bill, which is yet to be assented to by the President, is perhaps the most promising policy development in recent years. When signed into law, the Bill would transfer a substantial amount of funds from the country’s consolidated revenue fund to improve health services. State accountability for MNCH in Nigeria beyond free health care, however, is minimal. A number of civil society organizations (CSOs) in Nigeria are promoting voice and dialogue between state actors, healthcare providers, and citizens; improving governance; and involving the media to strengthen accountability within the health system. However, transparency of MNCH commitments at all levels calls for greater coordination among different stakeholders. Building on global lessons and country level work, NIAM was established, under the aegis of a larger network—Accountability for Maternal, Newborn, and Child Health in Nigeria (AMHiN)—to help ensure that civil society actors become an inherent part of the MNCH dialogue in Nigeria. 3. Accountability mechanisms and networks: Global lessons Substantial evidence suggests that accountability and transparency processes can have a positive impact on services [12]. In Brazil, for example, participatory governance councils helped to improve access to health services and their quality [13]. In India, an evaluation of citizen engagement through report cards noted an increase in public mobilization and awareness, and greater disposition by decision- makers and political leaders to make information more transparent to citizens [14]. In general, the term accountability can be explained through two concepts, answerability and enforceability [15], which helped define NIAM’s formation. Answerability refers to information that should be provided to various stakeholders to keep them abreast of issues. However, as mere information dissemination is not enough for change to ensue, enforcement mechanisms are needed when there is lack of or ineffective action so that those in positions of power respond to concerns [15,16]. Compared with the long route of accountability that enables citizens to exercise their vote in the electoral process to influence wider social and political change [17], the preferred method in this context has been the short route, which links providers and users
directly (through dialogue and negotiation) and can be effective if improved transparency is promoted as a crucial mechanism to improve health services [12,18]. Examples from India and elsewhere show that citizens can influence positive change when they are empowered to become active players in their own health care, are represented in various forums [19], and have the power to demand investigations and responses [15]. A civil society alliance of organizations in Odisha, India, found that operationally this translated to generating demand for better rights and services through information transmission, building on the expertise of mediators to legitimize citizen concerns through dialogue, and sensitizing providers and leaders to the health of women through negotiation [20]. Health center committees in eastern and southern Africa, which include a heterogeneous group of citizens, monitor public health systems and ensure plans and implementation strategies are responsive to community needs [21]. Networks built among civil society, media, donors, and advocates, for example, helped to establish accountability in the global response to HIV [22]. However, responsiveness among accountable partners depends on local social and political environments [23]. While vertical accountability mechanisms (such as civil society action, elections, complaints procedures, and laws) are important to hold governments accountable, evidence also shows that for effective accountability, these need to be combined with horizontal mechanisms within and between levels of government, such as internal procedures for administrative review or financial auditing [24]. Such hybrid forms of accountability (such as public sector-supported regulatory and supervisory bodies, e.g. independent commissions) would be more effective if they gave citizens a continuous presence and legal standing within them, as well as provided structured access to official documentation [24,25]. The accountability mechanism for Nigeria was conceived based on this understanding—that it would be citizen led but linked to government processes. The sections below describe this process and its outcome. 4. Citizens form the network: Accountability in MNCH in Nigeria A group of civil society organizations and health professional bodies gathered for a meeting in Abuja in June 2012 to discuss the question “Why accountability in maternal and newborn health in Nigeria?” An earlier study tour to Mexico by five Nigerian nongovernmental organizations (NGOs) and a health professional body prompted this question and the meeting. Study tour participants included Advocacy Nigeria, Civil Society Legislative Advocacy Center, the Society of Gynaecology and Obstetrics of Nigeria, Women Advocates Research and Documentation Centre, Women’s Health and Action Research Centre, and Community Health and Research Initiative. The Nigeria contingent learned from the experiences of Mexican NGOs about how they engaged with their government and the policies that promoted accountability. At the June 2012 meeting, critical barriers to saving maternal and newborn lives in Nigeria were explored. Insufficient funds to implement the full range of strategies, inadequate commodities (such as magnesium sulfate, oxytocin, misoprostol, and antibiotics) at the facility level, and weak national data on maternal health were identified as some key issues to be addressed. Several key questions about Nigerian policies were raised with regard to the level of implementation of the policies and their impact across the country. Participants at the meeting also recognized the lack of publically available information about these policies. It was unclear whether and how programs and policies were monitored and whether there were any efforts toward accountability. Participants at the Abuja meeting felt strongly that a national accountability platform was needed. Participant NGOs mobilized other national NGOs and called for a series of meetings to make this possible. AMHiN was established and was charged with monitoring, advocating, and tracking progress based on agreed MNCH indicators. By creating a
A.M. Garba, S. Bandali / International Journal of Gynecology and Obstetrics 127 (2014) 113–116
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space for information, dialogue, and negotiation to advance MNCH progress, AMHiN developed a way to facilitate transparency and action for results in Nigeria. AMHiN has since been closely aligned with the MNCH political and policy environment in Nigeria to help ensure commitments are met at all levels. The membership of this group consists of civil society, health professional bodies, and the media. The media helps increase the credibility and reach of this accountability initiative. The group has helped build a collective voice, solidarity, and capacity to influence change.
include representatives from the media, civil society, and health professional bodies across the six geopolitical zones of the country. The aim in having a diverse and representative membership was to pool knowledge and expertise on health information systems, civil society engagement, monitoring and evaluation, health financing, advocacy, tracking of resources, vital registration, maternal death reviews, and accountability. Members were selected through a transparent process (nomination from AMHiN) based on their expertise and ability to contribute to the aims of NIAM. Specific aims of NIAM include:
5. Global processes and AMHiN’s role
• Review progress and performance in the health sector against country health plans and budgets, particularly the roadmap on women and children’s health and international goals. • Assess whether health gains and investments are equitably distributed. • Periodically review and analyze barriers in access to health services for women, especially young women, and children. • Ensure that the highest levels of political authority, including the national and state Houses of Assembly, government ministries, and others act to ensure the results of the review inform subsequent national plans, together with commitments on budgets, timelines, and further accountability measures. • Identify and promote success stories in policy and program implementation related to women’s and children’s health. • Produce a shadow report (as needed) with recommendations based on a review of progress and performance against the roadmap and other health plans, and target this to those who can act on the information.
In October 2012, World Health Organization (WHO) sponsored a multicountry workshop in Harare to lay out a roadmap for progress [9], which would improve MNCH outcomes and accountability in each participating country. The workshop brought together government and other UN agencies to score country level progress on key MNCH indicators using WHO’s Country Assessment Framework. Seven priority areas laid out in the Global Strategy defined the framework: (1) Civil Registration and Vital Statistics System; (2) monitoring of results; (3) maternal death surveillance and response; (4) innovation and e-health; (5) monitoring of resources; (6) review processes; and (7) advocacy and outreach. As each country was encouraged to do their own scoring and develop their own roadmap, it was crucial to ensure that civil society voices were represented in the government processes and discussions. AMHiN members participated in the Harare workshop to ensure that citizens’ voices were heard and priorities were agreed accordingly. A follow-up national workshop was held in Nigeria in April 2013 [26], where country assessment scores and priority actions based on the scoring process were finalized. Before the national workshop, AMHiN convened all interested CSOs to ensure better understanding of the accountability framework tool, share evidence, conduct their own assessment of Nigeria’s progress, and identify priority actions for the roadmap. CSOs were thus organized with agreed collective goals and a strategy of engagement. With agreed messaging and evidence, and to ensure their voices were heard, CSO representatives spread themselves across the seven thematic discussions at the workshop. At this workshop there was general consensus on the need to establish two in-country mechanisms. First, the existing government-led steering committee would continue its role and stewardship of the roadmap in Nigeria, and the Department of Health Planning and Research and the Department of Family Health would coordinate the steering committee, which would include selected members from AMHiN. Second, CSOs, supported by the Evidence for Action program [4], proposed an independent expert review group using the existing AMHiN structure to independently monitor, review, and report on the Nigeria roadmap. This proposal was unanimously endorsed [26] and NIAM was created. NIAM includes eminent people from outside government to ensure its independence and is recognized within government to analyze and report periodically on the roadmap’s progress. The concept of NIAM received approval and encouragement at various national and international forums, as well as from the Federal Ministry of Health in Nigeria. 6. The Nigeria Independent Accountability Mechanism (NIAM) NIAM was created as a hybrid accountability mechanism, to be led by citizens but with national approval and recognition as an independent body to help track MNCH progress against the roadmap. NIAM interfaces with the government-led national steering committee, which is tasked with guiding the implementation of the national roadmap. A nine-member NIAM was inaugurated in May 2014 and given the mandate to validate the national scoring exercise conducted by AMHiN related to the seven thematic areas of the country’s roadmap. The nine members were nominated from the larger AMHiN membership and
NIAM is currently reviewing progress against key areas outlined in the roadmap over the period of 2013 (Box 1). The analysis will be used to invigorate the dormant government-led national steering
Box 1 Key areas in which Nigeria’s progress on maternal, neonatal, and child health will be scored and assessed by NIAM. 1. Rapid civic registration and vital statistics assessment conducted and disseminated. 2. Community reporting of births and deaths are in place in 36 states. 3. National policy on maternal death notification developed and disseminated. 4. Relevant institutions trained on maternal death notification. 5. States timely and regularly reporting maternal death. 6. One reproductive, maternal, newborn, and child health (RMNCH) monitoring and evaluation plan in place. 7. Technical working group at national and state level on RMNCH established/reactivated. 8. National e-Health Strategy developed and disseminated. 9. National health account (NHA) with dedicated budget by the Ministry of Health developed and used. 10. Annual report of financial commitment to NHA by development partners. 11. Annual performance and review in place in line with national strategic health development plan. 12. National assembly established accountability mechanism on RMNCH. 13. Active national coalition on civil societies on maternal, neonatal, and child health. 14. Percentage of annual commitment allocated for family planning commodities released. 15. Proportion of state governments reporting availability of family planning commodities at facility level. 16. Percentage of annual commitment allocated for life-saving commodities released.
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committee with the aim of stimulating action where there has been stagnation. 7. Conclusion As 2015 approaches, it is evident that among the 75 countries in which 98% of global maternal and child mortality is concentrated, only 17 will reach their targets for MDG 4 and only nine will achieve MDG 5 [27]. It is a crucial time in the post-2015 dialogue to build on successes achieved and leverage on existing and new resources available to sustain progress on women and children's health. The Nigeria experience provides an example of connecting expertise and groups with the government to influence and accelerate progress in MNCH. Engagement between government and civil society should become the norm rather than the exception in achieving national goals. Acknowledgments The Evidence for Action (E4A) program is funded by the UK Government’s Department for International Development (DFID). The authors wish to thank Tunde Segun for reviewing and providing input on the manuscript. Conflict of interest Aminu Magashi Garba and Sarah Bandali are supported by the DFIDfunded Evidence for Action (E4A) program at Options Consultancy Services. References [1] A Promise Renewed Web site. http://www.apromiserenewed.org/. Accessed 11 July 2014. [2] United Nations Foundation. Family Planning 2020 Web site. http://www. familyplanning2020.org/. Accessed 11 July 2014. [3] United Nations Foundation. Every Woman Every Child Web site. UN Commission on Life-Saving Commodities. http://www.everywomaneverychild.org/resources/ un-commission-on-life-saving-commodities. Accessed July 11, 2014. [4] Hulton L, Matthews Z, Martin-Hilber A, Adanu R, Ferla C, Getachew A, et al. Using evidence to drive action: A “revolution in accountability” to implement quality care for better maternal and newborn health in Africa. Int J Gynecol Obstet 2014;127(1). [5] WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2013. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva: WHO; 2014 . http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_ eng.pdf?ua=1. Accessed June 11, 2014. [6] Countdown to 2015. Accountability for maternal, newborn and child survival. The 2013 Update. Geneva: WHO; 2013. http://countdown2015mnch.org/documents/ 2013Report/Countdown_2013-Update_withprofiles.pdf. Accessed July 11, 2014. [7] World Health Organization. Accountability for Women’s and Children’s Health. Nigeria Commitment. Every Women Every Child. http://www.who.int/woman_ child_accountability/countries/nga/en/. Accessed May 29, 2014. [8] Commission on Information and Accountability for Women’s and Children’s Health. Keeping Promises, Measuring Results. Geneva: WHO; 2011. http://www.everywoman everychild.org/images/content/files/accountability_commission/final_report/Final_EN_ Web.pdf. Accessed June 17, 2014.
[9] World Health Organization. Country Accountability Framework (CAF) roadmap. Nigeria http://www.who.int/woman_child_accountability/countries/NGA_roadmap_ final_web.pdf. Accessed May 29, 2014. [10] Federal Ministry of Health, Nigeria. National Strategic Health Development Plan 2010-2015. Abuja: MoH; 2010. http://www.mamaye.org.ng/sites/default/files/ evidence/NSHDP-2010-2015.pdf Accessed July 11, 2014. [11] National Integrated Maternal Newborn and Child Health Strategy, UNICEF Brochure. http://www.unicef.org/nigeria/ng_publications_IMNCHbrochure.pdf. Accessed July 11, 2014. [12] Joshi A. Do they work? Assessing the impact of transparency and accountability initiatives in service delivery. Dev Policy Rev 2013;31(S1):S29–48. [13] Gaventa J, Barrett G. So what difference does it make? Mapping the outcomes of citizen engagement. IDS Working Paper 347. Brighton: Institute of Development Studies; 2010 http://www.ids.ac.uk/files/dmfile/Wp347.pdf. Accessed May 29, 2014. [14] Ravindra A. An assessment of the impact of Bangalore citizen report cards on the performance of public agencies. Evaluation Capacity Development working paper series; no. ECD 12. Washington DC: World Bank; 2004 http://www-wds.worldbank. org/external/default/WDSContentServer/WDSP/IB/2004/06/17/000011823_ 20040617170829/Rendered/PDF/293560NWP01120India.pdf. Accessed July 10, 2014. [15] George A. Accountability in health services: Transforming relationships and contexts. Working paper series, volume 13, number 1. Cambridge MA: The Harvard Center for Population and Development Studies; 2003 http://www.who.int/management/ partnerships/accountability/accountabilityhealthservicespdf.pdf. Accessed July 10, 2014. [16] Murthy RK. Strengthening accountability to citizens on gender and health. Glob Public Health 2008;3(Suppl. 1):104–20. [17] Standing H. Understanding the ‘demand side’ in service delivery: definitions, frameworks and tools from the health sector. London: DFID Health Systems Resource Centre; 2004. http://hdrc.dfid.gov.uk/wp-content/uploads/2012/10/Understandingthe-demand-side-in-service-delivery.pdf. Accessed July 10, 2014. [18] McNeil M, Mumvuma T. Demanding good governance. A stocktaking of social accountability initiatives by civil society in Anglophone Africa. Washington DC: World Bank; 2006 . http://siteresources.worldbank.org/WBI/Resources/Demanding_ Good_Governance-FINAL.pdf. Accessed July 10, 2014. [19] Barnes M. Users as citizens: collective action and the local governance of welfare. Soc Policy Adm 1999;33(1):73–90. [20] Papp SA, Gogoi A, Campbell C. Improving maternal health through social accountability: a case study from Orissa, India. Glob Public Health 2013;8(4):449–64. [21] Loewenson R, Machingura F, Kaim B, Training, Research Support Centre (TARSC) Rusike I (CWGH). Health centre committees as a vehicle for social participation in health systems in east and southern Africa. EQUINET discussion paper 101. Harare: TARSC with CWGH and Medico, EQUINET: Harare; 2014 http://www. equinetafrica.org/bibl/docs/EQUINET%20HCC%20Diss%20paper%20101%20FINAL. pdf. Accessed May 29, 2014. [22] Collins C, Coates TJ, Szekeres G. Accountability in the global response to HIV: measuring progress, driving change. AIDS 2008;22(Suppl. 2):S105–11. [23] Berlan D, Shiffman J. Holding health providers in developing countries accountable to consumers: a synthesis of relevant scholarship. Health Policy Plan 2012;27(4): 271–80. [24] Goetz AM, Jenkins R. Hybrid forms of accountability: Citizen engagement in institutions of public-sector oversight in India. Public Manag Rev 2001;3(3):363–83. [25] Goetz AM, Gaventa J. Bringing citizen voice and client focus into service delivery. IDS Working Paper 138. Brighton: Institute of Development Studies; 2001 https://www. ids.ac.uk/files/Wp138.pdf. Accessed July 10, 2014. [26] World Health Organization. Country Accountability Framework (CAF) national workshop report. Nigeria http://www.who.int/woman_child_accountability/countries/ NGA_CAF_NationalWorkshopReport_April2013.pdf . Accessed May 29, 2014. [27] World Health Organization. Every woman, every child: Strengthening equity and dignity through health. The second report of the independent Expert Review Group (iERG) on information and accountability for women’s and children’s health. Geneva: WHO; 2013. http://apps.who.int/iris/bitstream/10665/85757/1/9789241505949_ eng.pdf. Accessed July 10, 2014.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
EVIDENCE FOR ACTION
The Nigeria Independent Accountability Mechanism for maternal, newborn, and child health Aminu Magashi Garba a, Sarah Bandali b,⁎ a b
Evidence for Action, Abuja, Nigeria Evidence for Action, Options Consultancy Services, London, UK
a r t i c l e
i n f o
Keywords: Accountability Evidence for Action (E4A) Maternal, newborn, and child health Nigeria Transparency
a b s t r a c t Since the 2010 launch of the UN Secretary-General’s Global Strategy for Women’s and Children’s Health, worldwide political energy coalesced around improving the health of women and children. Nigeria acted on a key recommendation emerging from the Global Strategy and became one of the first countries to establish an independent group known as the Nigeria Independent Accountability Mechanism (NIAM). NIAM aims to track efforts on progress related to Nigeria’s roadmap for the health of women and children. It includes eminent people from outside government to ensure independence, and is recognized within government to analyze and report on progress. The concept of NIAM received approval at various national and international forums, as well as from the Nigeria Federal Ministry of Health. This experience provides an example of connecting expertise and groups with the government to influence and accelerate progress in maternal, newborn, and child health. Engagement between government and civil society should become the norm rather than the exception to achieve national goals. © 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
1. Background Since the launch of the UN Secretary-General’s Global Strategy for Women’s and Children’s Health in 2010, worldwide political energy coalesced around improving the health of women and children through several initiatives, including A Promise Renewed [1], Family Planning 2020 [2], and the Commission on Life-Saving Commodities [3]. Simultaneously, accountability and transparency came to the forefront of the discourse on maternal and newborn health in 2011, with the work of the Commission on Information and Accountability (CoIA) for Women’s and Children’s Health [4]. The emergence of new commitments and resources cemented the need to ensure transparency of results and accountability regarding the use of resources to improve outcomes for women and children. Often, however, translating this discourse into practical action is a challenge. The case of Nigeria has some experience to offer. Nigeria is one of the countries in Sub-Saharan African with a high maternal mortality ratio (MMR). Although the MMR decreased between 1990 and 2013, from 1200 to 560 per 100 000 live births [5], Nigeria will not reach its Millennium Development Goal (MDG) target
⁎ Corresponding author at: Evidence for Action, Options Consultancy Services, Devon House, 58 St Katharine’s Way, London, E1W 1LB, UK. Tel.: +44 20 7430 5158; fax: +44 20 7430 5191. E-mail address: [email protected] (S. Bandali).
of 275 by 2015. Coverage of key maternal, newborn, and child health (MNCH) interventions is abysmally low: met family planning need is at 29%; four prenatal care visits is at 45%; and skilled attendance at delivery is at 39% [6]. Child mortality decreased between 1990 and 2010, from 213 to 143 per 1000 live births, but the MDG target of 71 is far from sight [6]. Nigeria endorsed the Global Strategy for Women’s and Children’s Health and is implementing related interventions through its national and state health sector plans and strategies. It pledged to have government funding for the health sector at 15% in line with the 2001 Abuja Declaration, and has promised to allocate not less than 1% of its consolidated revenue fund under the National Health Bill to primary health care [7]. Despite these promises, the current average government budget allocation to health is 5% (compared with the 15% Abuja target) and the National Health Bill—passed by the Senate and House of Representatives—is awaiting assent by the President (as of June 2014). Concerted action to improve resource allocation and use for MNCH outcomes in accordance with commitments is needed. A specific CoIA recommendation was “all countries to have established national accountability mechanisms that are transparent, that are inclusive of all stakeholders, and that recommend remedial action” by 2012 [8]. For global oversight, CoIA also recommended setting up an independent Expert Review Group (iERG) that would report regularly on results and resources related to the Global Strategy and on progress in implementing CoIA’s recommendations.
http://dx.doi.org/10.1016/j.ijgo.2014.07.004 0020-7292/© 2014 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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Nigeria acted on these recommendations and became one of the first countries to establish an independent group known as the Nigeria Independent Accountability Mechanism (NIAM). As one of 75 countries facing high maternal and newborn mortality, Nigeria participated in a multicountry workshop in Harare, Zimbabwe, in October 2012, to find solutions to the crisis. In subsequent discussions in Abuja, Nigeria, this led to the development of a roadmap to advance progress on women’s and children’s health [9]. NIAM emerged as the accountability mechanism—an iERG equivalent at national level—to monitor the implementation status of the roadmap developed for Nigeria. The present paper describes how NIAM was established and its envisioned role in strengthening national level accountability in maternal, newborn, and child health. 2. Establishing accountability in Nigeria The Nigerian government has taken steps to address the challenges in MNCH. The National Strategic Health Development Plan (NSHDP) for 2010–2015 is a guiding document for health interventions that includes a costed framework for action, as well as an essential package of care for reproductive, maternal, and infant health [10]. In 2007, the country also adopted the Integrated Maternal, Newborn, and Child Health (IMNCH) strategy with assistance from UNICEF [11]. The strategy takes an integrated approach across all levels of government, strengthens the continuum of care for women and children and includes an essential childhood medicines scale-up plan. Nigeria’s Midwives Service Scheme (MSS) is one example of a national policy that reflects a relatively high level of harmonization among tiers of government, including clear roles and responsibilities for federal, state, and local authorities. The National Health Bill, which is yet to be assented to by the President, is perhaps the most promising policy development in recent years. When signed into law, the Bill would transfer a substantial amount of funds from the country’s consolidated revenue fund to improve health services. State accountability for MNCH in Nigeria beyond free health care, however, is minimal. A number of civil society organizations (CSOs) in Nigeria are promoting voice and dialogue between state actors, healthcare providers, and citizens; improving governance; and involving the media to strengthen accountability within the health system. However, transparency of MNCH commitments at all levels calls for greater coordination among different stakeholders. Building on global lessons and country level work, NIAM was established, under the aegis of a larger network—Accountability for Maternal, Newborn, and Child Health in Nigeria (AMHiN)—to help ensure that civil society actors become an inherent part of the MNCH dialogue in Nigeria. 3. Accountability mechanisms and networks: Global lessons Substantial evidence suggests that accountability and transparency processes can have a positive impact on services [12]. In Brazil, for example, participatory governance councils helped to improve access to health services and their quality [13]. In India, an evaluation of citizen engagement through report cards noted an increase in public mobilization and awareness, and greater disposition by decision- makers and political leaders to make information more transparent to citizens [14]. In general, the term accountability can be explained through two concepts, answerability and enforceability [15], which helped define NIAM’s formation. Answerability refers to information that should be provided to various stakeholders to keep them abreast of issues. However, as mere information dissemination is not enough for change to ensue, enforcement mechanisms are needed when there is lack of or ineffective action so that those in positions of power respond to concerns [15,16]. Compared with the long route of accountability that enables citizens to exercise their vote in the electoral process to influence wider social and political change [17], the preferred method in this context has been the short route, which links providers and users
directly (through dialogue and negotiation) and can be effective if improved transparency is promoted as a crucial mechanism to improve health services [12,18]. Examples from India and elsewhere show that citizens can influence positive change when they are empowered to become active players in their own health care, are represented in various forums [19], and have the power to demand investigations and responses [15]. A civil society alliance of organizations in Odisha, India, found that operationally this translated to generating demand for better rights and services through information transmission, building on the expertise of mediators to legitimize citizen concerns through dialogue, and sensitizing providers and leaders to the health of women through negotiation [20]. Health center committees in eastern and southern Africa, which include a heterogeneous group of citizens, monitor public health systems and ensure plans and implementation strategies are responsive to community needs [21]. Networks built among civil society, media, donors, and advocates, for example, helped to establish accountability in the global response to HIV [22]. However, responsiveness among accountable partners depends on local social and political environments [23]. While vertical accountability mechanisms (such as civil society action, elections, complaints procedures, and laws) are important to hold governments accountable, evidence also shows that for effective accountability, these need to be combined with horizontal mechanisms within and between levels of government, such as internal procedures for administrative review or financial auditing [24]. Such hybrid forms of accountability (such as public sector-supported regulatory and supervisory bodies, e.g. independent commissions) would be more effective if they gave citizens a continuous presence and legal standing within them, as well as provided structured access to official documentation [24,25]. The accountability mechanism for Nigeria was conceived based on this understanding—that it would be citizen led but linked to government processes. The sections below describe this process and its outcome. 4. Citizens form the network: Accountability in MNCH in Nigeria A group of civil society organizations and health professional bodies gathered for a meeting in Abuja in June 2012 to discuss the question “Why accountability in maternal and newborn health in Nigeria?” An earlier study tour to Mexico by five Nigerian nongovernmental organizations (NGOs) and a health professional body prompted this question and the meeting. Study tour participants included Advocacy Nigeria, Civil Society Legislative Advocacy Center, the Society of Gynaecology and Obstetrics of Nigeria, Women Advocates Research and Documentation Centre, Women’s Health and Action Research Centre, and Community Health and Research Initiative. The Nigeria contingent learned from the experiences of Mexican NGOs about how they engaged with their government and the policies that promoted accountability. At the June 2012 meeting, critical barriers to saving maternal and newborn lives in Nigeria were explored. Insufficient funds to implement the full range of strategies, inadequate commodities (such as magnesium sulfate, oxytocin, misoprostol, and antibiotics) at the facility level, and weak national data on maternal health were identified as some key issues to be addressed. Several key questions about Nigerian policies were raised with regard to the level of implementation of the policies and their impact across the country. Participants at the meeting also recognized the lack of publically available information about these policies. It was unclear whether and how programs and policies were monitored and whether there were any efforts toward accountability. Participants at the Abuja meeting felt strongly that a national accountability platform was needed. Participant NGOs mobilized other national NGOs and called for a series of meetings to make this possible. AMHiN was established and was charged with monitoring, advocating, and tracking progress based on agreed MNCH indicators. By creating a
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space for information, dialogue, and negotiation to advance MNCH progress, AMHiN developed a way to facilitate transparency and action for results in Nigeria. AMHiN has since been closely aligned with the MNCH political and policy environment in Nigeria to help ensure commitments are met at all levels. The membership of this group consists of civil society, health professional bodies, and the media. The media helps increase the credibility and reach of this accountability initiative. The group has helped build a collective voice, solidarity, and capacity to influence change.
include representatives from the media, civil society, and health professional bodies across the six geopolitical zones of the country. The aim in having a diverse and representative membership was to pool knowledge and expertise on health information systems, civil society engagement, monitoring and evaluation, health financing, advocacy, tracking of resources, vital registration, maternal death reviews, and accountability. Members were selected through a transparent process (nomination from AMHiN) based on their expertise and ability to contribute to the aims of NIAM. Specific aims of NIAM include:
5. Global processes and AMHiN’s role
• Review progress and performance in the health sector against country health plans and budgets, particularly the roadmap on women and children’s health and international goals. • Assess whether health gains and investments are equitably distributed. • Periodically review and analyze barriers in access to health services for women, especially young women, and children. • Ensure that the highest levels of political authority, including the national and state Houses of Assembly, government ministries, and others act to ensure the results of the review inform subsequent national plans, together with commitments on budgets, timelines, and further accountability measures. • Identify and promote success stories in policy and program implementation related to women’s and children’s health. • Produce a shadow report (as needed) with recommendations based on a review of progress and performance against the roadmap and other health plans, and target this to those who can act on the information.
In October 2012, World Health Organization (WHO) sponsored a multicountry workshop in Harare to lay out a roadmap for progress [9], which would improve MNCH outcomes and accountability in each participating country. The workshop brought together government and other UN agencies to score country level progress on key MNCH indicators using WHO’s Country Assessment Framework. Seven priority areas laid out in the Global Strategy defined the framework: (1) Civil Registration and Vital Statistics System; (2) monitoring of results; (3) maternal death surveillance and response; (4) innovation and e-health; (5) monitoring of resources; (6) review processes; and (7) advocacy and outreach. As each country was encouraged to do their own scoring and develop their own roadmap, it was crucial to ensure that civil society voices were represented in the government processes and discussions. AMHiN members participated in the Harare workshop to ensure that citizens’ voices were heard and priorities were agreed accordingly. A follow-up national workshop was held in Nigeria in April 2013 [26], where country assessment scores and priority actions based on the scoring process were finalized. Before the national workshop, AMHiN convened all interested CSOs to ensure better understanding of the accountability framework tool, share evidence, conduct their own assessment of Nigeria’s progress, and identify priority actions for the roadmap. CSOs were thus organized with agreed collective goals and a strategy of engagement. With agreed messaging and evidence, and to ensure their voices were heard, CSO representatives spread themselves across the seven thematic discussions at the workshop. At this workshop there was general consensus on the need to establish two in-country mechanisms. First, the existing government-led steering committee would continue its role and stewardship of the roadmap in Nigeria, and the Department of Health Planning and Research and the Department of Family Health would coordinate the steering committee, which would include selected members from AMHiN. Second, CSOs, supported by the Evidence for Action program [4], proposed an independent expert review group using the existing AMHiN structure to independently monitor, review, and report on the Nigeria roadmap. This proposal was unanimously endorsed [26] and NIAM was created. NIAM includes eminent people from outside government to ensure its independence and is recognized within government to analyze and report periodically on the roadmap’s progress. The concept of NIAM received approval and encouragement at various national and international forums, as well as from the Federal Ministry of Health in Nigeria. 6. The Nigeria Independent Accountability Mechanism (NIAM) NIAM was created as a hybrid accountability mechanism, to be led by citizens but with national approval and recognition as an independent body to help track MNCH progress against the roadmap. NIAM interfaces with the government-led national steering committee, which is tasked with guiding the implementation of the national roadmap. A nine-member NIAM was inaugurated in May 2014 and given the mandate to validate the national scoring exercise conducted by AMHiN related to the seven thematic areas of the country’s roadmap. The nine members were nominated from the larger AMHiN membership and
NIAM is currently reviewing progress against key areas outlined in the roadmap over the period of 2013 (Box 1). The analysis will be used to invigorate the dormant government-led national steering
Box 1 Key areas in which Nigeria’s progress on maternal, neonatal, and child health will be scored and assessed by NIAM. 1. Rapid civic registration and vital statistics assessment conducted and disseminated. 2. Community reporting of births and deaths are in place in 36 states. 3. National policy on maternal death notification developed and disseminated. 4. Relevant institutions trained on maternal death notification. 5. States timely and regularly reporting maternal death. 6. One reproductive, maternal, newborn, and child health (RMNCH) monitoring and evaluation plan in place. 7. Technical working group at national and state level on RMNCH established/reactivated. 8. National e-Health Strategy developed and disseminated. 9. National health account (NHA) with dedicated budget by the Ministry of Health developed and used. 10. Annual report of financial commitment to NHA by development partners. 11. Annual performance and review in place in line with national strategic health development plan. 12. National assembly established accountability mechanism on RMNCH. 13. Active national coalition on civil societies on maternal, neonatal, and child health. 14. Percentage of annual commitment allocated for family planning commodities released. 15. Proportion of state governments reporting availability of family planning commodities at facility level. 16. Percentage of annual commitment allocated for life-saving commodities released.
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committee with the aim of stimulating action where there has been stagnation. 7. Conclusion As 2015 approaches, it is evident that among the 75 countries in which 98% of global maternal and child mortality is concentrated, only 17 will reach their targets for MDG 4 and only nine will achieve MDG 5 [27]. It is a crucial time in the post-2015 dialogue to build on successes achieved and leverage on existing and new resources available to sustain progress on women and children's health. The Nigeria experience provides an example of connecting expertise and groups with the government to influence and accelerate progress in MNCH. Engagement between government and civil society should become the norm rather than the exception in achieving national goals. Acknowledgments The Evidence for Action (E4A) program is funded by the UK Government’s Department for International Development (DFID). The authors wish to thank Tunde Segun for reviewing and providing input on the manuscript. Conflict of interest Aminu Magashi Garba and Sarah Bandali are supported by the DFIDfunded Evidence for Action (E4A) program at Options Consultancy Services. References [1] A Promise Renewed Web site. http://www.apromiserenewed.org/. Accessed 11 July 2014. [2] United Nations Foundation. Family Planning 2020 Web site. http://www. familyplanning2020.org/. Accessed 11 July 2014. [3] United Nations Foundation. Every Woman Every Child Web site. UN Commission on Life-Saving Commodities. http://www.everywomaneverychild.org/resources/ un-commission-on-life-saving-commodities. Accessed July 11, 2014. [4] Hulton L, Matthews Z, Martin-Hilber A, Adanu R, Ferla C, Getachew A, et al. Using evidence to drive action: A “revolution in accountability” to implement quality care for better maternal and newborn health in Africa. Int J Gynecol Obstet 2014;127(1). [5] WHO, UNICEF, UNFPA, The World Bank. Trends in maternal mortality: 1990 to 2013. WHO, UNICEF, UNFPA and The World Bank estimates. Geneva: WHO; 2014 . http://apps.who.int/iris/bitstream/10665/112682/2/9789241507226_ eng.pdf?ua=1. Accessed June 11, 2014. [6] Countdown to 2015. Accountability for maternal, newborn and child survival. The 2013 Update. Geneva: WHO; 2013. http://countdown2015mnch.org/documents/ 2013Report/Countdown_2013-Update_withprofiles.pdf. Accessed July 11, 2014. [7] World Health Organization. Accountability for Women’s and Children’s Health. Nigeria Commitment. Every Women Every Child. http://www.who.int/woman_ child_accountability/countries/nga/en/. Accessed May 29, 2014. [8] Commission on Information and Accountability for Women’s and Children’s Health. Keeping Promises, Measuring Results. Geneva: WHO; 2011. http://www.everywoman everychild.org/images/content/files/accountability_commission/final_report/Final_EN_ Web.pdf. Accessed June 17, 2014.
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