Appendix 3 justification for mdg 5 maf

APPENDIX 3

Acceleration Analysis for MDG 5:

Justifications for Priority & Key Points from

the MDGs Acceleration Framework Analysis

Office of the Senior Special Assistant to the President on Millennium

Development Goals

March 2013

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APPENDIX 3

Introduction

In March a national stakeholder technical review was held to assess the efficiency of

current maternal health care policy. This was part of the implementation of the MDGs

Acceleration Framework (MAF) for MDG 5. The stakeholder review identified and

costed a number of key acceleration solutions across a five-year period. Stakeholders

were drawn from all levels of society relevant to the execution of policy relating to

maternal healthcare. This summary note highlights key motivating factors in the

selection of MDG 5 as the first of the MDGs to fed through the MAF process, and

also summarizes the key outcomes of the technical review process.

Wider Importance of MDG 5: Maternal Health Care

USAID estimates that maternal and newborn deaths cost the world $15 billion in lost

productivity. Evidence demonstrates that healthy women and girls can help their

families endure the global financial crisis. For example, the World Bank found that

during the economic crisis, poor families who sent women to work were less likely to

take on sustained debt. In Bangladesh, research shows that poor households with

maternal health complications spend 30% - 40% of their savings to cover expenses,

compared to only 8% for the richest quintile.

“When families incur this crushing debt, they sometimes sell off their daughters, and

the social consequences of this cannot be left out of the equation.”

– Mary Stanton (Senior Maternal Health Advisor USAID)

The Saving One Million Lives Initiative (2012) estimates 33,000 women are

estimated to die from pregnancy-related causes. Using estimates developed by the

WHO in an econometric analysis (2006) of the impact of MMR on per capita GDP in

Africa, one can loosely estimate that achieving the target for MDG 5 would add

$3,394.11 to per capita GDP in Nigeria across certain time horizons. It should be

noted that there are potential issues with the specification of the econometric model.

However, the overarching point is that the achievement of this target is likely to have

considerable economic effects, both directly through the channel of preventing

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APPENDIX 3

maternal death and increasing infrastructure and technical capacity which will have

supplementary positive effects.

Snapshot of Performance of the Maternal Mortality Ratio

2004 2008 2012 2015

800

545

350

250

Maternal Mortality Rate (per 100,000 live births)

Estim

ate

of D

eath

s pe

r 100

,000

Liv

e Bi

rths

Good progress has been made in this area. 2012 data shows that Nigeria is now 28%

away from this MDG target with Maternal Mortality down from the 1990 base of

1,000 deaths per 100,000 live births, to 350.

However it is estimated that about 4 maternal deaths occur in Nigeria per hour, 90

per day, and 2,800 per month for a total of about 34,000 deaths annually, with

wide regional and local variations. Similarly, skilled birth attendance improved

from 38.9% in 2008 to 53.6% in 2012, still far short of the target of 100% by

2015. The proportion of pregnant mothers attending antenatal care at least four

times has improved from 44.8% in 2008 to 57.6% in 2012, but still short of the

target of 100% by 2015. There is however lack of progress regarding ‘unmet need

for family planning’, as the indicator has barely improved from 20.6% in 2008 to

21.5% in 2012. Moreover, more than two-thirds of maternal deaths occur during

childbirth, and are closely linked to intrapartum stillbirths and early neonatal

deaths.

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APPENDIX 3

There are sharp disparities in maternal health between subnational units

(geopolitical zones and states) and there is a significant rural urban divide. For

example (data from the 2008 NDHS) urban maternal mortality estimates are

351/100,000 live births, where as rural estimates are 828/100,000. Maternal

mortality estimates in the North East zone are 1549/100,000 live births, compared

with 165/100,000 in the South West zone. In order for Nigeria to succeed in

achieving Goal 5 by 2015 a concerted effort is required to mitigate this growing in

country divergence. A related dimension of the inequality of access to maternal

healthcare services between the wealthiest quintile and poorest quintile; for

example, the difference in access to skilled birth attendance at delivery between

wealthiest quintile and poorest quintile is almost eight fold. Similarly, the

difference in full immunization coverage between the wealthiest and poorest

quintiles is almost 10-fold. Coverage of key interventions is low, quality of care is

inadequate, and most basic services do not reach the poorest segments.

Maternal health is strongly linked to other MDGs like child health, gender

equality, to poverty reduction and partially to education. Whilst maternal deaths

are rare statistical phenomena, the family impact is devastating and this has wider

community effects. The very fact that maternal deaths are rare makes impacting

them more difficult. Therefore the virtue of targeting this Goal is that there will be

knock on effects through the other health goals, for instance increasing the number

of skilled birth attendants present at birth requires that there are a greater numbers

of health personnel in rural areas.

Figure 1, using UNICEF 2008 data, demonstrates that compared to the next five

largest economies by GDP in Sub-Saharan Africa, Nigeria is doing worst with

regard to Maternal Mortality Ratios.

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APPENDIX 3

Figure 1

Figure 2 demonstrates the comparison of progress across Maternal, Infant and

Child Mortality. This shows that since 2003 the trend in both MDG 5 and 4 has

been positive. Figure 3 shows that the rate of progress in the reduction of Maternal

Mortality and Child Mortality is on track to meet the 2015 deadline, whilst the rate

of progress for Infant Mortality has slowed and is not on track to meet the target.

5

Ghana Ethiopia Kenya Sudan Nigeria0

100

200

300

400

500

600

700

800

900

Comparative UNICEF 2008 Maternal Mortality Ratios

APPENDIX 3

Figure 2

Figure 3

6

Maternal Infant Child

1000

91

191

800

100

201

545

75157

350

61 94

250

3064

Rates, Maternal per 100,000 Live Births, Infant & Child per 1,000 Live Births

1990 2003 2008 2012 Target 2015

Maternal Infant Child

20.00%

-9.89%

-5.24%

31.87%

25.00%21.89%

35.78%

18.67%

40.13%

28.57%

50.82%

31.91%

% Change From Previous Survey

2003 2008 2012 Target 2015

APPENDIX 3

As illustrated in Figure 4, the major causes of maternal deaths are: haemorrhage;

infection; malaria; toxemia/eclampsia; obstructed labour; anaemia; and unsafe

abortion.

Figure 4

Skilled attendance at birth (see Figure 5 for aggregate 2012 data; disaggregated

data will be available in April 2013) continues to have considerable disparities

within country, for example, with Imo State showing 98% skilled attendants at

birth to only 5% in Jigawa State. Available data puts delivery in health facilities at

35% while home delivery was rated at 62.1%, underscoring the need for improved

access and utilization for health facilities-based maternal health services. It is also

estimated that for every maternal death, at least 30 women suffer short-to-long

term disabilities such as vesico-vaginal fistula (VVF). Each year, some 50,000-

100,000 women in Nigeria sustain obstetric fistulae. Over 600,000 induced

abortions are also estimated to take place in Nigeria annually, and these are often

7

Maternal Infant Child

20.00%

-9.89%

-5.24%

31.87%

25.00%21.89%

35.78%

18.67%

40.13%

28.57%

50.82%

31.91%

% Change From Previous Survey

2003 2008 2012 Target 2015

APPENDIX 3

performed under unsafe conditions, with an estimated 40% performed in privately

owned health facilities.

Figure 5

2004 2008 2012 20150

10

20

30

40

50

60

70

80

90

100

36.3 38.953.6

100

Proportion of birth attended by skilled health personnel (%)

There has continued to be an increase in access to safe, affordable and effective

methods of contraception, which is providing individuals with greater choice and

opportunities for responsible decision-making in reproductive matters.

Contraceptive use contributes to improvements in maternal and infant health by

serving to prevent unintended or closely spaced pregnancies. Figure 6

demonstrates the trend. There is need for improvement given that various unmet

family planning needs have progressively risen since 2004 – particularly in the

rural areas where awareness is relatively low.

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APPENDIX 3

Figure 6

Antenatal care coverage is among the health interventions capable of reducing

maternal morbidity. Coverage (at least one visit) with a skilled health worker

increased to 67.7 per cent in 2012 from a decline of 61 per cent in 2008. The 2012

figure represents 6.7 per cent and 12.8 per cent increase over 2004 and 2008 figures.

In addition, antenatal coverage – at least four visits in 2012 rose to about 57.8 per

cent; an increase from 17 per cent in 2004 and 20.2 per cent in 2008 respectively

(Figure 7). However, this success is skewed to urban areas. Like in other indicators,

the rural areas are also lagging in antenatal coverage. The coverage rate in the rural

areas is 56.5 per cent for at least one visit and 47.7 per cent for four visits (2008 data,

2012 disaggregation to be released in April 2013.

9

2004 2008 20120

2

4

6

8

10

12

14

16

18

8.2

14.6

17.3

Contraceptive prevalence rate (%)

APPENDIX 3

Figure 7

2004 2008 20120

10

20

30

40

50

60

70 6154.5

67.7

47 44.8

57.6

Antenatal care coverage %

Antenatal coverage (at least once by any provider)

Antenatal coverage (at least four times by any provider)

The unmet need for family planning remains persistently high. In 2004, the figure was

17 per cent, while the 2008 figure was 20.2 per cent, the rate of progress fell further

with the increase to 21.5 per cent in 2012 (Figure 9).

Figure 9

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APPENDIX 3

2004 2008 20120

5

10

15

20

25

17

20.221.5

Unmet need for family planning (%)

Summary of Justifications

There are a number of key justifications for the selection of MDG 5 for acceleration

analysis. These justifications have been extracted verbatim from the proposals:

a) Focusing on MDG 5 is consistent with the Government’s Transformation

Agenda. At inception, the present administration launched an agenda for

addressing the most pressing development challenges facing the country. The

Agenda identified healthcare, among others, as a key development and policy

challenge. In the gamut of the health challenges, poor maternal health is iconic.

For Government, the underpinning policy for the inputs toward achieving the

human capital development goal of the Vision 20: 2020 Strategy is the National

Strategic Health Development Plan (NSHDP). The NSHDP is the vehicle for

actions at all levels of the health care service delivery system which seeks to foster

the achievement of the MDGs and other local and international targets and

declaration commitments.

b) The choice of MDG 5 for MDGs Acceleration Framework will address

persistent zonal disparities in health outcomes. Disparities in the achievement of

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APPENDIX 3

the goals of the MDGs across states and between the six geo-political zones of the

country abound, but much more dramatic with respect to MDG Goal 5 on

maternal mortality, given especially its immediate impact on human lives.

Whereas a zone like the South West, standing alone, had virtually met the target

even as early as at 2008, others, especially the North West and North East showed

performances way below the national average. By focusing on MDG 5, lessons

from regions with good outcomes can be used in areas of poor outcomes.

c) Sustaining and Improving Progress on MDG 5. As already indicated, on the

average some progress was made on all the three maternal health indicators

between 2003 and 2008. On the basis of this development, and factoring in what

appeared to be good prospects for achieving Goal 5, the 2010 MDGs +10 Report

suggested that MDG 5 could be a candidate for realisation if the momentum was

sustained. President Goodluck Jonathan in his Foreword to the 2010 MDG+10

Report, declared the achievement in MDG 5 up to 2008 as ‘unprecedented’.

d) As can be seen from the graphical projections reproduced below, the expectation

was that if the average performance on the MDG 5 is sustained, the target would

be met by 2015. This performance-based projection was the basis for the official

optimism that was shared with the rest of the world by President Jonathan in

September 2010. The Countdown Strategy (CDS) provided a roadmap, targeted

investment and ingredients of effective partnership which implementation would

have helped to sustain the observed trend of the three years to 2008 and which

formed the basis for the optimistic projection to meeting the target by 2015. For a

number of reasons associated with transition in administration, the implementation

of the CDS was delayed. A number of otherwise laudable initiatives like the MSS

programme were not anchored effectively on the roadmap of the CDS. Even with

the latest NBS data showing an MMR of 350 as a national average, there are still

wide differences within the least performing zones. The political commitment and

the associated resources devoted to the attainment of MDG 5 still remain a matter

of great concern. Added to the above is the largely unexpected eruption of

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APPENDIX 3

violence, especially the North East Zone on a scale never before seen in the

history of peace-time Nigeria. The North-East Zone has had recurrent troubled

performance on MDG Goal 5 in particular. This violence and the resulting social

and economic instability have contributed to a loss of the momentum towards the

attainment of MDG 5 in some parts of the country. The healthcare initiatives that

held the promise of raising the national average performance on MDG 5 -

Midwifery Services Scheme, Routine Immunisation, Rollback Malaria,

HIV/AIDS Control Programme, Health Systems Strengthening, Infrastructure and

even the SURE-P appear overwhelmed by insecurity in parts of the county where

their operations are needed most for the achievement of the health MDGs and in

particular goal 5.

e) MDG 5 is a proximate means of progress on other MDGs. Maternal health is

highly linked to other MDGs like child health, gender and women empowerment

and poverty reduction. It means that accelerating progress on MDG 5 could lead

to gaining some mileage with the other MDGs in which progress is currently slow.

A healthier mother is better able to work, earn a living, participate in household

decision-making and provide better for a child. Available data demonstrate this

correlation. For example, when national maternal mortality rate declined from 800

deaths per 100,000 live births to 545 deaths over the period 2003 to 2008, it

correlated with declines in infants and under five mortality rates as illustrated in

below. The focus on MDG 5 is therefore expected to have salutary effects on the

performance of other goals, especially Goal 4. Hence, for the good health of our

women in the vibrant age group of between 18 and 45 and for political

accountability, the choice of the MDG 5 for MAF is considered appropriate and

timely.

Key Points from the MAF Document

Prioritization of Key Interventions Within MDG 5

Through the consultation process, five key priority areas have been identified from a

list of twenty-plus major interventions:

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APPENDIX 3

a) Family Planning

b) Skilled Birth Attendants

c) Emergency Obstetric and New-born care

d) Universal Coverage of Ante-Natal and Post-Natal care

e) Improved Referral System

Bottleneck Analysis and Prioritization

Within these areas policy bottlenecks were identified. Sector-specific bottlenecks are

contained within the particular Federal, State Ministry or relevant Local Government

Department. Cross-cutting bottlenecks are inter-sectoral and economy-wide problems

that affect the implementation of the MDG 5 interventions.

Acceleration Solutions

From this analysis acceleration solutions were proposed for each of the five

prioritized intervention areas. These range from public education, retraining of birth

attendants (in particular traditional birth attendants), decentralizing ambulance usage,

maintenance of equipment, and engagement with civil society. See the MAF

document for further details.

The Budget

It is estimated that the acceleration solutions and constituent activities would cost N65

billion across a five-year period (see Table 1 for an outline, and the MAF document

for details, costed by OSSAP-MDGs procurement staff and health personnel). By far

the most costly intervention is the provision of skilled birth attendants.

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APPENDIX 3

In 2013 OSSAP-MDGs shall spend N29.5 billion on interventions that will have some

impact on maternal health care. This plan represents a 46% increase in maternal

health related expenditure within the 2013 budget.

Table 1

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