Appendix 4 sparc maf final draft report april 2003

APPENDIX 4

NIGERIA MDGs ACCELERATION

FRAMEWORK AND ACTION PLAN FOR MATERNAL

HEALTH (MDG5)

April 2013

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Table of Contents

Acknowledgement

Foreword

Abbreviations/Acronyms

Executive Summary8

List of Tables

List of Figures

Chapter 1: Introduction17

Chapter 2: Nigeria MDGs Status: An Overview with A Focus on MDG5 26

Chapter 3: Key Interventions to Accelerate MDG5 in Nigeria34

Chapter 4: MDG5 Bottlenecks Analysis and Prioritization47

Chapter 5: Acceleration Solutions50

Chapter 6: Monitoring & Evaluation Plan63

Chapter 7: Recommendations68

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References97

Appendices100

MDG – MAF Plan of Action & Budget Matrix

List of TablesTable 1 MDG 5 FocusTable 2 Bottlenecks affecting the Prioritised InterventionsTable 3 Bottleneck Assessment ScorecardTable 4 The Prioritized Bottlenecks are Scrutinised based on the Scorecard SchemaTable 5 MAF Prioritized Solutions and ResponsibilitiesTable 6 MAF Monitoring and Evaluation Calendar

List of FiguresFigure 1 CGS Implementation StructuresFigure 2 Ratio of Girls to Boys in Primary Schools 2008 (%)Figure 3 Under-5 Rate by Geo-political Zone, Nigeria 2011Figure 4 Infant Mortality Rate by Geo-political Zone, Nigeria, 2011Figure 5 Maternal Mortality RateFigure 6 Proportion of Births attended by Skilled Health PersonnelFigure 7 Contraceptive Prevalence RateFigure 8 Antenatal Care CoverageFigure 9 Unmet need for Family PlanningFigure 10 Trends in Maternal and Child mortality (1990 -2008)

Figure 11 Challenges: Coverage of High Impact Interventions for

MNCH

Figure 12 MSS Cluster ModelFigure 13 Overview of MSS Progress Figure 14 Flow of MDG5 monitoring data and information

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Acknowledgement

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ABBREVIATIONS/ACRONYMS

ANC Antenatal Care APHPN Association of Public Health Physicians of NigeriaBCC Behaviour Change Communication BEOC Basic Emergency Obstetrics CareBFHs Baby Friendly HospitalsBFI Baby Friendly InitiativeCAP Country Action PlanCBNC Community-Based Newborn CareCBO Community Based OrganizationCDS Countdown StrategyCEOC Comprehensive Emergency Obstetrics CareCGS Conditional Grant SchemesCHEWs Community Health Extension WorkersCLMS Core Lab Management SystemCMDs Chief Medical DirectorsCPR Contraceptive Prevalence RateCSO Civil Society OrganizationDFID Department for International DevelopmentELSS Expanded Life Saving SkillsEmONC Emergency Obstetrics and Newborn CareETAT Emergency Triage Assessment and TreatmentFANC Focused Antenatal CareFBO Faith-Based OrganizationsFCT Federal Capital TerritoryFHC Facility Health CommitteesFMoE Federal Ministry of EducationFMoH Federal Ministry of HealthFMoWA Federal Ministry of Woman AffairsFP Family PlanningGSM Global System for Mobil Communications HDI Human Development IndexHF Health FacilityHIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome ICT Information Communications TechnologyIDPs International Development PartnersIEC Information, Education and Communication IPT Intermittent Preventive TreatmentIYCF Infant and Young Child FeedingJCHEWs Junior Community Health Extension WorkersLGA Local Government AreaLSTM Liverpool School of Tropical Medicine

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LSS Life Saving SkillsMAF Millennium Accelerated Framework MDAs Ministries, Departments and AgenciesMDCN Medical and Dental Council of NigeriaMDGs Millennium Development GoalsM & E Monitoring and EvaluationMICS Multiple Indicator Cluster SurveyMLSS Modified Life Saving SkillsMMR Maternal Mortality Rate MNCH Maternal, Neonatal and Child Health MPSS Minimum Package of Service and StandardsMSS Midwives Service SchemeNCC National Communications CommissionNCCGS National Committee on Conditional Grants SchemeNDHS Nigerian Demographic and Health SurveyNGOs Non-Governmental OrganizationNHRC National Human Rights CommissionNHIS National Health Insurance SchemeNNPC Nigerian National Petroleum CorporationNMCN Nursing and Midwifery Council of NigeriaNMIS Nigeria Malaria Indicator SurveyNOA National Orientation AgencyNPC National Planning CommissionNPoC National Population CommissionNPHCDA National Primary Health Care Development AgencyNSHDP National Strategic Health Development PlanNURTW National Union of Road Transport WorkersNYSC National Youth Service SchemeNV National VisionODA Overseas Development AssistanceOSSAP-MDGs Office of the Senior Special Assistant to the President on Millennium

Development GoalsPAN Pediatric Association of NigeriaPCAMMDGs Presidential Committee for the Assessment and Monitoring of the MDGsPHC Primary Health CarePHCs Primary Health CentersPHS Primary Health ServicePMTCT Prevention of Mother-to-Child Transmission PNC Post-Natal CareSBA Skilled Birth AttendantsSBAs Skilled Birth AttendanceSMoH State Ministry of HealthSMoLG State Ministry of Local GovernmentSOGON Society for Obstetricians and GynecologySOPs Standard Operating ProceduresSP Sulphadoxine Pyrimethamine

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SPARC State Partnership for Accountability, Responsiveness and Capability

SPHCDA State Primary Health Care Development AgencySSAP Senior Special Assistant to the PresidentSURE-P Subsidy Reinvestment and Empowerment ProgrammeTOT Training of TrainersTT Tetanus ToxoidTWG Technical Working GroupUN United NationsUNDP United Nations Development Programme UNFPA United Nations Population FundUNGASS United Nations General Assembly Special SessionUNICEF United Nations Children’s FundUNO United Nations OrganizationVPF Virtual Poverty FundVVF Vesico-Vaginal FistulaWDC Ward Development CommitteeWHO World Health OrganizationYFHS Youth Friendly Health Services

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FOREWORD

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EXECUTIVE SUMMARY

In September 2010 the United Nations Organization (UNO) under its United Nations General Assembly Special Session (UNGASS), provided a platform for a comprehensive review of progress made so far in the implementation of Millennium Development Goals (MDGs) in the last decade. The review of the MDGs+10 afforded the participating nations the opportunity to peer review progress on the implementation of the MDGs and to further refresh their commitment to the attainment of the MDGs by 2015.

Like other nations, the Federal Republic of Nigeria presented her own Five-Year Countdown Strategy (CDS) at the UNGASS with the overarching objective of outlining a roadmap for accelerating progress towards achievement of the MDGs by 2015. But due to a variety of factors, implementation of the CDS did not gain the expected momentum and has thus caused MDGs that were once promising to suffer some set-backs.

The MDG Acceleration Framework (MAF) which was a key outcome of the MDG+10 review is a process that involves the preparation of a focused, agreed upon Action Plan to address specific lagging MDGs. This plan also requires the cooperation and support of all stakeholders that include the governments, the developments partners, civil society organizations and the private sector in providing the resources and other services needed to advance key policy reform and overcome identified constraints to achieving a given MDG target.

The key strategy of MAF is to identify and prioritize interventions with the potential for delivering the highest impact; analyse and prioritise bottlenecks hindering success of interventions and identify solutions and their sequencing. Based on these three steps, an accelerated action plan, along with an implementation and monitoring plan is then developed. Due to the overwhelming evidence of the synergies that progress with improved maternal health engenders for other MDGs and overall economic progress, Nigeria has chosen MDG 5 for MAF. To refresh memory, the Goals, Targets and Indicators of MDG 5 which the MAF will focus on are presented in tabular form below:

MAF-MGD5 Focus

Goal: 5 Target IndicatorsImprove Maternal Health

Target 5.A: Reduce by 3/4th between 1990 and 2015, the maternal mortality ratio

1. Maternal mortality ratio2. Proportion of births attended by

skilled health personnelTarget 5.B: Achieve, by 2015, universal access to reproductive health

3. Contraceptive prevalence rate4. Adolescent birth rate5. Antenatal care coverage (at least

one visit and at least four visits)6. Unmet need for family planning

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MAF Process Methodology Understandably the roll-out of MAF involves a rigorous process, more so in a federal and populous country like Nigeria. This process got the highest level of political endorsement from the Presidency through a stakeholder forum. Three key decisions that established the methodological point of departure were (a) the setting up of the institutional framework for effective coordination of the MAF process jointly driven by the Office of the Senior Special Assistant to the President on MDGs (OSSAP-MDGs), Federal Ministry of Health, and International Development Partners (IDPs), (b) the engagement of consultants to drive the technical process, and (c) the planning and organization of the stakeholders’ consultation technical workshop of which the Federal Ministry of Health played a catalytic role. The preparation of a comprehensive desk review provided the main input for the stakeholders’ technical workshop. Participants at this workshop were carefully selected to cover not only the geographical spread, but also different layers of professionals in the medical fields with hands-on experience in the implementation of the MDG 5. (See the list of participants in the appendix attached to the main report). The participants discussed and through elaborate process chose five prioritized interventions and also identified the prioritized bottlenecks. Subsequently, a two-day intensive bilateral discussion meetings between the consultants and key policy drivers and implementers (with support from IDPs), developed the suggested solution indicators, targets, timelines, the costing of MAF and the assignment of responsibilities for the implementation of the solutions contained in the Action Plan. The preparation of the final report benefitted further from the Validation workshop organised for critical policy makers, stakeholders and supporting IDPs. Prioritization of Key Interventions Following stakeholders’ consultation to accelerate the achievement of MDG 5, the under-listed five key priority areas were selected out of a list of over twenty major interventions without prejudice to state-level preferences in re-ordering the priorities:

a) Family Planningb) Skilled Birth Attendantsc) Emergency Obstetric and New-born cared) Universal Coverage of Ante-Natal and Post-Natal caree) Improved Referral System

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Bottleneck Analysis and Prioritization The bottlenecks that impede the success of prioritized interventions were identified as shown in the tabulation below. The tabulation shows two broad types of bottlenecks: sector-specific and cross-cutting. Sector-specific bottlenecks are under the control of the Federal and State Ministries of Health and Local Government Health Departments or affiliated agencies. Cross-cutting bottlenecks are inter-sectoral and economy-wide problems that affect the results-based implementation of the MDG5 interventions.

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Bottlenecks Impeding Prioritised InterventionsPrioritised bottleneck

Bottleneck category

Prioritised Interventions

Family planning services

Skilled birth attendants

Emergency Obstetric & Newborn Care

Universal Coverage of Antenatal and Postnatal Care

Improved Referral Services

Socio-cultural religious barrier

Cross cutting and systemic

Inadequate trained personnel

Service delivery

Low male involvement/ uptake

Systemic

Inadequate Skilled Birth Attendants

Service delivery

Uneven distribution of available Skilled Birth Attendants (SBA)

Service Delivery

Inadequate Referral Training for Skilled Birth Attendants (SBA)

Service delivery

Lack of functional equipment and facilities

Service delivery

Poor incentives especially in rural area

Budget and financing

Shortage of skilled health personnel

Service Delivery

Inadequate equipment and supplies

Service Delivery

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Prioritised bottleneck

Bottleneck category

Prioritised Interventions

Family planning services

Skilled birth attendants

Emergency Obstetric & Newborn Care

Universal Coverage of Antenatal and Postnatal Care

Improved Referral Services

Delay in accessing care services

Service Utilization

Inadequate political will

Cross-cutting

Poor access to health facilities in rural areas

Service Utilization

Poor attitude of health workers

Service Delivery

Lack of Legislation

Policy and Planning

Inadequate ambulance services

Service Delivery

Poor communication and feedback system

Service delivery

System delay Service Delivery

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Acceleration SolutionsWith due regard to cultural sensitivity, the acceleration solutions proposed for each of the five prioritized interventions and their numerous bottlenecks inter alia are listed as follows: Family Planning Intervention

a) Scale-up sensitization of traditional leaders, religious leaders, Community Based Organizations (CBO), Faith Based Organizations (FBO) through appropriate media.

b) Reinforce teaching of family life education in secondary schools curriculum.

c) Establish more functional youth friendly centres.a) Sensitization and mobilization of the male folk to take leadership in

health matters

Skilled Birth Attendants/Attendance Interventiona) Recruitment, Training and retraining of more Skilled Birth Attendants

(SBA).b) Task shifting/sharing for Skilled Birth Attendants (SBA).c) Scale up supply of basic equipment of supply for Skilled Birth

Attendance.d) Strengthening, reactivating and formation of Ward Development

Committees (WDC).

Emergency Obstetric and New-Born Care Intervention Additional Incentive for Health workers in hard to reach areas/difficult

terrain/rural areas. Scale up of in-service training and implementation of Life Saving Series

(LSS) and Community Based Newborn Care (CBNC). Incorporation of the Life Saving Series (LSS) and Community Based

Newborn Care (CBNC) into the pre-service Skilled Birth Attendants curriculum.

Regular maintenance of adequate Emergency Obstetrics and Newborn Care (EMONC) equipment and services.

Universal Coverage of Ante-natal and Post-natal Care Intervention Identified interest groups/ civil society should be trained to demand for their

rights. Civil society organizations should demand for their right of the vulnerable

groups. Creating outreaches closer to the people.

Improved Referral System Intervention Decentralization of ambulance to rural areas. Improvisation of functional ambulance services. E.g. Tricycles, Donkeys,

Speedboats, cows and Camels. Engagement of NURTW members or any community volunteer for a reward.

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Effective Two way referral system.

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The Budget Details of the recommended accelerated solutions to each of the identified bottlenecks are contained in the main report. It is estimated that the Acceleration Solutions and constituent activities would cost NGN65,521,997,572 (Sixty-Five Billion, Five Hundred and Twenty-One Million, Nine Hundred and Ninety-Seven Thousand, Five Hundred and Seventy-Two Naira). The mobilization of this amount is crucial to the successful implementation of the Action Plan.

Monitoring and Evaluation Plan A well-functioning results-based monitoring and evaluation system, established as integral element of implementation management, is central to the success of the MAF Action Plan. The Monitoring and Evaluation plan recommended for MAF has three main thrusts which are to:

a) Provide programme managers and stakeholders with data and information about the pace, nature and levels of progress in service delivery and service use;

b) Supply credible evidence base for management responses in bridging gaps, correcting weaknesses and consolidating gains in the implementation of the agreed solutions and actions;

c) Deliver a reporting and feedback system for tracking progress on MDG5 through 2015 based on the MAF results chain – inputs, outputs, outcomes and impacts – with respect to MDG 5.

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Key RecommendationsIt is recommended that an emergency meeting of the Presidential Committee on MDGs be convened to deliberate on the budget and commitments, as well as confirmation of responsibilities, as provided in the report, to various tiers and agencies of government for the implementation of the MAF Action Plan. International Development Partners (IDPs) are requested to make their specific commitments to the implementation of MAF Action Plan. With respect to the implementation of the overall MDGs it is recommended, among others, that the attainment of the MDGs be made the central focus of ongoing Centennial celebration.

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CHAPTER 1INTRODUCTION

Background

1. A remarkable push in the global drive towards fast-tracking the achievement of the Millennium Development Goals (MDGs) was made in 2010 when the United Nations Organization (UNO) provided a platform for a comprehensive review of progress made so far within a decade of its implementation. This global platform was the United Nations General Assembly Special Session (UNGASS) on MDGs+10 that took place in September 2010. The decade’s stock taking event came on the heels of new challenges and realities, such as the global economic and financial crises, climate change, as well as new evidence and innovations that needed to be factored into the MDGs implementation trajectory. The MDGs+10 as it were, was an epoch-making event that afforded different nations the opportunity to refresh their commitment to the MDGs, peer-review progress and redouble effort towards meeting the goals by 2015 in the light of new risks and challenges.

2. The Federal Republic of Nigeria was among the nations that presented a Five-Year Countdown Strategy (CDS) at the UNGASS on MDGs+10. The overarching objective of the CDS was to outline a roadmap for accelerating progress towards achievement of the MDGs by 2015. The specific objectives of the CDS were:

a) To identify the most effective mechanisms and interventions that have made progress against the MDGs

b) To re-emphasize the roles and responsibilities of all agencies, stakeholders, and each tier of government

c) To guide the institutional improvements, policies and human resources required

d) To chart the trajectory of MDGs financing and investment to 2015

e) To interface with Vision 20:2020 and (the then 7-Point Agenda) Transformation Agenda.

3. The CDS was designed to identify the gaps and lay out the policy actions, investments, and milestones that would help Nigeria scale-up its successes and remedy weaknesses. Whilst the CDS acknowledged the progress made up to 2010 including a notable “success story” (the Conditional Grant Scheme), it also addressed the critical challenges and gaps that accounted for the overall average/slow status in respect

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of the eight MDGs. In addition to the strategic initiatives that the government would introduce to tackle the challenges highlighted, sharply-focused strategies for scaling up the implementation of each of the eight goals (or a combination thereof) were spelled out in the CDS.

4. In its review of government’s investment plans, priorities and choices, the CDS highlighted the folding of the MDGs into the implementation plans of NV20-2020 and stresses the imperative of nurturing a combination of public and private investments to ensure acceleration of progress towards achieving the MDGs by 2015. Furthermore, it re-examined the existing costs assessment for achieving the MDGs and also highlighted the need to adopt a new financing strategy that would involve all the three levels of government as well as the arms of government and all relevant stakeholders to make solid commitment through a national partnership and fiscal compact for MDGs in the next five years. Finally, a roadmap for coordination, and monitoring & evaluation (M&E) is provided with an “Indicative Roadmap Matrix of Actions, Lead Responsibilities and Timeframe” covering only 2010 and 2011 – thereby leaving room for any refinements and modifications that a new administration might decide to introduce after presidential and legislative elections in 2011.

5. So far, owing to a variety of factors, implementation of the CDS has not gained adequate momentum to deliver the envisaged amount of progress; instead, some MDGs that were once promising have suffered set-backs. The Millennium Accelerated Framework (MAF) offers another avenue to resume and also accelerate progress. It enables nations to:

a) assess and identify their interventions with the aim of scaling up those with higher impact; (b) analyse and prioritise bottlenecks hindering success of others;

b) identify solutions and their sequencing; c) develop an accelerate action plan, along with an implementation

and monitoring plan.

6. Presently, MAF has become the fastest tool which any nation can adopt to operationalize her MDGs implementation strategy, and in the case of Nigeria, her Countdown Strategy. The MAF helps countries to analyze why they are lagging behind on specific MDGs, prioritize the bottlenecks to progress, and identify collaborative solutions involving governments and all relevant development stakeholders. It could also help to address new challenges related to meeting the MDGs in a particular country context; and integrate new evidence such as the strategic importance of energy and technology, the centrality of gender equality and women’s empowerment in relation to specific MDGs targets and indicators, and innovations in national and sub national efforts to accelerate and sustain progress towards the MDGs. In countries where rates of progress vary sharply across geographic

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regions and/or population groups, the MAF can help understand the reasons behind such differences in progress, and thereby address them through tailored solutions.

7. The MAF results in the preparation of a focused, agreed upon Action Plan to address the specific MDGs that rallies the efforts of governments and its partners, including civil society and the private sector, on providing the investments and services needed to advance key policy reform and overcome identified constraints.

8. The Office of Senior Special Assistant to the President on MDGs (OSSAP-MDGs) in collaboration with the Federal Ministry of Health and the International Development Partners (IDPs) (notably the United Nations Development Programmes (UNDP) and the United Kingdom’s Department for International Development–supported State Partnership for Accountability, Responsiveness and Capability (DFID/SPARC) along with other UN bodies) established a Technical Working Group (TWG) charged with the application of MAF in the operationalization of the CDS.

9. In line with the Federal Government’s recognition of the multiplier effects of the MDGs health goals to the overall success of the entire MDGs in Nigeria, and given the enormous time and resources involved in the application of MAF exercise, the OSSAP-MDGS selected Goal 5 (Improve Maternal Health) for

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Box 1: Overview of situation with Goal 5

With the current estimated maternal mortality ratio (MMR) of 545 per 100, 000 live births (NDHS, 2008), Nigeria still has one of the highest MMR in the world. 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. A little over a half (57.7%) of pregnant women aged between 15-49 years receive antenatal care from skilled providers. Skilled attendance at birth remains low at 39%; with great diversity, 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 deliveries 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 performed under unsafe conditions, with an estimated 40% performed in privately owned health facilities.

As illustrated in Figure 1, the major causes of maternal deaths are: haemorrhage; infection; malaria; toxemia/eclampsia; obstructed labour; anaemia; and unsafe abortion.

Goal: 5 Target IndicatorsImprove Maternal Health

Target 5.A: Reduce by 3/4th

between 1990 and 2015, the maternal mortality ratio

1. Maternal mortality ratio

2. Proportion of births attended by skilled health personnel

Target 5.B: Achieve, by 2015, universal access to reproductive health

3. Contraceptive prevalence rate

4. Adolescent birth rate

5. Antenatal care coverage (at least one visit and at least four visits)

6. Unmet need for family planning

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a special focus in the acceleration efforts. It is against this background that the OSSAP-MDGs, UN Country Team in Nigeria, DFID, and other partners are collaborating in the application of MAF to MDG Goal 5. More specifically, the assignment seeks to develop in close collaboration with the Expert Technical Working Group, a Country Action Plan (CAP) to accelerate the implementation of goal 5 which involves:a) Partnering with relevant sector agencies and other stakeholders to

identify and prioritize high impact interventions required to achieve the MDG Goal 5;

b) Conducting research, gathering data and holding workshops to ascertain what constitute bottlenecks to the implementation of Goal 5 and consequently, proffer solutions to the bottlenecks;

c) Develop a comprehensive MAF action plan including an implementation and monitoring plan to accelerate the achievement of Goal 5;

d) Produce recommendations on the next steps with the remaining 7 goals.

Nigeria’s Country Profile

10. The Federal Republic of Nigeria is located in the West African sub-region and is composed of 36 states and the Federal Capital Territory (FCT) Abuja. The 36 states are further divided into 774 local governments which are regarded as governments at the grassroots. For political purposes and convenience also, Nigeria is divided into six geo-political zones which are utilized to share some political appointments at the federal level. With a total land area of 923,768 square kilometers, Nigerian shares boundaries with the Republic of Niger to the north, Chad to the northeast, Cameroon to the east and southeast, Benin to the west, and the Gulf of Guinea to the south. By 2006 population census, Nigeria’s population was put at 140 million, and a 2011 projected population figure of approximately 168 million (NPC, 2011), Nigeria is the most populous country in Africa and in the entire black race. At a conservative growth rate of 3.2%, Nigeria’s projected population in the year 2020 is 221 million. Of the latest population projection of 168 million, it is estimated the females constitute 82 million, while the males account for 85 million. The 2011 projected figure represents a shift in the hitherto nearly 50-50 male-female ratio in the population census of 2006.

11. Politically, Nigeria has been running an uninterrupted presidential democracy since 1999. This is a significant departure from decades of military dictatorship and gross underdevelopment of healthy democratic culture. Socially, Nigeria is multi-ethnic in composition and has over 250 different ethnic groups.

12. Economically, Nigeria has a gross national product (GNP) of about US$195 billion in 2007 which rose to US$353.2 billion in 2009. The

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GDP per capita as at 2010 estimate stood at $1,324, and a real GDP per capita at purchasing power parity estimated at US$2,289. Crude oil is the main source of revenue, accounting for about 63 percent of government revenue and about 97 percent of export income. Besides crude oil, other fairly large deposits are natural gas, coal, tin, columbite, iron ore, limestone, lead, and zinc. The main non-oil exports include cocoa beans, palm oil, rubber, textiles, hides and skins.

13. Educationally, Nigeria has an adult literacy rate of 72 percent and average life expectancy of 48.4 years down from 51 years over a decade ago. Nigeria’s rank in the Human Development Index (HDI) of the United Nations Development Programme (UNDP) has been disappointingly low over the years. From 141st position (Human Development Report of 1997), to 159th position in 2006, it moved to 142nd in 2010. Nigeria’s HDI of 0.423 however placed it above the Sub-Saharan regional average of 0.389 in 2010. Taken together, along with an Inequality-adjusted HDI value of 0.246, intensity of deprivation of 57.9% (in terms of poverty) and 70% of the population living below poverty line (2007 estimate), the governance and developmental challenges facing Nigeria remain enormous.

High Level Endorsement of MAF

14. Given the inter-governmental character of the implementation of MDGs in Nigeria, any effort to accelerate the achievement of the MDGs not only requires the support of the Federal Government, but also requires both the support of the States and Local Governments as well as other critical stakeholders such as the international development partners, private sector, civil society organizations, community and faith-based organizations. In actual fact, in countries where there has been successful application of MAF to the MDGs, there was high level endorsement by their governments and critical stakeholders.

15. It was as a result of this that a Stakeholders Briefing on the Application of MAF in Nigeria was organized by OSSAP-MDGs in collaboration with international development partners on January 17, 2013 at the Transcorp Hilton Hotel, Abuja. The event was declared open by His Excellency, Arch. Namadi Sambo (GCON) the Vice-President of the Federal Republic of Nigeria. Arch. Sambo restated the commitment of the Federal Government to fast-track the implementation of the MDGs. He stated that the Federal Government welcomed the application of MAF to fast-track the progress of the MDGs and in particular Goal 5. Also, the National Assembly through the chairman of the Senate Committee on MDGs Senator Mohammed Ali Ndume restated the commitment of its members to offer the necessary assistance in the application of MAF. In actual fact, Senator Ndume made a case for a special allocation to the MDGs in order to

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realise the acceleration since as he rightly noted, Nigeria started five years behind schedule in the commencement of the implementation. The Honourable Minister of Health Prof. Onyebuchi Chukwu meticulously chronicled the key interventions in the health sector generally and in MDG 5-Improving Maternal Health specifically in Nigeria.

16. During the Stakeholders Briefing, the Nigeria Governors Forum, the UN System in Nigeria, DFID, Federal Ministries of Health, Finance, Education and Women Affairs, restated their commitments in the acceleration efforts. Also the presence of the Minister of Water Resources, Mrs. Sarah Ochekpe and that for Housing, Land and Urban Development, Ms. Ama Pepple, as well as Heads of parastatals under the Ministry of Health, and a host of other development partners was an encouraging demonstration of their support in the application of MAF in Nigeria.

Institutional Frameworks for the Implementation MDGs in Nigeria

17. Institutional Structures at the Federal Level: Nigeria maintains robust institutional frameworks for the implementation of MDGs. At the Federal level, the executive and legislative arms of government have institutional mechanisms that work jointly for the implementation of MDGs. Unlike what obtains in some other countries, the Federal Government established the MDGs Office in 2005 and appointed a Senior Special Assistant to the President (SSAP) to head the Office. The establishment of the OSSAP-MDGs which was meant to give MDGs both priority and visibility demonstrated government commitment to the achievement of the MDGs. In addition, the government established a Presidential Committee for the Assessment and Monitoring of the MDGs (PCAMMDGs). The members of the Presidential Committee (chaired by the President) include representatives of state governors, National Planning Commission (NPC), local and international Non-governmental organisations (NGOs) and ministers of implementing agencies of DRG programmes and projects. The Office of the SSAP serves as the secretariat of the Committee. Furthermore, some Ministries, Departments and Agencies (MDAs) were designated MDGs implementation Ministries through which the OSSAP-MDGs channelled funds for the MDGs implementation.

18. In order to give life to this institutional framework, MDG implementation was given a huge boost when the government pledged to apply the savings accruable from the Paris Club Debt Relief Deal in 2005 (labelled Debt Relief Gains, DRG) to pro-poor programmes and projects that would enhance the prospects of achieving the MDGs. To this end, a Virtual Poverty Fund (VPF) was adopted in the FGN’s budget to report on the nature of Debt relief expenditures. (The VPF is a coding system within an existing budget classification structure that

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enables the “tagging” and “tracking” of poverty-reducing spending). The reporting platform was provided by the Office of the Accountant General of the Federation through the Accounting Transaction Recording and Reporting System (ATRRS). In concrete terms, the VPF tracks the portion of federal government expenditures dedicated to supporting poverty-reducing activities.

19. At the National Assembly, both the Senate and the House of Representatives established MDGs committees that have been working in collaboration with OSSAP-MDGs and the relevant MDAs to fast-track the implementation of MDGs.

Inter-Governmental Institutional Arrangements

20. At the inter-governmental level, the Federal Government through the OSSAP-MDGs established structures for the implementation of one’s MDGs’ intervention success stories namely the Conditional Grants Scheme (CGS). The Conditional Grants Scheme operates through specific Federal, State and Local Governments’ structures shown in figure 1 below.

Figure 1: CGS Implementation Structures.

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Source: OSSAP-MDGs, CGS Implementation Manual, Revised edition, 2012s

21. A very brief description of these structures follows: a) The Presidential Committee on the Assessment and Monitoring of

MDGs (PCAM-MDGs). The PCAM-MDGs is chaired by Mr. President. Membership of the Committee is drawn from public and private sectors, civil society and the international development partners. It assesses and monitors progress of CGS projects towards the achievement of the MDGs in Nigeria.

b) The National Committee on Conditional Grants Scheme (NCCGS). The NCCGS is chaired by the Minister of Finance. Its membership is composed of the Minister of the National Planning Commission; the Ministers of key MDG line Ministries; the Director General of the Budget Office of the Federation; the Accountant General of the Federation; and the Senior Special Assistant to the President on MDGs.

c) The Office of the Senior Special Assistant to the President on MDGs (OSSAP-MDGs) which serves as the Secretariat to the PCAM-MDGs and NCCGS.

d) State Government Structures include (i) State CGS Implementation Committee, (ii) State CGS Project Support Unit, and (iii) Relevant State Ministries, Departments and Agencies.

e) Local Government Structures include(i) LGA MDGs Planning Committee, (ii) LGA MDGs Technical Team, (iii) Community, Traditional and Faith Based Institutions & Organizations, and iv) Civil Society Organizations.

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Objectives of MAF

22. A critical assessment of the operational effectiveness of these structures in the implementation of MDG 5 in the past decade is key to the application of MAF. Some important questions need to be examined in comprehending why critical interventions failed in many states and local governments. For example, to what extent were the structures at both the state and local government levels sufficiently empowered and enabled to perform their responsibilities? Secondly, to what extent did lack of effective collaborations between the state and their local governments impede the implementation of MDG 5? Thirdly, are grass root structures for the implementation of MDG 5 merely symbolic rather than substantive in their existence? Since the success of MDG 5 depends largely on the effectiveness of structures at the primary health care level, these questions are critical in the implementation of Nigeria’s MAF Action Plan

23. The overarching objective of MAF is to build partnership around maternal health issues in Nigeria especially among the various tiers of Governments (federal, State and Local Governments), within MDAs, CSOs, the private sectors, the UN agencies and other development partners working on neonatal and maternal health in the country. It primarily aims at providing deeper understanding of the key bottlenecks to the implementation of maternal health interventions in the country, collectively identifies key local solutions and develop an action plan that can help to reduce the risks impeding progress on maternal health in the country.

24. Specifically, the MAF seeks to:

a) assess past and existing maternal health policies and interventions;

b) identify the key bottlenecks to and gaps in the implementation and attainment of Goal 5;

c) develop feasible and cost-effective solutions that can accelerate progress towards maternal health in the country; and

d) prepare an action plan for implementing collectively identified interventions, monitor and evaluate progress.

Methodology of MAF Preparation and Roll-out

25. The preparation of MAF in a federal and populous country like Nigeria necessarily entails a complex methodological framework of operations. The sheer complexity of planning and organizational requirements in such a large and heterogeneous country no doubt require a multi-pronged methodological foundation that can maximize the highly competing goals in MAF preparation and its eventual roll-out. Be that as it may, three key decisions that established the

27

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methodological point of departure were (a) the setting up of the institutional framework for effective coordination of the MAF process jointly driven by OSSAP-MDGs and IDPs, (b) the engagement of consultants to drive the technical process, and (c) the planning and organization of the stakeholders’ consultation technical workshop of which the Federal Ministry of Health played a catalytic role.

26. The establishment of the Technical Working Committee composed initially of members from OSSAP/MDGS, UNDP and DFID-SPARC and subsequently enlarged to involve Federal Ministry of Health, (when MDG 5 became the main focus) and other IDPs, was one the milestones of the three-pronged methodological foundation meant to ensure quality assurance in the MAF preparation process. The second milestone was the actual engagement of four national consultants with wide-ranging expertise on MDGs in Nigeria to manage the technical process. The third milestone was the hosting of the MAF stakeholders’ workshop for wide consultative and participatory engagements.

27. The management of the technical process by the consultants began with a desk review of an array of existing relevant national and international policy documents and reports made available by OSSAP-MDGs, Federal Ministry of Health, UNDP, DFID-SPARC, other key UN of agencies as well as documents and reports assembled by consultants themselves. The completion of the desk review paved the way for the organization of the Stakeholders’ technical workshop.

28. The technical ground work for the workshop began when Dr. Ayodele Odusola, (MDG Advisor, Regional Bureau for Africa, UNDP, New York) met with the Consultants. Consequently a tripartite meeting of OSSAP-MDGs, UNDP and DFID-SPARC was called for further brainstorming with Dr. Odusola and the consultants. This meeting which was hosted by DFID-SPARC turned out to be one of the most fruitful meetings in the commencement of the MAF process in Nigeria. It was at this meeting that a careful and detailed selection of stakeholders for the workshop was carried out.

29. The selection of the stakeholders for the workshop involved a complex set of criteria aimed at ensuring representativeness of major voices that need to be heard on issues relating to the improvement of maternal health. There was a selection of key stakeholders in the health sector reflecting (a) wide geographical spread and geo-political zones (e.g. the selection ensured that all the 36 states and the FCT were represented); (b) occupational sub-sectors (e.g. doctors, nurses and midwives, CHEWs and traditional birth attendants were all represented in the selection); (c) tiers of government (federal, state and local governments were all involved); (d) professional associations (Nigerian Medical Association, and Nurses and Midwives Association selected); (e) grass roots representations and civil society organizations (PPFN, and Society for Family Health representing the

28

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marginalized interests); (f) key policy makers and executors in the MDGs line ministries, parastatals, OSSAP-MDGs and the National Assembly, and (g) host of international development partners comprising UNDP, DFID, DFID-SPARC, DFID-PRRINN-MNCH, WHO, UNFPA, UNICEF, UNMC, UN Women, One UN, World Bank, European Union, USAID, and CEDAR. A matrix showing the criteria for selection of key stakeholders from all the states and representing diverse interests enumerated above is in the appendix section of this Report.

30. The data gathering instruments for the MAF Stakeholders’ workshop were adapted from the United Nations-developed MDG Acceleration Framework-Operational Note made available to the consultants by MDG Advisor Dr. Odusola. Four main instruments in line with the four stages involved in the preparation of MAF were developed based on the UN generic templates. The first instrument, which was on the step 1 of the MAF process relates to the Priority Intervention on Maternal Health as well as the Intervention Selection Guidelines. Key selection guidelines are incremental outputs and outcomes, beneficiary population, impact ratio, speed of impact, and evidence of impact, all of which were geared towards the objectivity of the selection process. The second instrument on step 2 of the MAF process focused on the identification and prioritization of the bottlenecks, while the third set of instruments was on step 3 of the process. The three instruments provided (a) the solution impact evaluation guidelines, (b) the solution feasibility evaluation guidelines, and (c) the solution prioritization scorecard. The fourth instrument is a template for the MAF Action Plan.

31. This successful holding of the Stakeholders’ Technical workshop on February 20-21, 2013, was a major milestone in the preparation of MAF in Nigeria. There was high level participation of Federal Government officials and the UN System. Such high level participants included the Honourable Minister of Health (represented by an official of his ministry); the Senior Special Assistant to the President on Millennium Development Goals; Resident Coordinator of the United Nations in Nigeria; Head of DFID in Nigeria (by representation); Country Director of UNDP in Nigeria, and Country Director of UNDP in Ghana among others.

32. Participants at the Stakeholders’ workshop identified list of all the key interventions on maternal health and identified 5 of them as prioritized interventions. Secondly, they identified all the bottlenecks impeding success and thereafter identified 5 of them as prioritized bottlenecks. Thirdly and lastly, they also identified a list of acceleration solutions to the prioritized bottlenecks.

33. The next major activity was the hosting of a 2-day intensive Bilateral Discussion meeting on February 27-28, 2013. The

29

APPENDIX 4

participants at the meeting principally involved the consultants on one side, and the key policy drivers and implementers in the Federal Ministry of Health and its Parastatals, as well as representatives from the World Health Organization (WHO) on the other side. But more importantly, the planning of the Bilateral Discussion meeting was coordinated by OSSAP-MDGs, while DFID-SPARC hosted it. The UNDP as usual provided the technical backstopping, while the Federal Ministry of Health played the major role of mobilizing the participants for the discussions.

34. Based on the identified acceleration solutions, participants at the Bilateral Discussion meeting proceeded to identify the solution indicators, targets, timelines and responsible partners that would be involved in the implementation of the solutions and the Action Plan. It was at these meetings that the costing parameters emerged and costing experts who were in attendance commenced work immediately.

35. The MAF Validation workshop which was held on March 12, 2013 was another milestone in the application of MAF to MDG 5 in Nigeria. Like the Stakeholders’ workshop it also attracted a high level participation which involved the Honourable Minister of Health, Senior Special Assistant to the President on Millennium Development Goals, Honourable Minister/Vice Chairman of National Planning Commission; the Honourable Minister of State for Health, Resident Coordinator of the United Nations in Nigeria, Head of DFID in Nigeria; Executive Director/CEO, NPHCDA among others.

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CHAPTER 2NIGERIA MDGs STATUS: AN OVERVIEW WITH A FOCUS ON MDG

5

Overview

36. Since the MDGs was mainstreamed in national planning and budgeting, there have been successive country-level assessment and monitoring reviews, given by MDGs Status Reports 2004, 2005, 2006, 2007and 2010. The Reports show progress, trends and challenges in the march toward the MDGs 2015 targets. This overview of Nigeria MDGs status therefore draws from the cumulative and collective assessments in these reports, supplemented with updates based on recent statistics and with a special focus on why the MDG 5 is chosen for MAF.

37. Overall, Nigeria’s progress toward the achievement of the MDGs is a mixed bag especially when comparison is made across the different sub-national jurisdictions, as well as between urban and rural populations. With regard to MDG 1 to Eradicate extreme poverty and hunger, recent statistics show that the national poverty incidence increased from 54.4% in 2004 to 69.0% in 2010. Against the background of a rapidly rising population this percentage translates to 112.47 million people living in poverty in the country. In terms of zonal differences the poverty incidence varies from 59 per cent in Southwest to 78 per cent in Northwest. The significant point to note is that the poverty incidence whether by zone or rural comparison is way above 50 per cent. With respect to ‘hunger’ dimension of MDG 1, recent statistics estimate the proportion of under-5 children that are underweight at 24.0% in 20111, suggesting a reduction by at least two per cent annually to be able to meet the 2015 target of 17.85 per cent. If current trends continue, Nigeria is likely to achieve this target employing strategies that are sensitive to, the sharp differences between geopolitical zones and between states within a zone.

38. The MDG 2 which is to Achieve universal basic education has also witnessed a staggered progress. The net enrolment ratio in primary education which improved from 80 per cent in 2004 to 90 per cent in 2007 has continued to experience a steady decline since then to a low of 70.1% in 20102 and thus reseeding further from the target of 100 per cent set for 2015.

39. Similarly, both the ‘ratio of pupils starting primary 1 who reach primary 5’ which was well over 90 per cent in 2001 dropped to 72.3 per cent in 2008 while the ‘primary 6 completion rate’ that rose to 80 per cent in 2004 also declined to 67.5 per cent in 2008 and both have continued to suffer setbacks in the years since then. In terms of

1 Multiple Indicator Cluster Survey (MICS) 2011.2 Nigeria DHS EdData Survey 2010.

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differences between zones and states, while the net enrolment in primary education is as high as 87% in Ekiti State in the Southwest and 83% in Abia State in the Southeast, it is as low as 18% in Zamfara State in the Northwest and 21% in Borno State in Northeast Nigeria.

40. On MDG 3 which is to Promote gender equality and empower women, Nigeria is currently on track and has bright prospects of meeting MDG 2 with regard to the ratio of girls to boys in primary education as well as the ratio of girls to boys in secondary education. There are currently 90 girls per 100 boys in primary schools in 20103, as against the baseline of 70 girls per 100 boys in 1990; similarly, there are currently 93 girls per 100 boys in secondary schools in 2010, against the baseline of 75 girls per 100 boys in 1990. On these two indicators, consistent progress has been sustained over the years. There continue to be high disparities across zones and states on progress toward MDG 3. For example, gender parity in primary school has been achieved in Ekiti, Delta, Abia and Imo, but disparity persists in Sokoto, Jigawa, Katsina and Kebbi. These patterns are mirrored in the Figure 2 below:

41. The progress on MDG 4 to Reduce child mortality is uneven between zones and states as with other MDGs. Recent statistics4 estimate the under-5 mortality rate at about 158 per 1000 live births in 2011, against the 2015 target of 64 per 1000 live births. The most recent estimate for infant mortality rate is 97 per 1000 live births in 2011 against the 2015 target of 30 per 1000 live births. The wide zonal differences are illustrated graphically below:

Figure 3: Under-5 Rate by Geo-political Zone, Nigeria 2011

3 Nigeria DHS EdData Survey 2010 4 Multiple Indicator Cluster Survey (MICS) 2011

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Figure 4: Infant Mortality Rate by Geo-political Zone, Nigeria, 2011

42. Nigeria is on track to meeting the MDG 6 which is to Combat HIV/AIDS, malaria and other diseases with particular regard to the target ‘to halt and reverse the spread of HIV/AIDS’. Latest statistics, though in arrears, show that the country is progressing well and will likely achieve the target, if current trends continue. The HIV/AID prevalence rate declined from about 5.4% in 2000 to about 4.1% in 2008. However, critical challenges persist with regard to access to treatment for persons living with HIV/AIDS (PLWA) that are receiving treatment and prevention of mother-to-child transmission (PMTCT). Only one out of three persons living with HIV/AIDS gets treatment currently, against the target of universal coverage. Regarding the prevention of mother-to-child transmission, the country currently achieves a meagre 16%, against the 2015 target of 90%. Nigeria is also on track with respect to reducing malaria prevalence, given that malaria prevalence declined by 42.8% from 2024 per 100,000 in 2000 to 1157 per 100,000 in 2004.

43. Nigeria’s status on MDG 7 which is to Ensure environmental sustainability is widely divergent across the respective constituent indicators. On the one hand, there is modest progress on the 2015 target of halving the proportion of the population without sustainable access to safe drinking water and basic sanitation. About 58.5% of Nigerians has access to improved drinking water source in 20105, as

5 Nigeria Malaria Indicator Survey (NIMS) 2010.

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against the 2015 target of 77%. Similarly, about 42.6% of Nigerians have access to improved toilet/latrine facility in 20106, as against the 2015 target of 70%

44. On the other hand, the situation is not satisfactory with respect to halting deforestation and gas flaring. Only about 10% of gas produced is used domestically primarily for power generation while 24% is flared7. Gas flaring from joint venture oil companies represents roughly 60% of all emissions from Nigeria’s oil and gas sector. Equally, tackling the growing tide of slum dwellings will become even more challenging amidst the urbanisation wave sweeping across the country. It is estimated that Nigeria’s urban population would rise to about 60% by 2025, given the current growth rate of 5.8% per annum.

45. Nigeria is successful on MDG 8 to Develop a Global Partnership for Development as evidenced by the Paris Club debt relief as the primary source of funding of MDGs in Nigeria. But, overseas development assistance (ODA) has been lagging behind levels desired for meeting the MDGs. ODA to Nigeria increased from US$4.49 per person in 2004 to US$81.67 per person in 2006 and 2007, but, much of this increase came from the debt relief rather than from additional ODA from international development partners. Estimates show that per capita ODA was US$8.53 in 2008, but is still far short of the volume of funds required to make appreciable progress on the MDGs.

46. Nigeria’s progress on access to ICTs has been rising sharply, fuelled by the deregulation of the telecommunications subsector and market entry by private sector GSM operators. In 1990, there were only 0.3 telephone lines per 100 people in Nigeria. The number of GSM (Global System for Mobile Communications) lines increased from 0.27 million in 2001 to more than 1.57 million in 2002 and about 32 million in 2006. Thus, access to cellular phones increased from only 2 out of 100 persons in Nigeria in 2000 to nearly 42 per 100 in 2008. As of October 2012, Nigeria had a total 109,499,882 active telephone lines (mobile GSM, mobile CDMA and fixed wired/wireless), representing a teledensity of 78.21%, up from 1.89% in 2002. However, internet access lags far behind the growth of telephone lines. Internet users per 100 persons increased from 0.32 in 2002 to 15.86 in 2009. Despite this increase, the access to internet remains low, signifying large scope for improvement.

Focus on MDG 5: Improve maternal health

Figure 5: Maternal Mortality Rate

6 Nigeria Malaria Indicator Survey (NIMS) 2010.7 NNPC 2010.

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2004 2008 2012 2015

800

545

350250

Maternal mortality rate (per 1000 live birth)Pe

r tho

usan

d liv

e bi

rths

47. Improvement in maternal health is another area where the country has made an appreciable impact. The data (Figure 5.1) shows that maternal mortality has been reducing steadily: 800 per 100,000 in 2004; 545 per 100,000 in 2008; and 350 per 100,000 live-births in 2012.This represents about 56.2%and 35.8 per cent declined in 2004 and 2008 figure respectively. When compared with the 2015 benchmark, the 2012 figure is about 28.6 per cent away from the 250 target.

Figure 6: Proportion of births attended by skilled health personnel

2004 2008 2012 20150

102030405060708090

100

36.3 38.953.6

100

Proportion of birth attended by skilled health personnel (%)

48. The 35.8 per cent decline in 2012 in the number of women that die during child birth is in part attributable to the increase in coverage of births attended by skilled health personnel in the country. A skilled health professional (doctor, nurse or midwife/auxiliary midwife, community health worker) can administer interventions, either to prevent or manage life-threatening complications during child births. In Nigeria, the proportion of deliveries attended by skilled health personnel increased from 36.3 per cent in 2004 to 38.9 per cent in 2008. It further rose to 53.6 per cent in 2012.

Figure 7: Contraceptive prevalence rate

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2004 2008 20120

2

4

6

8

10

12

14

16

18

8.2

14.6

17.3

Contraceptive prevalence rate (%)

49. Increased access to safe, affordable and effective methods of contraception is providing individuals with greater choice and opportunities for responsible decision-making in reproductive matters. In addition, contraceptive use has contributed to improvements in maternal and infant health by serving to prevent unintended or closely spaced pregnancies. Contraceptive prevalence increased rapidly to 17.3 per cent from 8.2 per cent in 2004 but dropped to 14.6 per cent in 2008 (Figure 5.3). There is still room for improvement given that various unmet family planning need is progressively rising since 2004 – particularly in the rural areas where awareness is relatively low.

Figure 8: Antenatal care coverage

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)

50. Antenatal care coverage is among the health interventions capable of reducing maternal morbidity. It is critically important to reach women, and timely too, with interventions and information that promote health, wellbeing and survival of mothers as well as their babies. Coverage (at least one visit) with a skilled health worker significantly 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

36

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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 5.4). However, this spectacular 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 about 56.5 per cent for at least one visit and 47.7 per cent for four visits.

Figure 9: Unmet need for family planning

2004 2008 20120

5

10

15

20

25

1720.2 21.5

Unmet need for family planning (%)

51. The unmet need for family planning remains persistently high. The unmet need for family planning—expresses the percentage of women aged 15 to 49, married or in a union, who report the desire to delay or avoid pregnancy, but are not using any form of contraception. In 2004, the figure was about 17 per cent, while the 2008 figure was 20.2 per cent which further decelerated marginally to 21.5 per cent in 2012 (Figure 5.5).

52. As can be deduced from the overview in this chapter, there are a number of clear justifications for the choice of MDG5 for Nigeria’s MDG Acceleration Framework (MAF):

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.

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b) The choice of MDG 5 for MAF will address persistent zonal disparities in health outcomes. Disparities in the achievement of 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 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

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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.

Figure 10: Trends in Maternal and Child mortality (1990 -

2008)8

8 Chart adapted from ‘The Health MDGs (4, 5 & 6): Achievements and Lessons Learnt” Office Of The Senior Special Assistant to The President On MDGs (2012)

39

704

4987

192

800

52100

201

545

40 75157

0

100

200

300

400

500

600

700

800

900

MATERNAL NEONATAL INFANT UNDER 5

1990

2003

2008

APPENDIX 4

Source: OSSAP-MDG

CHAPTER 3

KEY INTERVENTIONS TO ACCELERATE MDG-5 IN NIGERIA

53. In Nigeria, MDG5 specific interventions are being delivered using the principles of integration of services along a continuum of life stages of care starting with: pre-pregnancy period; pregnancy period; intrapartum period (delivery); and the postnatal period. And over the years, a series of Health-MDG response frameworks and plans have been produced in concerted efforts to rise to the challenge of meeting the MDG targets by 20159,10,11,12. The packages of interventions that have been identified and implemented towards meeting the target for MDG-5 consist of the following:

a) Provision and facilitating demand for basic and sometimes comprehensive essential obstetric care services in health facilities to treat pregnancy and delivery-related complications such as eclampsia, haemorrhage, obstructed labour, sepsis, and abortion-related cases, and other causes of maternal mortality identified earlier. Government and development partners have stepped up initiatives to increase availability of Basic Emergency Obstetric and Newborn Care (BEONC) interventions projects across the country.. These are among other things addressing at least 3 well-known delays: delays in decision making to seek treatment; delays between decision-making and reaching a health facility; and delay between arrival at the health facility and receiving appropriate

9 FMOH: Health Sector Reform Programme, 2004-2007.

10FMOH: Achieving Health Related Millennium Development Goals in Nigeria. A Report of the Presidential Committee on Achieving MDG in Nigeria

11 FMOH: National Strategic Health Development Plan (NSHDP) 2010-2015,12 NPC-OSSAP: 5-Year Countdown Strategy: Roadmap to Accelerate Nigeria’s Progress towards Achieving the Millennium Development Goals

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treatment. A number of interventions have been put in place, responding to addressing these delays and in addressing the demand-side of the challenge to reproductive health services. For example, one such program, the Maternal and Child Health Integrated Program (MCHIP) addresses delays associated with maternal and newborn deaths by seeking to improve household and care-seeking practices, empowering the community to create and maintain an enabling environment for increased utilization of maternal and newborn care services wherever they are available, with the main thrust being improvement of EmONC services, with a recognition that response to potential pregnancy and child delivery complications starts in the antenatal period and continues through childbirth and the postnatal period.

b) Developing and implementing a coordinated behavioral change communication strategy to promote essential newborn care practices at community level through women’s groups, religious organizations and other community mobilization structures; scaling up the use of trained household counselors (for example in several northern states; educating women and their families about the danger signs in pregnancy, during and after childbirth; scaling up the use of trained male birth spacing motivators to educate men about the benefits of healthy timing and spacing of births and the use of long-acting contraceptive methods; implementing community systems to respond to immediate referral to primary health clinics and hospitals in the case of complications.

c) Equipping Community health workers with kits to visit pregnant women at home counsel them and encourage them on ANC, danger signs in pregnancy, delivery and after delivery to both mother and baby, birth preparedness with the family including the various preparations for facility delivery e.g. transportation, delivery with a skilled birth attendant and saving towards emergencies, birth spacing and appropriate referrals. These CHWs support the women in labour to the prearranged facility, and make home visits to support the new mother and baby and treat or refer promptly and appropriately in case of mother or baby needing care they cannot render. They counsel and support on appropriate feeding practices and encourage exclusive breastfeeding. This program is called Community based maternal and newborn care (CBNC).

d) Improving access to quality essential obstetric care services.

Health facilities providing maternal and reproductive health services are few and unevenly distributed across the country. Not only are facilities insufficient, majority of the available ones do not have the minimum required health staff (doctors, nurses, mid-wives, CHEWS and JCHWES, etc.), equipment and life-saving skills, to function properly and respond to patient’s needs and expectations, especially during emergencies.

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e) Establishing mentoring linkages between tertiary and primary care facilities and health workers to improve quality of obstetrics and newborn care.

f) Improvement of reproductive health/family planning services and usage. The lack of ready access, affordability and usage of reproductive health services, such as family planning is largely attributed to poverty and the lack of funds to procure these services. Interventions addressing these deficiencies improve usage of reproductive/family planning services and significantly improve maternal health and reduce maternal mortality.

g) Improved financial access to vulnerable groups, especially women. This has involved the implementation of various models of financial protection schemes, notably: conditional-cash-transfer schemes for pregnant women; and NHIS (Community Health Insurance Scheme), to address and ameliorate women’s financial access to services.

h) Improving access through improved geographic equity and access to health care services. Government at the Federal level, through the NPHCDA has been involved in the expansion of the construction of new PHC facilities. A number of States Governments have also launched various forms of initiatives, including free health care to targeted groups in addressing expansion and access to health care services.

i) Development of a network of PHC centers linked to secondary referral health facilities that are well equipped and staffed to facilitate access to emergency obstetric care facilities in case of emergency.

j) Renovation of health facilities with a focus on areas such as Antenatal Clinics, labour wards and general maternity sections, and provision of basic drugs, commodities, including equipment for treatment of common MNCH illnesses to improve the delivery of MNCH services.

k) Construction of boreholes for provision of portable water supply to improve quality of care in health facilities

l) Pregnancy period interventions, consisting of: focused Antenatal care (FANC); and Prevention of Mother to Child Transmission of HIV. The goals of focused antenatal care are to promote maternal and new-born health and survival through: Early detection and treatment of problems and complications, Prevention of complications and diseases, Birth preparedness and complication readiness and Health promotion.

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m) Strengthening referrals: identification and capacity building of referral systems including focal persons at community and in health facilities to effectively refer clients to the appropriate level of health facility.

n) Adolescent/Pre-pregnancy intervention consisting of: Family Planning services; prevention of unsafe abortion and post abortion care; prevention and management of sexually transmitted infections; and prevention of cancer of the cervix.

o) Prevention of Mother-To-Child Transmission (PMTCT) of HIV: Nigeria accounts for about 30% of Global burden of mother to child transmission of HIV. The risk of transmission of HIV through heterosexual means is higher during pregnancy. HIV can be transmitted to the unborn child during pregnancy, labour and delivery and through breastfeeding. ARV prophylaxis, provided during pregnancy and post natal period through breastfeeding in accordance with the recent WHO guidelines can reduce transmission below 5% and accelerate virtual elimination of mother to child transmission of HIV. Nigeria has an elimination plan for mother to child transmission of HIV.

p) Prevention of Cancer of the Cervix. Cancer of the cervix is the commonest cancer and the leading cause of cancer mortality among women in developing countries. About 270,000 women die from cancer of the cervix annually, 85% of which occurs in resource poor settings due to – late diagnosis and presentation in advance stages of the disease. In Nigeria – WHO has estimated that about 14, 550 new cases occur in 2008, 8 out of 10 presenting with an advanced disease and with mortality rate of about 23%. It is believed that HPV types 16 &18 are responsible for most cases in Nigeria as in other countries worldwide. Other risk factors may include: Tobacco use, lack of screening and adequate treatment of precancerous lesions and Human Papilloma Virus and Human immunodeficiency Virus (HIV) co-infection. The National cervical cancer control policy centered on Public Health approach employs a combination of vaccination, education, screening, treatment and linkages with other programmes. Primary prevention include the use of Bivalent Vaccine which acts against genotypes 16 and 18 - Cervarix –GSK and is recommended for ages 9-15 years and this delivered through School; Health Centre; and community outreach programmes. Secondary Prevention consists of screening for pre-cancerous lesions and early diagnosis followed by adequate treatment; and Visual Inspection with Acetic Acid/Lugol’s Iodine- VIA/VILI. Over 1000 service providers (Doctors and Midwives) have been trained on VIA/VILI. The focus is to integrate VIA into SRH and HIV services at PHCs level

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q) Intrapartum (Delivery) care intervention, consisting of access and use of skilled birth attendants, Emergency Obstetric and Neonatal care, and Referral.

r) Postnatal Care interventions, consisting of: Family planning; Prevention and management of post-partum sepsis and anaemia. A large proportion of maternal and neonatal deaths occur during the first 24 hours after delivery. Thus, prompt postnatal care is important for both the mother and the child to treat complications arising from the delivery, as well as to provide the mother with important information on how to care for herself and her child. It is recommended that all women receive a health check within three days of giving birth. According to NDHS 2008, 56% of women did not receive postnatal care up to 6 weeks after delivery. This intervention needs to be scaled up to avert maternal death occurring during the first 24 hours.

s) Improving access to health facilities for women and children in the community by training volunteer drivers to transport them to health facilities during emergencies (the Emergency Transport Scheme).

t) Developing, and distributing of service delivery protocols and job aids to health facilities and training of health workers to manage MNCH conditions according to standard protocols.

u) Setting up and building the capacity of Facility Health Committees (FHCs) to hold health facilities accountable to deliver quality care to the community and to participate in improving community response to the facility needs and care seeking. The members of these committees include community members and health providers.

v) Midwives Service Scheme: Deplored 2,488 midwives with 2323 retained as at April 2010. Seen as excellent initiative which promises good impact if kept on track.

w) Community Health Insurance Scheme: An excellent initiative targeting women and children and removing financial barriers to demand and utilization of health services.

x) Bi-annual Maternal, Newborn and Child Health Week (MNCHW) all over the country to improve coverage of selected high impact interventions and promote key MNCH household and community practices.

54. As illustrated in the chart below current coverage for all high impact interventions fall short of expected levels. With the exception of the South-West Zone with 165/100,000 MMR, which is below the

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MDG5 target of 250/100,000 MMR for Nigeria, other zones carry substantial burden of maternal mortality. Nigeria needs to do more in ANC, Skilled Birth Attendance, EmONC and PMTCT.

Prioritization of Key Interventions

55. Following stakeholders consultation to accelerate the achievement of MDG5, the under-listed intervention areas have been identified as key priority areas of work for the accelerated achievement of MDG5.

f) Family Planningg) Skilled Birth Attendantsh) Emergency Obstetric and New-born carei) Universal Coverage of Ante-Natal and Post-Natal carej) Improved Referral System

Fig. 11

Table 1: MDG 5 FocusMDG5 Target Indicators MAF Key

Intervention AreaImprove Maternal Health

Target 5.A: Reduce by 3/4th between 1990 and 2015, the maternal mortality ratio

1. Maternal mortality ratio

2. Proportion of births attended by skilled health personnel

Emergency Obstetric and Newborn Care

Skilled Birth Attendant

Improving Referral System

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Target 5.B: Achieve, by 2015, universal access to reproductive health

3. Contraceptive prevalence rate

4. Adolescent birth rate

5. Antenatal care coverage (at least one visit and at least four visits)

6. Unmet need for family planning

Family Planning

Family Planning

Focused Ante-Natal Care

Family Planning

56. Family Planning: Family planning is defined as a way of thinking or living that is voluntarily adapted based upon knowledge, attitude and responsible decision of an individual or couples in order to promote health and welfare of the family and thereby contributing to the socio economic development of the country. Family Planning (FP) is one of the fundamental pillars of safe mother hood and one of the quick wins in addressing maternal morbidity and mortality. Studies have shown that effective FP programme will reduce maternal deaths 30% and 20% for child deaths, currently FP utilization is low with CPR of 17.3% (MICS, 2012) and unmet need 21.5% (MICS, 2012). FP addresses the high risks pregnancies which constitutes about two-thirds of pregnancies.

57. Prevention of unsafe abortion and post abortion care consists of health care services, family planning counseling and referral services offered to unmarried adolescents to prevent unwanted pregnancies and to a woman as a result of complication arising from an induced or spontaneous abortion which could be inevitable, incomplete or septic. Unsafe abortion accounts for 11% of maternal deaths in Nigeria. In Nigeria, abortion is legally restricted to life threatening conditions affecting the mother. Approximately 610,000 abortions occur annually and 80% of patients with abortion complications are adolescents. Currently the Provision of Post abortion care services are being provided only in 12 States.

58. Effective family planning plays a pivotal role in the delay of first pregnancy, child-spacing and the prevention of sexually transmitted infections (STIs), including the Human Immunodeficiency Virus (HIV). Delaying first pregnancy requires the provision of adequate adolescent reproductive health information, including family planning, to all adolescents or young adults (15–24 years), preferably prior to

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marriage. Nigeria has a high total fertility rate of 5.7, with rates as high as 6.3 in the rural areas. Nigeria also has a high rate of early marriages and a low rate of modern contraceptive use. Only 17.3% of married women report use of modern contraceptives. Over 20% of Nigerian women have an unmet need for family planning, 15% for spacing and 5% for limiting pregnancies. Children born too soon after a previous birth, especially if the interval between the births is less than two years, have an increased risk of sickness and death at an early age. Yet 8% of births are less than 18 months apart and 24% have an interval of less than two years. Government has approved a policy on the distribution of free contraceptive commodities in all public health facilities to eliminate financial barrier to services, in addition to a Counterpart contribution of $3m annually from 2011 to support the free distribution of contraceptive commodities. At the London 2012 FP Summit commitments; Government has made a commitment to provide additional $8.35 million annually over the next four years for a dedicated budget line item for Life Saving UN Commission commodities. This increases Nigeria’s total commitment for the next four years from $12 million to $45.4 million, a significant increase. Government has further approved the integration of FP commodities in the National Health Insurance Scheme (NHIS) package

59. Skilled Birth Attendants: The skilled-birth attendant intervention refers to the process by which a pregnant woman and her infants are provided with adequate care during labour, birth and the post natal period by an accredited health professional who possesses the knowledge and a defined set of cognitive and practical skills that enable the individual to provide safe and effective health care during childbirth to women and their infants in the home, health center, and hospital settings. Skilled attendants include midwives, doctors, and nurses with midwifery and life-saving skills. This definition excludes traditional birth attendants whether trained or not (WHO, 2006). In order for this process to take place, the skilled birth attendant must have the necessary skills on Expanded Life Saving Skills (Doctors), Life Saving Skills (Midwives) and Modified Life Saving Skills (CHEWS) and must be supported by an enabling environment at various levels of the health care system, including a supportive policy and regulatory framework, adequate supplies, equipment and infrastructure. Emergency Obstetric and Newborn Care services ensure that care is provided by skilled birth attendants to pregnant women with obstetrics complications and their newborn. Generally, 85% of women will have safe delivery without complication with only 15% experiencing obstetric complications and it is this that contributes to the high maternal mortality ratio. According to W.H.O, Emergency Obstetric care can be divided into Basic and Comprehensive Emergency Obstetric care. The six Basic Emergency Obstetric Care service functions to be provided at the PHCs includes: Administer parenteral antibiotics; Administer uterotonic drugs (i.e. parenteral

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oxytocin); Administer parenteral anticonvulsants for preeclampsia and eclampsia (Magnesium sulphate); Manual removal of placenta; removal of retained products (e.g. manual vacuum aspiration, dilation and curettage); perform assisted vaginal delivery (e.g. vacuum extraction, forceps delivery). And in addition to the 6 functions of Basic Emergency Obstetric Care, Comprehensive Emergency Obstetric Care services are to: perform surgery e.g. Caesarean section; and perform blood transfusion services. Currently, there is no data in NDHS 2008 that capture the % of facilities providing Basic and Comprehensive Emergency obstetric services.

60. The Midwives Service Scheme (MSS) represents, to date, the most visible response, from Government, to address the issue of putting skilled birth-attendants to the reach of pregnant women. The innovation was launched in 2009 to reduce the high rates of maternal and child mortality. Significant changes have become apparent since launching the scheme with attendant challenges. Within the programme, key health systems issues are also being addressed such as the availability of essential health care commodities in addition to the redistribution of skilled human resources to remote rural areas, addressing some of the inequities in the health system.

61. The MSS specifically addresses the human resource needs for SBAs in rural primary care, based on the evidence that when the number of skilled-birth-attendants (SBAs) increases, utilisation of services increases, women’s satisfaction with care improves, and maternal and newborn mortality decrease.

62. The MSS engages three categories of midwives: the newly graduated, the unemployed and the retired but able. They are posted for one year (renewable subject to satisfactory performance) to selected primary healthcare centres (PHCs) in rural communities. The scheme is the largest of its kind on the continent of Africa; increasing the coverage of skilled birth attendants (SBAs) through the recruitment of 4,000 midwives and 1000 community health workers as frontline workers, for the provision of MNCH services including family planning. The scheme is being further expanded with additional 3,426 Midwives/CHEWs under the 2012 Subsidy Reinvestment and Empowerment Program (SURE-P) of the Federal Government

63. The scheme has encountered several challenges whilst making good progress towards achieving its objectives. Currently there is the need to fill existing gaps with midwives particularly in the North East and North West zones and this is mainly because of the inadequate production of midwives by the two zones and the recent security challenges in these zones. The specific objectives of the scheme remains:

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a) To increase the proportion of primary health care facilities manned by midwives offering 24Hr service by 80% in MSS target areas by December 2015.

b) To ensure that all midwives recruited under MSS are trained on Life Saving Skills (LSS).

c) To increase the proportion of primary health care facilities providing Basic Emergency Obstetric and Newborn Care (BEmONC) in MSS target areas by 60% by December 2015.

d) To increase the proportion of pregnant women receiving focussed antenatal care in MSS facilities by 80% by December 2015.

e) To increase the proportion of deliveries attended to by Skilled Birth Attendants in MSS target areas by 72.6% by December 2015.

f) To increase Family Planning attendance in MSS target areas by 50% by 2015.

g) To reduce Maternal, Newborn and Child mortality by 60% in the MSS target areas by December 2015.

64. Operationally, the MSS adopts a “Cluster Model” or a “Hub and Spoke” structure wherein four (4) selected primary health centres with the capacity to provide Basic Emergency Obstetric Care (BEmOC) are clustered around a General Hospital with the capacity to provide Comprehensive Emergency Obstetric Care (CEOC) which serves as the referral facility. Presently there are 250 Clusters comprising 1000 PHCs and 250 General hospitals. This needs to be considerably scaled up.

Fig. 12 MSS Cluster Model

65. Each of the PHC facility within the Cluster has a compliment of

four (4) midwives for 24 hour coverage. The midwives and community health workers (CHWs) provide facility and community based maternal, newborn and child health services including outreaches in rural hard to reach areas. In the existing MSS response, the CHWs are deployed to the North East, North West zones and some hard to reach facilities in the North Central zone where the mortality burden is

49

GH

PHC 4

PHC 3

PHC 2

PHC 1

APPENDIX 4

highest. This is to compliment the services of the midwives in the communities.

66. As an intervention, the MSS has made tremendous progress since inception and is now beginning to show benefits to the women and families in rural communities in Nigeria. The MSS has:

a) engendered a better nationwide coordinated response, resulting in the Governors of the 36 States and the FCT signing a Memorandum of Understanding (MOU) with the Federal Government to support and sustain the MSS by providing accommodation and supplementing the allowances paid to the midwives in the scheme; the scheme has begun to share its successes and challenges with states across the country and encouraging them to replicate the scheme in other rural PHC facilities. This will enable sustainability and coverage of the scheme’s services to communities in rural areas;

b) fostered the emergence of viable Ward Development Committees established around all MSS facilities for the purpose of engendering community participation and ownership which is an important component of the Scheme. The committees also have the responsibility of monitoring the presence of the midwives in the communities, providing them with accommodation, security and an enabling environment to provide services for their communities.

c) resulted in the provisioning of essential commodities as incentives to pregnant women and supports the smooth running of facilities. These include the provision of; Mama kits, Midwifery kits, Drugs, basic equipment like “Blood Pressure” apparatus, Stethoscopes, weighing scales, facility/community registers, protocols and service guidelines to all PHC facilities under the Scheme. For example, 588,000 doses of Misoprostol tablets with other relevant materials were distributed to all MSS facilities nationwide. This ensured availability of the drug in MSS facilities

d) piloted the use of ICT innovation in 160 MSS PHC facilities and 40 referral General hospitals connected with ICT facilities such as voice over rural telephony, data transmission and internet/video conferencing and remote training and mentoring. In addition the scheme utilizes a mobile health technology called “Mobile Application Data Exchange System” (MADEX) for the collection of data from rural MSS facilities and onward transmission to a central place for collation, analyses and reporting.

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e) resulted in quarterly cluster monitoring of the MSS facilities and midwives/community health workers and biannual Integrated Supportive Supervision (ISS) to mentor and support the midwives in the field.

f) trained 4000 Midwives on Emergency Life Saving Skills to enhance the quality of care provided to the communities.

g) conducted Expanded Life Saving Skills (ELSS) for Medical Officers from the designated referral General Hospitals in the 36 States and the FCT to strengthen their capacity on comprehensive emergency obstetric care.

h) engaged 1000 CHWs and trained them on Essential basic obstetric and new born care. They have been deployed to rural and hard to reach communities in the North East, North West and part of the North Central zones. All trainings were done in partnership with the Schools of Midwifery and Health Technology in the 36 States and Federal Capital Territory (FCT) of Nigeria.

i) trained Ninety Four Tutors from thirty seven Schools of Midwifery nationwide on the use of Misoprostol. The TOT was followed by the training of Midwives from 1,000 MSS facilities to enhance the effective management of postpartum haemorrhage at the Community and PHC levels using Misoprostol.

j) provided TOT on Quality improvement for One Hundred and Sixty One Midwife Tutors from the 37 schools of Midwifery with the following outcomes; establishment of critical mass of Quality Improvement Trainers nationwide, strengthen institutions on QI with its multiplying effect, QI champions were established nationwide and facilitation skills of participants were sharpened.

k) trained one thousand officer’s in-charge and four thousand Midwives from the 1000 MSS facilities on Quality Improvement to improve quality of service delivery at the facility level. Each facility currently has a functional Quality improvement team in place.

l) introduced routine Maternal Death Review or Audit (MDR) in MSS facilities/communities. The exercise was designed to determine the root causes of maternal mortality in a supportive environment, provide evidence for local decision-making on the appropriate interventions needed to reduce maternal mortality

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67. MSS Outcomes: Available information from MSS facilities by December 2012, when compared to the baseline data (December 2009) before the scheme started, provides evidence on progress towards achieving the objectives of the Midwives Service Scheme. The outcomes confirm significant improvements in the core indicators as compared to baseline data. Fig. 13: Overview of MSS Progress

68. The MSS remains a strategic intervention because of the recognition that improving the skills of birth-attendants in areas with the greatest need is achievable within a short period. The strategic redistribution of these health workers potentially serves as a model??? effective, realistic and efficient response. It can be adopted to suit the local situation to ensure successful implementation. Some of these include the signing of a Memorandum of Understanding (MoU) with all State Governors detailing their responsibilities and the setting up of Ward Development Committees where each of the 1000 MSS facilities is located. Benefits of the scheme also include raising awareness on the utilization of skilled birth attendants at delivery, as a human resource intervention. It has created platform for effective implementation of other health interventions particularly at the rural areas. In addition, the scheme adopted the approach of task shifting in areas where there are issues of retention of the midwives by engaging Community Health Workers (CHW) resident in these areas to overcome these challenges. The scheme has also fostered partnership, working with states and local governments as well as Development Partners to ensure synergy in implementation.

Emergency Obstetric and New-born care (EmONC)

69. Globally, 15% of all pregnant women develop obstetric complications, most of which are unpredictable. Services for

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emergency care must therefore be available in order to prevent maternal and/or neonatal death and disability. Certain critical services, or signal functions, have been identified as essential for the treatment of obstetric complications to reduce maternal deaths. These signal functions provide a basis for assessing, training, equipping, and monitoring obstetric services.

70. A Basic EmOC (BEmOC) facility can administer parenteral antibiotics, oxytocics and anticonvulsants. It can perform manual removal of the placenta and retained products and perform assisted childbirth. A Comprehensive EmOC (CEmOC) facility, in contrast, can perform all BEmOC functions in addition to performing surgery (e.g., caesarean section) and safe blood transfusions. The Nigerian BEmOC standard includes two additional signal functions in the guideline: 24-hour service coverage and a minimum of four midwives per facility. Neonatal resuscitation has been incorporated as a signal function to save newborn lives for basic and comprehensive care at the global level as an additional signal function which explains the renaming as basic and comprehensive EmONC.

71. WHO recommends that for every 500,000 population, the minimum acceptable level is five EmOC facilities, at least one of which provides comprehensive care. According to the FMOH/UNFPA EmOC survey in 2003, only Lagos state met the standard of four BEmOC facilities per 500,000 people, combining both public and private healthcare providers. Just seven states met the standard of one CEmOC facility per 500,000 people, considering public facilities alone. In all states surveyed, a higher proportion of private facilities met the EmOC standard compared with public health facilities, but both fell below the recommended EmOC levels. Many facilities in Nigeria do not meet the national staffing standard for BEmOC. While all tertiary facilities in 12 surveyed states provide 24-hour coverage, only 90% of secondary facilities provide the same service. Not only is there almost no 24-hour coverage in primary healthcare (PHC) facilities, which are often the closest facilities for pregnant women, but many do not have a qualified midwife present. One survey found that in all of Nigeria, only one PHC facility (in Lagos state) met the national BEmOC standard of a minimum of four midwives per facility with 24-hour service coverage. Many health facilities generally lack adequate material resources, as well as basic infrastructure such as water and electricity. This has a significant impact on health facilities’ ability to offer quality obstetric care. As one primary healthcare worker in the EmOC survey stated, “There is a lack of drugs and equipment, no suction machine, no water, no power supply. We deliver babies using light from lanterns and candles, and also do vaginal exams with them as well. The same EmOC survey shows that 21% of secondary health facilities and most primary healthcare centres have no functional equipment to take blood pressure measurement in their labour wards.

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The preceding situation obtained before the launching of the MSS programme in 2009.

72. The estimated proportion of women who will experience complications requiring a caesarean section is between 5% and 15%. The prevalence of women who give birth by caesarean section can serve as an indicator of whether EmOC facilities meet women’s needs when they present with obstetric emergencies. While a high caesarean section rate can also reflect poor services, Nigeria does not meet even the low threshold, as just about 2% of babies are delivered using this procedure and some zones recording coverage as low as 0.4%.

Universal Coverage of Ante-Natal and Post-Natal care

73. Women are advised to attend at least four antenatal visits, during which they should receive evidence-based examinations and screenings. These services are offered through a package referred to as focused ANC. The purpose of focused ANC is to provide better care for pregnant women with a goal-oriented approach, which emphasizes content rather than the sheer number of ANC visits. The content of ANC is an essential component of the quality of services. Focused ANC hinges on the principle that every pregnancy is at risk of complications and should be monitored. According to NDHS 2008, 87% of Nigerian mothers who attend ANC have their weight measured, 85% have a blood pressure taken and 74% have a blood sample taken. Three-quarters have a urine sample taken, 54% receive iron tablets, and 61% are informed of signs of pregnancy complications. Overall, 67.7% of Nigerian mothers make at least one ANC contact, and 57.6% made four or more ANC visits (MICS, 2012), with significant disparities between urban and rural mothers. Just over two-thirds (2/3rd) of urban women made four or more ANC visits compared with only 34% of rural women.

74. It is important that women attend ANC at the early stages of pregnancy in order to benefit from interventions that require early or repeat visits. Among all women who receive ANC in Nigeria, only 16% make their first ANC visit during the first three months of pregnancy. One survey of safe motherhood in northern Nigeria found that more than half (53%) of the women who attended ANC made their first visit from the sixth month of pregnancy. Culturally, it is common for Nigerian woman not to disclose their pregnancy early for fear of evil spirits.

75. A multi-country randomized control trial by WHO and a systematic review showed that essential interventions can be provided over four visits at specified intervals, at least for healthy women with no underlying medical problems. This evidence has prompted WHO to define a new model of ANC based on four goal-oriented visits. The

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Nigerian National Policy Guidelines for Reproductive Health has recommended a minimum of four ANC visits as follows:

a) Visit 1: before 16 weeks of pregnancyb) Visit 2: between 20 and 24 weeks of pregnancyc) Visit 3: between 28 and 32 weeksd) Visit 4: at 36 weeks or later

76. Two key interventions administered during FANC includes: Intermittent Preventive treatment (IPT) for Malaria using Sulphadoxine pyrimethamine (SP) and administration of Tetanus Toxoid (TT). The implementation of the FANC is based on WHO guidance of 2006 that countries should do away with the traditional every 4 weeks visit by pregnant women for check-up. However women with complications, special needs, or conditions beyond the scope of basic care may require additional visits.

Improved Referral System

77. Effective referral systems are considered critical for reducing maternal mortality, as these ensures ready and timely access to appropriate case management, especially in the case of pregnancy related and newborn complications. Some of the critical action steps in an effective referral systems include: engaging the community to develop effective community transport system for referral purposes; encouraging adequate awareness creation on birth preparedness to limit delays as much as possible in cases of emergency; providing ambulances and other transport evacuation arrangements to health facilities and their maintenance and sustainability; enabling two-way communication between the community, PHC facilities and referral centres including through the use of mobile phones; facilitating pre-payment schemes (such as the NHIS and other community mechanisms) for transport to a referral facility; putting functional triage systems in place to minimize delays at health facilities; ensuring 24-hour availability of maternity services at all health facilities.

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CHAPTER FOURMDG5 BOTTLENECKS ANALYSIS AND PRIORITISATION

Maternal Mortality in Perspective 78. In spite of successive policies and interventions to curb maternal

mortality and promote maternal health in Nigeria, there remain gaps between current status and 2015 MDGs targets on several maternal mortality indicators. Recent estimates indicate that up to 1 million13 women and children die every year in Nigeria from largely preventable causes; 33,000 women are estimated to die from pregnancy-related causes, and about 946,000 children under-5 die of which 241,000 are newborns. The preventable causes of morbidity and mortality among women include pregnancy, anemia due to malaria, intra-partum and post-partum hemorrhage, post-partum sepsis, eclampsia and complications from obstructed labor.

79. The scale and intensity of the challenges of accelerating progress on maternal health (MDG 5) are evidenced by the fact that many indicators lag behind the 2015 targets. Besides, the sharp disparity in maternal health between subnational units (geopolitical zones and states) constitutes an important dimension of the maternal mortality burden in the country. 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 the most basic services do not reach the poorest segments.

Evidence of the Gaps80. Recent statistics on maternal mortality rate point to improved

progress towards the 2015 target, as shown by a decline from 545 per 100,000 in 2008 to 350 per 100,000 in 2012, against the 2015 target of 250 per 100,000. 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-thirds14 of maternal deaths occur during childbirth, and are closely linked to intrapartum stillbirths and early neonatal deaths.

Bottlenecks to Implementation

13 Saving One Million Lives 2012.14 Integrated Maternal, Neonatal and Child Health Strategy Paper 2011.

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81. So far, MDG5 interventions are making slower-than-desired results towards the 2015 targets. The drawback comes from wide-ranging bottlenecks that impede implementation. There are two broad types of bottlenecks: sector-specific and cross-cutting. Sector-specific bottlenecks lie squarely within the ambit of the Federal and State Ministries of Health and Local Government Health Departments or affiliated agencies. Cross-cutting bottlenecks lie outside the powers of the Federal and State Ministries of Health and Local Government Health Departments. They are inter-sectoral and economy-wide problems that affect the results-based implementation of the MDG5 interventions.

82. Sector-specific bottlenecks can be reclassified to any of the following four categories: policy and planning; budget and financing; service delivery (supply-side); and, service utilization (demand-side). Existing monitoring and assessment reports and MDGs documentation have identified several bottlenecks militating against the achievement of targets.

Policy and planning83. Policy coordination difficulties: Like other development sectors, the

Nigeria health system is underpinned by policy and fiscal decentralization and concurrent responsibilities between the three tiers of government – federal, state and local governments. While responsibility sharing, by principle, could promote accountability, the lack of adequate coordination and synergy in the provision and management of healthcare across the three levels of governmental authority has tended to distort service delivery, reduce the coherence of actions and diminish collective impacts of interventions. While the local governments have critical mandates in primary health care, including maternal health, they lack the requisite institutional and human capacity and resources to effectively discharge their responsibilities. Consequently, there is often significant fragmentation of efforts, suboptimal coordination, and focus on inputs and processes15, rather than the outcomes and results that matter.

84. Inadequate engagement of the private sector: The private sector, which provides at least half of the health services is fragmented, poorly regulated, poorly understood and practically unengaged by the public health sector, especially at the primary care level.

85. Inadequate strategy for dealing with inequalities: The persistence of subnational (geopolitical zone, state, rural/urban) disparities in maternal healthcare services and the resultant sharp variations in MMR reveal the ineffectiveness of the existing strategy and approach to solving the imbalances.

15 Saving One Million Lives

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86. Inadequate monitoring and shortage of good quality tracking data: Effective monitoring of service delivery (performance of personnel, availability and quality of services, availability and use of commodities) for the reshuffling of resources and realignment of efforts require good quality data. The data should ideally mirror intervention pathways (including hiccups) from inputs/activities through outputs and outcomes. But, the data system for tracking the maternal healthcare results chain – from inputs through outputs and outcomes – is largely undeveloped, piecemeal and not institutionalized. Hence, the effectiveness of spending in translating to outputs and outcomes is not clearly delineated across the three tiers of government, thereby leaving ample room for ambiguity and anonymity in attribution of outcomes. Moreover, the lack of reliable and consistent maternal health service-delivery and service-use data makes it difficult for troubleshooting and benchmarking against baselines and targets. The situation hampers the ability of managers and operators of the maternal health care system to make the needed responses in precise and timely manner.

Financing and budgeting87. Despite improved public spending on health in recent years, up to

three quarters of total health expenditure is borne by households through out-of-pocket payments for healthcare. The cost of care, particularly in the case of obstetric emergency is one of the most important barriers to healthcare u

Service delivery (supply-side)88. To realise targets for maternal healthcare requires adequate and

well-motivated health personnel, sufficient supplies/inputs and key logistics that work towards good quality, very responsive and readily available maternal health care. The implementation pathways of MDG5 interventions are beset with missing links and difficulties. As enumerated in existing documents, these difficulties and missing links include shortage of skilled health personnel particularly in rural areas, irregularity of skilled health personnel in rural primary health care centres, delays between arrival and getting treatment, scarcity of emergency obstetric care services, lack of adequate kits for TBAs, shortage of critical supplies in primary health care centres and the lack of adequate attention to special (disadvantaged) groups of mothers. Other often-mentioned bottlenecks include non-availability of family planning services, delayed completion of primary health care centres and delays in furnishing with complementary inputs and sometimes inappropriate project selection/location. For example, it was specifically reported that most of the 23,000 frontline primary health care (PHC) facilities often lack skilled practitioners, and a large percentage of the facilities do not have basic pharmaceuticals and commodities consistently in-stock.

Service utilisation (demand-side)

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89. Services cannot be said to be successfully delivered until they are used beneficially by intended persons or groups. The manner and extent of use of maternal health care services is a final outcome that signals the effectiveness of the entire intervention chain. Existing reports show that the use of maternal health care services lags far behind what is required to achieve MDG5. Intended mothers are not able to use maternal health care services because of a number of bottlenecks in availability, access (physical and financial), regularity, lack of information about what to do in emergency cases, delay in decision to seek treatment, delay between decision to seek attention and reaching a health facility, inability of the poor to afford maternal health care services. Other user-related impediments to maternal health care are sociocultural and traditional beliefs, practices and attitudes.

90. Cross-cutting bottlenecks pertain to low public accountability, inadequate value for public spending, corruption, shortage of infrastructure (power and roads/transport), particularly in rural areas, negative attitudes towards serving in rural areas, lack of rigorous project appraisal and insecurity.

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Analysis and Prioritisation of the Bottlenecks

91. Specific Bottlenecks against the Prioritised Interventions: The identified bottlenecks have been analysed with respect to the respective prioritised interventions. The match of prioritised bottlenecks against the prioritised interventions is given in the table below:

Table 2: Bottlenecks affecting the prioritised interventionsPrioritised bottleneck

Bottleneck category

Prioritised Interventions

Family planning services

Skilled birth attendance

Emergency Obstetric & Newborn Care

Universal Coverage of Antenatal and Postnatal Care

Improved Referral Services

Sociocultural religious barrier

Cross cutting and systemic

Inadequate trained personnel

Service delivery

Low male involvement/ uptake

Systemic

Inadequate Skilled Birth Attendants

Service delivery

Uneven distribution of available Skilled Birth Attendants (SBA)

Service Delivery

Inadequate Referral Training for Skilled Birth Attendants (SBA)

Service delivery

Lack of functional equipment and facilities

Service delivery

Poor incentives especially in rural area

Budget and financing

Shortage of skilled health personnel

Service Delivery

Inadequate equipment and supplies

Service Delivery

Delay in accessing care services

Service Utilization

Inadequate political will

Cross-cutting

Poor access to health facilities in rural areas

Service Delivery

Poor attitude of health workers

Service Delivery

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Lack of Legislation Policy and Planning

Inadequate ambulance services

Service Delivery

Poor communication and feedback system

Service Delivery

System delay Service Delivery

92. Indications from matching bottlenecks against prioritised interventions: The matching of bottlenecks against the prioritised interventions reveals some critical tips as follows: Majority of the prioritised bottlenecks are in the service delivery category. They include: inadequate number of skilled health workers; inadequate training of health personnel; irregular services at care centres; uneven distribution of health professionals; uneven distribution of commodities; and poor attitudes of health workers. Un-supportive sociocultural and traditional beliefs, attitudes and practices cut across the prioritised interventions. The quantity and quality of funding is both an underlying and direct form of bottleneck for the prioritised interventions – underlying, in the sense of inadequate budget/funds for logistics, personnel incentives, infrastructure and commodities and ‘direct’ in the sense of poor quality of spending, leading to low value for money spent. The service delivery-related bottlenecks are underpinned by systemic failure of the supervision and monitoring system, as a result of which service readjustments are either non-existent or too slow to bring about positive results.

Prioritised Bottlenecks: Analysis of ‘Potential Impact and Solution Feasibility’

93. Further analysis on the bottlenecks was done by assessing the ‘potential impact’ and ‘feasibility’ of removing the specific bottleneck. The ‘potential impact’ relates to the extent to which removal of the bottleneck will accelerate achievement of the MDGs 2015 target for reducing maternal mortality rate. On the other hand, ‘feasibility’ refers to the prospects for solving the bottleneck in the near-term, that is, through 2015. Using this framework, the bottlenecks were assessed as follows:

Table 3: Bottleneck Assessment ScorecardColour code

Potential impact

Amenability to near-term solution

Achieves acceleration

Very amenable

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Potentially achieves acceleration.

Moderately amenable

Probably does not help acceleration

Marginally amenable

Does not help acceleration

Not amenable

Table 4: The prioritized bottlenecks are scrutinised based on the scorecard schema given above.Prioritized interventions

Identified bottlenecks

Possible Impact

Amenability to near-term solution

Overall Acceleration Potential

Family planning services

Sociocultural religious barrier

Not likely

Inadequate trained personnel

Yes

Inadequate male involvement

Likely

Skilled Birth Attendance

Inadequate trained personnel

Likely

Uneven distribution of available Skilled Birth Attendants

Yes

Inadequate referential training for Skilled Birth Attendants

Yes

Lack of functional equipment and facilities

Yes

Poor incentives

Yes

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Prioritized interventions

Identified bottlenecks

Possible Impact

Amenability to near-term solution

Overall Acceleration Potential

especially in rural areas

Emergency Obstetric & Newborn Care (EMONC)

Shortage of Skilled Health Personnel

Likely

Inadequate equipment and supplies

Yes

Delay in accessing care

Not likely

Universal Coverage of Antenatal and Postnatal Care

Socio-cultural and religious barrier

Not Likely

Inadequate political will

Not likely

Poor access to health facilities especially in rural areas

Likely

Poor attitude of health workers

Likely

Lack of legislation

Improved Referral Services

Inadequate ambulance services

Yes

Poor communication and feedback system

Likely

System delay Yes

CHAPTER 5ACCELERATION SOLUTIONS

Introduction

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94. Following the identification of the prioritized interventions as well as the prioritized bottlenecks, in the two preceding chapters, the focus of chapter 5 therefore is on the presentation of the acceleration solutions to the prioritized bottlenecks. The United Nations MAF Operational Notes define a solution as a single action or package of actions taken to resolve an intervention bottleneck in the near term to produce quick impact on the ground. Consequently, in order to get the right solution, a solution analysis was carried out during the Stakeholders’ Technical workshop. The workshop participants developed a comprehensive list of bottleneck solutions and after critical examination they, finally came up with a list of prioritized solutions which ultimately constitute the acceleration solutions for MDG 5.

Basis for Selecting the Acceleration Solutions

95. Participants at the Stakeholders’ workshop evaluated a solution on the basis of two dimensions namely: impact and feasibility. Accordingly, four criteria were used to assess an impact: its magnitude; described as the magnitude of the solution’s impact on solving the bottleneck, including impact on priority MDG target, indirect spill-over impact, and equitable impact; (b) speed of impact; described as length of time to realize the solution’s impact; (c) sustainability of impact; and (d) adverse impact; described as magnitude of negative impact, within or outside the sector.

96. The feasibility dimension of solutions is evaluated on the basis of four criteria also: (a) governance; seen in terms of rule of law, transparency and accountability mechanisms to implement the solution; (b) capacity; seen in terms of ability to plan, implement and monitor the solution; (c) funding availability; seen as the availability of funds to cover the solution’s cost; and, (d) additional factors; seen in terms of additional factors that may impede the solution.

97. The analysis of the impact and feasibility of a solution formed the basis for the final list of acceleration solutions. The rest of this chapter is a presentation of the acceleration solutions to the prioritized bottlenecks.

Family Planning

98. Solutions to Socio-Cultural Religious Barrierd) Scale-up sensitization of traditional leaders, religious leaders,

Community Based Organizations (CBO), Faith Based Organizations (FBO) through appropriate media.

e) Reinforce teaching of family life education in secondary schools curriculum.

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f) Establish more functional youth friendly centres.99. Solutions to Inadequate Trained Personnel

a) Recruitment of more trained personnel.b) Intensify training and retraining of health workers including

community based resourced persons100. Solution to Poor/Inadequate Male Involvement

b) Sensitization and mobilization of the male folk to take leadership in health matters

Skilled Birth Attendants/Attendance

101. Solutions to Inadequate Skilled Birth Attendantse) Recruitment of more Skilled Birth Attendants (SBA).f) Training and retraining of Skilled Birth Attendants (SBA).g) Mandatory posting of NYSC Skilled Birth Attendants (SBA) to

rural areas.h) Mandatory one year posting internship in rural areas.i) Task shifting/sharing for Skilled Birth Attendants (SBA).

102. Solutions to Uneven distribution of available Skilled Birth Attendants

a) Additional incentives for rural posting.b) Doctors at tertiary hospitals to mentor Skilled Birth Attendants

(SBA) in rural areas.103. Solutions to Inadequate Referential training for Skilled Birth

Attendants (SBA)a) More refresher courses for Skilled Birth Attendants (SBA) in

Emergency Obstetrics and Newborn Care (EMONC) skills. More refresher courses for Skilled Birth Attendants (SBA) in Emergency Obstetrics and Newborn Care (EMONC) skills.

b) Regular support supervision for Skilled Birth Attendants (SBA).104. Solutions to Lack of functional equipment and facilities

a) Scale up supply of basic equipment of supply for Skilled Birth Attendance.

b) Regular maintenance of facilities, structure, equipment and supplies.

105. Solutions to Poor Incentives especially in Rural Areasa) Provision of allowances for rural posting.b) Provision of accommodation for rural posting.c) Strengthening, reactivating and formation of Ward Development

Committees (WDC).

Emergency Obstetric and New-Born Care

106. Solutions to Shortage of Skilled Health Personnela) Recruitment of more Skilled Birth Attendants (SBA).

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b) Additional Incentive for Health workers in hard to reach areas/difficult terrain/rural areas.

c) Scale up of in-service training and implementation of Life Saving Series (LSS) and Community Based Newborn Care (CBNC).

d) Incorporation of the Life Saving Series (LSS) and Community Based Newborn Care (CBNC) into the pre-service Skilled Birth Attendants curriculum.

107. Solutions to Inadequate Equipment and Supplies a) Provision of adequate Emergency Obstetrics and Newborn Care

(EMONC) equipment and services.b) Regular maintenance of adequate Emergency Obstetrics and

Newborn Care (EMONC) equipment and services.c) Equitable and effective distribution of Emergency Obstetrics and

Newborn Care (EMONC) equipment and supply.108. Solutions to Delay in accessing Care Services

a) Awareness creation and sensitization campaign on Emergency Obstetrics and Newborn Care (EMONC) services and issues using appropriate media.

b) Promotion of key household and community service package.c) Promotion (or Provision) of GSM services (communication)

between clients and Skilled Birth Attendants (SBA) on Emergency Obstetrics and Newborn Care (EMONC).

d) Reduce delay at the Health Facilities through the use of Standard of Practice (SOP) on Emergency Obstetrics and Newborn Care (EMONC).

e) Establishment of Emergency Triage and Treatment (ETAT) for Emergency Obstetrics and Newborn Care (EMONC) at health facilities.

Universal Coverage of Ante-natal and Post-natal Care

109. Solution to Socio-Cultural and Religious Barrier a) Advocacy to traditional, community and religious leaders.

110. Solutions to Inadequate Political willa) Identified interest groups/ civil society should be trained to

demand for their rights.b) Civil society organizations should demand for their right of the

vulnerable groups.111. Solutions to Poor Access to Health facilities especially in

rural areasa) Creating outreaches closer to the people. b) Community involvement for ownership monitoring utilization of

health services.c) Scale up and strengthening of regular mobile health services.

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112. Solutions to Poor Attitude of Health Workersa) Reorientation of health workers to instil right values into them.b) Appropriate staffing ratio of health workers to patients.c) Recognition of Health Workers based on merit.d) Effective regular supervision and coordination.e) Enforcement of discipline.

113. Solution Lack of Legislationa) Support accelerated passage of Health Care Bill.

Improved Referral System

114. Solutions Inadequate Ambulance Servicesa) Decentralization of ambulance to rural areas.b) Improvisation of functional ambulance services. E.g. Tricycles,

Donkeys, Speedboats, cows and Camels.c) Engagement of NURTW members or any community volunteer

for a reward.d) Regular revision of referral directory.e) Effective Two way referral system.f) Regulation against and discipline for wrongful use of ambulance.

115. Solutions to Poor Communication Network and Feedback System.

a) Provisions of Phones.b) Provision of free toll lines by telecom companies

116. Solutions to System Delaya) Adherence to the use of Standard of Practice (SOP).b) Ambulance should be part of handing over process.

Table 5: MAF Prioritized Solutions and Responsibilities

S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

1 FAMILY PLANNING

1) Socio-cultural Religious barrier

a) Scale-up sensitization of traditional leaders, religious leaders, Community Based Organizations (CBO), Federal Based Organizations (FBO)

FMOH, OSSAP / NYSC, UNWOMEN, NOA,

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

through appropriate media b). Reinforced teaching of family life education in secondary schools curriculum.

FMoWA, FMYD, NPHCDA,

c). Establish of more functional youth friendly centre

FMoWA / Youth Development, UNFPA, OSSAP , NACA

2) Inadequate trained personnel

a). Recruitment of more trained personnel.

SMoH, FMoH, UNFPA,

b). Intensify training and retraining of health workers including community based resourced persons

FMoH, SMoH, UNFPA, OSSAP & NPHCDA

3) Poor / inadequate male involvement

a). Sensitization and mobilization of the male folk to take leadership in health matters

FMOH, OSSAP-MDG, UNWOMEN, NOA

2 SKILLED BIRTH ATTENDANTS

1) Inadequate Skilled Birth Attendants (SBA)

a). Recruitment of more Skilled Birth Attendants (SBA)

NPHCDA & Partners

b). Training and retraining of

NPHCDA & Partners, NACA.

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

Skilled Birth Attendants (SBA) c). Mandatory posting of NYSC Skilled Birth Attendants (SBA) to rural areas.

NYSC,LGAs, SMoH,

d). Mandatory one year posting internship in rural areas.

FMoH,

e). Task shifting /sharing for Skilled Birth Attendants (SBA)

NPHCDA/ SPHCDA

2) Uneven distribution of available Skilled Birth Attendants (SBA)

a). Additional incentives for rural posting.

FMOH, NPHCDA, SPHCDA, SMoH, MLA,

b). Doctors at tertiary hospitals to mentor Skilled Birth Attendants (SBA) in rural areas.

FMOH & SMOH

3) Inadequate referential training for Skilled Birth Attendants (SBA)

a). More refresher courses for Skilled Birth Attendants (SBA) in Emergency Obstetrics and Newborn Care (EMONC) skills.

FMoH, SMoH and NPHCDA,

b). Regular support supervision

FMoH, SMoH, NPHCDA

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

for Skilled Birth Attendants (SBA).

4) Lack of functional equipment and facilities

a). Scale up supply of basic equipment of supply of SBAs.

FMoH / SMoH, NPHCDA, OSSAP and partners.

b). Regular maintenance of facilities, structure, equipment and supplies.

SMoH, LGAs, and Partners

5) Poor incentives especially in rural area.

a). Provision of allowances for rural posting.

SPHCDA, SMoH, NPHCDA

b). Provision for accommodation for rural posting.

SPHCDA, SMoH, NPHCDA

c). Strengthening, reactivate and formulation of Ward Development Committees (WDC)

SPHCDA, SMoH, NPHCDA & MLGA

PRIORITIZED INTERVENTIONS

PRIORITIZED BOTTLENECKS

ACCELERATION SOLUTIONS

RESPONSIBLE PARTNERS

3 EMERGENCY OBSTERIC AND NEW-BORN CARE

1) Shortage of Skilled Health Personnel

a). Recruitment of more Skilled Birth Attendants (SBA)

LGAs, SMoH, NPHCDA

b). Additional Incentive for Health workers in

LGAs, SMoH, NPHCDA

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

hard to reach areas/difficult terrain/rural areas. c). Scale up of in-service training and implementation of Life Saving Series (LSS) and Community Based Newborn Care (CBNC).

LGAs, SMoH, NPHCDA

d). Incorporation for the Life Saving Series (LSS) and Community Based Newborn Care (CBNC) into the pre-service Skilled Birth Attendants curriculum.

FMoH, NMCoN, Community Health Directors.

2) Inadequate equipment and supplies

a). Provision of adequate Emergency Obstetrics and Newborn Care (EMONC) equipment and services.

FMoH, SMoH, OSSAP, NPHCDA and Partners

b). Regular maintenance of adequate Emergency Obstetrics

LGAs and Partners

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

and Newborn Care (EMONC) equipment and services. c). Equitable and effective distribution of Emergency Obstetrics and Newborn Care (EMONC) equipment and supply.

LGAs, SMOH and Partners,

3) Delay in accessing care services

a). Awareness creation and sensitization campaign on Emergency Obstetrics and Newborn Care (EMONC) services and issues using appropriate media.

LGAs, SPHCDA, SMOH & FMOH,

b). Promotion of key household and community service package.

NPHCDA, SMOH, and Partners

c). Provision of GSM services (communication) between clients and Skilled Birth Attendants (SBA) on

NCC, FMOH & partners

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

Emergency Obstetrics and Newborn Care (EMONC).d). Reduce delay at the Health Facilities through the use of Standard of Practice (SOP) on Emergency Obstetrics and Newborn Care (EMONC).

FMOH & SMOH and all stakeholders

e). Establishment of ETAT for Emergency Obstetrics and Newborn Care (EMONC) at health facilities.

FMOH & SMOH and Partners

PRIORITIZED INTERVENTIONS

PRIORITIZED BOTTLENECKS

ACCELERATION SOLUTIONS

RESPONSIBLE PARTNERS

4 UNIVERSAL COVERAGE OF ANTE-NATAL AND POST NATAL CARE

1)Socio-cultural and Religious barrier

a). Advocacy to traditional, community and religious leaders.

FMOH, OSSAP / NYSC, UNWOMEN, NOA,

2) Inadequate political will

b). Identified interest groups/ civil society should be trained to

FMoH, NHRC & NOA

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

demand for their right.c). Civil society organizations should demand for their right of the vulnerable groups

NGOs, CSOs NOAs, FMoH & NHRC

3) Poor access to health facilities especially in rural areas

a). Creating outreaches closer to the people.

LGAs, WDC,

b). Community involvement for ownership monitoring utilization of health services.

LGAs, NYSC, NPHCDA / SPHCDA, SMoH

c). Scale up and strengthening of regular mobile health services

LGAs, SMOH & SPHCDA.

4) Poor attitude of Health workers.

a). Reorientation of health workers to instil right values into them.

Regulatory Agencies under federal and state.

b). Appropriate staffing ratio of health workers to patients

SPHCDA, SMOH, FMOH,& LGAs

c). Recognition of Health Workers based on merit

Employers/Management

d). Effective LGAs, SMOH,

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

regular supervision and coordination

FMOH & NPHCDA.

e). Enforcement of discipline

Management / Regulatory bodies.

5) Lack of Legislation

a). Support accelerated passage of Health Care Bill.

CSOs, NGOs, Development Partners, SMOH & FMOH

PRIORITIZED INTERVENTIONS

PRIORITIZED BOTTLENECKS

ACCELERATION SOLUTIONS

RESPONSIBLE PARTNERS

5 IMPROVED REFERRAL SYSTEM

1) Inadequate ambulance services

a). Decentralization of ambulance to rural areas.

FMOH, SMOH and SPHCDA

b). Improvisation of functional ambulance services. E.g. Tricycles, Donkeys, Speedboats and Camels

LGAs & SMoH

c). Engagement of NURTW members or any community volunteer for a reward

LGAs, NURTW Management

d). Regular revision of referral directory.

FMOH

e). Effective Two way referral system.

SPHCDA, LGAs and FMOH

f). Law against

FMOH, SMOH and LGAs

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S/N

Prioritized Interventions

Prioritized Bottlenecks

Acceleration Solutions

Responsible Partners

wrongful use of ambulance.

2) Poor communication network and feedback system

a). Provision of phones.

NCC, FMOH & GSM/Telecom service providers

b). Provision of free toll lines by telecom companies.

NCC, GSM/Telecom service providers

3) System Delay

a). Adherence to the use of Standard Of Practice (SOP).

FMOH, SMOH & LGAs

b). Ambulance should be part of handing over process

SMOH and LGAs

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CHAPTER 6MONITORING AND EVALUATION PLAN

117. A well-functioning results-based monitoring and feedback system, established as integral element of implementation management, is central to the success of the MAF Action Plan. While monitoring and evaluation processes are usually built into national and subnational plans and programmes, lessons from the past show that the critical challenges lie in faithfully implementing them to achieve intended effects. Moreover, the unique action-oriented nature of MAF solutions necessitates a strong M & E mechanism.

118. For the purpose of MAF, the monitoring system will involve collecting, analysing, reporting and using data and information to gauge the implementation of solutions and the results (outputs, outcomes and impact). Specifically, the MAF M & E system will be functional as a follows: d) Provide programme managers and stakeholders with data and

information about the pace, nature and levels of progress in service delivery and service use;

e) Supply credible evidence base for management responses in bridging gaps, correcting weaknesses and consolidating gains in the implementation of the agreed solutions and actions;

f) Deliver a reporting and feedback system for tracking progress on MDG5 through 2015 based on the MAF results chain – inputs, outputs, outcomes and impacts – with respect to MDGs 5.

Scope and Nature of the M & E119. The monitoring of MAF Action Plan will cover multiple successive

levels of the results chain spanning inputs, outputs, outcomes and impacts.

(a)Input-level monitoring will cover tracking of funds/spending, staff deployments and material resources used in implementing the respective MAF solutions and actions.

(b)Output-level monitoring will be directed at tracking completed activities coupled with the first-level results achieved through the activities. Examples include number of health staff trained, number of new midwives recruited, amount of supplies delivered and quantity of equipment acquired.

(c) Outcome-level monitoring focuses on the delivery and use of services (for example, family planning, skilled birth attendance and EmONC).

(d)At the highest level, the impact monitoring pertains to the achievement of reduction in maternal mortality.

120. The MAF M & E will be operated based on best-practice principles and approaches which have eluded many past plans and programmes. The M & E will be conducted and organised to be timely, inclusive, participatory, credible, useful and evidence-based.

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Framework of M & E Indicators121. The MAF M & E system will measure and track implementation

progress and achievement of results based on the framework of indicators given in the Implementation and Action Plan. As provided in the Action Plan, there are a set of indicators for every prioritised acceleration solution. For the respective indicators, the tracking exercise will benchmark implementation progress and achievement of results against targets set in the Action Plan, in order to detect gaps/deviations and fashion corrective responses.

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M & E Resources

122. The MAF M & E will apply standard quality-assuring methods and tools for tracking implementation and the results. These include the following:

a) Calendar of Milestones: The MAF Action Plan will be further distilled into an operational “Calendar of Milestones” for gauging actual versus expected results. The milestones represent landmarks in achievements en route 2015 regarding service delivery and service use. These pre-identified landmarks serve as scheduled ‘checkpoints’ to assess whether service delivery and use are still on track.

b) Monitoring and evaluation scorecard: The M & E Scorecard will report metrics showing the trajectory of progress, quantification of observed deviations and determine whether implementation of solutions and impact of solutions (reduction in maternal deaths) are on track. It describes the extent to which the removal of bottlenecks through the applications of prioritized solutions is leading to targeted reductions in maternal mortality. It is a target-oriented measurement tool.

c) Reporting Requirements: The M & E system will involve periodic reports to track and document solution outputs and outcomes (service provision and use). The reporting will entail successive levels of tracking starting from local government areas, state-wide through national coverage. The reports will contain point-of-service monitoring data on maternal healthcare service delivery and use in the local governments, aggregated at the state and national levels. Within the framework of the MDGs reporting system, the MAF M & E reports will include

i. Quarterly Progress Report – describe progress on implementation and outputs in the reference 3-month period. This report will dwell on mostly facility-level (that is, service-level) data from the various local communities aggregated at the state and national levels.

ii. Semi-annual Progress Report – describes achievement of outcomes and impacts in the reference 6-month period

iii. MAF Completion Report – gives final status of outcomes and impacts achieved based on the acceleration solutions.

123. Sourcing and Management of Data: To be effective in bringing about the desired information and feedback, monitoring will be based on timely, relevant, accurate and useable data. The sources of data will include administrative records and periodic sample surveys. The administrative data will be collected at the facility-level (service delivery points) in local communities and collated by the State

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Ministries of Health for onward transmission to the Federal Ministry of Health. The data will constitute live evidence of the status and progress of maternal health services throughout the country and give timely information for management decision making. On the other hand, sample surveys will be carried out by the National Bureau of Statistics, as part of the data tracking mechanism. Data will cover critical variables including: funding levels and spending patterns; staffing and human resources; supplies and equipment; logistics; service delivery; service utilisation and maternal deaths.

Execution of the M & E Plan

124. To avoid the pitfalls of past M & E systems in national plans and programmes, the MAF M & E will follow a clear and focused agenda executed by dedicated task teams underpinned by unequivocal role division between the federal and state levels. The organisation of the MAF M & E process will be tripartite involving local governments, state governments and the federal government. Monitoring Task Teams (MTTs) will be constituted among relevant agencies at the three levels of government. Local government task teams will include local health departments and community representatives while state-level task teams will include the State Ministry of Health, MDGs Desk Officers, health-sector professional associations and state-level civil society representatives. Similarly, federal-level task teams will include MDGs Officers, Federal Ministry of Health (and affiliated agencies), National Planning Commission and national-level civil society representatives such as national-level health-sector professional association. In line with this tripartite organisation, the monitoring data will flow successively from local task teams through the state task teams to the federal M & E task teams.

125. The flow of data and information along the monitoring chain from local level to national level will be organised as follows:

Fig 14: Flow of MDG5 monitoring data and information

126. Making Use of Monitoring Data: Given the lessons from the past, the MAF M & E system will incorporate key enablers that

80

Local Govt. Monitoring Task

Teams

State-Level Monitoring Task

Teams

National Monitoring Task

Team

APPENDIX 4

promote effective monitoring as basis for feedback towards improved implementation. There will be central coordination of the M & E by OSSAP-MDGs in collaboration with the National Planning Commission. The MAF Management Information System (MIS) will be structured to transmit monitoring data into the decision-making mechanisms of the service-providing implementing line agencies. The feedback information is useful for programme realignment and redistribution of services and supplies. In addition to providing relevant forecasting data, the supply chain data from local healthcare facilities will serve as a guide to design responses in underperforming situations. To actualise the feedback value of monitoring data, OSSAP-MDGs will build and coordinate appropriate management response mechanisms that address observed implementation problems.

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Table 6: MAF Monitoring and Evaluation CalendarTime Schedule

M & E Activity

2nd Qtr 2013

3rd Qtr 2013

4th Qtr 2013

1st Qtr 2014

2nd Qtr 2014

3rd Qtr 2014

4th Qtr 2014

1st Qtr 2015

2nd Qtr 2015

3rd Qtr 2015

4th Qtr 2015

Formation of Monitoring Task Teams at the Federal and State levelsOperationalization of the M & E Indicators at the federal and state levelsPreparation of the “Calendar of Milestones” toolApplication of the “Calendar of Milestones” toolPreparation of the M & E Scorecard toolApplication of the M & E Scorecard toolData flow from local government to national levelQuarterly Reports (focused on milestones)Biannual Reports (focused on scorecard)MAF Completion Report

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CHAPTER 7RECOMMENDATIONS

Key Recommendations on MAF An emergency Presidential Committee on MDGs should be

convened to deliberate on the budget and commitments as well as confirmation of responsibilities to various tiers and agencies of government for the implementation of the MAF Action Plan.

The International Development Partners (IDPs) are requested to make their specific commitments to the implementation of MAF Action Plan.

The OSSAP-MDGs is required to work out a detailed MAF implementation plan that is sensitive to the status of MDGs in various geo-political zones and states. In this regard, special consideration should be given to the North-east and North-west geo-political zones in order for Nigeria to attain MDG 5. For this assignment, OSSAP-MDGs can seek for technical assistance from FMoH and IDPs.

The OSSAP-MDGs should embark on a strong mobilization campaign and consultation with state governments and key development actors for the immediate adoption and implementation of this MAF.

The OSSAP-MDGs should operationalise the MAF monitoring and feedback mechanism by coordinating and facilitating the establishment of the relevant indicators (along with baseline and milestones) for measuring and reporting periodic along the results chain-inputs, outputs, outcome and impact. The monitoring and feedback mechanism should be able to answer the question: has MAF made any difference in the attainment of MDGs 5 targets in 2015?

Recommendations for the Remaining Seven MGDsIn order to fast-track the implementation of the remaining 7 MDGs, the following recommendations are hereby proposed:

The governance and accountability environment needs to be continuously improved;

Efforts should be intensified towards ensuring the availability and harmonization of adequate and reliable data in particular the coordination of data generation on MDGs by the National Population Commission (NPoC) and National Planning Commission (NBS);

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There should be enhanced and up-to-date performance tracking of MDGs investments in all MDAs and reporting same on a routine basis to the Presidential Committee on MDGs;

The attainment of the MDGs should be a key element of the performance contract by ministers;

The Federal Government should recommend the extension of performance contract to commissioners at the state level with particular reference to MDGs;

The on-going Centennial celebration should have the attainment of the MDGs as its primary focus;

The State Governors and Local Government Chairmen should be recognized and honoured on the basis of their contributions to the attainment of the MDGs;

The Federal Government should provide incentives to the most performing and most improving states in the attainment of the MDGs.

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APPENDIX: MDG5 MAF ACTION PLAN /BUDGET MATRIX

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

FAMILY PLANNING

1. Scale-up sensitization of traditional leaders, religious leaders, Community Based Organizations (CBO), Federal Based Organizations (FBO) through appropriate media

Achieve universal access to reproductive health by 2015

1) Preparation and launching of FP logo/IEC/BCC materials

-

CPR Unmet need Adolescent Birth rate

1a) Review/develop existing FP logo and IEC/BCC materials (including Jingles & consultation)

a) No of review meetings held b) No of materials developed

25,000,000

25,000,000

1b) Printing and distribution of IEC/BCC materials

1,500,000,000

1,500,000,000

Nationwide

1c) Airing of Jingles

c) No of Jingles

3,120,000

Nationwide

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Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

aired 3,120,0002. Traditional & Religious leaders, CBO/FBO Engagement and Sensitization

-

2a) Stakeholder Identification and Mapping

3,500,000

3,500,000

2b) Sensitization/ Awareness creation meetings and signing RH compact with Traditional & Religious leaders, CBO/FBO

d) No of people reached

98,400,000

98,400,000

6 zonal meetings and community diagloue meetings (5 communities per each 774 LGA)

86

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

2. Reinforced teaching of family life education in secondary schools curriculum.

Ministry of Education

-

3. Integrate Youth Friendly Health Services into existing functional PHC, Secondary HF & Tertiary Hospitals

1. Providing Youth Friendly Health Services to young people

Integrate Youth Friendly Health Services (YFHS) into Primary Health Care facilities (within the MSS clusters) and secondary Health Facilities.

Number of Primary Health Care and Secondary Health Facilities providing YFHS and Number of Health Care trained to provide YFHS.

78,000,000

78,000,000

78,000,000

78,000,000

78,000,000

390,000,000

Target for now is the MSS facilities(3125HF) 2plHF

Training Health Care

The Number of Health

87

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

Providers to Provide Youth Friendly Health Services (YFHS)

Care Providers trained to provide YFHS

Provision of basic Equipment for the take-off of the Youth Friendly Facilities (Television sets, Tables, BCC materials, Indoor Sports Facilities, internet facilities etc.

Number of PHC and Secondary Health Facilities with basic equipment for the provision of YFHS

31,250,000

31,250,000

31,250,000

31,250,000

31,250,000

156,250,000

50,000/HF

Monitor and provide supportive supervision regularly

Number of PHC and Secondary Health Facilities implemen

21,850,000

21,850,000

21,850,000

21,850,000

21,850,000

109,250,000

20% of project cost - training & equipping facilities

88

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

ting YFHS.

2 Day Finalization meeting for the Minimum package of service & standards for Youth Friendly Health Services

Finalization meeting conducted

3,500,000

3,500,000

Printing & dissemination of minimum package of service & standards for Youth Friendly Health Services in Nigeria

No of MPSS copies printed

51,125,000

51,125,000

Total no of primary & secondary HF in Nigeria as at 2011 was 34,090

No HF in the states that have integrated YFHS

-

Printing & dissemination of National Guidelines

No of copies on national guidelines for

36,000,000

36,000,000

89

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

for integrating Youth Friendly Health services to PHCs in Nigeria

integrating YFHS printedNo of HF with guidelines for integrating YFHS

-

Conduct 6 Zonal TOTs on to build capacity of health care providers on YFHS 10/state

No of TOTs conducted

54,000,000

-

54,000,000

No of providers capacity built on YFHS per state

-

Needs assessment & training of service provider on YFHS at state & LGA level – planning for this to be led by State & LGA

20,000,000

17,000,000

37,000,000

90

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

4. Intensify training and retraining of health workers including community based resourced persons

1. Meetings to develop/adapt FP manual for CHEWs

No of review meetings held

7,000,000

7,000,000

2 meetings @ 3.5m

2. Printing of manual

No of manuals printed

9,000,000

9,000,000

3. Conduct 6 Zonal TOTs State on Contraceptive Technology Update - (4p/state, 5mper TOT)

No of Trainers trained

30,000,000

30,000,000

4. Conduct training on contraceptive technology for 6250 CHEWs from MSS HF

No of CHEWs trained

78,000,000

78,000,000

78,000,000

78,000,000

78,000,000

390,000,000

5. 1 wk training of 240

No of clinical service

500,000,000

250,000,000

250,000,000

250,000,000

1,250,000,000

91

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

clinical service providers on CLMS/state

providers trained on CLMS

5. Sensitization and mobilization of the male folk to take leadership in health matters

State Based Activity

No of IEC/BCC material developed

-

Meetings to develop IEC/BCC materials

No of dialogue meeting held

7,000,000

7,000,000

2 meetings @ 3.5m/meeting

-Engagement of male folk with age grade

No of people reached

50,000,000

50,000,000

Cost for dialogue meetings in 2500 communities @ 20,000/meeting

-Dissemination of IEC/BCC materials

30,000,000

15,000,000

15,000,000

15,000,000

75,000,000

Target- Male folk in the community and WDC members (200 male folk per communit

92

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

y)SUB TOTAL

2,636,745,000

491,100,000

474,100,000

474,100,000

209,100,000

4,285,145,000

SKILLED BIRTH ATTENDANCE

1. Recruitment of more Skilled Birth Attendants (SBA)

Target 2,500 PHC facilities by 2017

Increase PHC facilities by 1,000 and recruit 7,000 midwives and 4200 CHEWS by 2017

Recruit 7,000 midwives

1,144,000,000

1,144,000,000

1,144,000,000

572,000,000

4,004,000,000

Recruit 4200 CHEWS

470,400,000

392,000,000

392,000,000

392,000,000

1,646,400,000

2. Training and retraining of Skilled Birth Attendants (SBA)

Train 4200

CHEWS, 7000

midwives and 375 doctors by 2017.

Scale up training on LSS and EMONC for SBAs (1) Printing & dissemination of finalized Life Saving Skills manuals (MLSS, LSS & ELSS)

No of copies of the document printed

4,507,125

4,507,125

4,507,125

4,507,125

18,028,500

93

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

(2) Capacity building of Service Providers on Life Saving Skills (LSS) Nurses/Midwives ) in the 6geopolitical zones in the country

No of service providers trained on LSS per state

306,250,000

306,250,000

306,250,000

306,250,000

1,225,000,000

% of state training teams with full copies of the document

-

% of LSS centers with copies of reviewed Life Saving Skills Manual

-

Capacity Building of Service Providers on Expanded Life Saving Skills

No of Service providers trained on ELSS per States

2,460,281

2,460,281

2,460,281

2,460,281

9,841,124

94

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

(ELSS) (Doctors) in 6 geopolitical zonesCapacity Building of Service Providers on Modified Life Saving Skills (MLSS) - CHEWs in 6 geopolitical zones

No of Service providers trained on MLSS per States

114,151,800

114,151,800

114,151,800

114,151,800

456,607,200

3. Mandatory posting of NYSC Skilled Birth Attendants (SBA) to rural areas.

Conduct dialogue meetings with NYSC for the deployment of SBAs to rural areas

No of dialogue meetings held

300,000

300,000

100,000 per dialogue meeting at Federal Level x 3 meetings

Consensus built for the deployment of SBAs to rural areas

-

95

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

Orientation & Sensitization of NYSC SBA (Doctors & BSC Nurse/midwives) on EMONC in the 6 geopolitical Zones

No of sensitization meetings held in NYSC camps with NYSC SBAs

1,850,000

1,850,000

50,000 per meeting x 37 state camps

Mapping & Listing of NYSC SBAs (Doctors& BSC Nurse/midwives) in the orientation camp for the 6 geopolitical zones

Comprehensive listing of NYSC SBAs

1,850,000

1,850,000

Capacity Building on Expanded Life Saving Skills

No of NYSC doctors trained on ELSS per state

370,000,000

740,000,000

740,000,000

740,000,000

740,000,000

3,330,000,000

Target: an average of 30 doctors per state. This entails 2

96

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

(ELSS) for NYSC SBAs (Doctors) in 6 geopolitical zones

TOTs per state per batch. 2 x 37 x N5,000,000

Capacity Building on Life Saving Skills (LSS) for NYSC SBAs (Nurses) in 6 geopolitical zones

No of NYSC Nurses trained on LSS per state

60,337,380

120,674,760

120,674,760

120,674,760

120,674,760

543,036,420

One batch for 2013 and two batches for the remaining years

4. Task shifting/sharing for Skilled Birth Attendants (SBA)

Dialogue Meeting with stakeholders on task shifting and sharing

No of meetings

14,000,000

14,000,000

2 meetings

Meetings to review the pre-service curriculum on

No of meetings

7,000,000

7,000,000

2 meetings (a smaller meeting) *There is already an

97

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

EMONC for CHEWs

ongoing process on task shifting and sharing on EMONC for CHEWs by Jpheigo

5. Additional incentives for rural posting for the MSS

10,000 midwives (4 per 2500 MSS facilities)

Pay a rural posting allowance to 10,000 midwives in addition to their existing salary (10,000 is the existing no of midwives and expected scale-up)

No of midwives paid rural posting allowance

1,200,000,000

3,600,000,000

4,800,000,000

6,000,000,000

6,000,000,000

21,600,000,000

Rural posting allowance N50,000 per midwife *2013 calculated as for July to Dec

5,000 CHEWs (2 per 2500 MSS facilities)

Pay a rural posting allowance to 5,000 CHEWs in addition to

No of CHEWs paid rural posting allowance

300,000,000

900,000,000

1,200,000,000

1,500,000,000

1,500,000,000

5,400,000,000

Rural posting allowance N25,000 per CHEWs

98

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

their existing salary (5,000 is the existing no of CHEWs and expected scale-up)

*2013 calculated as for July to Dec

6. Tertiary hospitals to adopt PHCs in rural areas.

Orientation & Sensitization Meeting for CMDs of Tertiary institutions on the adoption of PHCs

Orientation & sensitization meeting held with CMDs of tertiary institutions

7,000,000

7,000,000

One meeting

No PHCs adopted by Tertiary Hospitals

-

No Tertiary Hospitals identified with existing rural PHC posting

-

99

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

programmes

7. More refresher courses for Skilled Birth Attendants (SBA) in Emergency Obstetrics and Newborn Care (EMONC) skills.

10000 midwives, 625 doctors

Training of Doctors & Nurse/Midwives on 5 Day refresher Competency Based Training on EMONC in the 6 Geopolitical Zone 15 Service Providers /LGA using the Liverpool School of Tropical Medicine (LSTM) protocol

a) No of doctors & midwives trained per state b)No of refresher courses held

425,000,000

212,500,000

212,500,000

212,500,000

1,062,500,000

Based on projected no of midwives and doctors for each year

100

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

Institutionalize mentoring Program

Conduct Dialogue Meeting with professional bodies - {Society of Obstetricians & Gynecology of Nigeria (SOGON), Pediatric Association of Nigeria (PAN),Association of Public Health Physicians of Nigeria (APHPN) & Experienced & retired Midwives identified by SMOH} for the establishment of

No of dialogue meetings conducted

7,000,000

7,000,000

One meeting

No professional bodies participating in the mentoring program

-

101

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

mentoring programm

Mapping of PHCs & linkage with mentoring team

Comprehensive lists of PHCs linked to mentoring teams available

3,500,000

3,500,000

1. Regular support supervision for Skilled Birth Attendants (SBA).

10000 midwives, 625 doctors

Conduct x no of supportive supervisory visits

No of supervisory visits conducted

137,697,416

137,697,416

137,697,416

137,697,416

550,789,665

2. Scale up supply of basic equipment and supplies for Skilled Births Attendance

Provision of 2,500 midwifery kits and 250,000 mama kits

525,000,000

525,000,000

Midwifery Kit- N10,000 & Mama Kit- N2,000

Conduct Needs assessment of essential MNCH medicines

% of states that have conducted Needs Assessment on

500,000,000

250,000,000

250,000,000

250,000,000

1,250,000,000

102

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

& supplies - {oxytocin, mgso4 & misoprostol, Antishock garments & blood loss estimating drapes, injectable antibiotics for the newborn, cholhexidineetc} needed in the 6 geopolitical zones

availability of essential medicines on the UN list of essential lifesaving commodities

Procure & distribute MNCH medicines & supplies to the MSS facilities

% of facilities with stocks of medicines on the UN list of essential Life Saving Commodit

750,000,000

1,125,000,000

1,500,000,000

1,875,000,000

1,875,000,000

7,125,000,000

750,000 per facilities

103

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

ies3. Provision for accommodation for rural posting.

LGAs should take responsibility

-

LGAs should take responsibility and build appropriate hostels, etc.

4. Strengthening, reactivate and formulation of Ward Development Committees (WDC)

Scale up to 2,500 (1,000 WDCs existing in line with MSS facilities)

To conduct participatory learning and action approach for the formation of WDCs for the upcoming 1,500 MSS facilities

No of WDCs formed

177,400,000

177,400,000

177,400,000

532,200,000

SUB TOTAL

6,352,304,002

9,226,641,382

11,101,641,382

12,404,641,382

10,235,674,760

49,320,902,909

EMERGENCY OBSTERIC AND NEW-BORN CARE

1 Community Based Newborn Care

5000 CHEWs

1. Rapid assessment of key neonatal interventions in

% of communities that have carried out Rapid

625,000,000

625,000,000

104

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

(CBNC). communities from selected LGAs in the state

assessment for CBNC

2. Conduct 6 Zonal TOTs on CBNC

No of TOTs conducted on CBNC

15,000,000

2,014

15,002,014

3. State Step down Training of CHEWs on CBNC

No of CHEWs

124,500,000

63,000,000

63,000,000

63,000,000

313,500,000

4. Procure toolkit for CBNC (Bag, timer, weighing scale thermometer & Pictorial counseling cards etc.)

% of CHEWs equipped with CBNC toolkit

10,000,000

2,500,000

2,500,000

2,500,000

17,500,000

5. Follow-up/supportive supervision of trained

No of follow-up visits conducted

150,000,000

300,000,000

375,000,000

825,000,000

105

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

CHEWs2. Establishment of baby friendly Health Facilities

1. To increase the number of mothers who initiate breastfeeding within 30 minutes of delivery from 38% to 80% in 2015.

1) 5-day Review / pre-test of BFI/WHO tool.

1. The % of Health facilities designated baby friendly compliant in the past 1 year.

7,000,000

7,000,000

2. To increase the number of mothers who exclusively breastfeed their infants 13% to 22.3% by

2) 5-day assessment of Health Facilities and communities for BFI in the existing 1000 MSS

2. The number of designated BFHs trained with emphasis on ten steps in the past 1 year.

15,000,000

15,000,000

106

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

2015 (annual rate of 3.1%)

3. To increase the number of hospitals/ existing Health facilities in Nigeria designated BF from 4.6% in 1991 to 10% by 2015.

3) 5-day training on Integrated IYCF of the designated BFH

62,500,000

31,250,000

31,250,000

31,250,000

156,250,000

4) Designation of health facilities and communities as Baby Friendly

5,000,000

5,000,000

5) Supportive supervision of BFHs

5. Number of supportive supervision conducted at the BFHs in the past 1 year.

30,000,000

60,000,000

75,000,000

165,000,000

4. Provision

Provision of more

Procurement of 2500

No of MSS

18,800,000

19,400,000

24,400,000

29,400,00

92,000,000

107

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

of adequate Emergency Obstetrics and Newborn Care (EMONC) equipment and services.

anti-shock garments and blood loss drapes in all the PHC facilities

anti-shock garments and blood loss estimating drapes

PHCs with anti-shock garments and blood loss estimating drapes

0

Distribution and anti-shock garments and blood loss estimating drapes

1,880,000

1,940,000

2,440,000

2,940,000

9,200,000

5. Awareness creation and sensitization campaign on Emergency Obstetrics and Newborn Care (EMONC)

All stakeholders should function in awareness creation. Establishment of radio talk shows and community

Safe motherhood day celebration at national & State Level on 22nd May every year

% of states have implemented SMH day celebration

39,000,000

39,000,000

39,000,000

39,000,000

39,000,000

195,000,000

108

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

services and issues using appropriate media.

jingles.

Commemoration of Bi annual MNCH week by states

% of states that have implemented the MNCH commemoration

13,000,000

13,000,000

13,000,000

13,000,000

13,000,000

65,000,000

Fully Funded by NPHCDA

Develop advocacy materials on RH issues

No of meeting held, No of advocacy materials/kits printed

7,000,000

7,000,000

Engage Women groups at community level on RH issues – To be implemented by State & LGs

No of women groups sensitized

98,400,000

98,400,000

6 zonal meetings and community diagloue meetings (5 communities per each 774 LGA)

Promotion of the Key Househo

Training of trainers on KHHP

15,000,000

15,000,000

109

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

ld & Community Service Package

Step down training of CPRPS on KHHP

124,500,000

63,000,000

63,000,000

63,000,000

313,500,000

6. Promotion of key household and community service package.

Supervision of CORPS on Community Based Information System

150,000,000

300,000,000

375,000,000

825,000,000

7. Promotion of GSM services (communication) between clients and Skilled Birth Attendants (SBA) on Emergency Obstetrics and Newborn Care

PHC facilities

Toll free phone lines should be provided and kept at the facilities.

No of HFs with toll free phones

6,000,000

3,000,000

3,000,000

3,000,000

15,000,000

110

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

(EMONC).8. Reduce delay at the Health Facilities through the use of Standard of Practice (SOP) on Emergency Obstetrics and Newborn Care (EMONC).

Meeting to review/update SOPs on EMONC

7,000,000

7,000,000

Printing of SOPs

30,000,000

30,000,000

Distribution of SOPs

7,500,000

7,500,000

9. Establishment of ETAT for Emergency Obstetrics and Newborn Care (EMONC)

Target 2,500 PHC facilities by 2017.

TOT on ETAT

27,750,000

27,750,000

Step down training

117,187,500

117,187,500

111

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

at health facilities.SUB TOTAL

1,707,017,500

896,092,014

1,066,590,000

247,090,000

52,000,000

3,968,789,514

UNIVERSAL COVERAGE OF ANTE-NATAL AND POST NATAL CARE

1. Advocacy to traditional, community and religious leaders.

LGAs should take

responsibilities

and CBO

1. Develop advocacy material for conducting community engagement for FANC & PNC including printing and distribution

% newborns and mothers visited within 48 hours of delivery by a skilled health care provider

1,525,000,000

1,525,000,000

ANC Coverage 4 visits

-

Advocacy Kit developed on FANC & PNC

-

2. Identify & map key traditional, community

Listing of key traditional,

3,500,000

3,500,000

112

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

and religious leader

community and religious leader available per state/community

3. Plan & Conduct community engagement of traditional, community and religious leaders on FANC & PNC

No of meeting held with key traditional, community and religious leader on FANC & PNC

98,400,000

98,400,000

2. Civil society organizations should demand for the right of vulnerable groups

CSO, FBO, NGO and community

1. Identification of interest groups/ civil society and hosting of Community dialogue/Focus

145,125,000

145,125,000

145,125,000

145,125,000

580,500,000

113

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

Group Discussion (FGD)

3. Creating outreaches closer to the people.

Ward Development committee WDC

Provision of outreaches by the WDC, facility based

25000000 37500000 50000000 62500000 175,000,000

Scale up and strengthening of regular mobile health services

150,000,000

450,000,000

600,000,000

750,000,000

1,950,000,000

4. Reorientation of health workers to instill right values into them.

Conduct trainings on quality of care

394,095,500

394,095,500

394,095,500

394,095,500

394,095,500

1,970,477,500

SUB TOTAL

2,341,120,500

1,026,720,500

1,189,220,500

1,351,720,500

394,095,500

6,302,877,500

IMPROVED REFERRAL SYSTEM

114

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

1. Decentralization of ambulance to rural areas.

To Identify health facilities without functional ambulance services

7,000,000

7,000,000

2. Improvisation of functional ambulance services. E.g. Tricycles, Donkeys, Speedboats and Cows.

Procure cost effective needs specific alternatives to vehicular ambulance & distribute to referral clusters (1) Procure 3 speedboats (Bayelsa and Rivers)

4,800,000

4,800,000

(2) Procure tricycles (kekenapep) for MSS facilities

350,000,000

175,000,000

175,000,000

175,000,000

875,000,000

3.Collabo Engageme

115

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

ration with NURTW members or any community volunteer to strengthen referral

nt of NURTW members or any community volunteer to strengthen referral services

10,500,000 15,750,000 21,000,00026,250,000

26,250,000 99,750,000

4. Effective Two way referral system.

Procurement & distribution of phones to referral clusters in the state

1,500,000

1,500,000

Printing & distribution of two way referral forms

3,000,000

1,500,000

1,500,000

1,500,000

7,500,000

SUB TOTAL

376,800,000

192,250,000

197,500,000

202,750,000

26,250,000

995,550,000

MDG Coordination, Monitoring and

Facilitate implementation and

To coordinate, monitor and tracking of

Bi annual overall progress/status reports

129,746,530

129,746,530

129,746,530

129,746,530

129,746,530

648,732,649

1% of total programme implement

116

APPENDIX 4

Acceleration

Solutions

Targets ActivitiesIndicator

s

Timeline and Annual Cost Total Cost Notes

2013 2014 2015 2016 2017

Tracking of the MAF implementation

reporting of the MAF implementation process

the MAF implementation by the FMOH & NPHCDA in line with International Best Practice

produced ation cost

GRAND TOTAL

13,543,733,532

11,962,550,426

14,158,798,412

14,810,048,412

11,046,866,790

65,521,997,572

117

APPENDIX 4

DOCUMENTS CONSULTED

1. Federal Ministry of Health (2004). Revised National Health Policy. Abuja.

2. Federal Ministry of Health (2004). Health Sector Reform Programme: Strategic Thrusts with a Logical Framework and Plans of Action, 2004-2007. Abuja.

3. Federal Ministry of Health (2005). Achieving Health Related Millennium Development Goals in Nigeria. A Report of the Presidential Committee on Achieving Millennium Development Goals in Nigeria. Abuja.

4. Federal Ministry of Health (2010). Health Related MDGs Report for Nigeria. July 2010. Abuja:

5. Federal Ministry of Health (2010). National Strategic Health Development Plan 2010-2015. Abuja.

6. Federal Republic of Nigeria (2004). Nigeria Millennium Development Goals 2004 Report. Abuja: National Planning Commission.

7. Federal Republic of Nigeria (2005). Nigeria Millennium Development Goals 2005 Report. Abuja: National Planning Commission.

8. of Health.

9. Federal Republic of Nigeria (2007). Nigeria Millennium Development Goals 2006 Report. Abuja: National Planning Commission.

10. Federal Republic of Nigeria (2010). Nigeria Millennium Development Goals 2005 Report. Abuja: National Planning Commission.

11. Federal Republic of Nigeria (2010). The MDG-DRG Funded Midwives Service Scheme: Concept, Process and Progress. Abuja: National Primary Health Care Development Agency.

12. Federal Republic of Nigeria (2009). ‘National Partnership on Health: Declaration on Mutual Accountability for Improved and Measurable Health Results in Nigeria by the President of the Federal Republic of Nigeria, Executive Governors of the 36 States and FCT Minister at the Presidential Summit on Health in Nigeria: Implementing the Health Sector Component of Vision 20:2020’.

13. Federal Republic of Nigeria (2010). ‘Achieving Measurable Results for Health through the National Strategic Health Development Plan 2010-2015. Country Compact between Federal Government of Nigeria and Development Partners’.

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14. Federal Republic of Nigeria (2011). Annual Health Sector Report 2010. Abuja.

15. Federal Republic of Nigeria (2011): National Strategic Health Development Plan (NSHP) 2010-2015

16. Federal Republic of Nigeria (2012). Saving One Million Lives. ‘Accelerating Improvement in Nigeria’s Health Outcomes through a new approach to basic services delivery’. Office of the Honourable Minister of State for Health, Federal Ministry of Health.

17. Government of Ghana (2011). Ghana MDG Acceleration Framework and Country Action Plan: Maternal Health. Accra: Ministry of Health, & United Nations Country Team in the Republic of Ghana

18. National Population Commission (2009). Nigeria Demographic and Health Survey (DHS) 2008. Abuja: National Population Commission.

19. OSSAP-MDGs (2006). Presidential Committee on the MDGs: Second Quarter Report for 2006. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

20. OSSAP-MDGs (2008). MDG Needs Assessment and Financing Strategy for Nigeria. Abuja: Office of the Senior Special Advisor to

the President, Millennium Development Goals and the United Nations Development Programme.

21. OSSAP-MDGs (2008). Mid-Point Assessment of the Millennium Development Goals in Nigeria 2000–2007. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

22. OSSAP-MDGs (2008). Presidential Committee on the MDGs: 2nd & 3rd Quarter Reports for 2007. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

23. OSSAP-MDGs (2008). Presidential Committee on the MDGs: 2nd & 3rd Quarter Reports for 2008. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

24. OSSAP-MDGs (2009). 2009 Monitoring and Evaluation Report of the DRG-Funded MDG Projects and Programmes in Nigeria 2006/2007. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

25. OSSAP-MDGs (2009): Implementation Manual for the Millennium Development Goals Conditional Grants Scheme. Abuja: Office of the

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Senior Special Advisor to the President, Millennium Development Goals.

26. OSSAP-MDGs (2009). Presidential Committee on the Assessment and Monitoring of the MDGs: 4th Quarter Report for 2009. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

27. OSSAP-MDGs (2009). Presidential Committee on the MDGs: 1st Quarter Report for 2009. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

28. OSSAP-MDGs (2009). Presidential Committee on the MDGs: 2nd & 3rd Quarter Reports for 2009. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

29. OSSAP-MDGs (2009). Report of the Presidential Committee and on the Strategy and Prioritization of the MDGs. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

30. OSSAP-MDGs (2010). Nigeria: Millennium Development Goals (MDGs), Countdown Strategy 2010 to 2015: Achieving the MDGs. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

31. OSSAP-MDGs (2010). Presidential Committee on the Assessment and Monitoring of the MDGs: 1st Quarter Report for 2010. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

32. OSSAP-MDGs (2010). Presidential Committee on the Assessment and Monitoring of the MDGs: 2nd Quarter Report for 2010. Abuja: Office of the Senior Special Advisor to the President, Millennium Development Goals.

33. United Nations (2011). MDG Acceleration Framework: Operational Note. New York: UNDP. Available at: http://www.undp.org/content/dam/...MAF%20Operational%20Note.

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APPENDIX 1: Participants at the Technical Workshop from States by Category STATES

NURSES AND MIDWIVES (14)

DOCTORS (6)

HMIS (MEDICAL RECORDS) (3)

CHEWs/VHWs (18)

TBAs (10)

PRIVATE SECTOR (NMA (2),PSN (2),NANM (2) ) TOTAL 6

NGOs (6) DIRECTORS OF HEALTH (4)/HODs HEALTH /PHC COORDINTORs AT LGA LEVEL(5)

Abia 1 1 (HOD AT LGA)

2

Adama 1 1 2

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waAkwa-Ibom

1 1 (DPH) 2

Anambra

1 1PSN 2

Bauchi 1 1 (FOMWAN)

2

Bayelsa

1 1 2

Benue 1 1 (HOD AT LGA)

2

Borno 1 1 2

Cross-River

1 1TULSI CHANGALIER

2

Delta 1 1 2

Ebonyi 1 1 (HOD AT LGA)

2

Edo 1 1 NMA 2

Ekiti 1 1 (HOD AT LGA)

2

Enugu 1 1 (DPH) 2

Gombe 1 1 2

Imo 1 1 NCWS 2

Jigawa 1 1 2

Kaduna 1 1 2

Kano 1 1 (NANM) 2

Katsina 1 1 2

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Kebbi 1 1 (DPH) 2

Kogi 1 1 (DPH) 2

Kwara 1 1 (SFH) 2

Lagos 1 PSN 2

Nasarawa

1 1 (SPHCDB) 2

Niger 1 1 (SPHCDB) 2

Ogun 1 1 (PPFN) 2

Ondo 1 1 (DPH) 2

Osun 1 1(ARFH) 3Oyo 1 1

CHESTRAD2

Plataeu 1 NANM 2

Rivers 1 1 2

Sokoto 1 1 2

Taraba 1 1 2

Yobe 1 1 2

Zamfara

1 1 2

Abuja FCT

1 NMA 1 HERFON 3

TOTAL 15 6 2 17 10 6 8 11 76

Appendix 2: The operational results-level M & E Indicators

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APPENDIX 4

Level of Results Indicators

Baseline

Milestones Means for Verification

IMPACT 2012 2013

2014

2015

2016

2017

Maternal mortality reduced

Annual

OUTCOMESFamily planning services enhancedSkilled Birth Attendance up scaled and improvedEmergency Obstetric and Newborn Care enhancedUniversal coverage of antenatal and postnatal care achievedReferral system improvedOUTPUTS (GOODS/SERVICES PRODUCED)

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Family PlanningSkilled Birth AttendanceEmergency Obstetric and Newborn CareUniversal coverage of antenatal and postnatal careReferral system

125