By Chukwuma Muanya
Recent figures indicate that Nigeria’s maternal mortality rate remains a significant public health concern and is one of the highest in the world at 512 deaths per 100,000 live births. According to the World Health Organisation (WHO), 800 women died every day around the world in 2020 from preventable causes related to pregnancy and childbirth. This means that one woman died every two minutes. This is certainly a far higher figure than the Sustainable Development Goal (SDG) targeting to reduce Maternal Mortality Ratio (MMR) to less than 70 per 100,000 live births by 2030. Approximately 99% of these maternal deaths took place in low and middle income countries, with over half of them in sub-Saharan Africa.
Several studies, which are supported by the WHO have shown that by providing timely and high-quality access to evidence-based maternal healthcare interventions, including contraception, a significant number of maternal deaths could be prevented. According to a Bloomberg School of Public Health model, the cost of ending preventable maternal deaths in 120 low and middle income countries, including Nigeria, is estimated at $115.5 billion from 2020 to 2030. Therefore, cooperation, ongoing investment from different stakeholders and innovative partnerships and collaborations are crucial requirements and consolidating solutions for women who most need them at an adequate scale. This is crucial to achieving the SDG target of reducing the global maternal mortality ratio.
Studies have also shown that the private sector plays a significant role in delivering maternal and newborn health services, particularly in low and middle income countries, where public health care systems are often poorly funded. It has been shown that private sector innovations and involvement can improve access to healthcare, increase the quality of services, enhance the efficiency of the healthcare system and bridge existing gaps in healthcare financing to improve maternal health outcomes. The private sector has played a vital role in expanding access to women’s reproductive health services. But to achieve the SDG target, developing systems, structures, partnerships and opportunities to fully harness the private sector capabilities, will be very crucial. Engagement with the private sector is also critical to the achievement of universal health coverage in Nigeria.
However, private sector integration in health care delivery also presents challenges, which include high fragmentation and weak governance, as well as poor regulation and coordination with the public sector. There is also the possibility of adverse practices, and due to financial and capacity constraints, monitoring and supervision of the private sector may be inadequate. This emphasizes the importance of making provisions to mitigate the potential challenges of a mixed health system.
To address this anomaly, Nigeria Health Watch with funding from MSD for Mothers organised a webinar to provide policy makers with actionable steps to effectively engage the private sector, to build resilient and sustainable maternal health systems that deliver quality maternal health care services in the country. Other objectives of the webinar were: to discuss strategies and key recommendations for effective collaboration and adequate engagement between the public and private sectors to build resilient maternal health systems; share lessons learnt from successful public-private partnerships and how these lessons can be replicated to strengthen the maternal healthcare system in Nigeria and recommend policy options that can enhance private sector integration in strengthening the maternal healthcare delivery system.
With the theme: “Building Resilient Maternal Health Systems through Private Sector Integration”, the webinar was held on Tuesday, June 27, 2023.
The webinar sought perspectives on the following areas as it relates to building resilient maternal health structure: ensuring quality standards while integrating the private sector and how it can be achieved; strengthening governance in the inclusion of private sector in healthcare delivery; policy options to advance the inclusion of the private sector in a mixed health system; and how best coordination of the private sector can be achieved.
The webinar was intended for a diverse audience of stakeholders, including policy makers across the 36 states and Federal Capital Territory (FCT) Abuja, and private sector representatives. Participants included: representatives of the Federal Ministry of Health (FMOH) and the States Ministry of Health (SMOH); National Primary Health Care Development Agency (NPHCDA); development partners; Private Sector Health Alliance of Nigeria (PSHAN); National Association of Nigerian Maritime Students (NANMS); Society of Gynecology and Obstetrics of Nigeria (SOGON); Health Maintenance Organisation (HMO); and National Health Insurance Authority (NHIA).
Managing Director, Nigeria Health Watch, Mrs. Vivianne Ihekweazu, said by the end of the webinar, participants were expected to have practical insights into opportunities, best practices, benefits and importance of private sector engagement and how private sector partnerships can strengthen maternal health care in a mixed health system; identify areas for policy development that will foster private sector integration and commence establishment of frameworks for action; and be better informed on the key success factors for public-private partnerships and the opportunities for scaling up such initiatives.
Ihekweazu said strengthening maternal health in Nigeria and the poor outcomes of mothers in the country and globally has been a huge challenge. She said although maternal mortality has reduced, it is on record that Nigeria accounts for about one- quarter of the global maternal mortality.
She said: “So, if we are to achieve the SDG goal to reduce the maternal mortality to less than 70 per 100,00 life births, there is quite a lot of work for us to do to accelerate progress. In advancing any improvement in maternal health, we need to re-address inequality in maternal health services, which will require all hands on deck because the improvement requires collaborations with different stakeholders and desks. It needs multi sectorial effort. Notably, we can say that the private sector does play a significant role and this is one of the reasons why we have decided to highlight and deliberate on equipping the private sector in an attempt to improve maternal health. In Nigeria, one in five births is done by the private sector, which makes the sector a key role player. They assisted the public sector with laboratory services during COVID-19 pandemic. So, in essence the two sectors are very important in building maternal health.”
Other speakers at the webinar included: Acting Unit Head, Health Systems Governance and Policy, WHO, Dr. David Clarke; and Advocacy Lead, MSD for Mothers, Temitayo Erogbogbo. Panelists included: President, Healthcare Federation of Nigeria (HFN), Dr. Pamela Ajayi; Director General, Delta State Contributory Health Commission (DSCHC), Dr. Ben Nkechika; and Former Honourable Commissioner for Health, Kaduna State, Dr. Amina Baloni.
Critical action points from the panel discussants included the need for public and private sectors to work together to revitalize existing health facilities that are either dilapidated and nonfunctional or dilapidated and functioning but producing poor outcomes; the need for private sector providers to be incentivized; the need to create a health fund or bank for maternal healthcare; the need to activate and create a soft cushioning for local manufacturing, while reducing the cost of importation of healthcare tools, materials and resources; the need to create sustainable financing systems for maternal health care and the need to foster stakeholder collaboration and coordination among public and private sector providers and clients from the community to state and the national levels.
The webinar provided an avenue for stakeholders to advocate to policy makers on the importance of private sector integration in Nigeria’s mixed health systems and to provide actionable steps to effectively engage the private sector to build resilient and sustainable maternal health systems that can deliver quality maternal healthcare services in the country.
Nkechika said DSCHS had enrolled 1.4 million with 5011 accredited health facilities. He said building resilient health care system into the private sector, which is integration, is pertinent. “Healthcare system is a system in which patients get the care they need, when they need it which is sustainable and not with financial and logistic consequences. It is lucid to say that the government has not been able to provide adequate finance to facilitate this resilient care over the years,” Nkechika said. The Harvard-trained health economist said a collaboration of the private and public health sectors is perceived to be the best effective way to achieve better health outcomes, which was a concept “we decided to follow-up in the DSCHS, though we spent lots of time determining the model and skills to implement in other to achieve the outcome within the stipulated time. Now situating it to the maternal healthcare concept, we have a baseline assessment to determine the status of healthcare service delivery.”
He added: “To achieve these outcomes, firstly, we must get the political will which was what made the DSCHS a success. We need a guarantee for payment, which was why we consulted the Pharm Access Foundation and were able to develop a clear framework with an implementation plan, which was quite robust. We engaged the Bank of Industry which agreed to partner with us. We consulted experts, stakeholders and individuals from all sectors in the society for opinion and support, which enabled us to build trust in the private sector and through this framework we were able to create a transparent system in which the interest and effort of the private and primary health care sector was evaluated. With this collaborative act, we were able to lift the financial burden of the private sector in Delta State. The focus of the concept was health outcome which is lucidly the satisfaction of the patient. In the rigorous process, we were able to establish a guaranteed system. So, in a nutshell, trust, openness, political will, a clear framework, stakeholders engagement, ensuring everybody is a part of the process formed the first step to the last step and also being conscious of the fact that we would be encountering challenges, we were guaranteed of the progress. What mattered the most was ensuring that patients get proper care and treatment and so subsequently we are looking forward to expand and engage more stakeholders into the system.”
Dr. David Clarke spoke on the role of the WHO Country Connector in working to improve country governments’ capacities to create ecosystems for effective public-private partnerships. In his words: “The Country Connector for the private sector in Health has recorded impact in ensuring governments achieve Universal Health Coverage (UHC) and health security for their populations by harnessing the public and private health sector’s collective national expertise and resources.”
He also reaffirmed the commitment of the WHO Country Connector to evolve from backing up countries with COVID-19 support, to helping governments make better use of their capacities to improve health systems and outcomes. Mr. Temitayo Erogbobo said there is an urgent need to integrate the private sector to aid the financing of health systems and improve health outcomes for Nigerians. He said a lot of attention has not been given to the quality of care and the outcomes, and that has to change. Erogbogbo said MSD for Mothers is helping reduce maternal mortality across the globe, especially for high burden countries like Nigeria with the highest world burden of maternal morality. He further explained: “Private care providers play a vital role in providing care across the country, so it is pertinent that we pay attention to the enhancement of the sector. We need to pay attention to the quality of care provision to the public in general, as life loss is high. Currently, it must be noted that to equip clinics with health infrastructures, development and quality health care as a routine for the private sector, issues around transportation, electricity and water sanitation have a major impact on health care delivery, which is a huge burden that requires a humungous amount of resources for developing countries like Nigeria. It is a huge investment.
About the need to draw capital from other sources, the critical aspect is the lack of structural policies that enable the integration of the private sector into the health systems and this is one of the issues some of our panelists are working on strategies by which this dynamics can be curbed.”
Ajayi said the private sector has lots of opportunities to play roles on the maternal health care as over 70% of the health care and facilitation given yearly is from the private sector. “So, maternal health is a sector that needs this improvement to enhance effective care. They have a crucial role to play and with collaboration with the new government, progress would the accelerated. Collaboration with government is key. So are the alignment of interests, and the need to invest,” Ajayi said. She said the sector has produced a national draft policy of incentives in health care provisions, which is yet to be signed into the law before kicking off with the process. Ajayi said it is necessary to carve out a maternal health fund to ensure availability of payment to make the private health care services affordable as well as supply of the basic infrastructures and new technologies that improve maternal health care.
Dr. Amina Baloni, former Kaduna State’s Health Commissioner said: “Kaduna state was one of the states with the highest maternal and infant mortality rates in Nigeria. She said that Kaduna had a society where 60 to 70 per cent of the people lived in the rural areas. The health authorities had to deal with the traditional practice of patriarchy which prevents women from accessing care added to the resistance to the change that would see women have deliveries in facilities. “So, with such background the government should be the biggest player in the health sector. The only private care the rural people access is the Patent Medicine Vendors (PPMVs), chemists and medicine shops that are very often managed by people who are not healthcare professionals. Kaduna state has more than a thousand Primary Health Care Centres (PHCs). So, what the state needs is for the government to strive to vitalize, put in health education and of course in collaboration with the traditional leaders make sure that we change the narrative and improve healthy seeking behaviour. Trying to involve the private sector, Kaduna state looked at it from the point of view that what it wanted to engage the private sector to supply chain service delivery or regulation. One of the first things we did was to elaborate the Public Private Partnership (PPP) for health policy which looked at the private partnership framework in the state, the health peculiarities, challenges and the integration.
“If there must be a framework, we have to understand what is requires. One of the things we found in our public facilities is that we had out of stock commodity of essential medicines, which assist in providing quality healthcare services. So, we engaged the private and pharmaceutical sector that manufacture in Nigeria and we pointed out that the stock-out was caused by the importation of health commodities. So, we entered into an agreement with the private companies and Pharmaceutical Manufacturers Group of the Manufacturers Association of Nigeria (PMG MAN) to provide essential drugs and commodities to be able to get the supply chain working, which made us jump from about 40 per cent to 80 per cent availability in facilities.
“Although these provisions were made, it was still difficult to reach the mapped rural areas due to security issues in the state which necessitated maternal mortality and so we partnered with a drone delivery company that delivered emergency medicines, which helped to cover 10,000 deliveries within six months. Also, a coordination platform was created to organize the private sector for integration. We mapped about 3,000 private facilities that provide medical care and about 2,000 plus are actually petty medicine shops of which we tried to engage them with regulation, standards and laws of health establishment. In so doing, we engaged the public sector for collaboration in terms of mapped plans and standards. So, the state’s focus was to enable the environment to get the private sector to support service delivery in supply chain. This chain service is available in just few states and needs a widespread functioning across the nation to achieve the Universal Health Coverage (UHC). So, we need strong policies, regulations and quality standards that are being invested in.”