1. APPENDIX 41 | P a g eNIGERIA MDGs ACCELERATIONFRAMEWORK ANDACTIONPLANFOR MATERNAL HEALTH(MDG5)April 2013
2. APPENDIX 42 | P a g eTable of ContentsAcknowledgementForewordAbbreviations/AcronymsExecutive Summary 8List of TablesList of FiguresChapter 1: Introduction 17Chapter 2: Nigeria MDGs Status: An Overview with A Focus on MDG5 26Chapter 3: Key Interventions to Accelerate MDG5 in Nigeria 34Chapter 4: MDG5 Bottlenecks Analysis and Prioritization 47Chapter 5: Acceleration Solutions 50Chapter 6: Monitoring & Evaluation Plan 63Chapter 7: Recommendations 68References 97Appendices 100MDG – MAF Plan of Action & Budget Matrix
3. APPENDIX 43 | P a g eList 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 CalendarList 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, 2011Figure5Maternal 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 MNCHFigure 12 MSS Cluster ModelFigure 13 Overview of MSS ProgressFigure 14 Flow of MDG5 monitoring data and information
4. APPENDIX 44 | P a g eAcknowledgement
5. APPENDIX 45 | P a g eABBREVIATIONS/ACRONYMSANC Antenatal CareAPHPN Association of Public Health Physicians of NigeriaBCC Behaviour Change CommunicationBEOC 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 CommunicationsHDI Human Development IndexHF Health FacilityHIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency SyndromeICT Information Communications TechnologyIDPs International Development PartnersIEC Information, Education and CommunicationIPT Intermittent Preventive TreatmentIYCF Infant and Young Child FeedingJCHEWs Junior Community Health Extension WorkersLGA Local Government AreaLSTM Liverpool School of Tropical MedicineLSS Life Saving SkillsMAF Millennium Accelerated FrameworkMDAs Ministries, Departments and AgenciesMDCN Medical and Dental Council of NigeriaMDGs Millennium Development Goals
6. APPENDIX 46 | P a g eM & E Monitoring and EvaluationMICS Multiple Indicator Cluster SurveyMLSS Modified Life Saving SkillsMMR Maternal Mortality RateMNCH Maternal, Neonatal and Child HealthMPSS 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 MillenniumDevelopment 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 TransmissionPNC 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 SulphadoxinePyrimethamineSPARC State Partnership for Accountability, Responsiveness and CapabilitySPHCDA 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 ProgrammeUNFPA United Nations Population Fund
7. APPENDIX 47 | P a g eUNGASS 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
8. APPENDIX 48 | P a g eFOREWORD
9. APPENDIX 49EXECUTIVE SUMMARYIn September 2010 the United Nations Organization (UNO) under its United Nations General AssemblySpecial Session (UNGASS),provided a platform for a comprehensive review of progress made so far in theimplementation of Millennium Development Goals (MDGs) in the last decade. The review of the MDGs+10afforded the participating nations the opportunity to peer review progress on the implementation of theMDGs 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 towardsachievement of the MDGs by 2015. But due to a variety of factors, implementation of the CDS did not gainthe 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 processthat involves the preparation of a focused, agreed upon Action Plan to address specific lagging MDGs. Thisplan also requires the cooperation and support of all stakeholders that include the governments, thedevelopments partners, civil society organizations and the private sector in providing the resources and otherservices needed to advance key policy reform and overcome identified constraints to achieving a given MDGtarget.The key strategy of MAF is to identify and prioritize interventions with the potential for delivering thehighest impact; analyse and prioritise bottlenecks hindering success of interventions and identify solutionsand their sequencing. Based on these three steps, an accelerated action plan, along with an implementationand monitoring plan is then developed. Due to the overwhelming evidence of the synergies that progress withimproved maternal health engenders for other MDGs and overall economic progress, Nigeria has chosenMDG 5 for MAF.To refresh memory, the Goals, Targets and Indicators of MDG 5 which the MAF will focus on are presentedin tabular form below:MAF-MGD5 FocusGoal: 5 Target IndicatorsImproveMaternal HealthTarget 5.A: Reduce by 3/4th between1990 and 2015, the maternal mortalityratio1. Maternal mortality ratio2. Proportion of births attended by skilledhealth personnelTarget 5.B: Achieve, by 2015, universalaccess to reproductive health3. Contraceptive prevalence rate4. Adolescent birth rate5. Antenatal care coverage (at least one visitand at least four visits)6. Unmet need for family planning
10. APPENDIX 410MAF Process MethodologyUnderstandably the roll-out of MAFinvolves a rigorous process, more so in a federal and populous countrylike Nigeria. This process got the highest level of political endorsement from the Presidency through astakeholder forum. Three key decisions that established the methodological point of departure were (a) thesetting up of the institutional framework for effective coordination of the MAF process jointly driven by theOffice of the Senior Special Assistant to the President on MDGs (OSSAP-MDGs), Federal Ministry ofHealth, and International Development Partners (IDPs), (b) the engagement of consultants to drive thetechnical process, and (c) the planning and organization of the stakeholders‘ consultation technical workshopof which the Federal Ministry of Health played a catalytic role. The preparation of a comprehensive deskreview provided the main input for the stakeholders‘ technical workshop. Participants at this workshop werecarefully selected to cover not only the geographical spread, but also different layers of professionals in themedical fields with hands-on experience in the implementation of the MDG 5. (See the list of participants inthe appendix attached to the main report). The participants discussed and through elaborate process chosefive prioritized interventions and also identified the prioritized bottlenecks.Subsequently, atwo-day intensivebilateral discussion meetings between the consultants and key policy drivers and implementers (with supportfrom IDPs), developed the suggested solution indicators, targets, timelines, the costing of MAF and theassignment of responsibilitiesfor the implementation of the solutions contained in the Action Plan. Thepreparation of the final report benefitted further from the Validation workshop organised for critical policymakers, stakeholders and supporting IDPs.Prioritization of Key InterventionsFollowing stakeholders‘ consultation to accelerate the achievement of MDG5, the under-listed five keypriority areas were selected out of a list of over twenty major interventionswithout prejudice to state-levelpreferences 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
11. APPENDIX 411Bottleneck Analysis and PrioritizationThe bottlenecks that impede the success of prioritized interventions were identified as shown in thetabulation 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 LocalGovernment Health Departments or affiliated agencies. Cross-cutting bottlenecks are inter-sectoral andeconomy-wide problems that affect the results-based implementation of the MDG5 interventions.
12. APPENDIX 412Bottlenecks Impeding Prioritised InterventionsPrioritisedbottleneckBottleneckcategoryPrioritised InterventionsFamilyplanningservicesSkilledbirthattendantsEmergencyObstetric&NewbornCareUniversalCoverage ofAntenatalandPostnatalCareImproved ReferralServicesSocio-cultural religiousbarrierCross cuttingand systemicInadequate trainedpersonnelService deliveryLow maleinvolvement/ uptakeSystemicInadequate SkilledBirth AttendantsService deliveryUneven distribution ofavailable Skilled BirthAttendants (SBA)Service DeliveryInadequate ReferralTraining for SkilledBirth Attendants(SBA)Service deliveryLack of functionalequipment andfacilitiesService deliveryPoor incentivesespecially in rural areaBudget andfinancingShortage of skilledhealth personnelService DeliveryInadequate equipmentand suppliesServiceDeliveryDelay in accessing careservicesServiceUtilizationInadequate politicalwillCross-cuttingPoor access to healthfacilities in rural areasServiceUtilizationPoor attitude of healthworkersServiceDeliveryLack of Legislation Policy andPlanningInadequate ambulanceservicesServiceDeliveryPoor communicationand feedback systemService delivery
14. APPENDIX 414Acceleration SolutionsWith due regard to cultural sensitivity, the acceleration solutions proposed for each of the five prioritizedinterventions and their numerous bottlenecks inter alia are listed as follows:Family Planning Interventiona) 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 mattersSkilled 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 BasedNewborn Care (CBNC). Incorporation of the Life Saving Series (LSS) and Community Based Newborn Care (CBNC) intothe pre-service Skilled Birth Attendants curriculum. Regular maintenance of adequate Emergency Obstetrics and Newborn Care (EMONC) equipmentand 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 andCamels. Engagement of NURTW members or any community volunteer for a reward. Effective Two way referral system.
15. APPENDIX 415The BudgetDetails of the recommended accelerated solutions to each of the identified bottlenecks are contained in themain report. It is estimated that the Acceleration Solutions and constituent activities would costNGN65,521,997,572 (Sixty-Five Billion, Five Hundred and Twenty-One Million, Nine Hundred andNinety-Seven Thousand, Five Hundred and Seventy-Two Naira). The mobilization of this amount iscrucial to the successfulimplementationof the Action Plan.Monitoring and Evaluation PlanA well-functioning results-based monitoring and evaluation system, established as integral element ofimplementation management, is central to the success of the MAF Action Plan. The Monitoring andEvaluation 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 andlevels of progress in service delivery and service use;b) Supply credible evidence base for management responses in bridging gaps, correcting weaknessesand 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 theMAF results chain – inputs, outputs, outcomes and impacts – with respect to MDG 5.
16. APPENDIX 416Key RecommendationsIt is recommended that an emergency meeting of the Presidential Committee on MDGs beconvened to deliberate on the budget and commitments, as well as confirmation ofresponsibilities, as provided in the report, to various tiers and agencies of government for theimplementation of the MAF Action Plan. International Development Partners (IDPs) arerequested to make their specific commitments to the implementation of MAF Action Plan. Withrespect to the implementation of the overall MDGs it is recommended, among others, that theattainment of the MDGs be made the central focus of ongoing Centennial celebration.
17. APPENDIX 417CHAPTER 1INTRODUCTIONBackground1. A remarkable push in the global drive towards fast-tracking the achievement of theMillennium Development Goals (MDGs) was made in 2010 when the United NationsOrganization (UNO) provided a platform for a comprehensive review of progress made sofar within a decade of its implementation. This global platform was the United NationsGeneral Assembly Special Session (UNGASS) on MDGs+10 that took place in September2010. The decade‘s stock taking event came on the heels of new challenges and realities, suchas the global economic and financial crises, climate change, as well as new evidence andinnovations that needed to be factored into the MDGs implementation trajectory. TheMDGs+10 as it were, was an epoch-making event that afforded different nations theopportunity to refresh their commitment to the MDGs, peer-review progress and redoubleeffort 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-YearCountdown Strategy (CDS) at the UNGASS on MDGs+10. The overarching objective ofthe CDS was to outline a roadmap for accelerating progress towards achievement of theMDGs by 2015. The specific objectives of the CDS were:a) To identify the most effective mechanisms and interventions that have madeprogress against the MDGsb) To re-emphasize the roles and responsibilities of all agencies, stakeholders, and eachtier of governmentc) To guide the institutional improvements, policies and human resources requiredd) To chart the trajectory of MDGs financing and investment to 2015e) To interface with Vision 20:2020 and (the then 7-Point Agenda) TransformationAgenda.3. The CDS was designed to identify the gaps and lay out the policy actions, investments, andmilestones that would help Nigeria scale-up its successes and remedy weaknesses. Whilst theCDS acknowledged the progress made up to 2010 including a notable ―success story‖ (theConditional Grant Scheme), it also addressed the critical challenges and gaps that accountedfor the overall average/slow status in respect of the eight MDGs. In addition to the strategicinitiatives 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 acombination thereof) were spelled out in the CDS.4. In its review of government‘s investment plans, priorities and choices, the CDS highlightedthe folding of the MDGs into the implementation plans of NV20-2020 and stresses theimperative of nurturing a combination of public and private investments to ensureacceleration of progress towards achieving the MDGs by 2015. Furthermore, it re-examinedthe existing costs assessment for achieving the MDGs and also highlighted the need to adopta new financing strategy that would involve all the three levels of government as well as thearms of government and all relevant stakeholders to make solid commitment through anational partnership and fiscal compact for MDGs in the next five years. Finally, a roadmapfor coordination, and monitoring & evaluation (M&E) is provided with an ―IndicativeRoadmap Matrix of Actions, Lead Responsibilities and Timeframe‖ covering only 2010 and
18. APPENDIX 4182011 – thereby leaving room for any refinements and modifications that a newadministration 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 adequatemomentum to deliver the envisaged amount of progress; instead, some MDGs that wereonce 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 higherimpact; (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 monitoringplan.6. Presently, MAF has become the fastest tool which any nation can adopt to operationalize herMDGs implementation strategy, and in the case of Nigeria, her Countdown Strategy. TheMAF helps countries to analyze why they are lagging behind on specific MDGs, prioritizethe bottlenecks to progress, and identify collaborative solutions involving governments andall relevant development stakeholders. It could also help to address new challenges related tomeeting the MDGs in a particular country context; and integrate new evidence such as thestrategic importance of energy and technology, the centrality of gender equality and women‘sempowerment in relation to specific MDGs targets and indicators, and innovations innational and sub national efforts to accelerate and sustain progress towards the MDGs. Incountries where rates of progress vary sharply across geographic regions and/or populationgroups, the MAF can help understand the reasons behind such differences in progress, andthereby address them through tailored solutions.7. The MAF results in the preparation of a focused, agreed upon Action Plan to address thespecific MDGs that rallies the efforts of governments and its partners, including civil societyand the private sector, on providing the investments and services needed to advance keypolicy reform and overcome identified constraints.8. The Office of Senior Special Assistant to the President on MDGs (OSSAP-MDGs) incollaboration with the Federal Ministry of Health and the International DevelopmentPartners (IDPs) (notably the United Nations Development Programmes (UNDP) and theUnited Kingdom‘s Department for International Development–supported State Partnershipfor Accountability, Responsiveness and Capability (DFID/SPARC) along with other UNbodies) established a Technical Working Group (TWG) charged with the application ofMAF in the operationalization of the CDS.
19. APPENDIX 4199. In line with the Federal Government‘srecognition of the multiplier effects of theMDGs health goals to the overall success ofthe entire MDGs in Nigeria, and given theenormous time and resources involved in theapplication of MAF exercise, the OSSAP-MDGS selected Goal 5 (Improve MaternalHealth) for a special focus in the accelerationefforts. It is against this background that theOSSAP-MDGs, UN Country Team in Nigeria,DFID, and other partners are collaborating inthe application of MAF to MDG Goal 5. Morespecifically, the assignment seeks to develop inclose collaboration with the Expert TechnicalWorking Group, a Country Action Plan (CAP)to accelerate the implementation of goal 5which involves:a) Partnering with relevant sector agenciesand other stakeholders to identify andprioritize high impact interventionsrequired to achieve the MDG Goal 5;b) Conducting research, gathering data andholding workshops to ascertain whatconstitute bottlenecks to theimplementation of Goal 5 andconsequently, proffer solutions to thebottlenecks;c) Develop a comprehensive MAF actionplan including an implementation andmonitoring plan to accelerate theachievement of Goal 5;d) Produce recommendations on the nextsteps with the remaining 7 goals.Nigeria’s Country Profile10. The Federal Republic of Nigeria is located inthe West African sub-region and is composedof 36 states and the Federal Capital Territory(FCT) Abuja. The 36 states are further dividedinto 774 local governments which are regardedas governments at the grassroots. For politicalpurposes and convenience also, Nigeria isdivided into six geo-political zones which areutilized to share some political appointments atthe federal level. With a total land area of923,768 square kilometers, Nigerian sharesboundaries with the Republic of Niger to thenorth, Chad to the northeast, Cameroon to theeast and southeast, Benin to the west, and the Gulf of Guinea to the south. By 2006Box 1: Overview of situation with Goal 5With the current estimated maternal mortalityratio (MMR) of 545 per 100, 000 live births (NDHS,2008), Nigeria still has one of the highest MMR inthe world. It is estimated that about 4 maternaldeaths occur in Nigeria per hour, 90 per day, and2,800 per month for a total of about 34,000 deathsannually, with wide regional and local variations. Alittle over a half (57.7%) of pregnant women agedbetween 15-49 years receive antenatal care fromskilled providers. Skilled attendance at birthremains low at 39%; with great diversity, forexample, with Imo State showing 98% skilledattendants at birth to only 5% in Jigawa State.Available data puts delivery in health facilities at35% while home deliveries was rated at 62.1%,underscoring the need for improved access andutilization for health facilities-based maternalhealth services It is also estimated that for everymaternal 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 inNigeria sustain obstetric fistulae. Over 600,000induced abortions are also estimated to take placein Nigeria annually, and these are often performedunder unsafe conditions, with an estimated 40%performed in privately owned health facilities.As illustrated in Figure 1, the major causes ofmaternal deaths are: haemorrhage; infection;malaria; toxemia/eclampsia; obstructed labour;anaemia; and unsafe abortion.Goal: 5 Target IndicatorsImproveMaternalHealthTarget 5.A:Reduce by 3/4thbetween 1990and 2015, thematernalmortality ratio1. Maternalmortality ratio2. Proportion ofbirths attended byskilled healthpersonnelTarget 5.B:Achieve, by2015, universalaccess toreproductivehealth3. Contraceptiveprevalence rate4. Adolescent birthrate5. Antenatal carecoverage (at leastone visit and atleast four visits)6. Unmet need forfamily planning
20. APPENDIX 420population census, Nigeria‘s population was put at 140 million, and a 2011 projectedpopulation figure of approximately 168 million (NPC, 2011), Nigeria is the most populouscountry 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 populationprojection of 168 million, it is estimated the females constitute 82 million, while the malesaccount 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 grossunderdevelopment of healthy democratic culture. Socially, Nigeria is multi-ethnic incomposition and has over 250 different ethnic groups.12. Economically, Nigeria has a gross national product (GNP) of about US$195 billion in 2007which rose to US$353.2 billion in 2009. The 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. Crudeoil is the main source of revenue, accounting for about 63 percent of government revenueand about 97 percent of export income. Besides crude oil, other fairly large deposits arenatural gas, coal, tin, columbite, iron ore, limestone, lead, and zinc. The main non-oil exportsinclude cocoa beans, palm oil, rubber, textiles, hides and skins.13. Educationally, Nigeria has an adult literacy rate of 72 percent and average life expectancy of48.4 years down from 51 years over a decade ago. Nigeria‘s rank in the Human DevelopmentIndex (HDI) of the United Nations Development Programme (UNDP) has beendisappointingly low over the years. From 141stposition (Human Development Report of1997), to 159thposition in 2006, it moved to 142ndin 2010. Nigeria‘s HDI of 0.423 howeverplaced it above the Sub-Saharan regional average of 0.389 in 2010. Taken together, alongwith an Inequality-adjusted HDI value of 0.246, intensity of deprivation of 57.9% (in termsof poverty) and 70% of the population living below poverty line (2007 estimate), thegovernance and developmental challenges facing Nigeria remain enormous.High Level Endorsement of MAF14. Given the inter-governmental character of the implementation of MDGs in Nigeria, anyeffort to accelerate the achievement of the MDGs not only requires the support of theFederal Government, but also requires both the support of the States and LocalGovernments as well as other critical stakeholders such as the international developmentpartners, private sector, civil society organizations, community and faith-based organizations.In actual fact, in countries where there has been successful application of MAF to theMDGs, 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 Nigeriawas organized by OSSAP-MDGs in collaboration with international development partnerson January 17, 2013 at the Transcorp Hilton Hotel, Abuja. The event was declared open byHis Excellency, Arch. NamadiSambo (GCON) the Vice-President of the Federal Republic ofNigeria. Arch. Sambo restated the commitment of the Federal Government to fast-track theimplementation of the MDGs. He stated that the Federal Government welcomed theapplication 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 SenatorMohammed Ali Ndume restated the commitment of its members to offer the necessaryassistance in the application of MAF. In actual fact, Senator Ndume made a case for a special
21. APPENDIX 421allocation to the MDGs in order to realise the acceleration since as he rightly noted, Nigeriastarted five years behind schedule in the commencement of the implementation. TheHonourable Minister of Health Prof.OnyebuchiChukwu meticulously chronicled the keyinterventions in the health sector generally and in MDG 5-Improving Maternal Healthspecifically 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 theircommitments in the acceleration efforts. Also the presence of the Minister of WaterResources, Mrs. Sarah Ochekpe and that for Housing, Land and Urban Development,Ms.AmaPepple, as well as Heads of parastatals under the Ministry of Health, and a host ofother development partners was an encouraging demonstration of their support in theapplication of MAF in Nigeria.Institutional Frameworks for the Implementation MDGs in Nigeria17. Institutional Structures at the Federal Level: Nigeria maintains robust institutional frameworks forthe implementation of MDGs. At the Federal level, the executive and legislative arms ofgovernment have institutional mechanisms that work jointly for the implementation ofMDGs. Unlike what obtains in some other countries, the Federal Government establishedthe 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 giveMDGs both priority and visibility demonstrated government commitment to theachievement of the MDGs. In addition, the government established a PresidentialCommittee for the Assessment and Monitoring of the MDGs (PCAMMDGs). The membersof the Presidential Committee (chaired by the President) include representatives of stategovernors, National Planning Commission (NPC), local and international Non-governmentalorganisations (NGOs) and ministers of implementing agencies of DRG programmes andprojects. The Office of the SSAP serves as the secretariat of the Committee. Furthermore,some Ministries, Departments and Agencies (MDAs) were designated MDGsimplementation Ministries through which the OSSAP-MDGs channelled funds for theMDGs implementation.18. In order to give life to this institutional framework, MDG implementation was given a hugeboost when the government pledged to apply the savings accruable from the Paris ClubDebt Relief Deal in 2005 (labelled Debt Relief Gains, DRG) to pro-poor programmes andprojects that would enhance the prospects of achieving the MDGs. To this end, a VirtualPoverty Fund (VPF) was adopted in the FGN‘s budget to report on the nature of Debt reliefexpenditures. (The VPF is a coding system within an existing budget classification structurethat enables the ―tagging‖ and ―tracking‖ of poverty-reducing spending). The reportingplatform was provided by the Office of the Accountant General of the Federation throughthe Accounting Transaction Recording and Reporting System (ATRRS). In concrete terms,the VPF tracks the portion of federal government expenditures dedicated to supportingpoverty-reducing activities.19. At the National Assembly, both the Senate and the House of Representatives establishedMDGs committees that have been working in collaboration with OSSAP-MDGs and therelevant MDAs to fast-track the implementation of MDGs.
22. APPENDIX 422Inter-Governmental Institutional Arrangements20. At the inter-governmental level, the Federal Government through the OSSAP-MDGsestablished structures for the implementation of one‘s MDGs‘ intervention success storiesnamely the Conditional Grants Scheme (CGS).The Conditional Grants Scheme operatesthrough specific Federal, State and Local Governments‘ structures shown in figure 1 below.Figure 1: CGS Implementation Structures.Source: OSSAP-MDGs, CGS Implementation Manual, Revised edition, 2012s21. 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 Committeeis drawn from public and private sectors, civil society and the international developmentpartners. It assesses and monitors progress of CGS projects towards the achievement ofthe MDGs in Nigeria.b)The National Committee on Conditional Grants Scheme (NCCGS). The NCCGS ischaired by the Minister of Finance. Its membership is composed of the Minister of theNational Planning Commission; the Ministers of key MDG line Ministries; the DirectorGeneral of the Budget Office of the Federation; the Accountant General of theFederation; 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) StateCGS Project Support Unit, and (iii) Relevant State Ministries, Departments andAgencies.
23. APPENDIX 423e)Local Government Structures include(i) LGA MDGs Planning Committee, (ii) LGAMDGs Technical Team, (iii) Community, Traditional and Faith Based Institutions &Organizations, and iv) Civil Society Organizations.Objectives of MAF22. A critical assessment of the operational effectiveness of these structures in theimplementation of MDG 5 in the past decade is key to the application of MAF. Someimportant questions need to be examined in comprehending why critical interventions failedin many states and local governments. For example, to what extent were the structures atboth the state and local government levels sufficiently empowered and enabled to performtheir responsibilities? Secondly, to what extent did lack of effective collaborations betweenthe state and their local governments impede the implementation of MDG 5? Thirdly, aregrass root structures for the implementation of MDG 5 merely symbolic rather thansubstantive in their existence? Since the success of MDG 5 depends largely on theeffectiveness of structures at the primary health care level, these questions are critical in theimplementation of Nigeria‘s MAF Action Plan23. The overarching objective of MAF is to build partnership around maternal health issues inNigeria especially among the various tiers of Governments (federal, State and LocalGovernments), within MDAs, CSOs, the private sectors, the UN agencies and otherdevelopment partners working on neonatal and maternal health in the country. It primarilyaims at providing deeper understanding of the key bottlenecks to the implementation ofmaternal health interventions in the country, collectively identifies key local solutions anddevelop an action plan that can help to reduce the risks impeding progress on maternalhealth 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 towardsmaternal health in the country; andd) prepare an action plan for implementing collectively identified interventions, monitorand evaluate progress.Methodology of MAF Preparation and Roll-out25. The preparation of MAF in a federal and populous country like Nigeria necessarily entails acomplex methodological framework of operations. The sheer complexity of planning andorganizational requirements in such a large and heterogeneous country no doubt require amulti-pronged methodological foundation that can maximize the highly competing goals inMAF preparation and its eventual roll-out. Be that as it may, three key decisions thatestablished the methodological point of departure were (a) the setting up of the institutionalframework for effective coordination of the MAF process jointly driven by OSSAP-MDGsand IDPs, (b) the engagement of consultants to drive the technical process, and (c) theplanning and organization of the stakeholders‘ consultation technical workshop of which theFederal Ministry of Health played a catalytic role.26. The establishment of the Technical Working Committee composed initially of membersfrom OSSAP/MDGS, UNDP and DFID-SPARC and subsequently enlarged to involve
24. APPENDIX 424Federal Ministry of Health, (when MDG 5 became the main focus) and other IDPs, was onethe milestones of the three-pronged methodological foundation meant to ensure qualityassurance in the MAF preparation process. The second milestone was the actual engagementof four national consultants with wide-ranging expertise on MDGs in Nigeria to manage thetechnical process. The third milestone was the hosting of the MAF stakeholders‘ workshopfor wide consultative and participatory engagements.27. The management of the technical process by the consultants began with a desk review of anarray of existing relevant national and international policy documents and reports madeavailable by OSSAP-MDGs, Federal Ministry of Health, UNDP, DFID-SPARC, other keyUN of agencies as well as documents and reports assembled by consultants themselves. Thecompletion 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.AyodeleOdusola, (MDGAdvisor, Regional Bureau for Africa, UNDP, New York) met with the Consultants.Consequently a tripartite meeting of OSSAP-MDGs, UNDP and DFID-SPARC was calledfor further brainstorming with Dr.Odusola and the consultants. This meeting which washosted by DFID-SPARC turned out to be one of the most fruitful meetings in thecommencement of the MAF process in Nigeria. It was at this meeting that a careful anddetailed selection of stakeholders for the workshop was carried out.29. The selection of the stakeholders for the workshop involved a complex set of criteria aimedat ensuring representativeness of major voices that need to be heard on issues relating to theimprovement of maternal health. There was a selection of key stakeholders in the healthsector reflecting (a) wide geographical spread and geo-political zones (e.g. the selectionensured 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 allrepresented in the selection); (c) tiers of government (federal, state and local governmentswere all involved); (d) professional associations (Nigerian Medical Association, and Nursesand Midwives Association selected); (e) grass roots representations and civil societyorganizations (PPFN, and Society for Family Health representing the marginalized interests);(f) key policy makers and executors in the MDGs line ministries, parastatals, OSSAP-MDGsand the National Assembly, and (g) host of international development partners comprisingUNDP, DFID, DFID-SPARC, DFID-PRRINN-MNCH, WHO, UNFPA, UNICEF,UNMC, UN Women, One UN, World Bank, European Union, USAID, and CEDAR. Amatrix showing the criteria for selection of key stakeholders from all the states andrepresenting 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 theUnited Nations-developed MDG Acceleration Framework-Operational Note made available to theconsultants by MDG Advisor Dr.Odusola. Four main instruments in line with the fourstages involved in the preparation of MAF were developed based on the UN generictemplates. The first instrument, which was on the step 1 of the MAF process relates to thePriority 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 theobjectivity of the selection process. The second instrument on step 2 of the MAF processfocused on the identification and prioritization of the bottlenecks, while the third set ofinstruments was on step 3 of the process. The three instruments provided (a) the solutionimpact evaluation guidelines, (b) the solution feasibility evaluation guidelines, and (c) the
25. APPENDIX 425solution prioritization scorecard. The fourth instrument is a template for the MAF ActionPlan.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 levelparticipation of Federal Government officials and the UN System. Such high levelparticipants included the Honourable Minister of Health (represented by an official of hisministry); the Senior Special Assistant to the President on Millennium Development Goals;Resident Coordinator of the United Nations in Nigeria; Head of DFID in Nigeria (byrepresentation); Country Director of UNDP in Nigeria, and Country Director of UNDP inGhana among others.32. Participants at the Stakeholders‘ workshop identified list of all the key interventions onmaternal health and identified 5 of them as prioritized interventions. Secondly, theyidentified all the bottlenecks impeding success and thereafter identified 5 of them asprioritized bottlenecks. Thirdly and lastly, they also identified a list of acceleration solutionsto the prioritized bottlenecks.33. The next major activity was the hosting of a 2-day intensive Bilateral Discussion meeting onFebruary 27-28, 2013. The participants at the meeting principally involved the consultants onone side, and the key policy drivers and implementers in the Federal Ministry of Health andits Parastatals, as well as representatives from the World Health Organization (WHO) on theother side. But more importantly, the planning of the Bilateral Discussion meeting wascoordinated by OSSAP-MDGs, while DFID-SPARC hosted it. The UNDP as usualprovided the technical backstopping, while the Federal Ministry of Health played the majorrole of mobilizing the participants for the discussions.34. Based on the identified acceleration solutions, participants at the Bilateral Discussionmeeting proceeded to identify the solution indicators, targets, timelines and responsiblepartners 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 werein attendance commenced work immediately.35. The MAF Validation workshop which was held on March 12, 2013 was another milestone inthe application of MAF to MDG 5 in Nigeria. Like the Stakeholders‘ workshop it alsoattracted a high level participation which involved the Honourable Minister of Health, SeniorSpecial Assistant to the President on Millennium Development Goals, HonourableMinister/Vice Chairman of National Planning Commission; the Honourable Minister ofState for Health, Resident Coordinator of the United Nations in Nigeria, Head of DFID inNigeria; Executive Director/CEO, NPHCDA among others.
26. APPENDIX 426CHAPTER 2NIGERIA MDGs STATUS: AN OVERVIEW WITH A FOCUS ON MDG 5Overview36. Since the MDGs was mainstreamed in national planning and budgeting, there have beensuccessive country-level assessment and monitoring reviews, given by MDGs Status Reports2004, 2005, 2006, 2007and 2010. The Reports show progress, trends and challenges in themarch toward the MDGs 2015 targets. This overview of Nigeria MDGs status thereforedraws from the cumulative and collective assessments in these reports, supplemented withupdates based on recent statistics and with a special focus on why the MDG 5 is chosen forMAF.37. Overall, Nigeria‘s progress toward the achievement of the MDGs is a mixed bag especiallywhen comparison is made across the different sub-national jurisdictions, as well as betweenurban and rural populations. With regard to MDG 1 to Eradicate extreme poverty andhunger, recent statistics show that the national poverty incidence increased from 54.4% in2004 to 69.0% in 2010. Against the background of a rapidly rising population this percentagetranslates to 112.47 million people living in poverty in the country. In terms of zonaldifferences the poverty incidence varies from 59 per cent in Southwest to 78 per cent inNorthwest. The significant point to note is that the poverty incidence whether by zone orrural 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% in20111, suggesting a reduction by at least two per cent annually to be able to meet the 2015target of 17.85 per cent. If current trends continue, Nigeria is likely to achieve this targetemploying strategies that are sensitive to, the sharp differences between geopolitical zonesand between states within a zone.38. The MDG 2 which is toAchieve universal basic education has also witnessed a staggeredprogress. The net enrolment ratio in primary education which improved from 80 per cent in2004 to 90 per cent in 2007 has continued to experience a steady decline since then to a lowof 70.1% in 20102and 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 wellover 90 per cent in 2001 dropped to 72.3 per cent in 2008 while the ‗primary 6 completionrate‘ that rose to 80 per cent in 2004 also declined to 67.5 per cent in 2008 and both havecontinued to suffer setbacks in the years since then. In terms of differences between zonesand states, while the net enrolment in primary education is as high as 87% in Ekiti State inthe Southwest and 83% in Abia State in the Southeast, it is as low as 18% in Zamfara State inthe Northwest and 21% in Borno State in Northeast Nigeria.40. On MDG 3 which is toPromote gender equality and empower women, Nigeria iscurrently on track and has bright prospects of meeting MDG 2 with regard to the ratio ofgirls 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 baselineof 70 girls per 100 boys in 1990; similarly, there are currently 93 girls per 100 boys insecondary schools in 2010, against the baseline of 75 girls per 100 boys in 1990. On thesetwo indicators, consistent progress has been sustained over the years. There continue to be1Multiple Indicator Cluster Survey (MICS) 2011.2Nigeria DHS EdData Survey 2010.3 Nigeria DHS EdData Survey 2010
27. APPENDIX 427high disparities across zones and states on progress toward MDG 3. For example, genderparity in primary school has been achieved in Ekiti, Delta, Abia and Imo, but disparitypersists in Sokoto, Jigawa, Katsina and Kebbi. These patterns are mirrored in the Figure 2below:41. The progress on MDG 4 toReduce child mortality is uneven between zones and states aswith other MDGs. Recent statistics4estimate the under-5 mortality rate at about 158 per1000 live births in 2011, against the 2015 target of 64 per 1000 live births. The most recentestimate for infant mortality rate is 97 per 1000 live births in 2011 against the 2015 target of30 per 1000 live births. The wide zonal differences are illustrated graphically below:Figure 3: Under-5 Rate by Geo-political Zone, Nigeria 2011Figure 4: Infant Mortality Rate by Geo-political Zone, Nigeria, 20114Multiple Indicator Cluster Survey (MICS) 2011
28. APPENDIX 42842. Nigeria is on track to meeting the MDG 6 which is to Combat HIV/AIDS, malaria andother diseases with particular regard to the target ‗to halt and reverse the spread ofHIV/AIDS‘. Latest statistics, though in arrears, show that the country is progressing welland will likely achieve the target, if current trends continue. The HIV/AID prevalence ratedeclined from about 5.4% in 2000 to about 4.1% in 2008. However, critical challenges persistwith regard to access to treatment for persons living with HIV/AIDS (PLWA) that arereceiving treatment and prevention of mother-to-child transmission (PMTCT). Only one outof three persons living with HIV/AIDS gets treatment currently, against the target ofuniversal coverage. Regarding the prevention of mother-to-child transmission, the countrycurrently achieves a meagre 16%, against the 2015 target of 90%. Nigeria is also on trackwith 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 widelydivergent across the respective constituent indicators. On the one hand, there is modestprogress on the 2015 target of halving the proportion of the population without sustainableaccess to safe drinking water and basic sanitation. About 58.5% of Nigerians has access toimproved drinking water source in 20105, as against the 2015 target of 77%. Similarly, about42.6% of Nigerians have access to improved toilet/latrine facility in 20106, as against the2015 target of 70%44. On the other hand, the situation is not satisfactory with respect to halting deforestation andgas flaring. Only about 10% of gas produced is used domestically primarily for powergeneration while 24% is flared7. Gas flaring from joint venture oil companies representsroughly 60% of all emissions from Nigeria‘s oil and gas sector. Equally, tackling the growingtide of slum dwellings will become even more challenging amidst the urbanisation wavesweeping across the country. It is estimated that Nigeria‘s urban population would rise toabout 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 asevidenced by the Paris Club debt relief as the primary source of funding of MDGs inNigeria. But, overseas development assistance (ODA) has been lagging behind levels desiredfor meeting the MDGs. ODA to Nigeria increased from US$4.49 per person in 2004 toUS$81.67 per person in 2006 and 2007, but, much of this increase came from the debt reliefrather than from additional ODA from international development partners. Estimates showthat per capita ODA was US$8.53 in 2008, but is still far short of the volume of fundsrequired to make appreciable progress on the MDGs.46. Nigeria‘s progress on access to ICTs has been rising sharply, fuelled by the deregulation ofthe telecommunications subsector and market entry by private sector GSM operators. In1990, 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 tomore than 1.57 million in 2002 and about 32 million in 2006. Thus, access to cellularphones increased from only 2 out of 100 persons in Nigeria in 2000 to nearly 42 per 100 in2008. As of October 2012, Nigeria had a total 109,499,882 active telephone lines (mobileGSM, mobile CDMA and fixed wired/wireless), representing a teledensity of 78.21%, up5 Nigeria Malaria Indicator Survey (NIMS) 2010.6 Nigeria Malaria Indicator Survey (NIMS) 2010.7NNPC 2010.
29. APPENDIX 429from 1.89% in 2002. However, internet access lags far behind the growth of telephonelines. Internet users per 100 persons increased from 0.32 in 2002 to 15.86 in 2009. Despitethis increase, the access to internet remains low, signifying large scope for improvement.Focus on MDG 5: Improve maternal healthFigure 5: Maternal Mortality Rate47. Improvement in maternal health is another area where the country has made an appreciableimpact. The data (Figure 5.1) shows that maternal mortality has been reducing steadily: 800per 100,000 in 2004; 545 per 100,000 in 2008; and 350 per 100,000 live-births in 2012.Thisrepresents 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 fromthe 250 target.Figure 6: Proportion of births attended by skilled health personnel48. The 35.8 per cent decline in 2012 in the number of women that die during child birth is inpart attributable to the increase in coverage of births attended by skilled health personnel inthe 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 deliveries8005453502502004 2008 2012 2015PerthousandlivebirthsMaternal mortality rate (per 1000 live birth)0204060801002004 2008 2012 201536.3 38.953.6100Proportion of birth attended by skilled healthpersonnel (%)
30. APPENDIX 430attended by skilled health personnel increased from 36.3 per cent in 2004 to 38.9 per cent in2008. It further rose to 53.6 per cent in 2012.Figure 7: Contraceptive prevalence rate49. Increased access to safe, affordable and effective methods of contraception is providingindividuals with greater choice and opportunities for responsible decision-making inreproductive matters. In addition, contraceptive use has contributed to improvements inmaternal 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 butdropped to 14.6 per cent in 2008 (Figure 5.3). There is still room for improvement given thatvarious unmet family planning need is progressively rising since 2004 – particularly in therural areas where awareness is relatively low.Figure 8: Antenatal care coverage50. Antenatal care coverage is among the health interventions capable of reducing maternalmorbidity. It is critically important to reach women, and timely too, with interventions andinformation 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 percent in 2012 from a decline of 61 per cent in 2008. The 2012 figure represents 6.7 per centand 12.8 per cent increase over 2004 and 2008 figures. In addition, antenatal coverage – at0246810121416182004 2008 20128.214.617.3Contraceptive prevalence rate (%)0204060802004 2008 20126154.567.747 44.857.6Antenatal care coverage %Antenatal coverage (at least once by any provider)Antenatal coverage (at least four times by any provider)
31. APPENDIX 431least four visits in 2012 rose to about 57.8 per cent; an increase from 17 per cent in 2004 and20.2 per cent in 2008 respectively (Figure 5.4). However, this spectacular success is skewed tourban 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 percent for four visits.Figure 9: Unmet need for family planning51. The unmet need for family planning remains persistently high. The unmet need for familyplanning—expresses the percentage of women aged 15 to 49, married or in a union, whoreport 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 whichfurther 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 clearjustifications for the choice of MDG5 for Nigeria‘s MDG Acceleration Framework (MAF):a) Focusing on MDG 5 is consistent with the Government’s TransformationAgenda. At inception, the present administration launched an agenda for addressingthe most pressing development challenges facing the country. The Agenda identifiedhealthcare, among others, as a key development and policy challenge. In the gamut ofthe health challenges, poor maternal health is iconic. For Government, the underpinningpolicy for the inputs toward achieving the human capital development goal of the Vision 20: 2020Strategy is the National Strategic Health Development Plan (NSHDP). The NSHDP is thevehicle for actions at all levels of the health care service delivery system which seeks to foster theachievement of the MDGs and other local and international targets and declaration commitments.b) The choice of MDG 5 for MAF will address persistent zonal disparities inhealth outcomes. Disparities in the achievement of the goals of the MDGs acrossstates and between the six geo-political zones of the country abound, but much moredramatic with respect to MDG Goal 5 on maternal mortality, given especially itsimmediate impact on human lives. Whereas a zone like the South West, standingalone, had virtually met the target even as early as at 2008, others, especially theNorth 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 inareas of poor outcomes.c) Sustaining and Improving Progress on MDG 5.As already indicated, on theaverage some progress was made on all the three maternal health indicators between2003 and 2008. On the basis of this development, and factoring in what appeared tobe good prospects for achieving Goal 5, the 2010 MDGs +10 Report suggested that05101520252004 2008 20121720.2 21.5Unmet need for family planning (%)
32. APPENDIX 432MDG 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 wasthat if the average performance on the MDG 5 is sustained, the target would be metby 2015. This performance-based projection was the basis for the official optimismthat was shared with the rest of the world by President Jonathan in September 2010.The Countdown Strategy (CDS) provided a roadmap, targeted investment andingredients of effective partnership which implementation would have helped tosustain the observed trend of the three years to 2008 and which formed the basis forthe optimistic projection to meeting the target by 2015. For a number of reasonsassociated with transition in administration, the implementation of the CDS wasdelayed. A number of otherwise laudable initiatives like the MSS programme werenot anchored effectively on the roadmap of the CDS. Even with the latest NBS datashowing an MMR of 350 as a national average, there are still wide differences withinthe least performing zones. The political commitment and the associated resourcesdevoted to the attainment of MDG 5 still remain a matter of great concern. Added tothe above is the largely unexpected eruption of violence, especially the North EastZone 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 aloss of the momentum towards the attainment of MDG 5 in some parts of thecountry. The healthcare initiatives that held the promise of raising the nationalaverage performance on MDG 5 - Midwifery Services Scheme, RoutineImmunisation, Rollback Malaria, HIV/AIDS Control Programme, Health SystemsStrengthening, Infrastructure and even the SURE-P--- appear overwhelmed byinsecurity in parts of the county where their operations are needed most for theachievement of the health MDGs and in particular goal 5.e) MDG 5 is a proximate means of progress on other MDGs. Maternal health ishighly linked to other MDGs like child health, gender and women empowerment andpoverty reduction. It means that accelerating progress on MDG 5 could lead togaining some mileage with the other MDGs in which progress is currently slow. Ahealthier mother is better able to work, earn a living, participate in householddecision making and provide better for a child. Available data demonstrate thiscorrelation. For example, when national maternal mortality rate declined from 800deaths per 100,000 live births to 545 deaths over the period 2003 to 2008, itcorrelated with declines in infants and under five mortality rates as illustrated inbelow. The focus on MDG 5 is therefore expected to have salutary effects on theperformance of other goals, especially Goal 4. Hence, for the good health of ourwomen in the vibrant age group of between 18 and 45 and for politicalaccountability, the choice of the MDG 5 for MAF is considered appropriate andtimely.
33. APPENDIX 433Figure 10: Trends in Maternal and Child mortality (1990 -2008)8Source: OSSAP-MDG8Chart adapted from ‗The Health MDGs (4, 5 & 6): Achievements and Lessons Learnt” Office Of The Senior Special Assistant toThe President On MDGs (2012)70449871928005210020154540751570100200300400500600700800900MATERNAL NEONATAL INFANT UNDER 5199020032008
34. APPENDIX 434CHAPTER 3KEY INTERVENTIONS TO ACCELERATE MDG-5 IN NIGERIA53. In Nigeria, MDG5 specific interventions are being delivered using the principles ofintegration of services along a continuum of life stages of care starting with: pre-pregnancyperiod; pregnancy period; intrapartum period (delivery); and the postnatal period. And overthe years, a series of Health-MDG response frameworks and plans have been produced inconcerted efforts to rise to the challenge of meeting the MDG targets by 20159,10,11,12. Thepackages of interventions that have been identified and implemented towards meeting thetarget for MDG-5 consist of the following:a) Provision and facilitating demand for basic and sometimes comprehensive essentialobstetric care services in health facilities to treat pregnancy and delivery-relatedcomplications such as eclampsia, haemorrhage, obstructed labour, sepsis, and abortion-related cases, and other causes of maternal mortality identified earlier. Government anddevelopment partners have stepped up initiatives to increase availability of BasicEmergency Obstetric and Newborn Care (BEONC) interventions projects across thecountry.. These are among other things addressing at least 3 well-known delays: delays indecision making to seek treatment; delays between decision-making and reaching a healthfacility; and delay between arrival at the health facility and receiving appropriatetreatment. A number of interventions have been put in place, responding to addressingthese delays and in addressing the demand-side of the challenge to reproductive healthservices. For example, one such program, the Maternal and Child Health IntegratedProgram (MCHIP) addresses delays associated with maternal and newborn deaths byseeking to improve household and care-seeking practices, empowering the community tocreate and maintain an enabling environment for increased utilization of maternal andnewborn care services wherever they are available, with the main thrust beingimprovement of EmONC services, with a recognition that response to potentialpregnancy and child delivery complications starts in the antenatal period and continuesthrough childbirth and the postnatal period.b) Developing and implementing a coordinated behavioral change communication strategyto promote essential newborn care practices at community level through women‘sgroups, religious organizations and other community mobilization structures; scaling upthe use of trained household counselors (for example in several northern states;educating women and their families about the danger signs in pregnancy, during and afterchildbirth; scaling up the use of trained male birth spacing motivators to educate menabout the benefits of healthy timing and spacing of births and the use of long-actingcontraceptive methods; implementing community systems to respond to immediatereferral to primary health clinics and hospitals in the case of complications.9 FMOH: Health Sector Reform Programme, 2004-2007.10FMOH: Achieving Health Related Millennium Development Goals in Nigeria. A Report of the PresidentialCommittee on Achieving MDG in Nigeria11 FMOH: National Strategic Health Development Plan (NSHDP) 2010-2015,12NPC-OSSAP: 5-Year Countdown Strategy: Roadmap to Accelerate Nigeria‘s Progress towards Achieving theMillennium Development Goals
35. APPENDIX 435c) Equipping Community health workers with kits to visit pregnant women at homecounsel them and encourage them on ANC, danger signs in pregnancy, delivery and afterdelivery to both mother and baby, birth preparedness with the family including thevarious preparations for facility delivery e.g. transportation, delivery with a skilled birthattendant and saving towards emergencies, birth spacing and appropriate referrals. TheseCHWs support the women in labour to the prearranged facility, and make home visits tosupport the new mother and baby and treat or refer promptly and appropriately in caseof mother or baby needing care they cannot render. They counsel and support onappropriate feeding practices and encourage exclusive breastfeeding. This program iscalled Community based maternal and newborn care (CBNC).d) Improving access to quality essential obstetric care services. Health facilities providingmaternal and reproductive health services are few and unevenly distributed across thecountry. Not only are facilities insufficient, majority of the available ones do not have theminimum 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 andexpectations, especially during emergencies.e) Establishing mentoring linkages between tertiary and primary care facilities and healthworkers to improve quality of obstetrics and newborn care.f) Improvement of reproductive health/family planning services and usage. The lack ofready access, affordability and usage of reproductive health services, such as familyplanning is largely attributed to poverty and the lack of funds to procure these services.Interventions addressing these deficiencies improve usage of reproductive/familyplanning services and significantly improve maternal health and reduce maternalmortality.g) Improved financial access to vulnerable groups, especially women. This has involved theimplementation of various models of financial protection schemes, notably: conditional-cash-transfer schemes for pregnant women; and NHIS (Community Health InsuranceScheme), 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 theexpansion of the construction of new PHC facilities. A number of States Governmentshave also launched various forms of initiatives, including free health care to targetedgroups in addressing expansion and access to health care services.i) Development of a network of PHC centers linked to secondary referral health facilitiesthat are well equipped and staffed to facilitate access to emergency obstetric care facilitiesin case of emergency.j) Renovation of health facilities with a focus on areas such as Antenatal Clinics, labourwards and general maternity sections, and provision of basic drugs, commodities,including equipment for treatment of common MNCH illnesses to improve the deliveryof MNCH services.k) Construction of boreholes for provision of portable water supply to improve quality ofcare in health facilities
36. APPENDIX 436l) Pregnancy period interventions, consisting of: focused Antenatal care (FANC); andPrevention of Mother to Child Transmission of HIV. The goals of focused antenatal careare to promote maternal and new-born health and survival through: Early detection andtreatment of problems and complications, Prevention of complications and diseases,Birth preparedness and complication readiness and Health promotion.m) Strengthening referrals: identification and capacity building of referral systems includingfocal persons at community and in health facilities to effectively refer clients to theappropriate 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 ofsexually transmitted infections; and prevention of cancer of the cervix.o) Prevention of Mother-To-Child Transmission (PMTCT) of HIV: Nigeria accounts forabout 30% of Global burden of mother to child transmission of HIV. The risk oftransmission of HIV through heterosexual means is higher during pregnancy. HIV canbe transmitted to the unborn child during pregnancy, labour and delivery and throughbreastfeeding. ARV prophylaxis, provided during pregnancy and post natal periodthrough breastfeeding in accordance with the recent WHO guidelines can reducetransmission below 5% and accelerate virtual elimination of mother to child transmissionof 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 andthe leading cause of cancer mortality among women in developing countries. About270,000 women die from cancer of the cervix annually, 85% of which occurs in resourcepoor settings due to – late diagnosis and presentation in advance stages of the disease. InNigeria – WHO has estimated that about 14, 550 new cases occur in 2008, 8 out of 10presenting with an advanced disease and with mortality rate of about 23%. It is believedthat HPV types 16 &18 are responsible for most cases in Nigeria as in other countriesworldwide. Other risk factors may include: Tobacco use, lack of screening and adequatetreatment of precancerous lesions and Human Papilloma Virus and Humanimmunodeficiency Virus (HIV) co-infection. The National cervical cancer control policycentered on Public Health approach employs a combination of vaccination, education,screening, treatment and linkages with other programmes. Primary prevention includethe use of Bivalent Vaccine which acts against genotypes 16 and 18 - Cervarix –GSK andis recommended for ages 9-15 years and this delivered through School; Health Centre;and community outreach programmes. Secondary Prevention consists of screening forpre-cancerous lesions and early diagnosis followed by adequate treatment; and VisualInspection 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 VIAinto SRH and HIV services at PHCs levelq) Intrapartum (Delivery) care intervention, consisting of access and use of skilled birthattendants, Emergency Obstetric and Neonatal care, and Referral.r) Postnatal Care interventions, consisting of: Family planning; Prevention andmanagement of post-partum sepsis and anaemia. A large proportion of maternal andneonatal deaths occur during the first 24 hours after delivery. Thus, prompt postnatalcare is important for both the mother and the child to treat complications arising fromthe delivery, as well as to provide the mother with important information on how to care
37. APPENDIX 437for herself and her child. It is recommended that all women receive a health check withinthree days of giving birth. According to NDHS 2008, 56% of women did not receivepostnatal care up to 6 weeks after delivery. This intervention needs to be scaled up toavert maternal death occurring during the first 24 hours.s) Improving access to health facilities for women and children in the community bytraining volunteer drivers to transport them to health facilities during emergencies (theEmergency Transport Scheme).t) Developing, and distributing of service delivery protocols and job aids to health facilitiesand training of health workers to manage MNCH conditions according to standardprotocols.u) Setting up and building the capacity of Facility Health Committees (FHCs) to hold healthfacilities accountable to deliver quality care to the community and to participate inimproving community response to the facility needs and care seeking. The members ofthese 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 andchildren 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 toimprove coverage of selected high impact interventions and promote key MNCHhousehold and community practices.54. As illustrated in the chart below current coverage for all high impact interventions fall shortof expected levels. With the exception of the South-West Zone with 165/100,000 MMR,which is below the MDG5 target of 250/100,000 MMR for Nigeria, other zones carrysubstantial burden of maternal mortality. Nigeria needs to do more in ANC, Skilled BirthAttendance, EmONC and PMTCT.Prioritization of Key Interventions55. 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 acceleratedachievement 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
38. APPENDIX 438Fig. 11Challenges: Coverage of high impact interventionsfor maternal, newborn and child health(NDHS2008) still remains low45%45%7%10%39%2%38%38%68%13%0% 10% 20% 30% 40% 50% 60% 70% 80%ANC (at least 4)TT2+IPTPMTCT motherSkiiled Birth AttendanceDelivery by C-SectionPostNatal Care (2days)Initiation BF 1hourInitiation BF 1dayExcl. BF <6mthsCoverage foruniversal accessTable 1: MDG 5 FocusMDG5 Target Indicators MAF Key Intervention AreaImproveMaternalHealthTarget 5.A:Reduce by 3/4thbetween 1990and 2015, thematernalmortality ratio1. Maternal mortalityratio2. Proportion ofbirths attended byskilled healthpersonnelEmergency Obstetric andNewborn CareSkilled Birth AttendantImproving Referral SystemTarget 5.B:Achieve, by2015, universalaccess toreproductivehealth3. Contraceptiveprevalence rate4. Adolescent birthrate5. Antenatal carecoverage (at leastone visit and atleast four visits)6. Unmet need forfamily planningFamily PlanningFamily PlanningFocused Ante-Natal CareFamily Planning56. Family Planning: Family planning is defined as a way of thinking or living that is voluntarilyadapted based upon knowledge, attitude and responsible decision of an individual or couplesin order to promote health and welfare of the family and thereby contributing to the socioeconomic development of the country. Family Planning (FP) is one of the fundamentalpillars of safe mother hood and one of the quick wins in addressing maternal morbidity andmortality. 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 whichconstitutes about two-thirds of pregnancies.57. Prevention of unsafe abortion and post abortion care consists of health care services, familyplanning counseling and referral services offered to unmarried adolescents to prevent
39. APPENDIX 439unwanted pregnancies and to a woman as a result of complication arising from an induced orspontaneous abortion which could be inevitable, incomplete or septic. Unsafe abortionaccounts for 11% of maternal deaths in Nigeria. In Nigeria, abortion is legally restricted tolife threatening conditions affecting the mother. Approximately 610,000 abortions occurannually and 80% of patients with abortion complications are adolescents. Currently theProvision 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-spacingand the prevention of sexually transmitted infections (STIs), including the HumanImmunodeficiency Virus (HIV). Delaying first pregnancy requires the provision of adequateadolescent reproductive health information, including family planning, to all adolescents oryoung adults (15–24 years), preferably prior to marriage. Nigeria has a high total fertility rateof 5.7, with rates as high as 6.3 in the rural areas. Nigeria also has a high rate of earlymarriages and a low rate of modern contraceptive use. Only 17.3% of married women reportuse of modern contraceptives.Over 20% of Nigerian women have an unmet need for familyplanning, 15% for spacing and 5% for limiting pregnancies. Children born too soon after aprevious birth, especially if the interval between the births is less than two years, have anincreased risk of sickness and death at an early age. Yet 8% of births are less than 18 monthsapart and 24% have an interval of less than two years. Government has approved a policy onthe distribution of free contraceptive commodities in all public health facilities toeliminate financial barrier to services, in addition to a Counterpart contribution of $3mannually from 2011 to support the free distribution of contraceptive commodities. At theLondon 2012 FP Summit commitments; Government has made a commitment to provideadditional $8.35 million annually over the next four years for a dedicated budget line item forLife Saving UN Commission commodities. This increases Nigeria’s total commitmentfor 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 NationalHealth Insurance Scheme (NHIS) package59. Skilled Birth Attendants: The skilled-birth attendant intervention refers to the process bywhich 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 theknowledge and a defined set of cognitive and practical skills that enable the individual toprovide safe and effective health care during childbirth to women and their infants in thehome, health center, and hospital settings. Skilled attendants include midwives, doctors, andnurses with midwifery and life-saving skills. This definition excludes traditional birthattendants whether trained or not (WHO, 2006). In order for this process to take place, theskilled birth attendant must have the necessary skills on Expanded Life Saving Skills(Doctors), Life Saving Skills (Midwives) and Modified Life Saving Skills (CHEWS) and mustbe supported by an enabling environment at various levels of the health care system,including a supportive policy and regulatory framework, adequate supplies, equipment andinfrastructure. Emergency Obstetric and Newborn Care services ensure that care is providedby skilled birth attendants to pregnant women with obstetrics complications and theirnewborn. Generally, 85% of women will have safe delivery without complication with only15% experiencing obstetric complications and it is this that contributes to the high maternalmortality ratio. According to W.H.O, Emergency Obstetric care can be divided into Basicand Comprehensive Emergency Obstetric care. The six Basic Emergency Obstetric Careservice functions to be provided at the PHCs includes: Administer parenteral antibiotics;Administer uterotonic drugs (i.e. parenteral oxytocin); Administer parenteral anticonvulsantsfor preeclampsia and eclampsia (Magnesium sulphate); Manual removal of placenta; removalof retained products (e.g. manual vacuum aspiration, dilation and curettage); perform assisted
40. APPENDIX 440vaginal delivery (e.g. vacuum extraction, forceps delivery). And in addition to the 6 functionsof Basic Emergency Obstetric Care, Comprehensive Emergency Obstetric Care services areto: 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 andComprehensive Emergency obstetric services.60. The Midwives Service Scheme (MSS) represents, to date, the most visible response, fromGovernment, to address the issue of putting skilled birth-attendants to the reach of pregnantwomen. The innovation was launched in 2009 to reduce the high rates of maternal and childmortality. Significant changes have become apparent since launching the scheme withattendant challenges. Within the programme, key health systems issues are also beingaddressed such as the availability of essential health care commodities in addition to theredistribution of skilled human resources to remote rural areas, addressing some of theinequities 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 andnewborn mortality decrease.62. The MSS engages three categories of midwives: the newly graduated, the unemployed andthe retired but able. They are posted for one year (renewable subject to satisfactoryperformance) to selected primary healthcare centres (PHCs) in rural communities. Thescheme is the largest of its kind on the continent of Africa; increasing the coverage of skilledbirth attendants (SBAs) through the recruitment of 4,000 midwives and 1000 communityhealth workers as frontline workers, for the provision of MNCH services including familyplanning. The scheme is being further expanded with additional 3,426 Midwives/CHEWsunder the 2012 Subsidy Reinvestment and Empowerment Program (SURE-P) of the FederalGovernment63. The scheme has encountered several challenges whilst making good progress towardsachieving its objectives.Currently there is the need to fill existing gaps with midwivesparticularly in the North East and North West zones and this is mainly because of theinadequate production of midwives by the two zones and the recent security challenges inthese zones. The specific objectives of the scheme remains:a) To increase the proportion of primary health care facilities manned by midwives offering24Hr 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 EmergencyObstetric and Newborn Care (BEmONC) in MSS target areas by 60% by December2015.d) To increase the proportion of pregnant women receiving focussed antenatal care in MSSfacilities by 80% by December 2015.e) To increase the proportion of deliveries attended to by Skilled Birth Attendants in MSStarget 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 byDecember 2015.
41. APPENDIX 44164. Operationally, the MSS adopts a ―Cluster Model‖ or a ―Hub and Spoke‖ structure whereinfour (4) selected primary health centres with the capacity to provide Basic EmergencyObstetric Care (BEmOC) are clustered around a General Hospital with the capacity toprovide Comprehensive Emergency Obstetric Care (CEOC) which serves as the referralfacility. Presently there are 250 Clusters comprising 1000 PHCs and 250 General hospitals.This needs to be considerably scaled up.Fig. 12 MSS Cluster Model65. Each of the PHC facility within the Cluster has a compliment of four (4) midwives for 24hour coverage. The midwives and community health workers (CHWs) provide facility andcommunity based maternal, newborn and child health services including outreaches in ruralhard to reach areas. In the existing MSS response, the CHWs are deployed to the NorthEast, North West zones and some hard to reach facilities in the North Central zone wherethe mortality burden is highest. This is to compliment the services of the midwives in thecommunities.66. As an intervention, the MSS has made tremendous progress since inception and is nowbeginning to show benefits to the women and families in rural communities in Nigeria. TheMSS has:a) engendered a better nationwide coordinated response, resulting in the Governors of the36 States and the FCT signing a Memorandum of Understanding (MOU) with theFederal Government to support and sustain the MSS by providing accommodation andsupplementing the allowances paid to the midwives in the scheme; the scheme has begunto share its successes and challenges with states across the country and encouraging themto replicate the scheme in other rural PHC facilities. This will enable sustainability andcoverage of the scheme‘s services to communities in rural areas;b) fostered the emergence of viable Ward Development Committees established around allMSS facilities for the purpose of engendering community participation and ownershipwhich is an important component of the Scheme. The committees also have theresponsibility of monitoring the presence of the midwives in the communities, providingthem with accommodation, security and an enabling environment to provide services fortheir communities.c) resulted in the provisioning of essential commodities as incentives to pregnant womenand supports the smooth running of facilities. These include the provision of; Mama kits,
42. APPENDIX 442Midwifery kits, Drugs, basic equipment like ―Blood Pressure‖ apparatus, Stethoscopes,weighing scales, facility/community registers, protocols and service guidelines to all PHCfacilities under the Scheme. For example, 588,000 doses of Misoprostol tablets withother relevant materials were distributed to all MSS facilities nationwide. This ensuredavailability of the drug in MSS facilitiesd) piloted the use of ICT innovation in 160 MSS PHC facilities and 40 referral Generalhospitals connected with ICT facilities such as voice over rural telephony, datatransmission and internet/video conferencing and remote training and mentoring. Inaddition the scheme utilizes a mobile health technology called ―Mobile Application DataExchange System‖ (MADEX) for the collection of data from rural MSS facilities andonward transmission to a central place for collation, analyses and reporting.e) resulted in quarterly cluster monitoring of the MSS facilities and midwives/communityhealth workers and biannual Integrated Supportive Supervision (ISS) to mentor andsupport the midwives in the field.f) trained 4000 Midwives on Emergency Life Saving Skills to enhance the quality of careprovided to the communities.g) conducted Expanded Life Saving Skills (ELSS) for Medical Officers from the designatedreferral General Hospitals in the 36 States and the FCT to strengthen their capacity oncomprehensive 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 partnershipwith the Schools of Midwifery and Health Technology in the 36 States and FederalCapital Territory (FCT) of Nigeria.i) trained Ninety Four Tutors from thirty seven Schools of Midwifery nationwide on theuse of Misoprostol. The TOT was followed by the training of Midwives from 1,000 MSSfacilities to enhance the effective management of postpartum haemorrhage at theCommunity and PHC levels using Misoprostol.j) provided TOT on Quality improvement for One Hundred and Sixty One MidwifeTutors from the 37 schools of Midwifery with the following outcomes; establishment ofcritical mass of Quality Improvement Trainers nationwide, strengthen institutions on QIwith its multiplying effect, QI champions were established nationwide and facilitationskills of participants were sharpened.k) trained one thousand officer‘s in-charge and four thousand Midwives from the 1000 MSSfacilities on Quality Improvement to improve quality of service delivery at the facilitylevel. Each facility currently has a functional Quality improvement team in place.
43. APPENDIX 443l) introduced routine Maternal Death Review or Audit (MDR) in MSSfacilities/communities. The exercise was designed to determine the root causes ofmaternal mortality in a supportive environment, provide evidence for local decision-making on the appropriate interventions needed to reduce maternal mortality67. MSS Outcomes: Availableinformation from MSS facilities by December 2012, whencompared to the baseline data (December 2009) before the scheme started, providesevidence on progress towards achieving the objectives of the Midwives Service Scheme. Theoutcomes confirm significant improvements in the core indicators as compared to baselinedata.Fig. 13: Overview of MSS Progress* Maternal deaths iscompared for 2011and 2012Summary of the progress Midwives Service Scheme has deliveredwithin three years of implementation+150%+104%ANC attendanceDeliveriesFamily PlanningattendanceMaternal DeathsNeonatal Deaths-19%-5%+234%2012200924048948983427877 69641316 257281 26724816 7299568. The MSS remains a strategic intervention because of the recognition that improving the skillsof birth-attendants in areas with the greatest need is achievable within a short period.Thestrategic 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 ensuresuccessful implementation. Some of these include the signing of a Memorandum ofUnderstanding (MoU) with all State Governors detailing their responsibilities and the settingup 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 birthattendants at delivery, as a human resource intervention. It has created platform for effectiveimplementation of other health interventions particularly at the rural areas. In addition, thescheme adopted the approach of task shifting in areas where there are issues of retention ofthe midwives by engaging Community Health Workers (CHW) resident in these areas toovercome these challenges. The scheme has also fostered partnership, working with statesand local governments as well as Development Partners to ensure synergy inimplementation.Emergency Obstetric and New-born care (EmONC)69. Globally, 15% of all pregnant women develop obstetric complications, most of which areunpredictable. Services for emergency care must therefore be available in order to prevent
44. APPENDIX 444maternal and/or neonatal death and disability. Certain critical services, or signal functions,have been identified as essential for the treatment of obstetric complications to reducematernal deaths. These signal functions provide a basis for assessing, training, equipping, andmonitoring obstetric services.70. A Basic EmOC (BEmOC) facility can administer parenteral antibiotics, oxytocics andanticonvulsants. It can perform manual removal of the placenta and retained products andperform assisted childbirth. A Comprehensive EmOC (CEmOC) facility, in contrast, canperform all BEmOC functions in addition to performing surgery (e.g., caesarean section) andsafe blood transfusions. The Nigerian BEmOC standard includes two additional signalfunctions in the guideline: 24-hour service coverage and a minimum of four midwives perfacility. Neonatal resuscitation has been incorporated as a signal function to save newbornlives for basic and comprehensive care at the global level as an additional signal functionwhich explains the renaming as basic and comprehensive EmONC.71. WHO recommends that for every 500,000 population, the minimum acceptable level is fiveEmOC facilities, at least one of which provides comprehensive care. According to theFMOH/UNFPA EmOC survey in 2003, only Lagos state met the standard of four BEmOCfacilities per 500,000 people, combining both public and private healthcare providers. Justseven states met the standard of one CEmOC facility per 500,000 people, considering publicfacilities alone. In all states surveyed, a higher proportion of private facilities met the EmOCstandard compared with public health facilities, but both fell below the recommendedEmOC levels.Many facilities in Nigeria do not meet the national staffing standard forBEmOC. While all tertiary facilities in 12 surveyed states provide 24-hour coverage, only90% of secondary facilities provide the same service. Not only is there almost no 24-hourcoverage in primary healthcare (PHC) facilities, which are often the closest facilities forpregnant women, but many do not have a qualified midwife present. One survey found thatin all of Nigeria, only one PHC facility (in Lagos state) met the national BEmOC standard ofa minimum of four midwives per facility with 24-hour service coverage. Many health facilitiesgenerally lack adequate material resources, as well as basic infrastructure such as water andelectricity. This has a significant impact on health facilities‘ ability to offer quality obstetriccare. As one primary healthcare worker in the EmOC survey stated, ―There is a lack of drugsand equipment, no suction machine, no water, no power supply. We deliver babies usinglight from lanterns and candles, and also do vaginal exams with them as well. The sameEmOC survey shows that 21% of secondary health facilities and most primary healthcarecentres have no functional equipment to take blood pressure measurement in their labourwards. The preceding situation obtained before the launching of the MSS programme in2009.72. The estimated proportion of women who will experience complications requiring a caesareansection is between 5% and 15%. The prevalence of women who give birth by caesareansection can serve as an indicator of whether EmOC facilities meet women‘s needs when theypresent with obstetric emergencies. While a high caesarean section rate can also reflect poorservices, Nigeria does not meet even the low threshold, as just about 2% of babies aredelivered using this procedure and some zones recording coverage as low as 0.4%.Universal Coverage of Ante-Natal and Post-Natal care73. Women are advised to attend at least four antenatal visits, during which they should receiveevidence-based examinations and screenings. These services are offered through a packagereferred to as focused ANC. The purpose of focused ANC is to provide better care for
45. APPENDIX 445pregnant women with a goal-oriented approach, which emphasizes content rather than thesheer number of ANC visits. The content of ANC is an essential component of the qualityof services. Focused ANC hinges on the principle that every pregnancy is at risk ofcomplications and should be monitored. According to NDHS 2008, 87% of Nigerianmothers who attend ANC have their weight measured, 85% have a blood pressure taken and74% have a blood sample taken. Three-quarters have a urine sample taken, 54% receive irontablets, and 61% are informed of signs of pregnancy complications. Overall, 67.7% ofNigerian 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% ofrural women.74. It is important that women attend ANC at the early stages of pregnancy in order to benefitfrom interventions that require early or repeat visits. Among all women who receive ANC inNigeria, 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 thewomen 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 ofevil spirits.75. A multi-country randomized control trial by WHO and a systematic review showed thatessential interventions can be provided over four visits at specified intervals, at least forhealthy women with no underlying medical problems. This evidence has prompted WHO todefine a new model of ANC based on four goal-oriented visits. The Nigerian National PolicyGuidelines for Reproductive Health has recommended a minimum of four ANC visits asfollows: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 later76. Two key interventions administered during FANC includes: Intermittent Preventivetreatment (IPT) for Malaria using Sulphadoxinepyrimethamine (SP) and administration ofTetanus Toxoid (TT). The implementation of the FANC is based on WHO guidance of2006 that countries should do away with the traditional every 4 weeks visit by pregnantwomen for check-up. However women with complications, special needs, or conditionsbeyond the scope of basic care may require additional visits.Improved Referral System77. Effective referral systems are considered critical for reducing maternal mortality, as theseensures ready and timely access to appropriate case management, especially in the case ofpregnancy related and newborn complications. Some of the critical action steps in aneffective referral systems include: engaging the community to develop effective communitytransport system for referral purposes; encouraging adequate awareness creation on birthpreparedness to limit delays as much as possible in cases of emergency; providingambulances and other transport evacuation arrangements to health facilities and theirmaintenance and sustainability; enabling two-way communication between the community,PHC facilities and referral centres including through the use of mobile phones; facilitatingpre-payment schemes (such as the NHIS and other community mechanisms) for transport to
46. APPENDIX 446a referral facility; putting functional triage systems in place to minimize delays at healthfacilities; ensuring 24-hour availability of maternity services at all health facilities.
47. APPENDIX 447CHAPTER FOURMDG5 BOTTLENECKS ANALYSIS AND PRIORITISATIONMaternal Mortality in Perspective78. In spite of successive policies and interventions to curb maternal mortality and promotematernal health in Nigeria, there remain gaps between current status and 2015 MDGs targetson several maternal mortality indicators. Recent estimates indicate that up to 1 million13women and children die every year in Nigeria from largely preventable causes; 33,000 womenare estimated to die from pregnancy-related causes, and about 946,000 children under-5 dieof which 241,000 are newborns. The preventable causes of morbidity and mortality amongwomen include pregnancy, anemia due to malaria, intra-partum and post-partumhemorrhage, post-partum sepsis, eclampsia and complications from obstructed labor.79. The scale and intensity of the challenges of accelerating progress on maternal health (MDG5) are evidenced by the fact that many indicators lag behind the 2015 targets. Besides, thesharp disparity in maternal health between subnational units (geopolitical zones and states)constitutes an important dimension of the maternal mortality burden in the country. Arelated dimension of the inequality of access to maternal healthcare services between thewealthiest quintile and poorest quintile; for example, the difference in access to skilled birthattendance at delivery between wealthiest quintile and poorest quintile is almost eight fold.Similarly, the difference in full immunization coverage between the wealthiest and poorestquintiles 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 2015target, 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 from38.9% in 2008 to 53.6% in 2012, still far short of the target of 100% by 2015. Theproportion of pregnant mothers attending antenatal care at least four times has improvedfrom 44.8% in 2008 to 57.6% in 2012, but still short of the target of 100% by 2015. There ishowever lack of progress regarding ‗unmet need for family planning‘, as the indicator hasbarely improved from 20.6% in 2008 to 21.5% in 2012. Moreover, more than two-thirds14ofmaternal deaths occur during childbirth, and are closely linked to intrapartum stillbirths andearly neonatal deaths.Bottlenecks to Implementation81. 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 aretwo broad types of bottlenecks: sector-specific and cross-cutting. Sector-specific bottleneckslie squarely within the ambit of the Federal and State Ministries of Health and LocalGovernment Health Departments or affiliated agencies. Cross-cutting bottlenecks lie outsidethe powers of the Federal and State Ministries of Health and Local Government HealthDepartments. 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: policyand planning; budget and financing; service delivery (supply-side); and, service utilization13Saving One Million Lives 2012.14 Integrated Maternal, Neonatal and Child Health Strategy Paper 2011.
48. APPENDIX 448(demand-side). Existing monitoring and assessment reports and MDGs documentation haveidentified several bottlenecks militating against the achievement of targets.Policy and planning83. Policy coordination difficulties: Like other development sectors, the Nigeria health system isunderpinned by policy and fiscal decentralization and concurrent responsibilities between thethree tiers of government – federal, state and local governments. While responsibilitysharing, by principle, could promote accountability, the lack of adequate coordination andsynergy in the provision and management of healthcare across the three levels ofgovernmental authority has tended to distort service delivery, reduce the coherence ofactions and diminish collective impacts of interventions. While the local governments havecritical mandates in primary health care, including maternal health, they lack the requisiteinstitutional 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 thehealth services is fragmented, poorly regulated, poorly understood and practically unengagedby 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 sharpvariations in MMR reveal the ineffectiveness of the existing strategy and approach to solvingthe imbalances.86. Inadequate monitoring and shortage of good quality tracking data: Effective monitoring of servicedelivery (performance of personnel, availability and quality of services, availability and use ofcommodities) for the reshuffling of resources and realignment of efforts require good qualitydata. The data should ideally mirror intervention pathways (including hiccups) frominputs/activities through outputs and outcomes. But, the data system for tracking thematernal healthcare results chain – from inputs through outputs and outcomes – is largelyundeveloped, piecemeal and not institutionalized. Hence, the effectiveness of spending intranslating to outputs and outcomes is not clearly delineated across the three tiers ofgovernment, thereby leaving ample room for ambiguity and anonymity in attribution ofoutcomes. Moreover, the lack of reliable and consistent maternal health service-delivery andservice-use data makes it difficult for troubleshooting and benchmarking against baselinesand targets. The situation hampers the ability of managers and operators of the maternalhealth 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 totalhealth 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 importantbarriers to healthcare uService delivery (supply-side)88. To realise targets for maternal healthcare requires adequate and well-motivated healthpersonnel, sufficient supplies/inputs and key logistics that work towards good quality, veryresponsive and readily available maternal health care. The implementation pathways ofMDG5 interventions are beset with missing links and difficulties. As enumerated in existing15Saving One Million Lives
49. APPENDIX 449documents, these difficulties and missing links include shortage of skilled health personnelparticularly in rural areas, irregularity of skilled health personnel in rural primary health carecentres, delays between arrival and getting treatment, scarcity of emergency obstetric careservices, lack of adequate kits for TBAs, shortage of critical supplies in primary health carecentres 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 withcomplementary 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 havebasic pharmaceuticals and commodities consistently in-stock.Service utilisation (demand-side)89. Services cannot be said to be successfully delivered until they are used beneficially byintended persons or groups. The manner and extent of use of maternal health care services isa final outcome that signals the effectiveness of the entire intervention chain. Existingreports show that the use of maternal health care services lags far behind what is required toachieve MDG5. Intended mothers are not able to use maternal health care services becauseof a number of bottlenecks in availability, access (physical and financial), regularity, lack ofinformation about what to do in emergency cases, delay in decision to seek treatment, delaybetween decision to seek attention and reaching a health facility, inability of the poor toafford maternal health care services. Other user-related impediments to maternal health careare sociocultural and traditional beliefs, practices and attitudes.90. Cross-cutting bottlenecks pertain to low public accountability, inadequate value for publicspending, corruption, shortage of infrastructure (power and roads/transport), particularly inrural areas, negative attitudes towards serving in rural areas, lack of rigorous project appraisaland insecurity.
50. APPENDIX 450Analysis and Prioritisation of the Bottlenecks91. Specific Bottlenecks against the Prioritised Interventions: The identified bottleneckshave been analysed with respect to the respective prioritised interventions. The match ofprioritised bottlenecks against the prioritised interventions is given in the table below:Table 2: Bottlenecks affecting the prioritised interventionsPrioritised bottleneck Bottleneck category Prioritised InterventionsFamilyplanningservicesSkilledbirthattendanceEmergencyObstetric&NewbornCareUniversalCoverage ofAntenatal andPostnatal CareImprovedReferralServicesSociocultural religiousbarrierCross cutting andsystemicInadequate trainedpersonnelService deliveryLow male involvement/uptakeSystemicInadequate Skilled BirthAttendantsService deliveryUneven distribution ofavailable Skilled BirthAttendants (SBA)Service DeliveryInadequate ReferralTraining for Skilled BirthAttendants (SBA)Service deliveryLack of functionalequipment and facilitiesService deliveryPoor incentives especiallyin rural areaBudget andfinancingShortage of skilled healthpersonnelService DeliveryInadequate equipment andsuppliesService DeliveryDelay in accessing careservicesService UtilizationInadequate political will Cross-cuttingPoor access to healthfacilities in rural areasService DeliveryPoor attitude of healthworkersService DeliveryLack of Legislation Policy and PlanningInadequate ambulanceservicesService DeliveryPoor communication andfeedback systemService DeliverySystem delay Service Delivery
51. APPENDIX 45192. Indications from matching bottlenecks against prioritised interventions: The matchingof bottlenecks against the prioritised interventions reveals some critical tips as follows:Majority of the prioritised bottlenecks are in the service delivery category. They include: inadequatenumber of skilled health workers; inadequate training of health personnel; irregular servicesat care centres; uneven distribution of health professionals; uneven distribution ofcommodities; and poor attitudes of health workers. Un-supportive sociocultural andtraditional beliefs, attitudes and practices cut across the prioritised interventions. Thequantity and quality of funding is both an underlying and direct form of bottleneck for theprioritised interventions – underlying, in the sense of inadequate budget/funds for logistics,personnel incentives, infrastructure and commodities and ‗direct‘ in the sense of poor qualityof spending, leading to low value for money spent. The service delivery-related bottlenecksare underpinned by systemic failure of the supervision and monitoring system, as a result ofwhich service readjustments are either non-existent or too slow to bring about positiveresults.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 towhich removal of the bottleneck will accelerate achievement of the MDGs 2015 target forreducing maternal mortality rate. On the other hand, ‗feasibility‘ refers to the prospects forsolving the bottleneck in the near-term, that is, through 2015. Using this framework, thebottlenecks were assessed as follows:Table 3:Bottleneck Assessment ScorecardColourcodePotentialimpactAmenability to near-term solutionAchievesaccelerationVery amenablePotentiallyachievesacceleration.Moderately amenableProbablydoes nothelpaccelerationMarginally amenableDoes nothelpaccelerationNot amenableTable 4:The prioritized bottlenecks are scrutinised based on the scorecard schema given above.PrioritizedinterventionsIdentifiedbottlenecksPossibleImpactAmenability tonear-termsolutionOverall AccelerationPotentialFamilyplanningservicesSocioculturalreligious barrierNot likelyInadequate trainedpersonnelYesInadequate maleinvolvementLikely
52. APPENDIX 452PrioritizedinterventionsIdentifiedbottlenecksPossibleImpactAmenability tonear-termsolutionOverall AccelerationPotentialSkilled BirthAttendanceInadequate trainedpersonnelLikelyUnevendistribution ofavailable SkilledBirth AttendantsYesInadequatereferential trainingfor Skilled BirthAttendantsYesLack of functionalequipment andfacilitiesYesPoor incentivesespecially in ruralareasYesEmergencyObstetric&NewbornCare(EMONC)Shortage of SkilledHealth PersonnelLikelyInadequateequipment andsuppliesYesDelay in accessingcareNot likelyUniversalCoverage ofAntenatal andPostnatal CareSocio-cultural andreligious barrierNot LikelyInadequatepolitical willNot likelyPoor access tohealth facilitiesespecially in ruralareasLikelyPoor attitude ofhealth workersLikelyLack of legislationImprovedReferralServicesInadequateambulance servicesYesPoorcommunicationand feedbacksystemLikelySystem delay Yes
53. APPENDIX 453CHAPTER 5ACCELERATION SOLUTIONSIntroduction94. Following the identification of the prioritized interventions as well as the prioritizedbottlenecks, in the two preceding chapters, the focus of chapter 5 therefore is on thepresentation of the acceleration solutions to the prioritized bottlenecks. The United NationsMAF Operational Notes define a solution as a single action or package of actions taken to resolve anintervention bottleneck in the near term to produce quick impact on the ground. Consequently, in order toget the right solution, a solution analysis was carried out during the Stakeholders‘ Technicalworkshop. The workshop participants developed a comprehensive list of bottlenecksolutions and after critical examination they, finally came up with a list of prioritizedsolutions which ultimately constitute the acceleration solutions for MDG 5.Basis for Selecting the Acceleration Solutions95. Participants at the Stakeholders‘ workshop evaluated a solution on the basis of twodimensions namely: impact and feasibility. Accordingly, four criteria were used to assess animpact: its magnitude; described as the magnitude of the solution‘s impact on solving thebottleneck, including impact on priority MDG target, indirect spill-over impact, andequitable impact; (b) speed of impact; described as length of time to realize the solution‘simpact; (c) sustainability of impact; and (d) adverse impact; described as magnitude ofnegative impact, within or outside the sector.96. The feasibility dimensionof solutions is evaluated on the basis of four criteria also: (a)governance; seen in terms of rule of law, transparency and accountability mechanisms toimplement the solution; (b) capacity; seen in terms of ability to plan, implement and monitorthe solution; (c) funding availability; seen as the availability of funds to cover the solution‘scost; and, (d) additional factors; seen in terms of additional factors that may impede thesolution.97. The analysis of the impact and feasibility of a solution formed the basis for the final list ofacceleration solutions. The rest of this chapter is a presentation of the acceleration solutionsto the prioritized bottlenecks.Family Planning98. Solutions toSocio-Cultural Religious Barrierd) Scale-up sensitization of traditional leaders, religious leaders, Community BasedOrganizations (CBO), Faith Based Organizations (FBO) through appropriate media.e) Reinforce teaching of family life education in secondary schools curriculum.f) Establish more functional youth friendly centres.99. Solutions to Inadequate Trained Personnela) Recruitment of more trained personnel.b) Intensify training and retraining of health workers including community basedresourced persons100. Solution to Poor/Inadequate Male Involvement
54. APPENDIX 454b) Sensitization and mobilization of the male folk to take leadership in health mattersSkilled Birth Attendants/Attendance101. 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 Attendantsa) 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 Obstetricsand Newborn Care (EMONC) skills. More refresher courses for Skilled BirthAttendants (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 facilitiesa) 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 Care106. Solutions to Shortage of Skilled Health Personnela) Recruitment of more Skilled Birth Attendants (SBA).b) Additional Incentive for Health workers in hard to reach areas/difficult terrain/ruralareas.c) Scale up of in-service training and implementation of Life Saving Series (LSS) andCommunity 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 Suppliesa) 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 Servicesa) Awareness creation and sensitization campaign on Emergency Obstetrics andNewborn Care (EMONC) services and issues using appropriate media.
55. APPENDIX 455b) Promotion of key household and community service package.c) Promotion (or Provision) of GSM services (communication) between clients andSkilled 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 EmergencyObstetrics and Newborn Care (EMONC) at health facilities.Universal Coverage of Ante-natal and Post-natal Care109. Solution to Socio-Cultural and Religious Barriera) 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.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 System114. 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 companies116. Solutions to System Delaya) Adherence to the use of Standard of Practice (SOP).b) Ambulance should be part of handing over process.
56. APPENDIX 456Table 5: MAF Prioritized Solutions and ResponsibilitiesS/N PrioritizedInterventionsPrioritizedBottlenecksAccelerationSolutionsResponsible Partners1 FAMILYPLANNING1) Socio-culturalReligious barriera) Scale-upsensitization oftraditional leaders,religious leaders,Community BasedOrganizations(CBO), FederalBased Organizations(FBO) throughappropriate mediaFMOH, OSSAP /NYSC, UNWOMEN,NOA,b). Reinforcedteaching of familylife education insecondary schoolscurriculum.FMoWA, FMYD,NPHCDA,c). Establish ofmore functionalyouth friendlycentreFMoWA / YouthDevelopment, UNFPA,OSSAP , NACA2) Inadequatetrained personnela). Recruitment ofmore trainedpersonnel.SMoH, FMoH, UNFPA,b). Intensifytraining andretraining of healthworkers includingcommunity basedresourced personsFMoH, SMoH,UNFPA, OSSAP &NPHCDA3) Poor /inadequate maleinvolvementa). Sensitization andmobilization of themale folk to takeleadership in healthmattersFMOH, OSSAP-MDG,UNWOMEN, NOA2 SKILLED BIRTHATTENDANTS1) InadequateSkilled BirthAttendants (SBA)a). Recruitment ofmore Skilled BirthAttendants (SBA)NPHCDA & Partnersb). Training andretraining of SkilledBirth Attendants(SBA)NPHCDA & Partners,NACA.c). Mandatoryposting of NYSCSkilled BirthAttendants (SBA) torural areas.NYSC,LGAs, SMoH,d). Mandatory oneyear postinginternship in ruralareas.FMoH,
57. APPENDIX 457S/N PrioritizedInterventionsPrioritizedBottlenecksAccelerationSolutionsResponsible Partnerse). Task shifting/sharing for SkilledBirth Attendants(SBA)NPHCDA/ SPHCDA2) Unevendistribution ofavailable SkilledBirth Attendants(SBA)a). Additionalincentives for ruralposting.FMOH, NPHCDA,SPHCDA, SMoH, MLA,b). Doctors attertiary hospitals tomentor Skilled BirthAttendants (SBA) inrural areas.FMOH & SMOH3) Inadequatereferential trainingfor Skilled BirthAttendants (SBA)a). More refreshercourses for SkilledBirth Attendants(SBA) in EmergencyObstetrics andNewborn Care(EMONC) skills.FMoH, SMoH andNPHCDA,b). Regular supportsupervision forSkilled BirthAttendants (SBA).FMoH, SMoH,NPHCDA4) Lack offunctionalequipment andfacilitiesa). Scale up supplyof basic equipmentof supply of SBAs.FMoH / SMoH,NPHCDA, OSSAP andpartners.b). Regularmaintenance offacilities, structure,equipment andsupplies.SMoH, LGAs, andPartners5) Poor incentivesespecially in ruralarea.a). Provision ofallowances for ruralposting.SPHCDA, SMoH,NPHCDAb). Provision foraccommodation forrural posting.SPHCDA, SMoH,NPHCDAc). Strengthening,reactivate andformulation of WardDevelopmentCommittees (WDC)SPHCDA, SMoH,NPHCDA & MLGAPRIORITIZEDINTERVENTIONSPRIORITIZEDBOTTLENECKSACCELERATIONSOLUTIONSRESPONSIBLEPARTNERS
58. APPENDIX 458S/N PrioritizedInterventionsPrioritizedBottlenecksAccelerationSolutionsResponsible Partners3 EMERGENCYOBSTERIC ANDNEW-BORN CARE1) Shortage ofSkilled HealthPersonnela). Recruitment ofmore Skilled BirthAttendants (SBA)LGAs, SMoH,NPHCDAb). AdditionalIncentive for Healthworkers in hard toreach areas/difficultterrain/rural areas.LGAs, SMoH,NPHCDAc). Scale up of in-service training andimplementation ofLife Saving Series(LSS) andCommunity BasedNewborn Care(CBNC).LGAs, SMoH,NPHCDAd). Incorporationfor the Life SavingSeries (LSS) andCommunity BasedNewborn Care(CBNC) into thepre-service SkilledBirth Attendantscurriculum.FMoH, NMCoN,Community HealthDirectors.2) Inadequateequipment andsuppliesa). Provision ofadequate EmergencyObstetrics andNewborn Care(EMONC)equipment andservices.FMoH, SMoH, OSSAP,NPHCDA and Partnersb). Regularmaintenance ofadequate EmergencyObstetrics andNewborn Care(EMONC)equipment andservices.LGAs and Partnersc). Equitable andeffective distributionof EmergencyObstetrics andNewborn Care(EMONC)equipment andsupply.LGAs, SMOH andPartners,
60. APPENDIX 460S/N PrioritizedInterventionsPrioritizedBottlenecksAccelerationSolutionsResponsible Partnersfor their right.c). Civil societyorganizations shoulddemand for theirright of thevulnerable groupsNGOs, CSOsNOAs,FMoH& NHRC3) Poor access tohealth facilitiesespecially in ruralareasa). Creatingoutreaches closer tothe people.LGAs, WDC,b). Communityinvolvement forownershipmonitoringutilization of healthservices.LGAs, NYSC,NPHCDA / SPHCDA,SMoHc). Scale up andstrengthening ofregular mobilehealth servicesLGAs, SMOH &SPHCDA.4) Poor attitude ofHealth workers.a). Reorientation ofhealth workers toinstil right valuesinto them.Regulatory Agenciesunder federal and state.b). Appropriatestaffing ratio ofhealth workers topatientsSPHCDA, SMOH,FMOH,& LGAsc). Recognition ofHealth Workersbased on meritEmployers/Managementd). Effective regularsupervision andcoordinationLGAs, SMOH, FMOH& NPHCDA.e). Enforcement ofdisciplineManagement /Regulatory bodies.5) Lack ofLegislationa). Supportaccelerated passageof Health Care Bill.CSOs, NGOs,Development Partners,SMOH & FMOHPRIORITIZEDINTERVENTIONSPRIORITIZEDBOTTLENECKSACCELERATIONSOLUTIONSRESPONSIBLEPARTNERS
61. APPENDIX 461S/N PrioritizedInterventionsPrioritizedBottlenecksAccelerationSolutionsResponsible Partners5 IMPROVEDREFERRALSYSTEM1) Inadequateambulance servicesa). Decentralizationof ambulance torural areas.FMOH, SMOH andSPHCDAb). Improvisationof functionalambulance services.E.g. Tricycles,Donkeys,Speedboats andCamelsLGAs &SMoHc). Engagement ofNURTW membersor any communityvolunteer for arewardLGAs, NURTWManagementd). Regular revisionof referral directory.FMOHe). Effective Twoway referral system.SPHCDA, LGAs andFMOHf). Law againstwrongful use ofambulance.FMOH, SMOH andLGAs2) Poorcommunicationnetwork andfeedback systema). Provision ofphones.NCC, FMOH &GSM/Telecom serviceprovidersb). Provision of freetoll lines by telecomcompanies.NCC, GSM/Telecomservice providers3) System Delay a). Adherence to theuse of Standard OfPractice (SOP).FMOH, SMOH &LGAsb). Ambulanceshould be part ofhanding overprocessSMOH and LGAs
62. APPENDIX 462CHAPTER 6MONITORING AND EVALUATION PLAN117. A well-functioning results-based monitoring and feedback system, established as integralelement of implementation management, is central to the success of the MAF Action Plan.While monitoring and evaluation processes are usually built into national and subnationalplans and programmes, lessons from the past show that the critical challenges lie in faithfullyimplementing them to achieve intended effects. Moreover, the unique action-oriented natureof 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 theresults (outputs, outcomes and impact). Specifically, the MAF M & E system will befunctional as a follows:d) Provide programme managers and stakeholders with data and information about thepace, nature and levels of progress in service delivery and service use;e) Supply credible evidence base for management responses in bridging gaps, correctingweaknesses and consolidating gains in the implementation of the agreed solutions andactions;f) Deliver a reporting and feedback system for tracking progress on MDG5 through 2015based on the MAF results chain – inputs, outputs, outcomes and impacts – with respectto MDGs 5.Scope and Nature of the M & E119. The monitoring of MAF Action Plan will cover multiple successive levels of the resultschain spanning inputs, outputs, outcomes and impacts.(a) Input-level monitoring will cover tracking of funds/spending, staff deployments andmaterial resources used in implementing the respective MAF solutions and actions.(b) Output-level monitoring will be directed at tracking completed activities coupledwith the first-level results achieved through the activities. Examples include numberof health staff trained, number of new midwives recruited, amount of suppliesdelivered 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 reductionin maternal mortality.120. The MAF M & E will be operated based on best-practice principles and approacheswhich have eluded many past plans and programmes. The M & E will be conducted andorganised to be timely, inclusive, participatory, credible, useful and evidence-based.Framework of M & E Indicators121. The MAF M & E system will measure and track implementation progress andachievement of results based on the framework of indicators given in the Implementationand Action Plan. As provided in the Action Plan, there are a set of indicators for everyprioritised acceleration solution. For the respective indicators, the tracking exercise willbenchmark implementation progress and achievement of results against targets set in theAction Plan, in order to detect gaps/deviations and fashion corrective responses.
63. APPENDIX 463M & E Resources122. The MAF M & E will apply standard quality-assuring methods and tools for trackingimplementation and the results. These include the following:a) Calendar of Milestones: The MAF Action Plan will be further distilled into anoperational ―Calendar of Milestones‖ for gauging actual versus expected results. Themilestones represent landmarks in achievements en route 2015 regarding service deliveryand service use. These pre-identified landmarks serve as scheduled ‗checkpoints‘ to assesswhether service delivery and use are still on track.b) Monitoring and evaluation scorecard: The M & E Scorecard will report metrics showingthe trajectory of progress, quantification of observed deviations and determine whetherimplementation of solutions and impact of solutions (reduction in maternal deaths) areon track. It describes the extent to which the removal of bottlenecks through theapplications of prioritized solutions is leading to targeted reductions in maternalmortality. It is a target-oriented measurement tool.c) Reporting Requirements: The M & E system will involve periodic reports to track anddocument solution outputs and outcomes (service provision and use). The reporting willentail successive levels of tracking starting from local government areas, state-widethrough national coverage. The reports will contain point-of-service monitoring data onmaternal healthcare service delivery and use in the local governments, aggregated at thestate and national levels. Within the framework of the MDGs reporting system, the MAFM & E reports will includei. Quarterly Progress Report – describe progress on implementation and outputs inthe reference 3-month period. This report will dwell on mostly facility-level (thatis, service-level) data from the various local communities aggregated at the stateand national levels.ii. Semi-annual Progress Report – describes achievement of outcomes and impactsin the reference 6-month periodiii. MAF Completion Report – gives final status of outcomes and impacts achievedbased on the acceleration solutions.123. Sourcing and Management of Data: To be effective in bringing about the desiredinformation and feedback, monitoring will be based on timely, relevant, accurate and useabledata. 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 localcommunities and collated by the State Ministries of Health for onward transmission to theFederal Ministry of Health. The data will constitute live evidence of the status and progressof maternal health services throughout the country and give timely information formanagement decision making. On the other hand, sample surveys will be carried out by theNational Bureau of Statistics, as part of the data tracking mechanism. Data will cover criticalvariables 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 Plan124. To avoid the pitfalls of past M & E systems in national plans and programmes, the MAFM & E will follow a clear and focused agenda executed by dedicated task teams underpinned
64. APPENDIX 464by unequivocal role division between the federal and state levels. The organisation of theMAF M & E process will be tripartite involving local governments, state governments andthe federal government. Monitoring Task Teams (MTTs) will be constituted among relevantagencies at the three levels of government. Local government task teams will include localhealth departments and community representatives while state-level task teams will includethe State Ministry of Health, MDGs Desk Officers, health-sector professional associationsand state-level civil society representatives. Similarly, federal-level task teams will includeMDGs Officers, Federal Ministry of Health (and affiliated agencies), National PlanningCommission and national-level civil society representatives such as national-level health-sector professional association. In line with this tripartite organisation, the monitoring datawill 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 nationallevel will be organised as follows:Fig 14: Flow of MDG5 monitoring data and information126. Making Use of Monitoring Data: Given thelessons from the past, the MAF M & Esystem will incorporate key enablers that promote effective monitoring as basis for feedbacktowards improved implementation. There will be central coordination of the M & E byOSSAP-MDGs in collaboration with the National Planning Commission. The MAFManagement Information System (MIS) will be structured to transmit monitoring data intothe decision-making mechanisms of the service-providing implementing line agencies. Thefeedback information is useful for programme realignment and redistribution of services andsupplies. In addition to providing relevant forecasting data, the supply chain data from localhealthcare 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 coordinateappropriate management response mechanisms that address observed implementationproblems.Local Govt.Monitoring TaskTeamsState-LevelMonitoring TaskTeamsNationalMonitoring TaskTeam
65. APPENDIX 465Table 6:MAF Monitoring and Evaluation CalendarTime ScheduleM & E Activity 2ndQtr20133rdQtr20134thQtr20131stQtr20142ndQtr20143rdQtr20144thQtr20141stQtr20152ndQtr20153rdQtr20154thQtr2015Formation ofMonitoring TaskTeams at theFederal and StatelevelsOperationalization of the M & EIndicators at thefederal and statelevelsPreparation of the―Calendar ofMilestones‖ toolApplication of the―Calendar ofMilestones‖ toolPreparation of theM & E ScorecardtoolApplication of theM & E ScorecardtoolData flow fromlocal governmentto national levelQuarterly Reports(focused onmilestones)Biannual Reports(focused onscorecard)MAF CompletionReport
66. APPENDIX 466CHAPTER 7RECOMMENDATIONSKey Recommendations on MAF An emergency Presidential Committee on MDGs should be convened to deliberate onthe budget and commitments as well as confirmation of responsibilities to various tiersand agencies of government for the implementation of the MAF Action Plan. The International Development Partners (IDPs) are requested to make their specificcommitments to the implementation of MAF Action Plan. The OSSAP-MDGs is required to work out a detailed MAF implementation plan that issensitive 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-politicalzones in order for Nigeria to attain MDG 5. For this assignment, OSSAP-MDGs canseek for technical assistance from FMoH and IDPs. The OSSAP-MDGs should embark on a strong mobilization campaign and consultationwith state governments and key development actors for the immediate adoption andimplementation of this MAF. The OSSAP-MDGs should operationalise the MAF monitoring and feedbackmechanism by coordinating and facilitating the establishment of the relevant indicators(along with baseline and milestones) for measuring and reporting periodic along theresults chain-inputs, outputs, outcome and impact. The monitoring and feedbackmechanism should be able to answer the question: has MAF made any difference in theattainment of MDGs 5 targets in 2015?Recommendations for the Remaining Seven MGDsIn order to fast-track the implementation of the remaining 7 MDGs, the followingrecommendations are hereby proposed: The governance and accountability environment needs to be continuously improved; Efforts should be intensified towards ensuring the availability and harmonization ofadequate and reliable data in particular the coordination of data generation on MDGs bythe National Population Commission (NPoC) and National Planning Commission(NBS); There should be enhanced and up-to-date performance tracking of MDGs investmentsin all MDAs and reporting same on a routine basis to the Presidential Committee onMDGs; The attainment of the MDGs should be a key element of the performance contract byministers; The Federal Government should recommend the extension of performance contract tocommissioners at the state level with particular reference to MDGs; The on-going Centennial celebration should have the attainment of the MDGs as itsprimary focus; The State Governors and Local Government Chairmen should be recognized andhonoured on the basis of their contributions to the attainment of the MDGs; The Federal Government should provide incentives to the mostperforming and most improvingstates in the attainment of the MDGs.
67. APPENDIX 467
68. APPENDIX 468APPENDIX: MDG5 MAF ACTION PLAN /BUDGET MATRIXAcceleration SolutionsTargets Activities IndicatorsTimeline and Annual CostTotal Cost Notes2013 2014 2015 2016 2017FAMILY PLANNING1. Scale-upsensitizationof traditionalleaders,religiousleaders,CommunityBasedOrganizations (CBO),FederalBasedOrganizations (FBO)throughappropriatemediaAchieveuniversalaccess toreproductive health by20151) Preparationand launchingof FPlogo/IEC/BCC materials-CPR UnmetneedAdolescentBirth rate1a)Review/develop existingFP logo andIEC/BCCmaterials(includingJingles &consultation)a) No ofreviewmeetingsheldb) No ofmaterialsdeveloped25,000,000 25,000,0001b) Printinganddistribution ofIEC/BCCmaterials1,500,000,000 1,500,000,000Nationwide1c) Airing ofJinglesc) No ofJingles aired 3,120,000 3,120,000Nationwide2. Traditional& Religiousleaders,CBO/FBOEngagementand-
96. APPENDIX 496DOCUMENTS CONSULTED1. Federal Ministry of Health (2004). Revised National Health Policy.Abuja.2. Federal Ministry of Health (2004). Health Sector ReformProgramme: Strategic Thrusts with a Logical Framework and Plans ofAction, 2004-2007. Abuja.3. Federal Ministry of Health (2005). Achieving Health RelatedMillennium Development Goals in Nigeria. A Report of thePresidential Committee on Achieving MillenniumDevelopment Goals in Nigeria. Abuja.4. Federal Ministry of Health (2010). Health Related MDGs Reportfor Nigeria. July 2010. Abuja:5. Federal Ministry of Health (2010). National Strategic HealthDevelopment Plan 2010-2015. Abuja.6. Federal Republic of Nigeria (2004).Nigeria MillenniumDevelopment Goals 2004 Report. Abuja: National PlanningCommission.7. Federal Republic of Nigeria (2005). Nigeria MillenniumDevelopment Goals 2005 Report. Abuja: National PlanningCommission.8. of Health.9. Federal Republic of Nigeria (2007).Nigeria MillenniumDevelopment Goals 2006 Report. Abuja: National PlanningCommission.10. Federal Republic of Nigeria (2010). Nigeria MillenniumDevelopment Goals 2005 Report. Abuja: National PlanningCommission.11. Federal Republic of Nigeria (2010). The MDG-DRG FundedMidwives Service Scheme: Concept, Process and Progress. Abuja:National Primary Health Care Development Agency.12. Federal Republic of Nigeria (2009). ‗National Partnership onHealth: Declaration on Mutual Accountability for Improvedand Measurable Health Results in Nigeria by the President ofthe Federal Republic of Nigeria, Executive Governors of the36 States and FCT Minister at the Presidential Summit onHealth in Nigeria: Implementing the Health Sector Componentof Vision 20:2020‘.13. Federal Republic of Nigeria (2010). ‗Achieving MeasurableResults for Health through the National Strategic HealthDevelopment Plan 2010-2015. Country Compact betweenFederal Government of Nigeria and Development Partners‘.14. Federal Republic of Nigeria (2011). Annual Health Sector Report2010. Abuja.15. Federal Republic of Nigeria (2011): National Strategic HealthDevelopment Plan (NSHP) 2010-201516. Federal Republic of Nigeria (2012). Saving One Million Lives.‗Accelerating Improvement in Nigeria‘s Health Outcomesthrough a new approach to basic services delivery‘. Office ofthe Honourable Minister of State for Health, Federal Ministryof Health.
97. APPENDIX 49717. Government of Ghana (2011). Ghana MDG AccelerationFramework and Country Action Plan: Maternal Health. Accra:Ministry of Health, & United Nations Country Team in theRepublic of Ghana18. National Population Commission (2009). Nigeria Demographicand Health Survey (DHS) 2008. Abuja: National PopulationCommission.19. OSSAP-MDGs (2006). Presidential Committee on the MDGs:Second Quarter Report for 2006. Abuja: Office of the SeniorSpecial Advisor to the President, Millennium DevelopmentGoals.20. OSSAP-MDGs (2008). MDG Needs Assessment and FinancingStrategy for Nigeria. Abuja: Office of the Senior Special Advisorto the President, Millennium Development Goals and theUnited Nations Development Programme.21. OSSAP-MDGs (2008). Mid-Point Assessment of the MillenniumDevelopment Goals in Nigeria 2000–2007. Abuja: Office of theSenior Special Advisor to the President, MillenniumDevelopment Goals.22. OSSAP-MDGs (2008). Presidential Committee on the MDGs: 2nd& 3rd Quarter Reports for 2007. Abuja: Office of the SeniorSpecial Advisor to the President, Millennium DevelopmentGoals.23. OSSAP-MDGs (2008). Presidential Committee on the MDGs: 2nd& 3rd Quarter Reports for 2008. Abuja: Office of the SeniorSpecial Advisor to the President, Millennium DevelopmentGoals.24. OSSAP-MDGs (2009). 2009Monitoring and Evaluation Report ofthe DRG-Funded MDG Projects and Programmes in Nigeria2006/2007. Abuja: Office of the Senior Special Advisor to thePresident, Millennium Development Goals.25. OSSAP-MDGs (2009): Implementation Manual for the MillenniumDevelopment Goals Conditional Grants Scheme. Abuja: Office of theSenior Special Advisor to the President, MillenniumDevelopment Goals.26. OSSAP-MDGs (2009). Presidential Committee on the Assessmentand 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: 1stQuarter Report for 2009. Abuja: Office of the Senior SpecialAdvisor 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 SeniorSpecial Advisor to the President, Millennium DevelopmentGoals.29. OSSAP-MDGs (2009). Report of the Presidential Committee and onthe Strategy and Prioritization of the MDGs. Abuja: Office of theSenior Special Advisor to the President, MillenniumDevelopment Goals.30. OSSAP-MDGs (2010). Nigeria: Millennium DevelopmentGoals (MDGs), Countdown Strategy 2010 to 2015: Achievingthe MDGs. Abuja: Office of the Senior Special Advisor to thePresident, Millennium Development Goals.
98. APPENDIX 49831. OSSAP-MDGs (2010). Presidential Committee on the Assessmentand Monitoring of the MDGs: 1stQuarter Report for 2010. Abuja:Office of the Senior Special Advisor to the President,Millennium Development Goals.32. OSSAP-MDGs (2010). Presidential Committee on the Assessmentand 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: OperationalNote. New York: UNDP. Available at:http://www.undp.org/content/dam/...MAF%20Operational%20Note.