APPENDIX 31Acceleration Analysis for MDG 5:Justifications for Priority& Key Points fromthe MDGs Acceleration Framework AnalysisOffice of the Senior Special Assistant to the President on MillenniumDevelopment GoalsMarch 2013
APPENDIX 32IntroductionIn March a national stakeholder technical reviewwas held to assessthe efficiency ofcurrent maternal health care policy. This was part of the implementation of the MDGsAcceleration Framework (MAF) for MDG 5. The stakeholder review identified andcosted a number of key acceleration solutions across a five-year period. Stakeholderswere drawn from all levels of society relevant to the execution of policy relating tomaternal healthcare. This summary note highlights key motivating factors in theselection of MDG 5 as the first of the MDGs to fed through the MAF process, andalso summarizes the key outcomes of the technical review process.Wider Importance of MDG 5: Maternal Health CareUSAID estimates that maternal and newborn deaths cost the world $15 billion in lostproductivity.Evidence demonstrates that healthy women and girls can help theirfamilies endure the global financial crisis. For example, the World Bank found thatduring the economic crisis, poor families who sent women to work were less likely totake on sustained debt. In Bangladesh, research shows that poor households withmaternal health complications spend 30% - 40% of their savings to cover expenses,compared to only 8% for the richest quintile.“When families incur this crushing debt, they sometimes sell off their daughters, andthe social consequences of this cannot be left out of the equation.”– Mary Stanton (Senior Maternal Health Advisor USAID)The Saving One Million Lives Initiative (2012) estimates 33,000 women areestimated to die from pregnancy-related causes.Using estimates developed by theWHO in an econometric analysis (2006) of the impact of MMR on per capita GDP inAfrica, one can loosely estimate that achieving the target for MDG 5 would add$3,394.11 to per capita GDP in Nigeria across certain time horizons. It should benoted that there are potential issues with the specification of the econometric model.However, the overarching point is that the achievement of this target is likely to haveconsiderable economic effects, both directly through the channel of preventing
APPENDIX 33maternal death and increasing infrastructure and technical capacity which will havesupplementary positive effects.Snapshot of Performance of the Maternal Mortality RatioGood progress has been made in this area. 2012 data shows that Nigeria is now 28%away from this MDG target with Maternal Mortality down from the 1990 base of1,000 deaths per 100,000 live births, to 350.However it is estimated that about 4 maternal deaths occur in Nigeria per hour, 90per day, and 2,800 per month for a total of about 34,000 deaths annually, withwide regional and local variations. Similarly, skilled birth attendance improvedfrom 38.9% in 2008 to 53.6% in 2012, still far short of the target of 100% by2015. The proportion of pregnant mothers attending antenatal care at least fourtimes has improved from 44.8% in 2008 to 57.6% in 2012, but still short of thetarget of 100% by 2015. There is however lack of progress regarding ‘unmet needfor family planning’, as the indicator has barely improved from 20.6% in 2008 to21.5% in 2012. Moreover, more than two-thirds of maternal deaths occur duringchildbirth, and are closely linked to intrapartum stillbirths and early neonataldeaths.8005453502502004 2008 2012 2015EstimateofDeathsper100,000LiveBirthsMaternal Mortality Rate (per 100,000 live births)
APPENDIX 34There are sharp disparities in maternal health between subnational units(geopolitical zones and states) and there is a significant rural urban divide. Forexample (data from the 2008 NDHS) urban maternal mortality estimates are351/100,000 live births, where as rural estimates are 828/100,000. Maternalmortality estimates in the North East zone are 1549/100,000 live births, comparedwith 165/100,000 in the South West zone. In order for Nigeria to succeed inachieving Goal 5 by 2015 a concerted effort is required to mitigate this growing incountry divergence. A related dimension of the inequality of access to maternalhealthcare services between the wealthiest quintile and poorest quintile; forexample, the difference in access to skilled birth attendance at delivery betweenwealthiest quintile and poorest quintile is almost eight fold. Similarly, thedifference in full immunization coverage between the wealthiest and poorestquintiles is almost 10-fold. Coverage of key interventions is low, quality of care isinadequate, and most basic services do not reach the poorest segments.Maternal health is strongly linked to other MDGs like child health, genderequality, to poverty reduction and partially to education. Whilst maternal deathsare rare statistical phenomena, the family impact is devastating and this has widercommunity effects. The very fact that maternal deaths are rare makes impactingthem more difficult. Therefore the virtue of targeting this Goal is that there will beknock on effects through the other health goals, for instance increasing the numberof skilled birth attendants present at birth requires that there are a greater numbersof health personnel in rural areas.Figure 1, using UNICEF 2008 data, demonstrates that compared to the next fivelargest economies by GDP in Sub-Saharan Africa, Nigeria is doing worst withregard to Maternal Mortality Ratios.
APPENDIX 35Figure 1Figure 2 demonstrates the comparison of progress across Maternal, Infant andChild Mortality. This shows that since 2003 the trend in both MDG 5 and 4 hasbeen positive. Figure 3 shows that the rate of progress in the reduction of MaternalMortality and Child Mortality is on track to meet the 2015 deadline, whilst the rateof progress for Infant Mortality has slowed and is not on track to meet the target.0100200300400500600700800900Ghana Ethiopia Kenya Sudan NigeriaComparative UNICEF 2008 MaternalMortality Ratios
APPENDIX 36Figure 2Figure 3Maternal Infant Child1,000911918001002015457515735061942503064Rates, Maternal per 100,000 Live Births, Infant &Child per 1,000 Live Births1990 2003 2008 2012 Target 201520.00%-9.89% -5.24%31.88%25.00%21.89%35.78%18.67%40.13%28.57%50.82%31.91%% Change From Previous Survey2003 2008 2012 Target 2015
APPENDIX 37As illustrated in Figure 4, the major causes of maternal deaths are: haemorrhage;infection; malaria; toxemia/eclampsia; obstructed labour; anaemia; and unsafeabortion.Figure 4Skilled attendance at birth (see Figure 5 for aggregate 2012 data; disaggregateddata will be available in April 2013) continues to have considerable disparitieswithin country, for example, with Imo State showing 98% skilled attendants atbirth to only 5% in Jigawa State. Available data puts delivery in health facilities at35% while home delivery was rated at 62.1%, underscoring the need for improvedaccess and utilization for health facilities-based maternal health services. It is alsoestimated that for every maternal death, at least 30 women suffer short-to-longterm disabilities such as vesico-vaginal fistula (VVF). Each year, some 50,000-100,000 women in Nigeria sustain obstetric fistulae. Over 600,000 inducedabortions are also estimated to take place in Nigeria annually, and these are often
APPENDIX 38performed under unsafe conditions, with an estimated 40% performed in privatelyowned health facilities.Figure 5There has continued to be an increase in access to safe, affordable and effectivemethods of contraception, which is providing individuals with greater choice andopportunities for responsible decision-making in reproductive matters.Contraceptive use contributes to improvements in maternal and infant health byserving to prevent unintended or closely spaced pregnancies. Figure 6demonstrates the trend. There is need for improvement given that various unmetfamily planning needs have progressively risen since 2004 – particularly in therural areas where awareness is relatively low.01020304050607080901002004 2008 2012 201536.3 38.953.6100Proportion of birth attended by skilled health personnel (%)
APPENDIX 39Figure 6Antenatal care coverage is among the health interventions capable of reducingmaternal morbidity. Coverage (at least one visit) with a skilled health workerincreased to 67.7 per cent in 2012 from a decline of 61 per cent in 2008. The 2012figure represents 6.7 per cent and 12.8 per cent increase over 2004 and 2008 figures.In addition, antenatal coverage – at least four visits in 2012 rose to about 57.8 percent; an increase from 17 per cent in 2004 and 20.2 per cent in 2008 respectively(Figure 7). However, this success is skewed to urban areas. Like in other indicators,the rural areas are also lagging in antenatal coverage. The coverage rate in the ruralareas is 56.5 per cent for at least one visit and 47.7 per cent for four visits (2008 data,2012 disaggregation to be released in April 2013.0246810121416182004 2008 20128.214.617.3Contraceptive prevalence rate (%)
APPENDIX 310Figure 7The unmet need for family planning remains persistently high. In 2004, the figure was17 per cent, while the 2008 figure was 20.2 per cent, the rate of progress fell furtherwith the increase to 21.5 per cent in 2012 (Figure 9).Figure 90102030405060702004 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)
APPENDIX 311Summary of JustificationsThere are a number of key justifications for the selection of MDG 5 for accelerationanalysis. These justifications have been extracted verbatim from the proposals:a) Focusing on MDG 5 is consistent with the Government’s TransformationAgenda. At inception, the present administration launched an agenda foraddressing the most pressing development challenges facing the country. TheAgenda identified healthcare, among others, as a key development and policychallenge. In the gamut of the health challenges, poor maternal health is iconic.For Government, the underpinning policy for the inputs toward achieving thehuman capital development goal of the Vision 20: 2020 Strategy is the NationalStrategic Health Development Plan (NSHDP). The NSHDP is the vehicle foractions at all levels of the health care service delivery system which seeks to fosterthe achievement of the MDGs and other local and international targets anddeclaration commitments.05101520252004 2008 20121720.221.5Unmet need for family planning (%)
APPENDIX 312b) The choice of MDG 5 for MDGs Acceleration Framework will addresspersistent zonal disparities in health outcomes. Disparities in the achievement ofthe goals of the MDGs across states and between the six geo-political zones of thecountry abound, but much more dramatic with respect to MDG Goal 5 onmaternal mortality, given especially its immediate impact on human lives.Whereas a zone like the South West, standing alone, had virtually met the targeteven as early as at 2008, others, especially the North West and North East showedperformances way below the national average. By focusing on MDG 5, lessonsfrom regions with good outcomes can be used in areas 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 indicatorsbetween 2003 and 2008. On the basis of this development, and factoring in whatappeared to be good prospects for achieving Goal 5, the 2010 MDGs +10 Reportsuggested that MDG 5 could be a candidate for realisation if the momentum wassustained. President Goodluck Jonathan in his Foreword to the 2010 MDG+10Report, declared the achievement in MDG 5 up to 2008 as ‘unprecedented’.d) As can be seen from the graphical projections reproduced below, the expectationwas that if the average performance on the MDG 5 is sustained, the target wouldbe met by 2015. This performance-based projection was the basis for the officialoptimism that was shared with the rest of the world by President Jonathan inSeptember 2010. The Countdown Strategy (CDS) provided a roadmap, targetedinvestment and ingredients of effective partnership which implementation wouldhave helped to sustain the observed trend of the three years to 2008 and whichformed the basis for the optimistic projection to meeting the target by 2015. For anumber of reasons associated with transition in administration, theimplementation of the CDS was delayed. A number of otherwise laudableinitiatives like the MSS programme were not anchored effectively on the roadmapof the CDS. Even with the latest NBS data showing an MMR of 350 as a nationalaverage, there are still wide differences within the least performing zones. The
APPENDIX 313political commitment and the associated resources devoted to the attainment ofMDG 5 still remain a matter of great concern. Added to the above is the largelyunexpected eruption of violence, especially the North East Zone on a scale neverbefore seen in the history of peace-time Nigeria. The North-East Zone has hadrecurrent troubled performance on MDG Goal 5 in particular. This violence andthe resulting social and economic instability have contributed to a loss of themomentum towards the attainment of MDG 5 in some parts of the country. Thehealthcare initiatives that held the promise of raising the national averageperformance on MDG 5 - Midwifery Services Scheme, Routine Immunisation,Rollback Malaria, HIV/AIDS Control Programme, Health Systems Strengthening,Infrastructure and even the SURE-P appear overwhelmed by insecurity in parts ofthe county where their operations are needed most for the achievement of thehealth 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 empowermentand poverty reduction. It means that accelerating progress on MDG 5 could leadto gaining some mileage with the other MDGs in which progress is currentlyslow. A healthier mother is better able to work, earn a living, participate inhousehold decision-making and provide better for a child. Available datademonstrate this correlation. For example, when national maternal mortality ratedeclined from 800 deaths per 100,000 live births to 545 deaths over the period2003 to 2008, it correlated with declines in infants and under five mortality ratesas illustrated in below. The focus on MDG 5 is therefore expected to have salutaryeffects on the performance of other goals, especially Goal 4. Hence, for the goodhealth of our women in the vibrant age group of between 18 and 45 and forpolitical accountability, the choice of the MDG 5 for MAF is consideredappropriate and timely.Key Points from the MAF DocumentPrioritization of Key Interventions Within MDG 5
APPENDIX 314Through the consultation process, five key priority areas have been identified from alist of twenty-plus major interventions:a) Family Planningb) Skilled Birth Attendantsc) Emergency Obstetric and New-born cared) Universal Coverage of Ante-Natal and Post-Natal caree) Improved Referral SystemBottleneck Analysis and PrioritizationWithin these areas policy bottlenecks were identified. Sector-specific bottlenecks arecontained within the particular Federal, State Ministry or relevant Local GovernmentDepartment. Cross-cutting bottlenecks are inter-sectoral and economy-wide problemsthat affect the implementation of the MDG 5 interventions.Acceleration SolutionsFrom this analysis acceleration solutions were proposed for each of the fiveprioritized intervention areas.These range from public education, retraining of birthattendants (in particular traditional birth attendants), decentralizing ambulance usage,maintenance of equipment, and engagement with civil society. See the MAFdocument for further details.The BudgetIt is estimated that the acceleration solutions and constituent activities would cost N65billion across a five-year period (see Table 1 for an outline, and the MAF documentfor details, costed by OSSAP-MDGs procurement staff and health personnel). By farthe most costly intervention is the provision of skilled birth attendants.
APPENDIX 315In 2013 OSSAP-MDGsshall spend N29.5 billion oninterventions that will have someimpact on maternal health care. This plan represents a 46% increase in maternalhealth related expenditure within the 2013 budget.Table 12013 2014 2015 2016 2017Family Planning 2.63 0.49 0.47 0.47 0.21 4.28Skilled Birth Attendants 6.35 9.22 11.10 12.40 10.23 49.32Emergency Obstetric and New-Born Care1.71 0.89 1.06 0.24 0.05 3.97Universal Coverage of Ante-Nataland Post-Natal Care2.34 1.02 1.89 1.35 0.39 6.30Improved Referral System 0.37 0.19 0.19 0.20 0.02 0.99Grand Total 13.54 11.96 14.16 14.81 11.04 65.52Acceleration SolutionsTimeline and Annual CostTotal CostN.B. Units in billions of Naira