Nigerian Northern States Maternal, Newborn and Child Health Initiative (MNCH)

Client DFID.

The UK-Norway Northern States Maternal, Newborn and Child Health Initiative (MNCH) is a four and a half year programme that aims to address the unacceptably high maternal, neo-natal and child health rates in 4 states in the north of Nigeria. The programme is one of a series of activities jointly supported by the UK and Norwegian governments in support of MDG 4 (the reduction of child mortality) and MDG 5 (the reduction of maternal mortality).

The states - Katsina, Zamfara and Jigawa in the North West and Yobe in the North East– all experience high levels of poverty, and significant levels of chronic poverty.
Maternal and child health indicators are above the national average in all cases, and in some states, significantly so. Although there are reform-minded individuals in all states, the overall governance context is challenging, with weaknesses in governance arrangements undermining the efficient and effective use of public resources. In the health sector this translates into services that are largely unresponsive to the needs of the poor, and citizens who lack the means to challenge accountability failures.

Programme Objectives
LATH is an associate partner in the programme and leads on technical matters relating to ‘Improved delivery of MNCH services via the Primary Health Care (PHC) System’ and ‘Human Resource Development’. This includes supporting state teams in capacity building and systems strengthening to improve the availability and quality of skilled birth attendants and emergency obstetric care in the target states. In human resources, LATH is supporting the creation of an intermediate cadre of Skilled Birth Attendants (SBAs),
and looking at financial allocations to increase the intake of a new SBA cadre, existing nurse-midwifes and Community Health Extension Workers (CHEWs). LATH is promoting specific changes to existing curriculums to be in line with evidence based standards for MNCH care in multi-sectoral efforts to increase the training intake of women.

LATH’s inputs are being led by Dr. Nynke Van den Broek on maternal health and Margaret Caffrey on human resources. In addition, LATH is providing two long term consultants who are seconded into the programme, a Maternal, Neonatal Health and Child Health (MNCH) Advisor, Anthony Aboda, and a Midwifery Advisor, Aishatu Abuakar.
Approach
The MNCH Initiative will facilitate the states to deliver their own health reform agendas in support of the revitalisation of PHC services, with a special focus on improving MNCH outcomes. The work in the states is being closely co-ordinated with the Partnership for Reviving Routine Immunization in Northern Nigeria (PRRINN), a five-year DFID programme focused on strengthening routine immunisation. The MNCH initiative operates alongside and adds value to PRRINN, enhancing the system strengthening focus of the latter.
Expected Outcomes
1. Revitalised primary health care in poorly served states in northern Nigeria, with a particular focus on improving maternal, newborn and child health (MNCH). This will include support to strengthen governance of the health sector; assistance in PHC planning and budgeting; MNCH systems development; and operational research.

2. Strengthened State and Local Government Area (LGA) governance of PHC systems geared towards MNCH by providing support for institutional change and advocacy at State level to enhance political commitment and stewardship.
Activities may include:
(i) Work with other partners on a high-level advocacy campaign for increased, transparent and evidence-based allocation of resources for MNCH services and improved budget monitoring and accountability;
(ii) Institutional and organisational analysis;
(iii) Identify and build relations with Change Agents;
(iv) Agree change management programme with each State;
(v) Establish links with partners involved in wider public sector reform and Government development strategies; and

(vi) Support State and LGA strategic and operational health planning and budgeting.
3. Improved human resource policies and practices for PHC by addressing the absolute shortage and poor distribution of trained staff. The shortage of trained midwives, other skilled birth attendants and staff trained to deal with obstetric and neonatal emergencies is a critical constraint in improving MNCH and will require considerable attention. Activities may include:

(i) Support development of HR policies and plans at all levels;
(ii) Support States and LGAs to address shortage and maldistribution of staff;
(iii) Support States and LGAs to develop and implement solutions to training and retaining midwives;
(iv) Address the need for an intermediate cadre of skilled birth attendant;
(v) Support State training institutions to improve pre-service, in-service and professional upgrading training; and

(vi) Strengthen supervision and performance management.
4. Improved delivery of MNCH services via the PHC system, with a focus on antenatal and postnatal services, skilled birth attendance, emergency obstetric care, neonatal care and the management of childhood illnesses. Activities may include:
(i) Work with other partners on a high-level advocacy campaign for strengthening PHC, including its interaction with polio eradication efforts;
(ii) Agree and support a minimum package of essential services;
(iii) Promote an integrated health and referral system;
(iv) Provide basic supplies, equipment and refurbishment for MNCH services using a performance-based approach;
(v) Support improvement of sustainable drug supply systems;
(vi) Develop a maintenance management system.
Recent activity:
Programme implementation recently included a competency based LSS (Life Saving Skills) EOC & NC training conducted in Katsona State from 7 th-9 th December 2009. It was the first to be delivered under the PRRINN MNCH Nigeria programme. The training was followed by a Train the Trainers course and a consensus workshop at the same venue. The participants were midwives and medical doctors from the PRRINN MNCH
supported states including medical/health training institutions. About half of the LSS EOC & NC trainees are also state trainers of LSS (1-4 week, didactic based training). The facilitators during the training included six obstetricians and two midwives (5 international and 3 national consultants). Four of the International Consultants were volunteers, and two of the national consultants were LSS and ELSS National trainers.

Evaluation of the first LSS EOC &NC training in Nigeria showed that participants reacted positively to the training and showed statistically significant overall improvement in knowledge and skills after the training. The consensus meeting was attended by 36 delegates from all PRRINN supported states, including representations from state MOH, state MOLG, PHCDA, Schools of Midwifery, LSS state and National trainers, WHO and state PRRINN offices. The delegates concluded that,

1. The new model of delivery is attractive and welcomed and is likely to complement the traditional method. Most participants identified the short duration of training, broad content, interactive adult education methods, sustainability, M&E and a wide range of mannequins for user in the session as the main difference between a traditional LSS training package and the LSTM/RCOG competency based package.

2.The new method is likely to improve midwifery education, through the provision of mannequins for training, updating the teaching skills and knowledge of midwifery tutors. This is a very important component which will influence positively the curriculum of midwifery education in the states. A review of the LSS training curriculum in Nigeria revealed that the current pre-service training curriculum for nurse/midwives and CHEWs, do not meet recommended international standards and are not delivered based on recommended evidence based educational techniques which result in improved professional service delivery and patient outcomes.

The newly introduced LSS EOC & NC training curriculum can positively improve the existing curriculum, in terms of improving the content, teaching methodology and duration of training. This model also has the potential of improving pre-service training quality, introducing objective monitoring and evaluation of the effect of the training, and ensuring sustainability of the training package in Nigeria.