Sure-P's maternal and child health intervention's been a success - Okoli

Dr. Ugo OkoliDr. Ugo Okoli is one professional that has performed excellently in the field of public health. Coming back from the United Kingdom where she had stints

as a Medical Director and a Public Health Director of Enfield Primary Care Trust in London, a Fellow of the Faculty of Public Health Medicine UK and Fellow of Royal Society of Medicine UK, she was appointed as a consultant for the National Primary Healthcare Development Agency before her performance earned her a place as Project Director SURE-P Maternal and Child Health Care.

In this interview, Dr. Okoli shares her experience during her three years of service, improving the health of mothers and children through the SURE- P MCH programme.

You assumed leadership as Coordinator of the Sure-P Maternal and Child Healthcare programme in 2012; So far, can you also say it’s being so good?

We have been on a long journey from where we started in January 2012 to date, considering that the project was supposed to be a three year intervention. I will say that the project has been a great success and we have touched people’s lives positively, intervening significantly in improving maternal and child health care especially in rural communities. Maternal and child mortality is a major challenge in the Nigerian context, and deserved the extra attention, which we provided through the Sure-P MCH programme. The programme added extra human, technical and infrastructural resources to ensure safe and healthy deliveries as well as reducing the number of deaths recorded annually, so we have come a long way.

Nigeria's maternal and child health care indicators are poor. Numbers available to us suggest that about 33,000 women and 950,000 children die annually, what has Sure-P MCH done to combat this trend?

Well let me wind back to how we started Sure-P MCH in 2012, when we already had a scheme called the Midwives Service Scheme (MSS) managed by the National Primary Healthcare Development Agency (NPHCDA), before the Sure-P intervention. Fortunately, I was part of the Midwives Service Scheme, acting as the National Consultant to the scheme.  That particular scheme actually had a huge impact on maternal and child health in the rural communities. However, in all interventions you learn your lessons and then move on to correct what did not work in that particular intervention. 

Sure-P MCH, which came from cost savings resulting from the partial subsidy removal was, established building on the existing MSS. We tried to improve on the things that we learned from the MSS within the new Sure-P MCH intervention. Sure-P MCH started by actually working in partnership with the states by allowing them to select the primary health care facilities where SURE P MCH interventions would be directed and agreeing with them the criteria with which these PHC’s would be selected. One of our criteria then was that selected PHC’s must be in rural areas and hard to reach communities; we did not want to have interventions in the urban areas where there are already general hospitals. We wanted the interventions to be located in the areas of greatest need. 

So in view of this, the states actually selected one thousand (1000) facilities, spread across 36 states and FCT where we intervened. This was done based on the maternal mortality health burden within the states. For instance, in the North East and North West regions we intervened in more facilities, given the greater burden. In the seven states in the North West and the six states in the North East we supported 32 facilities each. In Ebonyi too, given their large burden, we also selected 32 facilities while in all other states we supported 24 facilities. We organized it in such a way that in each of the 393 local governments we intervened, we had four health facilities and a referral centre, creating a hub-and-spoke approach. Sure-P MCH was designed in a way to ensure that we put skilled birth attendants in the PHCs supported by SURE-P MCH, because of the lack of skilled midwives in many of these facilities, before the intervention. 

Also, we found that the infrastructure in many primary health care facilities in Nigeria was very poor, and we also had to intervene in this area. In effect, we had four objectives, one was to employ and deploy the skilled staff to work in the facilities that I talked about. Second, was to ensure that we supply them regularly with the drugs and consumables needed to do their work effectively. We also had commodities, such as Mama Kits, which are kits given to the pregnant woman to support their needs during birth.

The third objective was to renovate the PHCs because a facility has to be comfortable and functional for the women to come there to receive services. In renovating them, we also included boreholes to ensure that they had clean water.  As you can imagine, these things didn’t only affect the women, but also other members of the communities, because they would all use the water provided. SURE-P MCH built a total of about 625 boreholes in primary health care facilities. In addition, SURE-P MCH built accommodation for the midwives; a total of 145 units and renovated about 600 primary health care facilities across the country.  The contractors who were engaged to renovate these health centres employed labour from these communities thus providing employment locally. 

Lastly we had another component we called demand side, increasing the demand for such interventions in the target populations. Because of the years of neglect, despite the improvement in service, many women still lacked confidence in the facilities. We therefore used a strategy called the “Conditional Cash Transfer Scheme” or CCT to generate demand for services.

Altogether, we deployed 12,110 health care workers across the 36 States and FCT and all these people came out of unemployment. In fact we had three categories employed; skilled midwives, community healthcare workers or what we call “CHEWs”, and village health care workers. We also employed the midwives that were retired but still able to work, especially those that lived in that community. In addition, we hired people fresh from school, who had completed three years of training but needed placement for industrial training to get their license.

Aside from the earlier mentioned challenges, what other challenges were faced by Sure-P's MCH in its mission to tackling the issues of Child and Maternal mortality?

Dr. Okoli - Aside from the availability of midwives, one other associated challenge was retention of the midwives. Many were deployed to areas far from their homes and while this was easy initially, it became increasingly difficult over time. Another challenge was the level of education of the target audience that we serve. You will agree with me that in the rural areas a lot of women are not well educated and a lot of them are still rooted in their belief systems and their culture. In some parts of the North, there were particular challenges in accessing the facilities, as some women have to take permission from their husbands and mother in-laws before they could use the facilities. These are people who before the emergence of SURE-P MCH had probably given birth to their children at home and thus there will be some resistance to using the facility. In summary, the challenges are partly educational, partly cultural and partly caused by poverty.

Before SURE-P MCH, the attitude of some of the healthcare workers in these facilities was not professional and not attractive to women giving birth. Therefore, one of the things that we did in response to these challenges was to provide refresher training to all health care workers engaged under SURE P MCH.  We provided them with what we call ‘Life Savings Skills Training’ and the “Helping Babies Breathe” training.

One of the biggest causes of maternal deaths is bleeding during pregnancy and we concentrated on training on how to prevent and treat this complication in pregnancy. We also worked with partners like UNFPA to conduct these training sessions. Throughout this period, we were working in partnership with the states. In some states we had minimal support while others provided a lot of support. A good example is Ondo State; while waiting on the new administration to provide new directives, Ondo State has absorbed all the midwives deployed under SURE-P MCH. Some communities have been funding these midwives and paying them from their own purse to retain them. Although we have an MOU with the states to provide some additional allowances to the health care workers, not every state has been able to fulfil this.

What of the issue of budgeting?

The issues we have with budgets are mostly related to the timing of the release of funds.  Unfortunately, we have sometimes had to owe our midwives for about two months. The backlog was paid as soon as the funds were released. But, I must say that between 2012 and 2015 all our appropriated funds were released except in 2012 when we were supposed to get 15.9 billion Naira but got 3.8 billion Naira, due to the teething problems we faced at the initial stages. This year (2015) we got 3.5 billion Naira instead of the budgeted 12 billion Naira, because of the fall in the oil price. In terms of salaries to health care workers, we have paid up all salaries until April, based on the allocation that we received.

Let's move to the novel approach of using Conditional Cash Transfer, CCT which is a demand side component of the Sure P MCH.

When I talked about the Midwives Service Scheme (MSS) and the lessons we learnt, one of them was the fact that our interventions with the MSS were only on the supply side. The supply side means the supply and training of human resources, renovation of infrastructure, supply of the drugs etc., and the demand side is all about creating the demand to use the facilities by women.  We needed to increase the number of women accessing and using the facilities and coming back to deliver their babies at these facilities. We studied other countries that had gone through similar situations and how they overcame them.  The former Minister of State for Health, Dr. Ali-Pate and his team then conceived and designed the CCT component. Countries like Mexico implemented a similar programme, as well as Brazil, Kenya and a host of other countries. 

In planning this innovative approach we had the privilege, through Dr. Pate of bringing in Mexican colleagues on a voluntary basis to help us for three months to draw up a framework for the CCT that would fit into the Nigerian environment. We also undertook as study trip to Kenya to learn how the cash was transferred to the women. At this stage we are still at the pilot stage in one local government in eighteen states. We started with only nine states but people started clamouring that they needed it in their states because of its success and we added nine more states in 2014.

UNFPA has recently helped us to do a review and it has been adjudged a success. The programme is designed to encourage women stay with the facility throughout their period of pregnancy. When pregnant women register they get a thousand Naira and when they attend the PHC another three times for antenatal care, they get an additional thousand Naira, when they deliver they get two thousand Naira and finally after delivery when they come for family planning or to immunise their baby they get another one thousand Naira, making it five thousand Naira all together. Each time we carry out pay outs, large crowds of women who have given birth at the PHCs turn up. They are usually all enthused and this has definitely helped to increase the number of safe deliveries because the news has gone round. 

Some people say we are encouraging women to get pregnant often because of the cash incentive but the truth is that we have a data system and women can only claim after two years since the previous claim, so the programme actually encourages child spacing. Also some will say that we are giving even rich women the N5, 000. A visit to the location of SURE-P MCH supported facilities will lead to the quick dismissal of this. Only pregnant women who live in the geographical area where the SURE P MCH supported facility is located are entitled to the CCT. Let’s say a woman lives somewhere like Maitama and decides to go to Dei-Dei for antenatal care because the CCT is operational in Dei-Dei, considering the cost of transportation from Maitama to Dei-Dei throughout her period of pregnancy, it is almost impossible.  CCT has reached over 50,000 women and it is a success story.

Could you give us rough figures before the intervention of Sure-P MCH and the figures now?

Before Sure-P MCH started most of the health centres didn’t even have midwives, what they had were community health workers and attendance of the pregnant women was sometimes poor as these health workers were not regular in most of the facilities. So on the whole before we came on board we had some facilities recording only two births in a month but with our intervention we have witnessed some having 40 deliveries in some places monthly and up to 100 yearly. I can tell you that for the whole program we delivered over 300,000 babies safely. We have seen over two million women in antenatal care (ANC) and have observed a 42% increase in ANC attendance, 56% increase in facility deliveries and more than 50% reduction in maternal deaths in these communities when compared to the baseline when we started.

How do you monitor the programme across the country from Abuja including the replacement of midwives and other health workers should the need arise?

Very, very true, like you said we cannot be in Abuja and be monitoring over 1,000 centres all over Nigeria in rural areas at the same time. One thing that was important to us was monitoring and evaluation. So one of the things that we put in place were State Program Assistants (PAs) and they were based in the states and one of their roles was to supervise the work going on in these centres, and send this in every month. This included presence of health care workers at the facilities. Beside this, we have Ward Development Committees (WDCs) in the areas that we work who had direct channels of communication with us. They would sometimes lay complaints about midwives who aren’t coming to work or who are treating these women wrongly and as a result we have laid off a number of them, after investigation.  Sometimes, midwives alert us on their inability to continue in some areas as a result of marriage and other reasons and we try to be flexible and reassign them to the nearest facility to them while replacing them with other health care workers within such communities.

And how do you also ensure drug supplies are monitored?

For the drugs supply, there is an issue with drugs security in facilities in this country.  It is very possible for workers in the facilities to take the drugs supplied and go and sell them elsewhere. But we have the PAs who record the drugs supplied; we have a system of Independent Verification Officers who confirm that the supplies have been made. When drugs are supplied there is a lot of paper work to be completed and signed off and even the communities through their WDCs working with us also have to confirm that these drugs were supplied. We have worked in partnership with John Snow Incorporated/Deliver project on to develop supply and logistics systems for SURE P MCH. The regular supply to the facilities is another improvement made by SURE P MCH on the once a year supply that took place under the MSS. 

Furthermore, SURE-P MCH intervention is extensively monitored and audited by the National Planning Commission, the SURE-P Committee, Price Waterhouse Coopers (PWC) and independent auditors from the SURE-P Committee.

Your CV looks impressive with stints at top medical centres in the UK, given your track record and the relatively easier life abroad why did you choose to come back and work in Nigeria?

Well that is a very easy question.  First and foremost I am a Nigerian, born and bred in Nigeria. Where did I train? Who trained me? It was all here in Nigeria; I had most of my education here from primary to secondary and tertiary. So the country has given me a lot and I just have to give back. I have learnt a lot from where I was and I am passionate about public health issues.  I spent five years as Director of Public Health and Medical Director in the UK and had the privilege and great opportunities to learn and improve my skills in public health.  The least I can do is to use those skills in my country.  I am glad I made the decision to come home considering the contribution one has made which is reflected in a few awards one has received such as the “most outstanding SURE P Director” from the Nigerian Medical Students Association and a few other awards from community groups to the SURE P MCH management. Let me use this opportunity to say that I am grateful to all the midwives, the community and village health workers and the communities where we have intervened, my colleagues as well as the States.  We have requested the health care workers to be patient as we wait for our government to give us directive on the future of the programme.

Igboeli Arinze