Being the concluding part of the lecture delivered at the 2nd Annual Public Health Leadership Forum And in Honour of Professor Adetokunbo Lucas on Monday, November 28, 2011 by Professor Friday Okonofua of Department of Obstetrics and Gynecology, University of Benin, Benin City, Edo State. The second part was published on Friday, December 30, 2011SOME of the indicators of increased political commitment to maternal and child health which I identified in a previous presentation include the following: 1) the level of awareness of maternal health by top political leaderships, as typified for example by the number of speeches spontaneously made by leaders about the problem; 2) the extent to which states drive their own agenda on maternal and child health rather than waiting to implement externally driven agenda; 4) the number of state policies and programs developed and implemented for addressing maternal health (example: the compulsory registration of maternal deaths by the Ondo state government). Also, the passage of the national Health Bill will be one evidence of Federal Government's commitment to promoting maternal and child health; 3) percent of budget devoted to health and to maternal and child health (example: to what extent is the state complying to the 2001 Abuja Declaration that recommends that African governments should allocate 15% of their budget to health'); 4) the extent to which states re-build infrastructures that impact on maternal health ' power, roads, agriculture, etc; and 5) the extent to which governments promote transparent, accountable and effective governance based on the rule of law and anti-corruption that leads to the improvement of the standard of living of their people and the alleviation of the social determinants of maternal mortality.Improvement of Health infrastructure and national Health SystemThe re-building and maintenance of health infrastructures, improvement of the nation's health system and the development of human resources are critical in efforts to reduce maternal and neonatal mortality in Nigeria. Only skilled birth attendants can reduce maternal mortality and so, Nigeria must invest in providing adequate numbers of midwives and doctors and provide incentives to enable them work in all locations across the country. Although some have argued for the re-training of unskilled traditional birth attendants (TBAs) especially in contexts where skilled attendants are not available, international consensus is now moving towards a recognition that TBA re-training has limited cost-effectiveness and may actually do more harm than good. The establishment of the midwifery scheme by the National Primary Health Care Development Agency (NPHCDA), whereby retired midwives are recruited and re-trained to work in Primary Health Centres (PHCs) in rural areas, where the highest proportion of maternal deaths occur, is a welcome development. However, adequate funds must be deployed to ensure its sustained implementation, and Local Government Councils must be encouraged to execute appropriate supervisory and oversight functions over PHCs as envisioned in the nation's constitution.Although the federal government has identified PHC as its strategy for improving women's access to maternal and child health services, it should be recognised that PHC alone cannot reduce maternal mortality. This is because some of the obstetric complications that lead to mortality such as haemorrhage, eclampsia, and severe puerperal infection cannot be treated at the level of primary care. PHC can provide primary prevention services including family planning, antenatal services, normal delivery care and basic reproductive health services, but women experiencing complications who require secondary and tertiary prevention must be referred to secondary and tertiary care facilities. Secondary and tertiary prevention services include operative delivery, emergency obstetrics care, blood transfusion, and specialised obstetrics care normally provided by General and Specialist/Teaching hospitals.The dilemma that the country currently faces is the lack of effective referral services between PHCs and secondary/tertiary maternity care facilities. Thus, although the government is currently investing heavily on improving PHCs, concomitant attention need to be paid to referral of women who experience severe complications at that level. Professor Olikoye Ransome-Kuti as Minister of Health attempted to find ways to improve referral services between PHCs and secondary/tertiary facilities in the early 1990s, but since then nothing additional has been done. A strong recommendation is being made to policymakers to include the strengthening of referral services in the country in their overall plan for improving maternal health and reducing maternal and neonatal morbidity and mortality.Furthermore, there is a need to completely overhaul and reform the health sector to enable it respond more effectively to tackle the challenges posed by high rates of maternal mortality. Health sector reform was the major thrust of President Obasanjo's health policy, especially at the time that Professor Eyitayo Lambo took the mantle as Minister of Health in the second half of the administration. The Health Sector Reform Program (HSRP) was designed in 2003 as part of the National Economic Empowerment and Development Strategy (NEEDS), with an overall goal to prioritize health as an entry point for poverty alleviation, to attain the accelerated achievement of the MDGs especially with respect to reduction in infant, neonatal and maternal mortality rates, and to stimulate national efforts at combating under-development.The specific objective of the HSRP was to correct all the factors that had led to the poor performance of the Nigerian health sector in previous years, propelling it to greater cost-effectiveness and efficiency so that it can respond to the yearning need for increased access to evidence-based services for all Nigerians and be a catalyst for reducing the burden of maternal morbidity and mortality in the country.The Health Sector Reform Agenda was developed by the Federal Ministry of Health, through a participatory process that involved all stakeholders, including development partners and various implementers/policymakers at the sub-national level.The overall mission of the HRSP as stated in the policy document was to undertake a government-led comprehensive reform aimed at strengthening the national health system to enable it deliver effective, efficient, qualitative and affordable health services and thereby improve the health status of Nigerians and the health sectors contribution to breaking the vicious cycle of ill-health, underdevelopment and poverty.The seven strategic thrusts of the HRSP were as follows: 1) improvement of the performance of the stewardship role of the government; 2) strengthening the national health system and improvement of its management; 3) improvement of the availability of health resources and their management; 4) the improvement of the physical, financial access to quality health services; 5) the reduction of the burden of disease attributable to priority health problems; 6) the promotion of effective public-private partnerships in health; and 7) increased consumer awareness of their health rights and obligations.During the period 2004-2007, major progress was made in implementing different components of the health reform agenda. The national health policy was updated, and a national strategic plan for health sector reform was approved by the Federal Executive Council. In addition, several policy documents to guide implementation and action in health care were developed. By the middle of 2007, 18 ancillary policies, eight medium term strategic plans and four guidelines for implementing the reform agenda were either completed or were at various stages of completion. The legislation processes to enact a health bill that would provide a legal backbone for the operation of Federal Medical Centres, traditional medical practice, teaching hospitals and the NHIS were set in motion in 2007. In particular, a new commission, the National Hospital Services Commission designed to improve the quality and availability of tertiary services was proposed and included as part of the major component of the bill.The plans and activities of the HSRP were subjected to various reviews by several stakeholders, including the office of the President, the National Health Conference, Civil Society Advocates and Development partners. The consensus reached after these series of reviews is that the HRSP is an important initiative that would improve the health sector in Nigeria if properly implemented. The National Assembly passed the national health bill in April 2011, but we are all now living witnesses to the fact that the health bill is yet to be passed into law by the Presidency.This government needs to demonstrate its commitment to health and to reducing maternal and child mortality by urgently taking action in passing and implementing the national health bill.Poverty Alleviation and the provision of safety netsSeveral reviews have identified poverty as the major reason that pregnant women do not use evidence-based maternity services, and why they frequently resort to traditional and faith-based birth attendants. A Presidential Task Force set up to identify ways to accelerate the attainment of MDGs 4 and 5 in Nigeria35, reported that inability to pay for services was the major barrier identified by women for not using maternal and child health services.Thus, the problem of poverty would need to be addressed as part of the overall strategy to achieve MDGs 4 and 5. The short term solution, which has been proposed by the WHO, and is currently being implemented by several African countries, including Ghana, Senegal, Mali and Burkina Faso, is to eliminate or subsidize antenatal care and delivery costs for pregnant women. Fortunately, this approach is also being implemented by several states in Nigeria, but there needs to be greater coherence, better planning and more funding devoted to these efforts.The long term solution is to reduce the level of poverty and its attendant consequences in the country through well articulated economic development policies. The structural adjustment program that was introduced into the country in the mid-1980s severely impoverished the poor with its policy on currency devaluation, removal of subsidies and payment of user-fees for essential services and worsened the health situation in Nigeria, especially of vulnerable women and children. The proportion of Nigerians living on less than 1.2 dollars a day rose to an all time high of 70 percent as a result of structural adjustment. The present administration would need to be advised that its proposal to remove some subsidy from petroleum products will have more terrible and untoward effects on the health of our women and children and further jeopardise Nigeria's chance of achieving MDGs 4 and 5.Investing in women and community educationFor several years, Professor Kelsey Harrison emphasized the need to promote women's education as a strategy for reducing maternal mortality in this country. This was borne out by the fact that among the cohort of women who suffered maternal deaths in northern Nigeria, the majority were women who had no education or had only a primary level of education. Our 1992 data from Ile-Ife confirmed the same finding, and indeed, no woman with a tertiary education suffered a maternal death in our cohort of women.Thus, the education of women remains a powerful but rather under-utilised tool for promoting maternal health in this country. Governments must make long term investment in the education of women, especially in northern Nigeria, where women tend to attend informal education and to be given out in early child marriages. Indeed, the enrolment of girls in school would appear to be the most cost-effective intervention for preventing early marriage in northern Nigeria and reducing maternal mortality in the region.Aside from formal education, there is also a need for broad-based public health education to counter the harmful traditional and religious beliefs, norms and practices that impact negatively on maternal health.When women and community gate-keepers are made aware of the real issues surrounding maternal and child health, it will increase the use of family planning services for the prevention of unwanted pregnancies; it will increase women's use of evidence-based maternity services for antenatal and delivery care; and it will mitigate the effects of unwholesome beliefs and practices that lead women to unfavourable pregnancy outcomes. It is my considered opinion that a massive investment in public health education on maternal health targeting various segments can lead to a significant reduction in maternal mortality in Nigeria.The socio-economic empowerment of womenThe fact that maternal mortality affects only women, especially poor, illiterate and under-nourished rural women pose questions of gender equity, human rights and social justice. The political and economic marginalization of women has repeatedly been cited as key factors in the sustenance of the vulnerabilities that expose women to increased risks of maternal morbidity and mortality. The fact that maternal morbidity and mortality is higher in countries with poor performances in gender development indices (e.g. Afghanistan and Nigeria) further confirm the strength of association between the disempowerment of women and higher risks of reproductive mortality. But this is not always so, as some countries such as Saudi Arabia have low rates of maternal mortality despite being low in gender development ranking. Women must have voices of their own and relevant power and authority that is commensurate with their increasing contribution to the informal labor sector. As part of efforts to promote maternal health and reduce maternal mortality, official policies must be tailored to ensure gender parity or a level playing field in such areas as education, employment, political representation and economic opportunities.Conclusion: A call for ActionIn September 2000, 189 countries agreed to support a set of development agenda that were encapsulated in the Millennium Development Goals. The fifth goal anticipates a reduction in the maternal mortality ratio by 75% between 1990 and 2015. A near-term global assessment evaluation has shown that it is possible to reduce maternal mortality by three-quarters within 25 years in some countries. By contrast, due to inadequate demographic, economic, political and socio-cultural circumstances, it is unlikely that Nigeria would achieve the goal in 2015. However, we must not lose faith ' we must remain focussed on the MDG target, while thinking beyond 2015 and keeping an eye on the broad picture. High level political will and a strategy that encourages the alignment of our maternal health strategy with the overall development plans of the country are vitally needed. The vision 20:20:20 for example, must not only target the overall economic growth of the country, it must also focus on ensuring the overall improvement of the living conditions of Nigerians. A significant and sustained reduction in maternal and neonatal morbidity and mortality will provide the best evidence that this has taken place. Concerted effort is required at all levels, from international to in-country efforts and among community stakeholders, health professionals and academicians. A strong political leadership that understands the multi-dimensional nature of the problem and that has an eye for social justice, equity and protection of the rights of its people is needed to drive the mission for the sustained reduction in maternal and neonatal morbidity and mortality in Nigeria.
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