Nigeria is considered a country with the second highest maternal mortality rate globally with 1 in 3 women dying in childbirth. While the country recorded a reduction of 43%- from 1,100 deaths per 100,000 live births in 1990 to 630 per 100,000 in 2010, it is still far from the Millennium Development Goal 5 target of a 75% reduction by 2015.
For this unfavourable health condition, the John D. and Catherine T. MacArthur Foundation identified reduction in maternal mortality as a priority area in Nigeria, one of the three Population and Reproductive Health focus countries (India and Mexico being the other two). The foundation held a meeting in Mexico, in 2012, with grantees from the three focus countries to share experiences in accountability strategies for improving maternal and reproductive health, generating the working definition of accountability: the exercise of power constrained by external means or internal norms. Discussions at this meeting were organized around four accountability strategies that became the basis for the MacArthur Foundation’s maternal health accountability grant portfolio in Nigeria.
The MacArthur Foundation now funds a portfolio of seven 3-year grants in Nigeria focused on government accountability to maternal and reproductive health. The grants aim to achieve maternal health accountability by: 1) increasing government commitments at federal, state and local levels to fund maternal health; 2) ensuring government compliance with commitments already made; and 3) ensuring higher quality maternal health services that reflect an understanding of the reasons for maternal deaths in Nigeria and how to prevent them. Awarded in 2013, the portfolio focuses on four accountability strategies: budget analysis, community mobilization, legal approaches, and maternal death audits, and spans three government levels (federal, state, local), 12 states and the Federal Capital Territory (FCT), and five geopolitical zones.
The grantees, their accountability strategies and states of operation are: Advocacy Nigeria on community mobilization (policy advocacy) in Adamawa, Gombe and Zamfara State; Community Health Research Initiative, (CHR),on community mobilization (policy advocacy) and budget analysis in Bauchi, FCT, Jigawa, Kano, Niger and Sokoto State; Civil Society Legislative Advocacy Centre, (CISLAC), on community mobilization (policy advocacy) in Jigawa, Kaduna, Kano and Katsina State; Development Communications Network, (DevComs), on community mobilization (media) and policy advocacy in FCT, Jigawa, Kaduna and Lagos State; Society of Gynecology and Obstetrics in Nigeria, (SOGON), on maternal death audits in FCT; Women Advocates Research and Documentation Centre, (WARD C), on community mobilization (policy advocacy) and legal approaches in Enugu, Kaduna, Lagos State; Women’s Health Action Research Centre, (WHARC), on maternal death audits in Lagos State.
The Foundation has prioritised learning-focused evaluation to illuminate for the Foundation and its grantees: what is working well to advance maternal health in Nigeria, what could be improved in the current grants and portfolio design and implementation, and what alternative strategies could be considered for increasing government accountability for maternal health. As part of a series of evaluative activities for the portfolio, the MacArthur Foundation commissioned EnCompass, LLC to refine the grant portfolio theory of change, conduct a baseline, and build grantee capacity to monitor their grants.
The baseline data collection was conducted in April and May, 2014, before the grant activities fully began. It provided landscape metrics through the lens of the four accountability strategies that would be used to assess progress and results at midline and endline, and inform the grant portfolio going forward. Resources constraints however, limited the baseline data collection to eight states and the Federal Capital Territory. Through interviews, focus-group discussions, document review and consultation meeting, the evaluation team, with the MacArthur Foundation and grantees collected data in the eight states and the FCT from journalists, civil society representatives, government officials, external stakeholders, and Maternal Death Review (MDR) committee members.
The baseline findings, validated at the Abuja Data Consultation meeting in October 2014 with external and internal stakeholders confirming the findings to be accurate and grounded in the Nigeria’s context, indicated that the assumptions and information on which the grant portfolio was built remain relevant. The seven grants, four accountability pathways, and theory of change respond to the existing challenges and opportunities to advance maternal health and reduce maternal mortality in Nigeria.
The general public seems disenfranchised to take action needed to foster change in maternal mortality. Without a ‘thirsty’ public, there is little incentive to publish stories, participate in MDRs, bring maternal health cases to court, or implement policies. The grant portfolio is addressing this challenge through the community mobilization strategy by fostering collaboration among civil society to monitor health service delivery and advocate for policy implementation (including budget performance), improving media coverage, and improving the maternal death audit processes. In order to strengthen the maternal health evidence base, grantees are organizing and mobilizing CSOs to monitor maternal health service delivery, and marshaling media for increased and improved frequency and coverage of maternal health and mortality. Government commitment to social change also depends on a vibrant and empowered media sector to collect and disseminate information on service delivery performance, and to expose corrupt practices through awareness-building and investigative reporting.
There is a need, however, for more emphasis in the portfolio on budget performance; one grantee seems insufficient given the importance of this accountability strategy in Nigeria. Also there is strong resistance and suspicion from the Federal Ministry of Health down to facilities regarding the MDR process and reporting, which the Foundation and grantees need to address stridently.