Improving Human Resource for Health in Rural Northern Nigeria

Inadequate number of health workers in rural areas is a major concern in many countries. It causes underutilization, prevents equitable access of health services, and is a barrier to universal health coverage. To increase the number and improve retention of health workers in rural areas, the World Health Organization (WHO) issued global recommendations to improve the rural retention of the health workforce. This paper presents the experiences of adopting and implementing the WHO recommendations in four states in Northern Nigeria. It highlights the results, challenges and lessons learnt with the implementation. We used an implementation research approach and evaluated the implementation at three stages: the pilot; full implementation; and immediate post exit. A total of 477 midwives were recruited and deployed to rural health facilities over a period of four years. Of these, 196 (41%) were in Jigawa, 126 (26.4%) in Yobe, 78 (16.4%) in Zamfara and 77 (16.1%) in Katsina. Midwives’ retention rates increased gradually over the four years. In three (Jigawa, Katsina and Zamfara) of the four states, midwives’ retention rates increased from 69.2% in Jigawa in 2013 to 98% in 2016; from 53.3% in Katsina in 2013 to 100% retention in 2016. Zamfara made the most progress with a poor retention rate of 42.8% in 2013 to 100% retention rate in 2016. In Yobe state, the retention rate of 47% in 2013 gradually increased to 100% in 2015. This however slightly dropped to 90% in 2016 as a result of the deteriorating security situation in 2015. Other effects of the initiative included: heightened determination of states to increase the production of indigenous midwives; reversal of policy directives that banned the recruitment of health workers including midwives; and to provide incentives such as safe and comfortable accommodation

Comparison of high- versus low-intensity community health worker intervention to promote newborn and child health in Northern Nigeria

In Northern Nigeria, infant mortality rates are two to three times higher than in the southern states, and, in 2008, a partnership program to improve maternal, newborn, and child health was established to reduce infant and child mortality in three Northern Nigeria states. The program intervention zones received government-supported health services plus integrated interventions at primary health care posts and development of community-based service delivery (CBSD) with a network of community volunteers and community health workers (CHWs), who focus on educating women about danger signs for themselves and their infants and promoting appropriate responses to the observation of those danger signs, consistent with the approach of the World Health Organization Integrated Management of Neonatal and Childhood Illness strategy. Before going to scale in the rest of the state, it is important to identify the relative effectiveness of the low-intensity volunteer approach versus the more intensive CBSD approach with CHWs. We conducted stratified cluster sample household surveys at baseline (2009) and follow-up (2011) to assess changes in newborn and sick child care practices among women with births in the five prior years (baseline: n = 6,906; follow-up: n = 2,310). The follow-up respondents were grouped by level of intensity of the CHW interventions in their community, with “low” including group activities led only by a trained community volunteer and “high” including the community volunteer activities plus CBSD from a CHW providing one-on-one advice and assistance. t-tests were used to test for significant differences from baseline to follow-up, and F-statistics, which adjust for the stratified cluster design, were used to test for significant differences between the control, low-intensity, and high-intensity intervention groups at follow-up. These analyses focused on changes in newborn and sick child care practices. Anti-tetanus vaccination coverage during pregnancy increased from 69.2% at baseline to 85.7% at follow-up in the intervention areas. Breastfeeding within 24 hours increased from 42.9% to 59.0% in the intervention areas, and more newborns were checked by health workers within 48 hours (from 16.8% at baseline to 26.8% at follow-up in the intervention areas). Newborns were more likely to be checked by trained health personnel, and they received more comprehensive newborn care. Compared to the control communities, more than twice as many women in intervention communities knew to watch for specific newborn danger signs. Compared to the control and low-intensity intervention communities, more mothers in the high-intensity communities learned about the care of sick children from CHWs, with a corresponding decline those seeking advice from family or friends or traditional birth attendants. Significantly fewer mothers did nothing when their child was sick. High-intensity intervention communities experienced the most decline. Those who did nothing for children with fever or cough declined from 35% to 30%, and with diarrhea from 40% to 31%. Use of medications, both traditional and modern, increased from baseline to follow-up, with no differentiation in use by intervention area. The community-based approach to promoting improved newborn and sick child care through community volunteers and CHWs resulted in improved newborn and sick child care. The low-intensity approach with community volunteers appears to have been as effective as the higher-intensity CBSD approach with CHWs for several of the key newborn and sick child care indicators, particularly in the provision of appropriate home care for children with fever or cough

Early results of an integrated maternal, newborn, and child health program, Northern Nigeria, 2009 to 2011

Background: This paper describes early results of an integrated maternal, newborn, and child health (MNCH) program in Northern Nigeria where child mortality rates are two to three times higher than in the southern states. The intervention model integrated critical health systems changes needed to reinvigorate MNCH health services, together with community-based activities aimed at mobilizing and enabling women to make changes in their MNCH practices. Control Local Government Areas received less-intense statewide policy changes. Methods: The impact of the intervention was assessed using a quasi-experimental design, comparing MNCH behaviors and outcomes in the intervention and control areas, before and after implementation of the systems and community activities. Stratified random household surveys were conducted at baseline in 2009 (n = 2,129) and in 2011 at follow-up (n = 2310), with women with births in the five years prior to household surveys. Chi-square and t-tests were used to document presence of significant improvements in several MNCH outcomes. Results: Between baseline and follow-up, anti-tetanus vaccination rates increased from 69.0% to 85.0%, and early breastfeeding also increased, from 42.9% to 57.5%. More newborns were checked by trained health workers (39.2% to 75.5%), and women were performing more of the critical newborn care activities at follow-up. Fewer women relied on the traditional birth attendant for health advice (48.4% to 11.0%, with corresponding increases in advice from trained health workers. At follow-up, most of these improvements were greater in the intervention than control communities. In the intervention communities, there was less use of anti-malarials for all symptoms, coupled with more use of other medications and traditional, herbal remedies. Infant and child mortality declined in both intervention and control communities, with the greatest declines in intervention communities. In the intervention communities, infant mortality rate declined from 90 at baseline to 59 at follow-up, while child mortality declined from 160 to 84. Conclusions: These results provide evidence that in the context of ongoing improvements to the primary health care system, the participatory and community-based interventions focusing on improved newborn and infant care were effective at changing infant care practices and outcomes in the intervention communities

Estimating Maternal Mortality Level in Rural Northern Nigeria by the Sisterhood Method

Maternal mortality is one of the major challenges to health systems in sub Saharan Africa. This paper estimates the lifetime risk of maternal death and maternal mortality ratio (MMR) in four states of Northern Nigeria. Data from a household survey conducted in 2011 were utilized by applying the “sisterhood method” for estimating maternal mortality. Female respondents (15–49 years) were interviewed thereby creating a retrospective cohort of their sisters who reached the reproductive age of 15 years. A total of 3,080 respondents reported 7,731 maternal sisters of which 593 were reported dead and 298 of those dead were maternal-related deaths. This corresponded to a lifetime risk of maternal death of 9% (referring to a period about 10.5 years prior to the survey) and an MMR of 1,271 maternal deaths per 100,000 live births; 95% CI was 1,152–1,445 maternal deaths per 100,000 live births. The study calls for improvement of the health system focusing on strategies that will accelerate reduction in MMR such as availability of skilled birth attendants, access to emergency obstetrics care, promotion of facility delivery, availability of antenatal care, and family planning. An accelerated reduction in MMR in the region will contribute towards the attainment of the Millennium Development Goal of maternal mortality reduction in Nigeria

Impact of alternative community engagement strategies on improved maternal and child health behaviours and outcomes among the most vulnerable in northern Nigeria

Low-status women typically have poorer maternal and child health outcomes. In northern Nigeria, we piloted alternative models for engaging vulnerable women and facilitating an improvement in their maternal health outcomes.  We assess the net impact of an integrated health system improvement model focusing on ensuring emergency obstetrical services for clusters of affiliated primary health care clinics, on the relative additional impact of alternative community engagement (CE) strategies.  Analysis of baseline to endline survey data (2009-2013) showed that proportions of women making antenatal care (ANC) visits and who delivered with a skilled birth attendant doubled.   Maternal and infant mortality also declined.  Greater improvements with more ANC visits and skilled birth attendance were associated with being   non-poor, owning a cell-phone, being less socially excluded, being satisfied with improvements in the clinic, and participating more in CE activities. Efforts to increase participation in CE activities can further enhance outcomes for the vulnerable wome

Lessons learned from setting up the Nahuche Health and Demographic Surveillance System in the resource-constrained context of northern Nigeria

Background: The present time reflects a period of intense effort to get the most out of public health interventions, with an emphasis on health systems reform and implementation research. Population health approaches to determine which combinations are better at achieving the goals of improved health and well-being are needed to provide a ready response to the need for timely and real-world piloting of promising interventions. Objective: This paper describes the steps needed to establish a population health surveillance site in order to share the lessons learned from our experience launching the Nahuche Health and Demographic Surveillance System (HDSS) in a relatively isolated, rural district in Zamfara, northern Nigeria, where strict Muslim observance of gender separation and seclusion of women must be respected by any survey operation. Discussion: Key to the successful launch of the Nahuche HDSS was the leadership's determination, stakeholder participation, support from state and local government areas authorities, technical support from the INDEPTH Network, and international academic partners. Solid funding from our partner health systems development programme during the launch period was also essential, and provided a base from which to secure long-term sustainable funding. Perhaps the most difficult challenges were the adaptations needed in order to conduct the requisite routine population surveillance in the communities, where strict Muslim observance of gender separation and seclusion of women, especially young women, required recruitment of female interviewers, which was in turn difficult due to low female literacy levels. Local community leaders were key in overcoming the population's apprehension of the fieldwork and modern medicine, in general. Continuous engagement and sensitisation of all stakeholders was a critical step in ensuring sustainability. While the experiences of setting up a new HDSS site may vary globally, the experiences in northern Nigeria offer some strategies that may be replicated in other settings with similar challenges

Awareness, Use, and Unmet Need for Family Planning in Rural Northern Nigeria

Access to quality reproductive health and family planning services remain poor in Nigeria. We present results on family planning awareness and use from a survey of 3,080 women (age 15-49 years) in Jigawa, Katsina, Yobe, and Zamfara States. About 43.0% had heard of any method of contraception whereas 36.6% had heard of any modern method. Overall, 7.0% of all currently married women reported ever using a method of contraception; 4.4% used a modern method and 2.9% used a traditional method. Only 1.3% of women in union (currently married or cohabiting) used modern contraception methods at the time of the survey; 1.3% of women in union used traditional methods. Unmet need for family planning was 10.3%. Low family planning use in the presence of low awareness and low felt need suggests, among other things, a need to increase awareness and uptake and make family planning commodities available.L'accès à la santé de la reproduction de qualité et des services de planification familiale demeure pauvre au Nigeria. Nous présentons les résultats sur la sensibilisation à la planification familiale et l'utilisation à partir d'un sondage de 3.080 femmes (âgées de 15-49 ans) dans les Etats de Jigawa, Katsina, Yobe et Zamfara. Environ 43,0% d’elles avaient entendu parler d'une méthode de contraception alors que 36,6 % avaient entendu parler d'une méthode moderne. Dans l'ensemble, 7,0 % des toutes les femmes actuellement mariées ont déclaré avoir déjà en utilisé une méthode de contraception dans le passé ; 4,4 % utilisaient une méthode moderne et 2,9 % utilisaient une méthode traditionnelle. Seulement 1,3 % des femmes en union (actuellement mariées ou en concubinage) utilisaient des méthodes modernes de contraception au moment de l'enquête; 1,3% des femmes en union utilisaient des méthodes traditionnelles. Le taux de besoins non satisfaits en planification familiale a été de 10,3 %. La faible utilisation de la planification familiale en présence d'une faible prise de conscience et le faible besoin ressenti suggèrent, entre autres, la nécessité d'accroître la sensibilisation et l'adoption et d’assurer la disponibilité des produits de planification familiale

Reinvigorating Health Systems and Community-Based Services to Improve Maternal Health Outcomes

Background: Maternal health outcomes in Nigeria, the most populous African nation, are among the worst in the world, and urgent efforts to improve the situation are critical as the deadline (2015) for achieving the Millennium Development Goals draws near. Objective: To evaluate the results of an integrated maternal, newborn, and child health (MNCH) program to improve maternal health outcomes in Northern Nigeria. Design: The intervention model integrated critical health system and community-based improvements aimed at encouraging sustainable MNCH behavior change. Control Local Government Areas received less intense statewide policy changes. Methods: We assessed the impact of the intervention on maternal health outcomes in 3 northern Nigerian states by comparing data from 2360 women in 2009 and 4628 women in 2013 who had a birth or pregnancy in the 5 years prior to the survey. Results: From 2009 to 2013, women with standing permission from their husband to go to the health center doubled (from 40.2% to 82.7%), and health care utilization increased. The proportions of women who delivered with a skilled birth attendant increased from 11.2% to 23.9%, and the proportion of women having at least 1 antenatal care (ANC) visit doubled from 24.9% to 48.8%. ANC was increasingly provided by trained community health extension workers at the primary health center, who provided ANC to 34% of all women with recent pregnancies in 2013. In 2013, 22% of women knew at least 4 maternal danger signs compared with 10% in 2009. Improvements were significantly greater in the intervention communities that received the additional demand-side interventions. Conclusions: The improvements between 2009 and 2013 demonstrate the measurable impact on maternal health outcomes of the program through local communities and primary health care services. The significant improvements in communities with the complete intervention show the importance of an integrated approach blending supply- and demand-side interventions