Dr Mimiko
KEYNOTE ADDRESS OF HIS EXCELLENCY, DR. OLUSEGUN MIMIKO, CON TITILED “THE POLITICS OF MATERNAL HEALTH IN NIGERIA – BUILDING A LEGACY FOR THE FUTURE”
AT
THE 50TH ANNUAL GENERAL MEETING AND SCIENTIFIC CONFERENCE OF THE SOCIETY OF GYNAECOLOGY & OBSTETRICS OF NIGERIA, AKURE 2016
PROTOCOL
All protocol duly observed.
INTRODUCTION
My distinguished audience, it is heartwarming for me to be present among you once again. This is especially so on this occasion of our 50th Annual General Meeting and Scientific Conference with a germane theme; “Women’s Health and the Sustainable Development Goals in Nigeria: Policies and Strategies.’ I am proud to welcome you all, perhaps for the first time, to the state-of-the-art International Conference Centre located here in Akure, the capital of the Sunshine State. (pause).
As if that is not good enough, I have the honour of delivering the keynote address at this Conference, titled; “The politics of maternal health in Nigeria – building a legacy for the future”. I will strive to meet up to your expectations in doing justice to this topic bearing in mind I have before me an audience who in their own individual rights are masters on maternal health issues. (pause).
The presentation outline is as shown on the screen. (pause).
GLOBAL BACKGROUND ON MATERNAL HEALTH
One of the most important globally accepted indicators used to measure the state of women’s health is the maternal mortality ratio (MMR) defined as the number of maternal deaths per 100,000 live births in a specific time period. Maternal mortality has remained an intractable public health concern in many developing countries. The latest and most comprehensive study on maternal mortality ratios by The World Health Organisation (WHO) revealed that the global figure fell by nearly 44% in the past 25 years. This was from 385 maternal deaths per 100,000 in 1990 to an estimated 216 in 2015. However, that same report revealed that Nigeria with 58,000 maternal deaths overtook India (with 45,000) as the country with the heaviest global burden.
NATIONAL BACKGROUND ON MATERNAL HEALTH
The WHO estimated Nigeria’s MMR as 814 per 100,000 in 2015, an increase of 30% from the 2010 figure of 630. On the other hand, the 2014 Nigeria Demographic and Health Survey (NDHS) quoted a figure of 576 per 100,000 live births, an increase from that of 545 in 2008. Whichever one is chosen, it is clear that the state of maternal health in Nigeria as a whole is poor. Incidentally, it was the NDHS report of 2008 that revealed Ondo State had the worst maternal and child health indices in the south western zone of the country.
Ironically, since the landmark Zaria Maternity Survey by our own Emeritus Professor Kelsey Harrison in 1985, several policies and programmes have been introduced by successive governments at the national level. These include the Safe Motherhood Initiative, Millennium Development Goals (which has morphed into the Sustainable Development Goals) and Midwives Service Schemes, just to mention a few. In my opinion, what has hampered the success of these otherwise laudable programmes include poverty, illiteracy and superstition as well as inadequate access of marginalised citizens to quality health services. Others are injudicious appropriation of human and financial resources as well as lack of sustained political will to invest in health care.
POLITICS OF MATERNAL HEALTH IN NIGERIA
This brings me to the core issue of the politics of maternal health in Nigeria. Undoubtedly, the death of a woman from complications of pregnancy and childbirth is a loss not only to her family but community, local government, State and nation as a whole. The critical role of a wife and/or mother in any society cannot be over-emphasised. She is often a co–breadwinner of her immediate family responsible for the moral and physical upbringing of the children as well as promotion of cultural values.
Should anyone then wonder why Nigeria is going through her present economic predicament having perhaps relegated women to the background of political discourse for so long? A recent World Bank study reported that African countries lose up to $90million annually as a result of the low representation of women in the labour force. It is therefore, not surprising that researchers have succeeded in identifying a positive correlation between improved maternal health on one hand and economic growth as well as poverty reduction on the other. To date, only few governments in Nigeria have been able to identify the positive relationship between investment in maternal health and the well-being of the population. This is a major challenge we need to overcome as the country grapples with socio-economic development. Please note that currently, two of the most economically advanced countries in the western hemisphere (i.e. Germany and the United Kingdom) are governed by women. In addition, the United States of America is on the verge of electing her first female President, come November this year. (pause) .
THE ABIYE (SAFE MOTHERHOOD) PROGRAMME
In Ondo State, we decided on assumption of our administration to do things differently. It is no longer news that we met a poorly funded, inadequately equipped health infrastructure manned by an ill-motivated, demoralised and under-staffed professional work force. In addition, Ondo at that time had the unenviable reputation of being the only southwestern State and one of the few nationwide without a State-run teaching hospital for under- and post-graduate training.
It was clear there had to be a total overhaul and reform of the system and we chose to put maternal health at the front burner. We were resolute in our conviction that finances should not be a barrier to qualitative healthcare and for us to succeed all pregnant women must be tracked from conception to delivery. We adopted this mantra, determined to permanently reverse the unsavory trend and prove that things can change for the better if there is strong political will. Seven years down the line our home-grown Abiye (safe-motherhood) programme is today, arguably one of the most successful and talked about healthcare initiatives in the developing world.
OUR SCORECARD
The Mother & Child Hospital located in Akure was commissioned in February, 2009. It remains among the busiest and most impactful maternity centres in the country. The mission statement is to run integrated maternal and child care facility fully poised to offer qualitative and critical interventions when required, free of charge. This is irrespective of ethnicity or social status of patients.
As at May, 2016, the Mother and Child Hospital Akure (MCHA) had registered a total of 139,368 patients. Out of this figure, 59,478 were antenatal patients and 79,890 were children under five years. The total deliveries were 36,713, including 30,193 vaginal and 6,520 caesarean sections. A facility-based five-year audit of maternal mortality ratios at the MCHA showed a reduction from 708 per 100,000 births in 2010 to 208 in 2014, another fall of about 70%. (pause for effect). The counterpart facility in Ondo city, also doing well, was incidentally accredited for post-graduate residency training in O & G within three years of operations by the National Postgraduate Medical College of Nigeria and the West African College of Surgeons.
Perhaps nothing emphasises the economic significance of the free maternal healthcare policy of our administration more than the fact that the Mother & Child Hospitals have jointly conducted over 9,000 life-saving caesarean sections. If one estimates the average cost of caesarean section to be N100,000, then our policy has saved the teeming masses of Ondo State and environs a whopping N900 million! (pause for effect).
The Confidential Enquiry into Maternal Deaths in Ondo State (CEMDOS), the first in Nigeria, was signed into Law in May, 2010. It mandated the reporting and investigation of circumstances around all maternal deaths. According to its latest 2015/2016 preliminary report, Ondo State had a 70% reduction in her maternal mortality ratio from a baseline of 545 per 100,000 births (referencing NDHS, 2009) to a verifiable 171 as at May 2016.
It is also worthwhile to mention our homegrown Agbebiye Initiative that has received commendations from home and abroad. It serves to proffer a sustainable solution to the menace of traditional and mission home birth attendants. In fact, the first CEMDOS report identified over 90% of unfortunate maternal deaths as being linked to mismanagement or delayed referrals from such unskilled hands. In the first quarter of 2014, we launched the innovative and pragmatic collaboration with traditional and mission home birth attendants which incentivised their referrals of pregnant women for delivery in public health facilities while gradually being phasing out. This collaboration gave rise to the coinage ‘Agbebiye”. To the best of our knowledge this is the first successful and sustainable statewide intervention that addresses the menace of unskilled attendance at deliveries. As at December of last year, 14,802 pregnant women were referred from various traditional and mission birth homes to various health facilities across the state. The resultant deliveries included 29 twins, 13 triplets and one quadruplet.
FAMILY PLANNING
At this point, I would like to draw your attention to the role of family planning in improving maternal health in the State. This is before we are, once again, accused of encouraging population explosion through our Abiye (safe-motherhood) programme. The evidence we have is that there has been an uptake in contraceptive prevalence especially long acting injectables and postpartum insertions of intrauterine uterine contraceptive devices at the Mother and Child Hospitals. After all, is it not the mother that is available to orthodox facility care that would be receptive to family planning counseling, consent and practice?
In Ondo State, by removing all the impediments militating against facility deliveries, we have increased capacity utilisation in its entirety. In addition, the average couple in Ondo State now takes for granted that their newborn would live beyond the age of 5 years as a result of free access to tertiary-level health services, immunisation coverage and qualitative basic education as well as bus shuttles to and from school. In that regard, the average couple knows they don’t require many children to hedge their bets most would not live beyond infancy.
The lesson learnt is simply that family planning uptake would likely not succeed where qualitative facility deliveries, child survival strategies and girl-child education are not prioritised and instituted. Furthermore, a five-year survey at the Mother and Child Hospital Akure showed that, contrary to the opinion in some quarters, more than 36% of parturients were primiparous and less than 5%, grand multiparous. In essence, most of the mothers delivering at the facilities are first-timers, who might not be candidates for aggressive family planning counseling.
BUILDING A LEGACY FOR THE FUTURE
In view of our modest achievements in the maternal health sector in the last seven years, we are often inundated with questions on how we intend to sustain these policies beyond our administration. Needless to say, many laudable programmes at various tiers of government have become defunct as a result of failure to outlive the administrations that introduced them. The major causes I gather were lack of funding, poor implementation and misplaced political priorities of succeeding governments. As far as Ondo State is concerned, the sustainability strategies of our maternal health policies have already been set in motion.
For instance, it is our intention to establish a full fledge functional State Health Trust Agency partly funded with a mandatory insurance to eliminate financial barrier at the point of care. For this to succeed we will require community participation. The introduction of health tax as a percentage of every contract in the State will also help to increase the pool of funds.
We have already introduced the State residency smart card popularly known as “kaadi igbeayo” for effective planning. This multi-application smart card allows tracking of taxable adults benefiting from the administration’s social welfare policies like free maternal and child care services. Possession of the card also helps to differentiate bona fide residents of Ondo from those coming in from adjoining States who want to take advantage of the free and qualitative health care services at the two Mother & Child Hospitals. This unrestricted influx often strains available resources in the facilities. We have also begun the process of giving legislative backing to all programmes as was done with the CEMDOS Law. This ensures sustainability and promotes universal health coverage.
SUSTAINABLE FINANCING
As regards financing we know that cost of care (i.e. cost of drugs and medical consumables) of the average pregnant woman from conception to delivery, irrespective of mode of delivery, is about N5,000! When some overhead costs and exigencies are added to the figure, the total is about N480 million to cater for 40,000 parturients per year. This means that for one million taxable adults in Ondo State out of a total population of four million, they are only required to pay about forty naira each per month in an insurance pool to perpetually enjoy the benefits of free and qualitative maternal and child care services. You will agree with me that this is much less than the average Nigerian spends on phone credits. At the end of the day, it’s a strong political will that drives impactful policies and the people of Ondo State have leveraged on that in the last seven years.
It is the inalienable right of people to elect whoever they deem fit to govern them and Ondo State citizens are no exception. Nevertheless, it is clear from the current retinue of candidates seeking to take over the mantle of office that who is most familiar with the policies of this administration and possesses the political will to build on the present achievements in the health sector.
HUMAN CAPITAL DEVELOPMENT
In support of increased clinical activities in the maternal health sector, we invested in human capital development in the last seven years. It is to our credit that from just two O & G specialists in 2009, we now have 18 on ground. Along with the employment is a robust remuneration package that has been maintained despite the dwindling financial resources of the State. This massive intake of healthcare professionals extended to other cadre like nurse-midwives, pharmacists, medical laboratory scientists, etc.
In addition, the paediatrics departments of the two Mother & Child Hospitals are currently collaborating with the prestigious University of Iowa Hospitals & Clinics and Children’s Hospital of Philadelphia, both in the United States of America. The collaborations entail research grants and exchange programmes that allowed our doctors and nurses to undertake clinical postings in the institutions. Our selection for the collaborations was in recognition of the impactful quality of care exhibited at the facility level. The University of Medical Sciences epitomises a determination of Ondo State to sustain manpower development in the health sector. Our goal is to be the destination of all West Africans seeking qualitative health care. UNIMED is presently the first Medical University in Nigeria and third in Africa. It is now among 32 universities offering medical courses; 12 being State-owned.
At this point, I would like to point out that one major worrisome trend militating against the optimal success of our maternal health policy is the incessant industrial actions by different cadre of healthcare professionals. Our findings have consistently shown that when our public hospitals shut down, the pregnant women who cannot afford private facilities suffer the dire consequences. I do understand the compulsion to stand up against perceived injustice and maltreatment. However, you will agree with me that these agitations have been taken to an intolerable level in our country. I posit that we are duty-bound as the recognised leaders in the health system to develop innovative and ingenious ways of expressing our grievances without punishing the innocent, needlessly. The fact that Nigeria of today ranks poorly on almost all healthcare indices is a pointer to the fact that the future is bleak should this unfortunate and embarrassing trend be allowed to continue.
OTHER LANDMARKS IN THE HEALTH SECTOR IN ONDO STATE
As I round up this presentation, time would not allow me to discuss in detail our landmark achievements in other areas such as child health care. I will, however, mention that through our “Orirewa” programme, Ondo has on two consecutive occasions been accorded the State with the best immunization coverage nationwide, courtesy the prestigious Bill and Melinda Gates National Leadership Award in Eradication of Polio in 2013 and 2014, respectively.
In 2014, the Federal Ministry of Health ranked all States in the country according to the performances of their primary health care systems. Ondo State came first with a score of 91% whilst some others scored as low as 6%. One or two even scored 0%. This is illustrated on the screen. Please note that in a recent survey, our primary health centres have seen an increase in number of safe deliveries just as those in our secondary and tertiary facilities have reduced. This attests to the resources allocated to upgrading majority of the primary health centres.
The Ondo State Emergency Medical Services (ODEMSA) was established to provide unfettered access to emergency services for victims of road crashes on our high ways. It comprises of five base stations, a Call Centre as well as the Trauma and Surgical Centre. The base stations are strategically located along the major highways traversing the State while the Call Centre is in the world class Medical Village in Ondo city. Other facilities in the Medical Village are the Gani Fawehinmi Diagnostic Centre, the Trauma and Surgical Centre, the Mother and Child Hospital Ondo, the Kidney Care Centre as well as the University of Medical Sciences. The Diagnostic Centre was named after legendary lawyer and human rights activist, Gani Fawehinmi who died of cancer in 2009. It is a world class centre, in partnership with ME-CURE Healthcare Limited, to help in early detection and diagnosis of medical conditions useful to both indigenous population and investors in Nigeria. The Trauma and Surgical Centre was to cater for various surgical specialties and victims of road traffic crashes. The Centre is accredited for post-graduate training in various surgical sub-specialties and has successfully performed 1,765 surgical procedures since inception in December, 2013 to June, 2016. This is aside the over 1,400 free ophthalmological procedures performed during a festival of surgeries conducted last year. Another facility in the Medical Village is the fully equipped Kidney Care Centre, established in March, 2014, which continues to impact lives by performing over 3,500 dialysis sessions in over 1,300 patients, as at June, 2016. This makes it one of the busiest of such centres in the country.
CONCLUSION
In conclusion, ladies and gentlemen, we aver that investment in maternal health in Nigeria can only be driven and sustained by strong political commitment by the leadership. The indisputable fact that the socio-economic rating of any nation is partly measured by its maternal health indicators should be a pointer to their significance. Governments have an important role to secure these important democratic dividends for their people. It is quite disheartening that though politicians often solicit for the block vote of our womenfolk, many relegate their cause to the background once in office. It is left for the Nigerian populace to make sure candidates for political office present in clear terms their manifestoes for improving the status of maternal health.
As for Ondo State, we remain committed to the areas of convergence of interest with the federal government, other States as well as SOGON. This is in line with a joint mandate to make universal access to affordable and qualitative healthcare services an ultimate goal in improving maternal health in Nigeria. To achieve this, there must be formulation of evidence-driven policies premised on data-backed outcome measures. Such positive outcomes would further encourage increased investment in the sector. I pray the Almighty God continues to strengthen our collaborations as we strive to better the lot of our wives, mothers, daughters and sisters.
On a final note, I enjoin our visitors to use this occasion to bask in the hospitality and peaceful ambience of Akure. At the end of your stay in the capital city of the Sunshine State, I have no doubt that you will become worthy ambassadors as you make your way back to your homes. Thank you for listening and God Bless.
