As Nigerians continue to yearn for the concrete benefits of the country’s 20 year old democratic experience, expectations of citizens appear to be shifting towards the results of good governance. Gone are the days when the talks about democratic freedoms were considered as ends in themselves, without an assessment of the social conditions.
Citizens can clearly see that those in government position are not only enjoying the democratic freedoms, they are equally feeding fat from the collectively owned resources, which could have been used to provide decent life for the majority of the citizens.
One of the many social issues, which has been engaging the attention of activists and good governance advocates, as they campaign for citizens’ interests to be reflected in the democratic process, is the issue of maternal healthcare.
As detailed in many global and national reports, statistics on maternal deaths, especially in sub-Saharan Africa remain disheartening.
A 2018 factsheet released by the World Health Organisation (WHO) puts the figure of daily global maternal deaths at 830 and goes on to note that 99 percent of the deaths happened in developing countries.
Another critical point, which campaigners pointed out, is the pattern of deaths, especially as the WHO factsheet makes it clear that maternal mortality is higher among women living in rural communities and among poorer communities. Across the globe therefore, campaigners are working with the target in the Sustainable Development Goals (SDGs), which hopes to reduce the maternal mortality ratio to 70 per 100,000 live births.
However, campaigners have warned that this ambitious global target would not be achieved without robust local initiatives to drive the discourse in communities, which are the hardest hit by the problem.
In Kano State, North West Nigeria for instance, campaigners have been using the rights and responsibility approach to push for a culture of accountability in the maternal health service delivery chain.
Human rights organizations are collaborating with activists, women groups, and social influencers within communities to build synergies.
Collectively, these grassroots coalitions are working to enlighten the people that they can use their voice as citizens to make accountability demands with respect to how funds earmarked for maternal health are expended.
A series of project events targeted at activists and women groups from Gwale and Kumbotso Local Government Areas of Kano State provided an opportunity for a frontline human rights organization, the Resource Centre for Human Rights and Civic Education (CHRICED) to galvanize local level actors, and remind them of their roles and responsibility in the race to drastically reduce maternal deaths.
First, there was a community enlightenment sessions, a briefing for the media and a Statewide Consultative Meeting, which all explored modalities for accountability and transparency in resource budgets for maternal health in Kano State.
At the meetings, citizens told heart-rending stories of how poor maternal health services claimed the lives of loved ones, friends, and neighbours.
A nurse, Rabi Bala Hassan narrated how a recent case, which could not be handled by the Primary Healthcare Centre in one of the rural communities, resulted in the death of both the mother and her new born.
Other participants similarly gave stories of how daily deaths of women occur due to lack of basic equipment or the poor skill level or attitude of healthcare personnel running the Primary Healthcare Centers.
These stories brought to the fore the multi-dimensional nature of the maternal health crisis in Nigeria’s most populous state, Kano.
A Professor of Law at the Bayero University, Kano, Prof. Abdulmumini Ahmed, who led the research component of the CHRICED project on maternal health said that one of their startling findings was that there are over 800 medical doctors in Mallam Aminu Kano Hospital, a federal medical facility, but that in 20 Local Government Areas in the State, there is not a single medical doctor.
“Now, this goes to show that if somebody has a medical emergency in any of these local governments, the person will have to travel all the way to the city of Kano to be treated. In most situations, the patient is dead before he gets to Kano. This is particularly on maternal issues, there are always emergency problems, and if emergency medical attention is not given, then danger to life is the situation,” Ahmed said.
The Chairman of CHRICED Advocacy Committee, Alhaji Garba Musa, mentioned lack of release of budgeted funds for maternal health as one of the major challenges faced in the sector. He said, “Going round in the cause of the advocacy, we learnt that the monies that are supposed to be released for maternal health expenditure, have not been released. So we should ask the question, why are monies not released. All stakeholders have to concert their efforts to press the government to release funds for urgent priorities in the maternal health sector.
“Unless we are serious, we will continue to helplessly witness the death of women in the process of having children. Then the other critical thing is that healthcare professionals do not want to go to the rural areas because those places don’t have modern facilities, no supermarket, proper schools and recreational facilities of the standard that would make these healthcare professionals want to stay there.”
The Maternal Health Advocacy Committee Chairman therefore called on the government to do much more by getting to the depth of the problem. This he said could be done by providing the amenities and facilities, which would make professionals in the medical sector, want to stay and take care of people in these areas. On the challenges of budget, a state official lamented that there are several institutional issues, which have to be addressed. He said the State has a flawless system of budgeting, but the problem is in relevant institutions pushing for releases.
He said: “Last year a development partner helped us to access additional N4billion for our agency. But the problem is that these budgets are not meant to be released; I say they are not meant to be released because, I am sad to mention that our agency did not even ask for that money. There were even no memos written wherein the agency requested that it needed so and so in the budget to address the issues in the maternal health sector.”
The official however pointed out that the fundamental problem affecting maternal health in Kano State is one of human resource in Kano State.
According to him, the state has a myriad of health programmes, but when it comes to human resource; its performance is quite dismal.
He said, “For a long time, there has been no recruitment of medical personnel both in the secondary and primary healthcare facilities. As at today, we have many doctors that are indigenes of Kano State, who are not employed. The reality as we speak today is that Kano State has less than 350 doctors in its employment to cater for a population of over nine million. In the Primary Healthcare Management Agency for instance, there are only four medical doctors.”
Notwithstanding these demoralizing stories, the enlightenment and consultative sessions provided opportunity for local community activists to be taken through processes for accountability demands, including writing letters, drafting community charters, and leveraging on new technologies as exemplified by social media to draw attention of government agencies to the challenges, which contribute to the unacceptably high rate of maternal deaths. Community actors are also having their capacity built on the use of data driven App to track maternal health funds.
According to the campaigners, the strategy of arming civic actors at the grassroots to raise their voice collectively come from the significant developments in the Nigerian polity, which have opened up funding channels for Local Government Councils.
For instance, beginning in June 2019, the guidelines of the Nigeria Financial Intelligence Unit (NFIU) became operational thereby ensuring the availability of direct funds from the federation account to Local Government Councils across the states.
According to the Executive Director, CHRICED, Dr. Ibrahim M. Zikirullahi, the milestone of stopping governors from their previous hijack of Local Government funds is an out of many years of campaigns, which citizens at the local level should now take advantage of to push for accountability.
“The result of the NFIU guidelines is that LGAs are now receiving monthly alerts. This important development should be of utmost interest to campaigners at the communities working to end maternal deaths. The Local Government Councils must therefore take up their own share of responsibility with respect to maternal healthcare implementation and accountability “Importantly too, the campaign for active participation of grassroots leaders and activists to push for accountability in the use of funds for maternal healthcare is taking its foothold from the recent increases in the budgetary allocation for healthcare in Kano State. The share of the budget for health in state has risen steadily to almost 15 percent, which is the percentage recommended in the Abuja Declaration.
“It is pertinent to recall that in April 2001, the African Union countries met and pledged to set a target of allocating at least 15percent of their annual budget to improve the health sector and urged donor countries to scale up support. Stakeholders have been celebrating Kano State for the big win it has recorded in the area of allocating more resources for healthcare, but there is a word of caution that citizens on the ground have to participate in following the money to ensure that the milestone of the big budget translates into meaningful impact in terms of the state of health facilities, and the quality of care citizens get from those facilities,” Zikirullahi said.
According to him, this urgent need necessitated the new phase of its project of title Social Mobilization for Accountability in the Implementation of Health Resource Budgets in Kano State supported by MISEREOR/KZE, Germany.
The trainings, campaigns, and community tracking of health expenditures in the Primary Healthcare Centers are built around the notion that the right to quality and affordable healthcare is a right, well addressed in the Constitution governing the Federal Republic of Nigeria.
The organization specifically points to Section 17 of the 1999 Constitution, as amended, which focuses on the social objective of the Nigerian State, with the mandate that the social order is founded on the ideals of freedom, equality and justice.
According to Comrade Zikirullahi, an aspect of the ideal of social justice, which the Constitution mandates the State to ensure, is clearly situated in Section 17(3) (c).
That section focuses on the role of the state in ensuring the health, safety and welfare of all persons in employment are safeguarded and not endangered or abused.
He said: “This is closely followed by the express provisions in Section 17 (3) (d), which clearly points out that the State should work to bring about a social order where “there are adequate medical and health facilities for all persons.”
Campaigners are also quick to remind of Agenda 2030, which outlines the Sustainable Development Goals (SDGs).
The SDGs puts forward certain key targets in the area of health. Target3.1 of the SDGs talks about reducing the global maternal mortality ratio to less than 70 per 100 000 live births by 2030. SDG target 3.2 is focused on ending preventable deaths of newborns and children under 5 years of age by 2030.
Grassroots activists and campaigners constantly warn that despite the many ongoing efforts at the global level to reduce neonatal mortality to at least, as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births, poor rural communities will continue to be blighted by maternal deaths, if citizens fail to take interest and participate actively. As one activist puts it, “these ambitious global targets will not be achieved if there is no commensurate effort at the local level.”