In this report, Sunday Ehigiator examines how proper financing of maternal medicines-drugs and medication, can help reduce the high rate of maternal mortality in Nigeria given that many pregnant women still can’t afford or lack access to quality healthcare and drugs, before, during and after labour.
Maternal mortality and morbidity have continued to be a significant problem in low-income countries like Nigeria, despite a worldwide focus on the need to improve maternal health.
According to the 2018 Nigeria Demographic and Health Surveys (NDHS), “Maternal mortality includes the death of women during pregnancy, delivery, and 42 days after delivery, excluding deaths that were due to accidents of violence.”
The NDHS report pegs the Maternal Mortality Ratio (MMR) for Nigeria at 512 deaths per 100,000 live births for the seven-year period before the survey.
Similarly, the World Health Organisation (WHO) pegs the lifetime risk of a Nigerian woman dying during pregnancy, childbirth, postpartum or post-abortion, at one in 22 women, in contrast to the lifetime risk in developed countries estimated at one in 4900 women.
As the country’s population continues to increase, so does the demand for good and affordable healthcare for pregnant women. Unfortunately, many pregnant women, who genuinely require this care, do not usually have access to them.
To increase access, various financing options have been used. Despite this, maternal mortality rates remain high and spending is still largely out of pocket.
According to ‘Trends in Maternal Mortality (2000-2017) Report’, 23 per cent of global maternal deaths occur in Nigeria.
While expanding access to quality, affordable maternal medicines have been identified as critical to making progress in reducing maternal mortality, poor financing of maternal medicine has however significantly impeded such access.
Many women, especially in rural communities are still vulnerable to common and preventable causes of maternal mortality due to lack of access to antenatal health care and required maternal medicines and medications.
The plight of Agboyi Women – a Reflection of the Maternal Status in Nigeria
Agboyi-Owode, a community located under Agboyi-Ketu Local Council Development Area (LCDA), in Kosofe Local Government (LG) of Lagos State, is one of such places where women still have very poor access to quality and affordable maternal healthcare and medicines.
The island community which is home to no fewer than 30,000 inhabitants can only be accessed by a propeller paddled canoe, as it is surrounded by a very deep lagoon.
Upon visitation to Agboyi, it was gathered that the community only has one poorly-funded and grossly dilapidated PHC, which was built over 70 years ago, located at the riverbank as you arrive into the community.
Upon arrival at the healthcare centre on Wednesday, September 8, 2021, at exactly 1:50 pm, THISDAY met the clinic under lock. The nurses and other staff (cleaners) had all closed for work and gone home. From information gathered, they closed for work at about 1:30 pm after conducting immunisation exercises on some children between ages 0-4 years old.
We were however able to gain entrance into the building with the help of some concerned members of the community, and volunteer staff (also a member of the community) of the clinic who is always in charge of the keys.
Upon entering, we were welcomed by a muddy floor, which tripped this reporter off his feet. Every part of the centre was untidy and seriously leaking water from the roof
Upon entering the maternity ward and labour room, the rooms look unkempt and waterlogged at the corners. More disturbing was the empty drug dispensary of the clinic.
Findings revealed that the last time the facility took delivery was in 1992 (29 years ago), and ironically so, the delivery was handled by a popular Traditional Birth Attendant (TBA) in the community called Mrs. OlasunboAgoro, a.k.a. IyaAbiola. It has also not provided antenatal care for pregnant women since that period.
The state of the health care centre has forced women in the village to patronise Traditional Birth Attendants (TBA) for care during pregnancy and labour.
Only very few who can afford modern-day hospital care go through the length of travelling across the river for proper antenatal care at private hospitals around Ketu. Even so, people suffer a high rate of maternal mortality especially when there are complications during delivery by a TBA.
Speaking with THISDAY, a 29-year old mother of two, currently nursing a four-month-old son, Mrs. Debora Ojulari said, “My first son is four years old and my second son, whom I’m holding is just four-month-old.
“I gave birth to both of them with the help of a TBA. All through the time of their pregnancy till the point I gave birth to them, I spent roughly N15,000. I spent N5,000 for the herbs I was taking during pregnancy, and N10,000 for delivery costs.
“We don’t deliver or get antenatal care at the PHC because they don’t provide such services. We only go there to immunise ourselves and our child after birthing them. The other option we have is to get care or give birth in private hospitals across the water. However, they are too expensive compared to our TBA here in the village.
“If you are using a private hospital, between the period of pregnancy and when you eventually put to bed, you spend not less than N100,000.”
Also speaking, 28 years old mother of three, Mrs. Kafayat Owolowo reiterated, “We only visit the centre to immunise ourselves and our children after giving birth. And it is free of charge. Other than that, there aren’t any other services rendered by the centre, except now that they have also begun vaccination against COVID-19. If you want to be vaccinated, you can go there from 11 am.
By that time you are sure to meet them, but anytime from 2 pm, you may not meet them because they don’t stay long.
“Two years ago, a family in this village lost their only child to convulsion. It was in the afternoon at about 3 pm when the boy of two years old was convulsing. They rushed him to the clinic, but no one was there. Before they could rush him to a private hospital across the water, the boy died inside the canoe. This made the family pack out of this village to another place.”
Cry for Help
Speaking with THISDAY, the Paramount Ruler of the Community, His Royal Majesty (HRM), Oba. Mao Oladega said, “Women in this community face a lot of issues during pregnancy and childbirth due to the bad state of the healthcare center.
“Every part of the centre is leaking, no drugs at the centre or funding from the government. We have written several letters to the LCDA about the situation of the place but nothing has been done.
“We have over 30,000 people in this community and the majority of them are women and children. And the population keeps growing. And we are all supposed to be using just this one health.
“I am over 50 years old now; this healthcare centre has been in existence long before I was born. This village is over 600 years old and used to be an economic strength for the state. However, things have become very bad now.
“TBA has gained a lot of popularity here. Only a few that can afford the cost go across the waters to get care at private hospitals.
“But I can say that over 90 per cent of pregnant women in this community patronise TBA, and we all know the risk that comes with that especially when there are emergencies.
“Most of these deliveries take place in the dead of the night. And IF there are complications, before you get a boat to take the woman across the water, and then find a car to take her to the nearest private hospital, she would have lost her life due to loss of blood and exhaustion.
“This is why we are begging the government and every other concerned Nigerians to come to our help. They should help us at least upgrade and equip it within the immediate need. Then also provide us with a proper hospital with well-trained doctors,” he noted.
OOP Expenditure and Other Financing Options
Currently in Nigeria, the health financing system puts much financial burden on the population, which is difficult to shoulder when it is considered that the vast majority of Nigerians live below the poverty line.
It is not difficult to appreciate the dilemma faced by a man who earns a dollar a day (N500) and needs to find the resources to cater for a family of four, pay N50,000 (in some facilities over N100,000) for the antenatal care of an unplanned but urgently needed caesarean section.
Similarly, a fisherman somewhere as Agoboyi-Owode community, whose wife delivers during the dry season when the catch is low and earns less than N10,000 in a month, then needs to pay over N100,000 for four units of whole blood because the wife had primary postpartum haemorrhage and blood, is needed urgently is not to be envied.
According to the WHO the existence of a high proportion of total health care expenditure coming from out of pocket payments is indicative of the lack of protection of the people against the unpredictable risks of disease including those associated with pregnancy and delivery.
What is obvious from the foregoing is that the Nigerian health system runs a very unfair and inequitable health financing system. There is clearly no provision to ensure access to health for the poor and unemployed.
Government expenditure on health is still very low and the contribution of the national health insurance scheme is still relatively negligible.
Speaking with THISDAY, Pharmacist and CEO, Advantage Health Africa, Abimbola Adebakin said apart from Out of Pocket (OOP) spending for healthcare (including medication), the other major alternative is health insurance, offered by the regulator/social health insurance (NHIS), the state-run equivalents and private Health Maintenance Organisations (HMOs).
“There are no other solutions I am aware of, although I know some of us in the health innovation space are creating alternatives that should become operational soon.”
Importance of Financing for Maternal Medicines
Adebakin continued that ensuring people have access to preventive, promoting, curative, restorative and rehabilitative care was a very integral aspect of healthcare financing.
“When health is unaffordable, all efforts at quality and access become futile. So, on a general basis, it is essential for all parties in the ecosystem to consider as many options as possible to enable health financing.
“We have an alarming maternal and child care situation, with mortality rates among the highest in the world. So, definitely, finding sustainable and holistic financing for maternal medicines is very important as it would reduce the burden of healthcare needs at a time that should otherwise be a time of joy.
“When you consider the risky health-seeking behaviour of a large population of Nigerians at the bottom of the pyramid, it becomes even more imperative to create solutions for funding healthcare during the pregnancy and newborn baby phase. Nigeria needs working maternal care and medication financing solutions.”
Affordability, Quality and Availability
On affordability, quality and availability of maternal medicines for pregnant women and new mothers, Consultant Obstetrics and Gynecologist, Dr. Halimah Sunmonu said, “we can’t talk about reducing maternal mortality without taking a critical look at an integral part of financing maternal healthcare through maternal medicines.
According to her, for each of the identified causes of maternal mortality, such as, haemorrhage, hypertensive disease, sepsis, unsafe abortion, etc. “there are drugs and medicines that are vital in its successful management to prevent mortality. Unfortunately, Nigeria has not made much progress in financing maternal medicines.
“The tetanus toxoid, malaria prophylaxis and hematinics (a nutrient supplement required for the formation of blood cells during pregnancy) for instance are practically the only free drugs available during antenatal care in most government hospitals now.
“Programmes like the conditional cash transfer that encouraged delivery in the facilities have fizzled out. Out of pocket spending is still the major source of financing which has made access to quality healthcare a mirage for many.
“This is very difficult, usually a bitter pill to swallow when you know these medicines can help, but patients cannot afford it. Sometimes, we doctors have to pay for this.
“You see some of these drugs are life-saving, like the drugs used when a woman is having an eclamptic fit. Affordability depends on your earning power; we all know what the economic situation of the country is like now.
“Most government hospitals have the essential medicines in their emergency packs which thankfully patients can access in emergency situations but sadly inequality already exists in the geographical distribution of our health facilities.
“Many people, especially in the informal sector, also do not have access to the health insurance scheme which would make accessibility easier.”
Adding her voice, Adebakin said, “For uncomplicated pregnancies, I will say the medication is fairly priced and available. Well managed licensed pharmacies, clinics, public hospitals and patent medicine stores typically have a sufficient stock of maternal medicines at relatively affordable rates.
“However, seeing the impact of supply chain vulnerabilities and challenges we became more aware of during the lockdown accompanying the global pandemic in 2020, we cannot rest on our oars that there is affordable medication.”
She said until Nigeria is self-sufficient in the local manufacturing of maternal medications, just like with several other critical health issues, we cannot achieve accessibility.
“You need medication for any complication, an example being oxytocin, which has been a challenge for thousands of births at the point of need. We have similar maternal medication unaffordable or not sufficiently accessible in Nigerians.”
Supply Challenges
Speaking further, Adebakin said the challenges associated with the supply of maternal medicines are the same as the challenges associated with most pharmaceuticals.
“The fact that they are mostly imported and so there’s instability in cost and availability. We also struggle with opaque supply or distribution systems, a large part remaining unregulated due to this poor visibility (especially downstream).
“Nigeria is still at the early stages of adopting modern and reliable tracking and tracing solutions, where available and utilised, it is applied to still a narrow spectrum and by few players upstream.
“I am confident however that in a few more years, the inputs, logistics and regulatory oversight needed to assure the country of medication access, quality and affordability will be in place.”
Also speaking, a Gynecologist with one of the General Hospitals in Lagos, who only agreed to speak on condition of anonymity said, “Let me add that at the Primary Healthcare Centers (PHC), maternal medicines such as hematinics needed for pregnancy and growth are part of essential medicines that must be available at all times, we must not be out of stock. But have you gone to any PHC and checked how many of them have this?
“Reproductive medicines such as misoprostol, oxytocin, chlorhexidine, magnesium sulphate, etc. are part of UN life-saving commodities that must not be out of stock, but I can tell you for a fact that you can’t find them in stock at many primary healthcare centres in Lagos.”
Role of NAFDAC
According to Dr. Sunmonu (a Gynecologist), “aside from affordability, other challenges of accessibility include poor distribution network, stock-out in our hospitals, fake products, corruption, and poor regulation which NAFDAC has a central role in.
“They have a role to play in ensuring that authentic products get to the public, and push for the establishment of government policies to ease accessibility and affordability of maternal medicines. It should be an ‘all stakeholder’s effort.”
Procurement Policies
On maternal medicine procurement policies, Adebakin said, “I am unaware of any specific procurement policies or procedures for maternal medicines at the moment in Nigeria.
“On general medication procurement policies, yes, we could do much more. From production and importation policies to warehousing and local distribution through transparent channels that offer assurance of medication integrity (case in point being cold chain medication, other being those that are sensitive to light and moisture); policies on handling by certified personnel, reporting, and management of expired or damaged medication.
“Policies on controlled medication and duplication or overlapping responsibilities and finally oversight of actual use of medication by individual consumers- prescribing practices, record keeping, compliance management and adverse reactions reporting and response management.
“We have other aspects I might have missed, but you can see that we can always find a subset of these that cover maternal medication, with focus on the safety of the unborn and newly born.
“We have a somewhat frightening drug distribution network that allows (intentionally and unintentionally) unsafe practices that come back to bite us with counterfeits and substandard medication.
“According to some reports, we have up to 17 per cent incidence of counterfeits in Nigeria, so all hands must be on deck to tackle this menace. It can affect anyone. My people say when you throw a rock in a market; it will hit your family member. No one is immune.”
Efforts to find out if the country or state has a procurement policy for maternal medicines at the Lagos State Ministry of Health proved abortive as requests made to the ministry on August 31, 2021 (also acknowledged on the same date) were not responded to before the publication of this report.
Recommendation to Government
In her recommendations, Adebakin said, “we need a government that consults far and wide, beyond workshops and events. We need benchmark studies and lessons taken from other places that are getting it right. There is no pride right now.
“A 20-year plan to ensure self-sufficiency in our sector will go a long way. Do you know we have nothing yet, in terms of the active pharmaceutical ingredients production within the country?
“I learnt of the beautiful news recently that our foremost local manufacturer, Emzor, is about to do something about producing pharmaceutical ingredients in Nigeria, that’s in one area of medication, I love it and want to see more.
“Government should seek more ways to stimulate such deliberate interventions, sponsor it where possible, guide interested parties to it or simply enable an environment that gives reward to those staking their fortunes in the upstream sector of our pharmaceutical industry.
“As we go further downstream, we need a diverse and well-empowered ecosystem of operators creating solutions and using technology that could address grey areas of our medicine distribution, such as a Public-Private Partnership (PPP) in the area of procurement and supply.
“We need financing that truly gets to the retail end which will reduce the burden of financing businesses in medication provision and distribution. Healthcare is an essential part of our lives and when we have that covered; I think we will be a better nation.
“What many of our citizens are looking for abroad is a reliable healthcare system, not a cheaper one. You will not be surprised that people pay multiples of what is demanded here, they just need the peace of mind associated with spending so much on care and medication.
“That’s what I think the government should focus on. Not just cheaper, but more reliable financing for healthcare, can cushion the way people pay, and also make it convenient to pay in instalments through health financing instruments.”
Dr. Sunmonu also noted that the government needed to provide better coverage of the health insurance schemes, especially in the informal sector.
According to her, “there should be fee exemption policies for pregnant women especially in the underserved areas, increase in budgetary allocation to maternal medicine and maternal health, subsidies on essential drugs in maternal health, improving the economic indices of the country as a whole.”
Innovative Approaches Towards Financing Maternal Medicines
Speaking on some innovative approaches towards financing maternal medicines, Adebakin said, “We are in a time when financial solutions are leveraging technology, entertainment, hospitality, e-commerce, etc.
“Ensuring maternal medicine gets better financing, so it can reach isolated rural and urban areas; we must 100 per cent, leverage technology.
“Case in point is what we do at Advantage Health Africa with our flagship ‘myMedicines’, we are giving thousands of people peace of mind regarding their medication, as we find genuine sources and ensure delivery at the last mile in every state of Nigeria. There are other issues people can tackle, till we get a well-developed ecosystem.”
The ‘Esusu’ approach
Also speaking with THISDAY, Health System-Communities Strategist and Project lead at Linka.ng, Dr. Noimot Balogun recommended a ‘Community-based Thrift Collection Mechanism’, a.k.a. ‘Esusu’, as a viable means of financing maternal medicines especially in rural and underserved communities.
According to her, “Esusu has been documented to be a reliable community approach to meeting future expenses, unfortunately, even though Nigerian communities keep their money for emergency needs, they do not show the same disposition to health savings towards Health insurance schemes.
“According to a report from PWC, while health insurance has been operational in Nigeria for over 15 years, the uptake has remained low. As of 2016, only 3 per cent of healthcare expenditure in Nigeria was paid for using health insurance.
“A survey by the Lagos Bureau of Statistics revealed that only 11 per cent of household members in the state have their healthcare costs covered by any form of health insurance. The thrift collection approach may help mitigate these difficulties.
“Monetary transactions are a social interaction that is based on trust in many communities in Nigeria. As such, community people prefer to engage in monetary transactions with people in their informal circles that they can trust and have a track record of.
“This is the underlying principle with thrift collectors. Many of them have an earlier reputation of credibility that has been proven through referrals.
“Also, the average Nigerian does not want to think of ill health or death. Therefore, efforts should also be geared towards integrating healthcare with wellbeing and productivity. This can be achieved through a number of awareness programs delivered through various types of media in and out of homes.
“Health financing is a very important approach to sustainable healthcare delivery. It is therefore imperative that the formal health system begins the move for innovative engagement solutions to a perception disruption campaign to address the gap in communities-health system delivery,” she said.
In conclusion, Nigeria can also take a clue from the various health financing policies of different developed countries around the globe, and localise the same to address our peculiarities.
Furthermore, a mixture of all recommendations stated above could also be explored in order to improve access to quality healthcare, and maternal medicines, so as to reduce the negative indices of MMR in the country.