Using collective voices to enhance state-level accountability in Nigeria

The federal and state governments in Nigeria have made substantial commitments to improving reproductive, maternal, newborn and child health (RMNCH), which have been spurred on by global declarations to reduce maternal and child mortality through the Sustainable Development Goals.

For decades, Nigeria has had one of the world’s highest Maternal Mortality Ratios. Maternal deaths are often avoidable and arise as a result of tradition or culture, as well as lack of access to quality services, dearth of skilled health personnel or lack of funding. Prior to the emergence of state-level accountability mechanisms (SLAMs), state-level accountability was inconsistent and difficult to monitor, with no clear reporting or engagement mechanism. To address this gap, the Maternal Newborn and Child Health programme (MNCH2) used existing civil society organisation (CSO) platforms to establish the SLAMs to promote accountability, improve transparency and advocate for improved delivery and access of RMNCH services.

What is a SLAM?

The World Health Organization defines a well-functioning health system as one “that responds, in a balanced way, to a population’s needs and expectations.” SLAMs provide a voice for the people to speak directly to decision makers about issues that are of the most concern to their community.

SLAMs are evidence-based mechanisms which have several key priorities:

• to provide public scrutiny and hold state leaders to account
• increase transparency of health expenditure and advocate for sufficient budget allocation to health, as well as the effective spending of that budget
• prioritisation of RMNCH within state plans and polices.

Who is part of a SLAM?

SLAM membership has been designed to capture a range of stakeholders, including CSOs, health professional bodies and unions, the media, State Ministries of Health, and Hospital Services Management Boards. The membership is gender-sensitive and is in line with best practice guidelines from the UN Commission on Information and Accountability, as well as the Commission on Life-Saving Commodities for Women and Children.

Achieving success through scorecards and advocacy

RMNCH scorecards have been developed and used by SLAMs in all six states where MNCH2 is working . The RMNCH scorecards are a simple and visual way to engage busy decision-makers. They are used to influence change by highlighting priority areas against strategies, commitments and budgets. Additionally, scorecards also create a consistency of reporting and make it easy to compare state performance.

MNCH2 provides assists with analysis of data, tracking of health budgets, packaging of information and using scorecards for advocacy. We also build capacity to engage and empower key groups and individuals in continuing the evidence-based advocacy work of the SLAMs.

Real impact

Advocacy, using the scorecards, has resulted in a number of achievements.

• In Kano state there has been a provision of more blood banks in some secondary health facilities, in addition to an increase of state budgetary allocation for free RMNCH services from 9.74% in 2016 and 12.4% in 2017. Other states have also experienced an increase in funding..
• In Jigawa state, advocacy visits by the SLAMs to the State Ministry of Health led to the hiring of 450 new health workers for Primary Health Care services.

The SLAMs have also worked to reach the public with vital information and to include them directly in advocacy.

• In Katsina, the SLAM has been instrumental in the implementation of a series of radio programmes to reach the public with vital information on RMNCH, on the leading causes of maternal deaths, measles and other critical issues.
• In Kaduna, they are integrating social media with more traditional advocacy efforts. The Kaduna state RMNCH SLAM (KADMAM) used Twitter as a promotional tool to drive awareness and advocate to decision makers with the creation of the #OpenKaduna hashtag. The Twitter campaign promoted the quarterly media forum held by KADMAM and the State Health Commissioner.

“Engaging with MNCH2 as members of the evidence sub-committee has given us the opportunity to monitor, mentor and track Free RMNCH implementation across the state at various Health Centres. MNCH2 has supported us in our activities, creating linkages for us with relevant MDAs on Health” – Fatima Abdulhafiz member Evidence Sub-committee JIMAF

Yobe (YoSAMM) scorecard

The Abuja Declaration of 2011 was a commitment by African leaders to advance progress in the health sector, by allocating at least 15% of their annual budgets to their health sectors. Yobe State has never met this target. In 2017 the proportion of budget allocated to health declined from 12% (2016) to 11%, with only 41% and 50.5% of the allocated budget, respectively, being spent on health-related investment.

With the support of MNCH2, the Yobe State Accountability Mechanism on Maternal, Newborn and Child Health (YoSAMM), has used evidence to successfully influence an increase in the budget allocation to meet the 15% target. Armed with evidence, YoSAMM intervened in key budget planning fora to highlight the issues and demands of the group.

The Yobe State Government has committed to using the 15% allocation to upgrade health facilities, supply essential and life-saving commodities for women, provide more equipment and support the full functioning of the Yobe State Teaching Hospital.

Having secured the budget, YoSAMM’s next area of focus is to press for the timely release of funds, ensuring that they reach intended beneficiaries to meet the objectives outlined by the SLAM including:

• Increased funding for free RMNCH services
• Ensuring the functionality and sustainability of the National Blood Transfusion Services
• Institution of a standing order for immediate employment of graduates of health training institutions
• Strengthening of health management information systems
• Entrenching operational research in health.

The Maternal, Newborn and Child Health Programme in Northern Nigeria (MNCH2) is a UKAid-funded five-year programme, led by Palladium, designed to improve maternal and child health across six states – Jigawa, Kaduna, Kano, Katsina, Yobe and Zamfara. SLAMs are an intervention that have been led by Options.