She is 38 weeks pregnant and is wondering what state is her baby….She has not done any pregnancy ultrasound scan, she has not received any medical counsel… She has experienced many danger signs (pains and intermittent bleedings but the Traditional Birth Attendant(TBA) has assured her of a safe delivery and she hopes the curtains don’t fall on her or the baby and that she gets to birth and nurture her baby…. …Who is She?
She is every woman living in a community where medical care for pregnant women, new mothers and infant is inaccessible either due to the natural limits of access due to geography or the material limits of resources (finances, infrastructure, healthcare professional and health commodities).
Studies have shown that the quality of maternal healthcare in a country is inextricably linked to healthcare standards in the communities. This is evident by World Health Organization’s observations that majority of preventable maternal deaths occur in low-resource settings such as rural communities and the high number of maternal deaths in some areas of the world reflect inequities in access to health services, and highlight the gap between the rich and poor.
According to the World Health Organization, nearly half of deaths among children below five years of age occur in the first 28 days of life known as the neonatal period and many of these deaths are avoidable if a skilled health care provider is present at delivery and immediately after birth.
According to the latest report by UNICEF on “The situation of Women and Children in Nigeria”, Nigeria’s over 40 million women of childbearing age suffer a disproportionally high level of health issues surrounding birth as Nigeria currently contributes 10 per cent of global deaths for pregnant mothers. The report also indicates worsening statistics, as maternal mortality rate is put at 576 per 100,000 live births in Nigeria, which is the fourth highest globally. With regards to newborn, infant and child mortality rates, approximately 262,000 babies die at birth in Nigeria, the world’s second highest neonatal. Infant mortality currently stands at 69 per 1,000 live births while under-fives’ mortality is at 128 per 1,000 live births ( https://www.unicef.org/nigeria/situation-women-and-children-nigeria).
Many of the major causes of maternal death such as postpartum hemorrhage, infection/sepsis. obstructed labor, hypertensive disorders of pregnancy, complications of abortion and major cause of newborn death such as preterm birth complications related to prematurity, intrapartum related complications, sepsis/tetanus/meningitis and birth defects are preventable in the presence of skilled medical personnel during delivery. Access to healthcare facilities during pregnancy and at the time of birth will also reduce maternal and newborn deaths significantly.
In response to these challenges, EHAI strongly believes that to improve the health of community members (especially women and children), it is critical that a community driven, structured and comprehensive health intervention package, anchored on a functional healthcare system, health financing mechanism with financial risk protection and supported by an economic empowerment intervention, is implemented. Unfortunately, Health Insurance efforts in Nigeria today are focused mainly on the formal sector because the scheme makes it mandatory for employers (with over 10 employees) to enroll their employees on Health Insurance. This results in a staggering gap in the informal sector that is mainly impoverished, vulnerable and make up over 70% of the population including women and children whose precarious situation are further worsened by out of pocket payment (OOP) for health services. To bridge this gap, EHAI recognizes a dire need to innovatively and sustainably scale-up Social Health Insurance interventions to the Informal sector of the population.
This clearly aligns with EHAI’s mission to ensure access to equitable, quality and affordable health care services for Nigerians especially those living in rural, under-served and hard to reach communities as well as vulnerable and key population. This passion of eliminating OOP in the informal sector informed EHAI’s quest for accreditation by the National Health Insurance Scheme (NHIS) to serve as Technical Facilitators and/or Program Managers on Community Based Social Health Insurance Program ( CBSHIP) schemes in Nigeria. This accreditation was obtained in 2014. Community-based health insurance has been identified as an avenue to ensure healthcare among the informal sector and vulnerable population by virtue of its guiding principles of mutual aid and solidarity amongst its members. It is simply a cohesive group of households/individuals or occupation based groups, formed on the basis of the ethics of mutual aid, social capital and the collective pooling of health risks, in which members take part in its management.
Equitable Heath Access Initiative also went to further develop the EASE model for a sustainable CBSHIP scheme in Nigerian communities starting with Ondo State. The EASE model simplifies the process of establishing sustainable CBSHIP and considers the cultural and socio-economic challenges facing informal sector enrolment on Social Health Insurance schemes. It also ensures Social and Behaviour Change towards communal ownership and management of healthcare systems in Nigerian communities.
EASE is an acronym for the 4 components of the intervention model i.e.:
- E – Engage the Community
- A – Adopt Technology
- S – Service Provision
- E – Economic Empowerment
Engage the community including assessment to aid community relations, participation and institution of a reliable governance structure.
- Adopt technology to ensure consistent M-health, accurate Electronic Medical Records and to introduce mobile money technology and cashless processes into premium payments for ease of payment, transparency, accountability, efficiency and security of pooled resources.
- Service provision to ensure optimum maternal and newborn healthcare service delivery through Clinical and Quality Improvement as well as Monitoring and Evaluation strategies.
- Economic empowerment of women, pregnant women and new born mothers. There is an obvious synergy between poverty and ill health. Poverty is a major determinant of ill health and ill health aggravates poverty. The Economic Empowerment activities will empower the beneficiaries to gain financial independence to ensure sustainability of the CBSHIP Scheme.
Through the EASE model enabled CBSHIP, there will be:
- • Sustainable support for access to essential and quality health care services for communities especially women and children
• Improves community engagement in health decisions.
• Enables healthy community environments for safe births and care of the newborn.
• Strengthens the capacity of selected primary health centers.
• Conducts outreach and health education for pregnant women, nursing mothers and their children.
In relation to the Sustainable Development Goals (SDGs) technically facilitating CBSHIP sets Nigeria in motion to achieve these SDG 3 (Good Health and Well-being) targets:
• Target 3.1 of SDG 3 aims at reducing the Maternal Mortality Ratio (MMR) to less than 70 per 100,000 live births in Nigeria.
• Target 3.2 of SDG 3 aims at ending preventable deaths of new-borns and children under 5 years of age to as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births by 2030 in Nigeria.
• Target 3.8 of SDG 3 aims at achieving Universal Health Coverage (UHC), including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all in Nigeria.
Ease Model Enabled CBSHIP is an efficient approach to generate and sustain action by healthcare managers, development partners and community members towards achieving zero maternal and infant mortality rates in Nigerian communities by 2030 because #shedeservestolivewithherbaby!
This article was developed by Dr. Timothy Akinmurele drawing from the following references:
UNICEF, Nigeria. Situation of women and children in Nigeria; Challenges faced by women and children in Nigeria. Available at https://www.unicef.org/nigeria/situation-women-and-children-nigeria Retrieved May 7, 2019
WHO, SDG 3: Ensure healthy lives and promote well-being for all at all ages. Available at https://www.who.int/sdg/targets/en/ Retrieved April 29, 2019