Chinyere Ndukwe, Ph.D
Department of Public Administration
Ebonyi State University, Abakaliki
Email: ndukwechinyere@ymail.com
Abstract
This paper evaluated the free maternal healthcare policy in Ebonyi state, with a view to determining its impact on women. The primary objective was to determine the effectiveness of this policy. The study adopted a descriptive survey, using a proportional sampling technique. Related literature was reviewed. The elite theory was adopted as the theoretical framework of analysis. The data for the research were collected using structured questionnaire. The findings were: that free maternal healthcare policy in Ebonyi state has helped in reducing maternal mortality and morbidity on women. There is significant level of awareness on the policy among the women. There is reduction in patronage of traditional birth attendants, spiritual homes and other quacks. Critical factors like corruption, lack of health personnel in the rural areas pose a setback to the policy. The implication of this study is that despite the reduction in maternal mortality ratio resulting from the free maternal health care policy of Ebonyi State Government, unacceptable number of women is still dying from pregnancy and child birth. The study recommends, among others, that government facilities be optimally staffed and equipped; government to focus the policy on the lower social class in the rural areas, rather than thinly spreading the scarce funds on the rich who do not really need them; sustain current high level of awareness of the policy; traditional birth attendants should be integrated into the policy, and inter-sectoral collaboration should be encouraged.
Key words: Maternal, Healthcare, Policy, Rural, Urban, Women, Mortality.
INTRODUCTION
Any nation which overlooks the quality of health, especially the maternal health of its people, will be jeopardizing its socio-economic and political development (Nwana, 1996). As rightly observed by Usoro (2000), a healthy population is the key determinant of a country’s economic development. This makes it imperative for policy efforts to be geared towards the maintenance and improvement of the health of the populace. Women of child-bearing age constitute a special population at risk and their reproductive health is currently a national and international issue. In the year 2000, the United Nations Organization (UNO) devoted one out of the eight goals of the Millennium Development Goals (MDGs) to the improvement of the health of women and another to child mortality. These goals have direct bearing on the health of women (MDG, 2008). Part of the Beijing declaration also included strategies to increase women’s access throughout their life cycle to appropriate, affordable and quality health care (Report of World Summit ,1995). In promoting the right of women and girl child, health policies are necessary to meet the health needs of women especially the urban poor and rural women. Furthermore, available and affordable primary health care services of high quality, including sexual and reproductive health care, family planning information and services, and giving particular attention to maternal and emergency obstetric care is to be pursued (Beijing, 1995).
Reducing maternal mortality and reaching the Millennium Development Goals (MDG) 5 targets by 2015, are posing a serious challenge to many developing countries, Nigeria
inclusive. Some developing countries in Africa have decided to face this problem by providing free medical services to some groups of people (Writter, 2009).
The female medical practitioners in Nigeria suggested that a free and effective maternal health care delivery system is the key to the attainment of the Millennium Development Goals on the reduction of child mortality by half and improvement in the maternal health by the year 2015 (Akogwu, 2010).
Nigeria is among the countries where maternal mortality is very prevalent. It is estimated, that 145 women die daily and 53,000 annually all over the world (Umeha, 2010).Ninety percent of these deaths occur in developing countries of which Nigeria is among (MDG, 2008). Recent statistics show that the number has continued to rise annually. With a national average maternal ratio of 800-1000/100,000 (NHDR) Nigeria records the highest rate in the West African sub region (Umeora, 2005). Health experts have asserted that the estimates of maternal deaths occur more in the rural areas where there are inadequate health facilities to address emergency obstetric conditions that are prevalent there (Egwuatu, 2003).
Attempts have been made towards reducing the problem locally and globally, too. For instance, the federal government of Nigeria introduced some policies to tackle the problem (Federal Ministry of Health,2004). The goal of the national health policy is to bring about an effective comprehensive health care system based on primary health care that is promotive, protective, preventive, restorative and rehabilitative to every citizen of the country. There is a three-tier system of health care namely, primary health care, secondary health care and tertiary health care.
In Nigeria, Kano State was the first in the country to initiate the free maternity service in all its secondary and tertiary health facilities. Other programmes in the state included; free treatment for the under 5, and free vesico-vaginal fistula repairs (Galadanri, et al 2010). Other states like Bornu, Bauchi, Lagos, Enugu, Niger, Kaduna and Ebonyi joined in the fight against maternal mortality. It is necessary to point out that the policy and the services to be rendered free differ from state to state, and some of these states collaborated with some non- governmental organizations to make the programme a success.
Nationally, the number of states offering comprehensive free maternal services increased from four to nine, the state offering partial free maternal services increased from eleven to fourteen, while those not offering any form of free treatment decreased from twenty-two to fourteen (Okonofua, et. al, 2011).
Ebonyi state, which was created in 1996 from the old Enugu and Abia states, is also affected by high level of maternal mortality. In Ebonyi state, the maternal mortality ratio as at 2005, was estimated as follows: ‘one thousand eight hundred and fifty seven f 1,857) women died as a result of pregnancy or pregnancy related causes out of every hundred thousand women who gave birth’ (Umeora, 2005). Ebonyi State government had also made serious attempts to reduce the problem of maternal mortality. During the 2001 international women’s day, the then state Governor. Dr. Sam O. Egwu announced the free health care delivery service for pregnant women in Ebonyi State which will enable them obtain free medical services from conception to delivery. In his words, Egwu (2001:9) declares;
Pregnant women in Ebonyi State are to enjoy free child delivery scheme with government offsetting their medical bills from antenatal to child delivery. The scheme is to be implemented in all the hospitals.
To address this problem as part of the national policy, the state government teamed up with donor agencies and Federal Ministry of Health to conduct programmes in addressing HIV/AIDS, Guinea Worm Eradication Programme, National Programme on Immunization, Onchorcerciasis (Riverblindness) Control. The state free mobile clinic and employment of health staff (doctors, nurses, pharmacists, etc) were also part of the efforts to actualize the policy. Seed grants were given as financial support to major mission hospitals in the state. These policy thrusts were pursued in the second dispensation of the administration of Governor Egwu, with verifiable results (Egwuatu, 2003).
The policy was adopted by Mrs. Josephine Elechi under a new nomenclature -Mother and Child Care Initiative (MCCI). A bill for the Mother and Child Care Initiative and related Matters Law 2008 (Law No. 2 of 2008), was then passed by Ebonyi State House of Assembly and assented to by the Executive Governor, Chief. Martin Elechi, on 5th August, 2008. This has become the instrument for the implementation of free maternal health care policy in Ebonyi State till date.
After some years of implementing this free maternal health care policy in Ebonyi State, it still remains unclear as to its impact on the maternal health care needs of the state. The main objective of the paper is to evaluate the free maternal health care policy in Ebonyi State from 2001 to 2010.
Scope of the Study
The study covered the entire Ebonyi State from 2001 to 2010, the activities of the health facilities in the state and how government policies have impacted on women in Ebonyi State. Also, health workers at Ebonyi State University Teaching Hospital now part of the Federal Teaching Hospital Abakaliki, Mater Misericordae hospital, Presbyterian Joint hospital Uburu ,Rural Improvement Mission hospital Ikwo, St. Vincent Ndubia and Mile 4 hospitals, were involved ,as part of the improved health facilities whom the state government gave seed grants.( The reason for the period of study indicate the period when the policy was at its peak. Women of reproductive age from the urban and rural area were studied. Male from the health facilities formed part of the respondent.
Maternal Health and Poverty
It is on record that 99% of more than 530,000 maternal mortalities per annum, worldwide, occur in the low income countries (World Bank, 2009). For each of these deaths, 15-30 women suffer lifelong disabilities and ailments (Ronsmans, et. al 2006). Poverty inhibits provision and capacity to utilize maternal health services. In order to reduce maternal deaths and improve life chances of poor mothers, it has been proposed by Paruzzolo, et al ( 2010), that policies and programmes should address poverty and gender inequality which they tagged as two interrelated root causes of maternal deaths. Rural women need to remain in good health to be able to keep generating income, as the subsistent farming cause them to live a ‘hand to mouth’ life and have little or no savings. This justifies the need for a sustainable maternal health policy in any community that wishes to develop.
Free Health Services in Nigeria
Health is on the concurrent legislative list of services in the 1999 constitution of the Federal Republic of Nigeria. Meaning that it is the responsibility shared by the three tiers of government – federal, state and local government. The policy of free health care was proclaimed during the second republic. This lasted for few years and the second republic was aborted with military rule, the entire country reversed back to user charges. In 1999, with the return of civilian rule, many states declared the free health services for different groups of people. For instance, Niger and Kano declared free health services for pregnant women and under five – years old children. Some states were in collaboration with some non governmental agencies. In the same 1999, the Federal government launched the National Health Insurance scheme which is supposed to reduce high expenditure during illness, especially among the poor.
In late 2005, the federal government announced a free maternal and child health care programme in her hospitals which is intended to reduce the burden of maternal /child mortality in the country. This announcement, however, is yet to be fully operationalized in the federal teaching hospitals and federal health centres.
The big question remains: how beneficial are the free health services to the poor in Nigeria? The reason remains that these policies most times are politically motivated. They lack proper planning and are defective in implementation. The policy declaration differs from what is obtainable since the treatment are not free. Poor staffing of these government hospitals makes it difficult for the policy to work efficiently. Also there is the problem of equipment and supplies. Free services being expensive to run most times the level of poverty in the country make the clients to want to misuse the opportunity given to them. There is poor quality health services that cannot meet the needs of the people including the poor and vulnerable for which the free health policy is supposed to be for (Ijadunola, 2005 ).
Reasons for Maternal Health Policy
Part of the national health policy is the national policy on reproductive health. According to World Health Organization report (2007), Nigeria recorded the second highest number of maternal deaths worldwide (WHO, 2007). Statistics show that one out of every nine maternal death in the world occurs in Nigeria. It is estimated that 145 women die daily and 53, 000 annually (Umeha, 2010). The Nigerian National health policy has the objective of strengthening the national health system such that it would be able to provide effective, efficient, quality, accessible and affordable health care services that will improve the health status of Nigerians through the achievement of the health-related Millennium Development Goals (Federal Republic of Nigeria, 2004). This should take place both at the primary health care, secondary health care and the tertiary health care levels.
Ebonyi is one of the states in the country with high maternal mortality ratio. The government announced the free maternal health care in the state to take care of women during pregnancy, labour and within the first six weeks after delivery, while the patients are to take care of the cost of blood transfusion and neonatal services. Adeoye (2000:101) opined that “there is unaccountably high maternal mortality ratio, especially in the rural areas”.
The commonest direct causes are prolonged labour, hemorrhage, pre-eclampsia, eclampsia, anemia and infection. The underlying factors are occasioned by delay in intervention which includes poverty, ignorance, cultural beliefs, inadequate facilities, poor referral system and activities of quacks and unskilled birth attendants. These problems lead to delay. Delay in decision making, delay in going to hospital because of bad terrain and poverty and, finally, delay in accessing the health facilities (Adeoye, 2001).
The World Health Organization has identified four main interventions as critical in effort to reduce maternal mortality in developing countries (WHO, 2005). These are family planning, antenatal care, skilled birth attendance, and emergency obstetrics care.
Under Chief Mrs. Josephine Elechi’s Mother and Child Care Initiative (MCCI), different committees were formed at the State, Local Government and Ward levels. With the Maternal Mortality and Morbidity Monitoring Law (MMMM), rural women are encouraged to register for ante-natal care to facilitate booking and early referral of women in labour within the time frame often hours. All maternal deaths are to be reported to the Wards and Local government. In the words of Chief Mrs. Josephine Elechi, all maternal death in the state is to be reported. These to her will bring the activities of unskilled birth attendant to the bearable minimum. The Mission Director of the United State Agency for International Development (USAID) Ray Kirkland (2010: 2) said that,
The United States government through USAID, has been a key partner in supporting Nigeria to realize its objective in reducing maternal morbidity and mortality and improving reproductive health outcomes. The US government through the Acquire Fistula Care project has also partnered with the Mother and Child Care Initiative (MCCI) to mobilize communities prevention of fistula and to provide information and counseling on the other maternal and child health issue
The maternal mortality and morbidity monitoring law (MMMM) if properly implemented, will ensure that all maternal deaths are recorded and that women deliver under the care of a trained health care provider.
The rationale for the free maternal health policy is as a result of the high maternal mortality rate in Ebonyi state mostly in the rural areas where these poor women die in the process of giving life, caused by poverty, ignorance, cultural belief, inadequate facilities and etc.
Statistics of the Six- Assisted Rural Hospitals in Ebonyi State (2006 -March 2010)
Table 1: Ante-natal Care
| Name of health centre | 2006 | 2007 | 2008 | 2009 | 2010 |
| Sudan United | 2012 | 3004 | 5295 | 11912 | 1900 |
| Mile 4 hospital | 7961 | 8509 | 8671 | 8847 | 2377 |
| St. Vincent hospital Ndubia. | 2610 | 2341 | 2134 | 21806 | 6403 |
| Presbyterian Uburu | 2731 | 3232 | 3320 | 4301 | 945 |
| Mater Misericordae Afikpo | 3101 | 4277 | 4748 | 9748 | 421 |
| Total | 18456 | 21393 | 24369 | 57664 | 13966 |
Source: Ebonyi State Free Maternal Health Program at a Glance
Looking at the ante-natal care statistics in the six assisted rural hospitals in Ebonyi State, the ante-natal care visit among the women keep fluctuating. Either in the increase or decrease .For instance in Mater misericordae, Afikpo, the ante-natal care visits in 2006 were three thousand one hundred and one (3101) but in 2010, they dropped to four hundred and twenty one (421). When there is a drop n ante-natal care visit, there is increase in maternal death. As this women who refused to visit hospitals for special attention will resort to quacks and untrained traditional attendants.
The decrease in the number of women seeking for ante-natal care cut across all the vocal areas in the study looking at the table above.
Table 2: Hospital Delivery Statistics of the Six Assisted Rural Hospitals in Ebonyi State
| Name of | |||||
| Health centre | 2006 | 2007 | 2008 | 2009 2010 | |
| Booked | |||||
| Rim Ikwo | 4 | 9 | 17 | 48 984 | |
| Sudan United | 50 | 100 | 499 | 1234 300 | |
| Mile 4 | 1676 | 2046 | 2789 | 2216 624 | |
| St. Vincent Ndubia | 87 | 45 | 68 | .633 183 | |
| Presb. Uburu | 276 | 267 | 270 | 276 108 | |
| Mater Afikpo | |||||
| 100 | 853 | 870 | 2270 300 | ||
| Total | 2,193 | 3320 | 3913 | 7109 2499 | |
| Unbooked | |||||
| Rim Ikwo | 0 | 0 | 11 | 68 | 793 |
| Sudan U. | 25 | 35 | 40 | 100 | 10 |
| Mile 4 | 41 | 53 | 71 | 146 | 19 |
| St. Vincent Ndubia | 16 | 27 | 35 | 49 | 19 |
| Presb. Uburu | 20 | 7 | 31 | 70 | 31 |
| Mater Afikpo Total | 5 107 | 10 132 | 6 234 | 100 533 | 30 902 |
Source: Ebonyi State Free Maternal Health Program at a Glance
Table 3: Maternal Deaths
| Name of health centre | 2006 | 2007 | 2008 | 2009 | 2010 |
| Rim Ikwo Sudan United | 1 10 | 3 8 | 0 5 | 0 0 | 0 0 |
| Mile 4 | 8 | 10 | 8 | 13 | 3 |
| St. Vincent Nduabia | 0 | 0 | 0 | 0 | 3 |
| Presb Uburu | 8 | 6 | 5 | 2 | 0 |
| Mater Afikpo | 5 | 4 | 0 | 5 | 2 |
Total 32 31 23 17 6
Source: Ebonyi State free maternal Health program at a glance.
The Table 3 above shows that in the mission assisted hospitals there is still record of maternal deaths. The fact still remains that some of the deaths outside the hospitals are not reported.
Some of the cases referred from these assisted rural hospitals are cases that are difficult to revise as some of the women die in the process of giving birth or are maimed for life.
Theoretical Framework of Analysis
In social and behavioral sciences, many theories exist which explain the appropriateness of a given research problems. In this study, the researcher adopted the elite theory, postulated by Vifredo Paret (1848-1923), popularized by other elite theorists who include; Mosca (1923), Michels (1956), Wright Mills (1956), Dye (1972), etc. Elite theory contends that public policies are creations of the government elite. Public policy is viewed by the theory as the preference and values of the governing or political elite (Dye, 1975).
People are apathetic and ill-informed about public policies. Meanwhile, the elite actually shape mass opinion on policy question more than masses shape elite opinion.
The elites, who are few in society, wield power and influence, allocate values and rule. The majorities, the masses, only obey, and are guided, controlled and governed by the few. The elites consist of those who hold leading positions in the strategic aspects of society. They include; political or governing elites, bureaucratic elites, religious elite, etc. Mosca (1923) emphasized from a sociological view that the society is divided into two groups; namely, the ruling class, and the class that is ruled. The elites are drawn from upper socio-economic strata of the society. They have higher income, higher education and status. The elites share consensus that public policy does not need the input of the masses; rather they are made in the best interest of the citizenry (Obasi, 2005). The principle underlying the elite theory is that the elites assume and occupy superior position, make rules and policies for the ruled, which are meant to obey.
Methodology
This study was based on survey design, using proportional sampling technique of probability sampling. This was to enable us ascertain the impact of the free maternal health care policy which cannot be determine effectively by only available literature.
The study made use of primary data. These primary data included responses to structured questionnaire from members of the six selected Local Government Areas, members of the academia and other informed citizens of Ebonyi state.
The secondary source included all the official documents, government reports, gazettes, journals, textbooks, published and unpublished works and conference papers, magazines, research works, existing theses, internet and dissertations in related field with special focus on the population of study. This helped to corroborate information from primary data.
The relevant population of study is estimated at one million fifty three thousand, three hundred and thirty one (1,053,331). The sample size using the Taro Yameni (1967) formular was estimated at 400 respondents.
Area of Study
The study largely focused on women in Ebonyi state of Nigeria. Two Local Government Areas each from the three senatorial zones of the state were chosen where the health facilities in these Local Government Areas were assessed. The then Ebonyi State University Teaching Hospital and some mission hospitals in the state were treated as facility areas.
Evaluation of the Impact of Free Maternal Health Care Policy in Ebonyi State
The free maternal health care policy in Ebonyi state at the peak of the policy recorded positive result. According to Egwuatu (2003) maternal mortality rate reduced by 50%. Umeora (2005) assessing clients’ satisfaction in a free antenatal care setting agreed that about 75% of two hundred women who participated in the study were satisfied over the services of the Ebonyi state teaching hospital that acted as a referral point. Mbazor (2005) assessed the hidden cost of the policy in Ebonyi state, stating that the free maternal care in EBSUTH is still high.
The situation of the teaching hospital with the incessant strike action by doctors as a result of nonpayment of the new salary approved by the federal government has reduced peoples trust in the performance of the hospital. The rural women either visit the missionary hospitals in the state or the private hospital. Also, some of the consultants and other professionals attracted by the former administration have dissected the place in search of a greener pasture. The bad terrain which these rural women pass through before assessing these facilities makes them to better trying their strength at home rather than on the road. The health centers, general hospitals and other government health facilities run shortage of drugs, qualified manpower as cemetery keepers take delivery in the health centers in the state. The maternal mortality rate in the state is still on the high side as those who cannot afford the high charges of private doctors look for an easy way of helping themselves.
Problems of Free Maternal Health Care Policy
The federal government has indicated some laudable policies and programmes geared towards reducing maternal mortality which will help to reach the millennium development goal target by 2015. Nationally, shortage of fund, corruption, non implementation of the budget, by the implementation of such policies and incessant strike by health workers has posed a serious problem to free maternal, health care policy.
In Ebonyi state, the story has remained the same. After about nine years of free maternal health care policy in Ebonyi state, the state cannot fund the programme as well as pay the consultants, resident doctors, nurses and other health workers. The then Ebonyi university teaching hospital now Federal teaching hospital still lacks basic equipments for the smooth running of the policy.
Another problem of free maternal health care policy is transportation. Many of the roads are not motor able for the rural women involving the services of the nearest traditional birth attendant becomes a better evil.
Other logistics like ambulances, equipping the health centers and having resident doctors in the rural areas remains a serious problem to these health facilities located in the rural areas that should act as first point of call when these rural women are in labour.
The need to sensitize these rural women and educate them on the need for girl child education has no alternative because it will in turn reduce poverty and negligence among the rural women.
Findings
The following findings were made;
1. The implementation of the free maternal health care policy has been effective in reducing the rate of maternal mortality among women in Ebonyi state.
2. There is significant level of awareness among the target beneficiaries on the free maternal healthcare policy on women in Ebonyi State.
3. The third major finding is that the implementation of free maternal healthcare policy has helped in reducing the rate of patronage of traditional birth attendants, quacks and spiritual homes.
4. The fourth major finding of the study is that there is significant relationship between critical factors like corruption, lack of health personnel etc militating against the implementation of the free maternal healthcare policy in Ebonyi.
Conclusion
Free maternal health care policy in Ebonyi state has achieved a modest positive impact on maternal mortality and morbidity among the women. These women are aware of the policy, the services and some of them had the advantage of its utilization. Unfortunately, the implementation is inefficient and associated with some hidden costs which have reduced the patronage and full realization of the desired impact. Patronage of traditional birth attendants and other quacks is still on despite the policy, as they are considered culturally convenient, cheaper and more users friendly by their clients. Other factors which have militated against the realization of the free health policy objectives include: corruption, ignorance, harmful cultural beliefs, illiteracy, poverty, health facility based logistic constraints, and paucity as well as poor morale of health workers.
Recommendations
Based on the foregoing research findings and conclusion drawn from the study, the following recommendations are made:
1. Policy makers in Ebonyi state should ensure equipping the various health facilities participating in the free maternal healthcare services with modern and functioning as well as properly maintained medical instruments, drugs and consumables, to improve their service capacity.
2. Government should ensure adequate budgetary provision for employment, accommodation and proper remuneration for requisite trained personnel to man the various services in the various tiers of maternal healthcare facilities with emphasis on rural areas. This will ensure prompt availability of basic and comprehensive emergency obstetric care all over the state and improve on the impact of the programme on maternal mortality and morbidity.
3. In the presence of economic constraints, government should focus the policy of free maternal health services on the lower social class particularly in the rural areas and urban poor rather than thinly spreading the scarce fund on the rich who do not really need them. This will improve the policy impact on the women.
4. The currently existing high level of awareness of the policy should be sustained. The mass media and local media should have provision in the policy as collaborators with health workers to reinforce the existing knowledge of rural dwellers on the benefits of modern obstetric services particularly in preventing untimely death of mothers, and preventing maternal injury at childbirth.
5. Traditional birth attendants should be integrated into the policy through according them registration, periodic training, retraining, equipment and supervision. Guidelines should be drafted defining the scope of their activities to ensure that they handle only uncomplicated pregnancies and child deliveries and refer complicated ones promptly. Such guidelines should provide and ensure enforcement of sanctions for erring attendants. This will harness the gains of high patronage of these practitioners without promoting maternal mortalities as is currently the case.
6. The policy should be encouraged inter sectoral collaboration between the health and education, women affairs, public utilities as well as local communities to promote girl child education, enhance women empowerment, abrogate harmful traditional practices that are inimical to maternal wellbeing, promote compulsory antenatal attendance as well as a local provision of emergency preparedness and response in case of obstetric emergencies.
7. The National health Insurance scheme to be made accessible to the rural and urban poor since this will give the group access to secondary and tertiary health services at a cheaper rate.
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