How State-Led Accountability Mechanisms are steering Nigeria’s health progress

  • Photo credit: Nigeria Health Watch
In Nigeria, advocates from civil society, media and government are spinning the wheel towards progress on the Sustainable Development Goal 3 ensuring State governments deliver on commitments for better healthcare for all-especially women, girls, and babies. In this blog our Senior Evidence Advisor, Ali Bwala shares how strategic these advocates are on tracking advocacy results.

Situation Overview of Nigeria 

The World Health Organization (WHO) analytical facts sheet of March 2023 identified Nigeria as one of the African countries with extremely high maternal mortality ratio. Between the period of 2017 and 2020, Nigeria had an estimated 1047 deaths per 100 000 live births ranking closely to South Sudan and Chad. 

Trends in the last two decades show Nigeria’s maternal mortality ratio has remained high. Currently the country is accounting for about 1 out of every 5 of global deaths for women and girls during pregnancy and childbirth. 

To this point, the Federal and State governments, civil society actors and media know what it takes to reduce preventable cases of maternal and newborn deaths in line with Sustainable Development Goal (SDG) 3 targets. Nigeria’s solution is in strengthening the health systems, improve health financing and quality of care across all the states. 

Already in Lagos, Yobe and Kaduna States, where the Evidence for Action (E4A) is providing technical support to multi-stakeholder coalitions to hold government accountable to providing better health services to mothers and their newborns, stakeholders have embraced evidence-based advocacy to identify root causes of death for mothers and babies, hold dialogue and agree on how best available resources can be effectively used to ensure survival and provide best quality of care that is accessible and affordable to all. These states are already taking progressive actions to address preventable deaths, using evidence. These stakeholders have a system to systematically track advocacy results and hold duty bearers in the States accountable. 

Role of State-Led Accountability Mechanisms 

In Nigeria, State-Led Accountability Mechanisms (SLAMs) are multi-stakeholder organisations consisting of government, civil society and the media who aim to build a culture of mutual accountability among health stakeholders. The SLAMs work to identify the reasons why women, girls and babies are dying, and learning how to navigate the politics and use evidence to influence decisions on how available resources can be used effectively to save lives. By doing so, they change accountability ecosystems by radically shifting power imbalances in favor of more equal participation in decision-making through evidence-based dialogue. 

Since 2012, E4A-MamaYe has provided technical assistance to the SLAMs to conduct evidence-based advocacy to stakeholders to achieve increased investment in health and improve quality of services for mothers and newborns. The SLAMs have a goal to contribute to reduction of all preventable maternal and child deaths in the states of their operation and the country at large.

  • Lagos SLAM members developing advocacy communication materials
    Lagos SLAM members developing advocacy communication materials
  • Kaduna SLAM members during an evidence generation activity
    Kaduna SLAM members during an evidence generation activity

SLAMs use innovative tools and approaches

Through mentorship from E4A-MamaYe, the SLAMs use innovative tools and approaches to document and track advocacy processes and results. These SLAMs have developed performance indicators, baselines, and targets for tracking advocacy priority issues. This is important as it serves as benchmarks to measure progress towards achievement of short-, medium- and long-term advocacy results. They have integrated the benchmarks into their M&E system, so that they can holistically track and report on advocacy as part of their overall program results. 

The E4A-MamaYe’s Health Budget Advocacy Toolbox has packaged these innovative tools and made them accessible for SLAM members. This toolbox includes useful toolkits to be used for health budget analysis, mapping funding in the States, planning for and engaging in public budget participation, developing evidence briefs and scorecards. 

SLAMs develop and use the Steps to Change (S2C) model

The S2C model is a tool developed by E4A-MamaYe that helps advocates to develop an advocacy plan and holistically track key steps in their advocacy towards achieving their targets. The S2C provides a pathway towards achieving advocacy goals, objectives, and targets. The SLAMs use the S2C to track incremental changes in advocacy processes, actions, and results. 

Integrating use of Political Economy Analysis (PEA) the SLAMs map decision makers based on their level of influence, power, and interest on RMNCAH+N priorities. This is important as it helps them to know how to engage them and messages to use. 

A great example to put this into perspective is in July 2023, when the Permanent Secretary of the Kaduna State Planning Commission approved all memos in respect to 1% equity and 25% state counterpart funds for Basic Health Care Provision Fund (BHCPF) implementation and sent them to the Ministry of Finance for cash backing, with the assurance that the funds will be released as soon as the accounts of the state are opened for transactions. 

In Yobe State, the Honorable Speaker of the House of Assembly, committed to aligning the State's health budget with the Abuja Declaration, aiming for 15% allocation in 2024.This is critical, as the State’s health budget allocation was consistently below 15% in the last three years, 7% in 2021, and 12% in 2022 and 2023. 

Kaduna State government increased state health budget to 15.09% in 2023 from 14.7% in 2022, following sustained evidence-based advocacy by the Kaduna State Maternal Accountability Mechanism (KADMAM). 

Advocates from KADMAM have also been tracking an increase in health budget allocation, release of funds, expenditure, and utilization to provide much needed services. Through their advocacy, the Kaduna State government allocated NGN840 million ($ 1,822,271) in the 2023 annual budget for Basic Health Care Provision Fund (BHCPF). NGN70 million ($151,856) was released for the month of January 2023, and further commitment to release a similar amount monthly was made. 

The SLAMs in the three states, Lagos, Kaduna and Yobe regularly produce and use scorecards to track essential commodity stock out at facilities for preventable maternal deaths and commitments to cash back procurement. 

These advocates now track progress towards country level indicators in line with Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality (EPMM) targets. These indicators have been integrated into the SLAM’s monitoring & evaluation framework. Tracking ENAP and EPMM indicators provides evidence which is used during dialogues with decision makers in the states. 

SLAMs have been formed in more than 10 States now. This is strategic towards improving Nigeria’s health indicators for women, girls, and babies. E4A-MamaYe is providing platforms for peer-to-peer learning and knowledge exchange among SLAMs. We shall continue to provide technical assistance to enable SLAMs strengthen their systems for use of evidence and tracking of advocacy results, documenting lessons and best practices and putting in place the right tools for sustainability. The SLAMs accountability model can be borrowed and contextualized for other geographies too beyond Nigeria.

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