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Addressing Female Health Worker Shortage in Northern Nigeria:
Community Level Accountability
Community Level Accountability
Introduction
The dual centres of power continue to exist in many African countries where the traditional system of authority flourishes side by side with state power. These systems are often used by state leaders in Northern Nigeria to push their agendas that communities view as suspicious, such as polio eradication. The recognition of this traditional power, especially in the context of reproductive health, is critical as social norms are set by traditional power holders. By extension, it is essential that this power be challenged and community leaders also be held accountable in realizing reproductive health rights. This understanding has greatly influenced the “Women for Health” community engagement approach, which this article describes. The Women for Health (W4H) programme (2012-20201), funded by DFID and implemented by DAI Global Health2, is facilitating six state governments in Northern Nigeria to increase the female health workforce as well as retain them. W4H focuses on midwives, female nurses, community extension workers and their deployment in rural health facilities for maximum impact and reduction of maternal mortality. This paper shares the approach of W4H in stimulating community leaders to become accountable and responsible for support in increasing frontline health workers from the community, rather than waiting for the government to post health workers.
The problem
Though wielding the largest health workforce in Africa, Nigeria still ranks 7th among 49 countries classified as facing a critical shortage of health workers by WHO. The distribution of health workforce in Nigeria is skewed towards urban areas, southern parts, in tertiary health care services; and in delivery and curative care (Nigeria HRH Profile 2008).
The maternal and child mortality rates in both North East and West Nigeria are above the national average, with North East experiencing 155 maternal deaths per 1000 live births- ten times higher than the South West, which has 17 maternal deaths per 1000 live births. The contraceptive use statistics also show a similar asymmetry in the regions. The Contraceptive Prevalence Rate in the North West is 3.6% and 2.7% in the North East, compared to 0.5% in the W4H implementing states of Kano and Yobe.
The efforts of the government to address the issue of unequal distribution of health workers between South and North, urban and rural regions through different schemes like the Midwifery Compulsory Service Scheme, which involves rural posting allowances, and - the community midwifery schemes and task shifting have recorded limited success. Most of the female health workers deny postings outside the state capital, citing marital and family reasons. A snap study of 24 nurses, midwives, and their spouses in W4H states, shows 75% of partners did not permit their wives to take a rural posting.
“No matter the incentive my husband will not permit me…No incentive will compensate for my children's education”- Midwife in W4H state, (PRRINN-MNCH, 2011.)
Some socio-cultural factors also prevent women from taking the postings in the far off areas. There are concerns that, prolonged absence from the house may lead to a possibility of the husband taking another wife, and it may reduce the influence of the woman in the household besides being accused by the in-laws of neglecting the husband and children.
Majority of young women in the region miss out on the educational opportunities due to early marriages. The average age at first marriage for women in the North West is 15.7 years and is 15.9 years in the North East (NDHS, 2013) with the percentage of child-bearing at this age, being 32.1% and 35.7% respectively. Education can facilitate progress into any form of career but often early marriages reduce educational or training opportunities for women in these areas. In such a context, pursuing a health career is a struggle, daunting, particularly given that social norms in rural areas of Northern Nigeria prohibit women from receiving care from male health workers.
A community leader in a W4H state stated: “I visited a health facility in this community where a male health worker was attending to a woman after delivery. There was a lot of intimacy in the process which is not acceptable in our culture and in our religion. That's - when I decided my wife will never give birth in these facilities.” (Women for Health, 2016)
The dual centres of power continue to exist in many African countries where the traditional system of authority flourishes side by side with state power. These systems are often used by state leaders in Northern Nigeria to push their agendas that communities view as suspicious, such as polio eradication. The recognition of this traditional power, especially in the context of reproductive health, is critical as social norms are set by traditional power holders. By extension, it is essential that this power be challenged and community leaders also be held accountable in realizing reproductive health rights. This understanding has greatly influenced the “Women for Health” community engagement approach, which this article describes. The Women for Health (W4H) programme (2012-20201), funded by DFID and implemented by DAI Global Health2, is facilitating six state governments in Northern Nigeria to increase the female health workforce as well as retain them. W4H focuses on midwives, female nurses, community extension workers and their deployment in rural health facilities for maximum impact and reduction of maternal mortality. This paper shares the approach of W4H in stimulating community leaders to become accountable and responsible for support in increasing frontline health workers from the community, rather than waiting for the government to post health workers.
The problem
Though wielding the largest health workforce in Africa, Nigeria still ranks 7th among 49 countries classified as facing a critical shortage of health workers by WHO. The distribution of health workforce in Nigeria is skewed towards urban areas, southern parts, in tertiary health care services; and in delivery and curative care (Nigeria HRH Profile 2008).
The maternal and child mortality rates in both North East and West Nigeria are above the national average, with North East experiencing 155 maternal deaths per 1000 live births- ten times higher than the South West, which has 17 maternal deaths per 1000 live births. The contraceptive use statistics also show a similar asymmetry in the regions. The Contraceptive Prevalence Rate in the North West is 3.6% and 2.7% in the North East, compared to 0.5% in the W4H implementing states of Kano and Yobe.
The efforts of the government to address the issue of unequal distribution of health workers between South and North, urban and rural regions through different schemes like the Midwifery Compulsory Service Scheme, which involves rural posting allowances, and - the community midwifery schemes and task shifting have recorded limited success. Most of the female health workers deny postings outside the state capital, citing marital and family reasons. A snap study of 24 nurses, midwives, and their spouses in W4H states, shows 75% of partners did not permit their wives to take a rural posting.
“No matter the incentive my husband will not permit me…No incentive will compensate for my children's education”- Midwife in W4H state, (PRRINN-MNCH, 2011.)
Some socio-cultural factors also prevent women from taking the postings in the far off areas. There are concerns that, prolonged absence from the house may lead to a possibility of the husband taking another wife, and it may reduce the influence of the woman in the household besides being accused by the in-laws of neglecting the husband and children.
Majority of young women in the region miss out on the educational opportunities due to early marriages. The average age at first marriage for women in the North West is 15.7 years and is 15.9 years in the North East (NDHS, 2013) with the percentage of child-bearing at this age, being 32.1% and 35.7% respectively. Education can facilitate progress into any form of career but often early marriages reduce educational or training opportunities for women in these areas. In such a context, pursuing a health career is a struggle, daunting, particularly given that social norms in rural areas of Northern Nigeria prohibit women from receiving care from male health workers.
A community leader in a W4H state stated: “I visited a health facility in this community where a male health worker was attending to a woman after delivery. There was a lot of intimacy in the process which is not acceptable in our culture and in our religion. That's - when I decided my wife will never give birth in these facilities.” (Women for Health, 2016)
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Holding Communities accountable Confronted with these realities, W4H adopted an approach that holds communities responsible for generating a cadre of own health workers. Community participation is widely recognised as essential for the success and sustainability of projects. This participation is often defined and practiced in a narrow sense without consideration to the power structures and relations within the community. Communities are used to waiting for government and non-government actors to deliver on their needs. Very often, community mapping is conducted to delineate who is who and who has what power to secure 'buy-in', rather than to facilitate holding those with power accountable. Many challenges in reproductive and maternal health are community related - yet when searching for a solution, their role is not explicitly defined. The Foundation Year Programme (FYP) is designed as a strategy to enable young women to pursue education as per the required standards as well as to engage communities generate a cadre of female health workers, and ensure that the young women return to serve the communities. Community leaders, in collaboration with Local Government Authorities, are responsible for identifying, nominating, interviewing and sponsoring, promising young women to graduate as health workers. |
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Two courses have been established in the FYP, a nine-month Bridging Course for those who have not achieved five credits in the school exams and a three-month Preparatory Course for those who already have five credits, to prepare them for the entry process for the training schools. Those in the Bridging Courses get promoted automatically to the Preparatory Course. Till December 2017; 1,951 young women from 912 communities were enrolled in the FYP. Out of 1951, 183 have graduated and 130 are due to graduate by the end of 2018.
There is a higher number of health facilities in rural areas and towns in the region relative to the doctors, nurses and midwives required in them. A health facility serves catchment communities comprising of 10,000 - 50,000 people. In the FYP, health facilities without resident frontline health workers were identified. Catchment communities were mobilized to participate in discussions, focusing on the benefits and challenges of supporting the creation of -local, reliable female health workforce. If communities rely on female health workers from urban or distant areas, they run the risk of losing the health worker, if she is denied travel or asked to leave the job by her spouse. In such a situation the community is ultimately accountable for generation of reliable female health workforce, which is capable of meeting the needs of local women.
Within the context of such a social contract, a collective sense of responsibility gets developed. Consent forms are signed not only by the young female participants and their family members, but also by community leaders. This commitment includes financial, logistical, emotional and social support to the FYP participants since their induction in the educational programme till their deployment as health workers. The - agreement bond sets out the responsibilities of each partner as follows1) State Ministries of Health to accept all FYP students who pass the entrance examination, into nursing, midwifery or Community Health Extension Workers training at Health Training Institutions upon completion of the FYP; 2) State Ministries of Health and Ministry of Local Government to offer full time, pensionable appointments to students upon completion of training; 3) FYP students to commit to return to work within their communities/Local Government upon completion of the training.
Effectiveness of the strategy
In the first two years resistance from spouses and parents of the female health workers was observed. The male partners and parents desired that the female health workers should withdraw from their tasks. Some husbands were ridiculed and called names such as dankwali ya jawo hula (scarf drags hat; means the husband cannot say No to his wife and she has total control over him), mijin ungwazoma (husband of a birth attendant) and were labelled 'yes ma' husbands(means that he follows her to where ever she goes, she moves and he follows) W4H has recorded two cases of withdrawal, while there have also been cases of FYP participants' male partners becoming polygamous or seeking divorce on the grounds of their wife's absence. Religious and community leaders have helped to mitigate some of these challenges through mediation. These leaders have helped the programme to identify key messages from religious texts to emphasise upon the importance of women working to save lives and also helped to spread the reach of these messages to rural communities. Mosques and other preaching platforms have been used to share messages on the importance of getting communities involved in generating a cadre of health workers, from the community itself.
The communities continue to support their young women. As these young women graduate, it takes time for the state governments to recruit and post them in their communities. However communities have mobilized, with support of W4H, have become pressure groups and are collaborating with their state assembly members to pressure the government to honor the bonding agreements. While, some communities provide transport and security services for the FYP qualified nurses and midwives to provide outreach services and to work at night.
Even as the program began as an effort to address the health workforce shortage, its impact has been far reaching. Perhaps the most important effect of the programme is its influence on how parents now perceive girl's education as a significant issue. A community leader in one of the communities noted, 'I am encouraged by this initiative of FYP, especially as it relates to the issue of girl-child education. We are not taking girl-child education seriously; perhaps that explains why we are facing a lot of difficulties. We don't have female health workers to attend to our women in our health facilities and in schools '(Daily Trust Newspaper, December 5: 29). Similarly, many of the FYP graduates have attested to change of attitudes towards girls' education in their communities. This change further reinforces the need to look at gender equity in all spheres while working with communities, rather than adopting a narrow approach of increasing reach of health programs.
There is a higher number of health facilities in rural areas and towns in the region relative to the doctors, nurses and midwives required in them. A health facility serves catchment communities comprising of 10,000 - 50,000 people. In the FYP, health facilities without resident frontline health workers were identified. Catchment communities were mobilized to participate in discussions, focusing on the benefits and challenges of supporting the creation of -local, reliable female health workforce. If communities rely on female health workers from urban or distant areas, they run the risk of losing the health worker, if she is denied travel or asked to leave the job by her spouse. In such a situation the community is ultimately accountable for generation of reliable female health workforce, which is capable of meeting the needs of local women.
Within the context of such a social contract, a collective sense of responsibility gets developed. Consent forms are signed not only by the young female participants and their family members, but also by community leaders. This commitment includes financial, logistical, emotional and social support to the FYP participants since their induction in the educational programme till their deployment as health workers. The - agreement bond sets out the responsibilities of each partner as follows1) State Ministries of Health to accept all FYP students who pass the entrance examination, into nursing, midwifery or Community Health Extension Workers training at Health Training Institutions upon completion of the FYP; 2) State Ministries of Health and Ministry of Local Government to offer full time, pensionable appointments to students upon completion of training; 3) FYP students to commit to return to work within their communities/Local Government upon completion of the training.
Effectiveness of the strategy
In the first two years resistance from spouses and parents of the female health workers was observed. The male partners and parents desired that the female health workers should withdraw from their tasks. Some husbands were ridiculed and called names such as dankwali ya jawo hula (scarf drags hat; means the husband cannot say No to his wife and she has total control over him), mijin ungwazoma (husband of a birth attendant) and were labelled 'yes ma' husbands(means that he follows her to where ever she goes, she moves and he follows) W4H has recorded two cases of withdrawal, while there have also been cases of FYP participants' male partners becoming polygamous or seeking divorce on the grounds of their wife's absence. Religious and community leaders have helped to mitigate some of these challenges through mediation. These leaders have helped the programme to identify key messages from religious texts to emphasise upon the importance of women working to save lives and also helped to spread the reach of these messages to rural communities. Mosques and other preaching platforms have been used to share messages on the importance of getting communities involved in generating a cadre of health workers, from the community itself.
The communities continue to support their young women. As these young women graduate, it takes time for the state governments to recruit and post them in their communities. However communities have mobilized, with support of W4H, have become pressure groups and are collaborating with their state assembly members to pressure the government to honor the bonding agreements. While, some communities provide transport and security services for the FYP qualified nurses and midwives to provide outreach services and to work at night.
Even as the program began as an effort to address the health workforce shortage, its impact has been far reaching. Perhaps the most important effect of the programme is its influence on how parents now perceive girl's education as a significant issue. A community leader in one of the communities noted, 'I am encouraged by this initiative of FYP, especially as it relates to the issue of girl-child education. We are not taking girl-child education seriously; perhaps that explains why we are facing a lot of difficulties. We don't have female health workers to attend to our women in our health facilities and in schools '(Daily Trust Newspaper, December 5: 29). Similarly, many of the FYP graduates have attested to change of attitudes towards girls' education in their communities. This change further reinforces the need to look at gender equity in all spheres while working with communities, rather than adopting a narrow approach of increasing reach of health programs.
