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Sustainability of Donor Supported Maternal, Newborn and Child Health Interventions in Bauchi State, Nigeria: Exploring the Perspectives of Stakeholders

Robbinson Yusuf

Directorate of Hospital Services, Hospitals Management Board, Bauchi, 740212, Nigeria

Abstract: Objectives: This study was designed to gain insight into the perspectives of stakeholders in the maternal, newborn and child health services in Bauchi State, Nigeria, regarding sustainability of MNCH interventions supported by donors. Methods: This is a qualitative exploratory study. Recorded semi-structured in-depth interviews and focus group discussions were carried out with three key stakeholder groups selected purposively: program officers (n = 6); healthcare providers (n = 3); and lay community members (n = 3). Qualitative data obtained were transcribed verbatim and subjected to thematic content analysis through inductive and deductive processes. Results: Stakeholders’ perspectives regarding understanding of the concept of sustainability and knowledge of the different donor supported MNCH interventions in the state showed convergence. Several factors that promote and challenge sustainability emerged from the analysis, with community involvement and government commitment being the most recurrent according to stakeholders. Recommendations for enhanced sustainability of MNCH interventions in Bauchi state correlated to major factors influencing sustainability. Conclusion: The use of stakeholders provided contextualised opinions regarding sustainability of donor supported MNCH interventions. Strengthened community involvement that improves their capacity to engage with political leaders and leverage more government funding for MNCH interventions can enhance sustainability more.

Keywords: sustainability, MNCH interventions, Bauchi Nigeria, stakeholders’ perspectives

Received March 09, 2020; Revised April 12, 2020; Accepted May 11, 2020

Citation: Robbinson Yusuf, Sustainability of Donor Supported Maternal, Newborn and Child Health Interventions in Bauchi State, Nigeria: Exploring the Perspectives of Stakeholders. American Journal of Public Health Research, 8 (3). 93-99. January 2020. doi:10.12691/ajphr-8-3-3

1. Introduction

1.1. Sustainability of Public Health Interventions with Emphasis on MNCH Interventions

The challenge of meeting the health and development challenges of the twenty-first century, particularly among the low- and middle-income countries who contribute the most to the mortalities and morbidities that result from both communicable and non-communicable diseases which afflict particularly women and children, has required diverse and multiple forms of international and inter-sectoral cooperation [1]. Massive amounts of funds and technical assistance have been mobilized to support the poorest countries [1,2]. Much of this support from international donors to Africa, which reached USD 44 billion in 2006, and accounted for 36% of total aid to all parts of the world, went towards supporting the attainment of the MDGs [2,3].

The concern for sustainability of public health programs, to which the then Secretary General of the United Nations Ban Ki Moon lent his voice in calling for sustainable investments into women’s and children’s health [4], is premised on the following:

i) Programs terminating while diseases they target still remain can be counterproductive and lead to reversal of health gains

ii) Since the full impact of programs often require long period of time to be achieved, withdrawing funds or support could result in loss of such start-up costs earlier expended in the form of human, financial, and technical resources

iii) Communities may develop mistrust for future programs when they are abruptly discontinued or not sustained [5,6].

1.2. Health System Context of Bauchi State and Nigeria with Regards to Maternal, Newborn and Child Health

Nigeria is a country located in the West African sub-region. Administratively the country is made up of 36 states and a Federal Capital Territory (FCT) clustered into six zones, namely, the North-East, North-West, North-Central, South-East, South-West, and South-South geo-political zones. The states are further sub-divided into a total of 774 local government areas (LGAs), each comprising wards, being the smallest political and administrative units which exist in the country, and which has been adopted by the health system [7,8].

According to the Federal Ministry of Health [9], the Nigerian health system and the health status of its citizens witnessed a period of decline from the 1990s into the 2000s as evidenced in the WHO World Health Report 2000 ranking that reported Nigeria as 187th out of 191 countries [10]. Within Nigeria, Bauchi State in the Northeast is one of the states with unsalutary health indices, particularly maternal and newborn indices below national averages, in spite of huge investments in health made by successive administrations in the State, as well as by Development Partners over the past decade [11].

1.3. Conceptualizations of sustainability

According to Olsen [12] and Shediac-Rizkallah and Bone [5], several definitions and concepts of sustainability exist in the health and other literature, although without as yet sufficient consensus on conceptualization of core constructs [6,13]. A further review of the literature on sustainability necessitated the exclusion of literature on sustainability from other systems such as eco-systems, business and corporate finance and marketing, engineering, and the arts, as well as sustainability of health programs of specific contexts other than MNCH (e.g. HIV/AIDS, Communicable Diseases).

The term ‘sustainability’ gained prominence in the 1980s, particularly in the World Commission on Environment and Development report of 1987 which considered development as sustainable when “it meets the needs of the present without compromising the ability of future generations to meet their own needs” [[12], pp. 287]. Since then, the concept of sustainability has assumed significance in the domain of public health management principally in response to the international donor community’s concerns for the low level of capacity observed among recipient countries and communities to sustain developmental gains, in spite of several decades of resources in the form of financial and technical assistance known as official development assistance (ODA) being transferred to developing countries, notably in Sub-Saharan Africa, Nigeria inclusive [2,5,9,14].

1.4. Exploring stakeholders’ perspectives

According to Edvardsson et al [15], much of the research in the field of sustainability that have sought to answer questions such as what important components of health care innovations [programs] make for sustainability have been undertaken in the quantitative paradigm. However, they assert that more qualitative studies are required, since they can further understanding of the ‘why’ sustainability can or cannot be reached, by exploring not only the reasons behind the behaviours of health professionals alone, but indeed of all relevant stakeholders [15,16].

The diversity of stakeholders in health ranging from donor partners themselves, country or state ministries of health, communities, health professionals, to private sector players, necessarily suggests diversity of interests [1]. Furthermore, evidence suggest that the interaction of capable local stakeholders and communities are key to the sustainability of public health program achievements [17].

1.5. Rationale for This Study

The review of the literature examined a book, documents, articles, reviews and reports, which dealt with the subject of sustainability in both the qualitative and quantitative paradigms, as well as articles that explored the perspectives of stakeholders. However, there was no article found that specifically focused on exploring the perspectives of stakeholders regarding sustainability of donor supported MNCH interventions, since much of the studies focused more on conceptualization of sustainability. Furthermore, because of the complete absence of a Bauchi State specific study, this study seeks to add to knowledge on the subject of sustainability of donor supported public health interventions with particular focus on MNCH interventions in Bauchi State.

2. Methods

2.1. Study Design, Sampling and Setting

A qualitative exploratory approach using in-depth interviews and focus group discussions was adopted in exploring the perspectives of relevant stakeholders within the setting of choice. A purposive sample of stakeholders whose roles as program officers (POs), healthcare workers (HCWs) and lay community persons in the MNCH health services of Bauchi State, some of who are well known to the researcher, were selected. 11 stakeholders were selected and initial contact through phone calls and direct personal contact to explain the nature of the study was made. Participants received copies of the personal information sheet (PIS) in English before consenting to be interviewed by signing consent forms. 8 in-depth interviews were undertaken with 5 program officers at the State Ministry of Health, 2 health care workers in Gar PHC in Alkaleri LGA of Bauchi State, and 1 lay community person who was then the Ward Development Committee (WDC) chairman for Gar ward. 2 focus group discussions (FGDs) were conducted – the first with 5 POs (and a sixth assistant PO) at the SMOH, and the second with a mix of 3 HCWs and 3 lay community persons who were all members of the Gar Ward Development Committee at the premise of Gar PHC. Inclusion criteria were involvement in MNCH services and ability to read and understand, as well as carry on conversation in English. See Table 1 and Figure 1 & Figure 2 below

2.2. Data Collection

All in-depth interviews and focus group discussions took place between July and August 2015 with the use of semi-structured interview guides. All interviews were recorded with a digital recording devise (Apple iPad), and they lasted between 45 – 60 minutes each for the in-depth interviews and about 90 minutes each for the focus groups. Interview guide topics were designed to probe participants’ understandings and views about sustainability, as well as their perspectives on how to ensure sustainability of these MNCH interventions in the State. Interview instruments were first pilot tested by interviewing one participant each at the SMOH and at the health facility.

2.3. Data Analysis

All data generated from the interviews and focus groups were transcribed and then analysed using the thematic content analysis (TCA) approach. The initial verbatim transcription was re-arranged in a tabular format with each dialogue on a separate line which was numbered for ease of reference, and then commenced the process of comparing and contrasting interview data, identification of key elements in each respondent’s account, as well as identification of recurring themes from the data. The final themes and sub-themes which emerged however were derived through a combination of this inductive process and a more deductive process based on pre-determined categories from the interview guide.

Table 1. Participants Demographics 1

Figure 1. Location of Bauchi State in Nigeria (Google Maps)

Figure 2. Map of Bauchi State showing Alkaleri LGA and Gar community (Google Maps)

3. Results

Using the process of TCA, the data collected from the in-depth interviews and FGDs were coded into themes, and the result presented in a summary 5 themes and 19 sub-themes (refer Table 2). Direct quotes from data are inserted and codes are used to anonymize participants (refer Table 1).

Understanding the concept of sustainability

In exploring the perspectives of participants, an understanding of the meanings they give to the concept of ‘sustainability’ was explored.

Definition of sustainability: Each of the participants’ responses demonstrated a convergence of meanings to this. For example:

P6 “Taking good care of something for future benefit of community”

Importance of sustainability: Again comparison of responses here revealed a convergence in views, with agreement that important gains from donor supported interventions should not be allowed to fail.

P7 “… death of children under five is now reducing after donors have come and supported us sometime … so that we cannot allowed to go back to square one, that is why we must sustainable and continue doing this”.

Different actions for sustainability: Although respondents all showed a high level of appreciation for sustainability actions being required to be implemented at different levels such as government, legislature, health MDAs, health facility or health care provider, and at community level, emphasis was more on government’s actions:

P4 “… the government as the head, need to see that they take charge of the, providing all the necessary things, the policies, the guidelines that will help the ministry or the Agency to carry out their responsibilities … also quick and timely release of budget for health …”.

Sustainability planning: All respondents showed good understanding of the need to have sustainability planning but they all lacked well-articulated plans independent of donor partner efforts.

P3 “if government will emulate what the partners done after closure they continue with it sustainability is assured”.

MNCH programs/interventions supported by donor partners

The understanding of respondents regarding MNCH programs and interventions supported by donors in the State was explored under three sub-themes as follows:

Common MNCH programs: All the participants’ responses demonstrated that they were familiar with MNCH interventions generally, since many are being implemented in the State. No significant difference observed in the examples of MNCH interventions and programs given by POs, the Gar HF staff and community members.

MNCH programs supported by donor partners in Bauchi State: All the MNCH programs listed by participants were programs they were familiar with as being implemented in the Bauchi State health system, albeit at various levels of sustainability apart from donor partners’ support.

Sustaining MNCH interventions/programs: Participants were dissatisfied with the experience of sustainability of these programs in time past, especially in as far as it had depended on governments.

P9 “…so we are requesting the government that to give free drugs to pregnant women and children under five in age because we are mobilizing them throughout WDCs, VDCs … if all those people from the communities come to the health facility without getting that free those drugs for pregnant women and children under five years they see that … sometimes will break our activities”

Factors that promote and challenge sustainability

This section highlights what participants viewed as most important influences affecting sustainability.

Community involvement: All participants emphasized community involvement, and acknowledged that the high level of community engagement with the establishment of community structures, the use of community volunteers to reach ‘hard to reach’ people with commodities, and training and capacity building for community members, no doubt impacted positively on the commitment shown by HF staff.

P4 “…why there are so many reasons but basically, ehm sustainability people are being carried along…”

P9 “…because some people in the community they don’t even know they don’t even want to come because they don’t have money and others don’t have knowledge of coming to hospital, and with the involvement of the community they seriously come to the hospital by then … we need support to go the community for mobilization, because without mobilization you will not see clients or patients in the facility”

Government commitment and political will: All participants reported this as an important factor for promoting sustainability of MNCH interventions, which should be advocated for at State and local government levels.

P5 “when the commitment from the politics, the political will on the government part, may be it will continue … by paying advocacy visit to the policy makers, thereby … policy visit … as we said policy visit … is to the State Government…”

P3 “…so basically we need to see that the government begin to take ownership of all this thing …”

Funding for MNCH programs: Funding challenges in the form of inadequate or lack of budget line for specific MNCH interventions and activities was a recurrent response, as well as the lack of release or delay in release of budgeted funds from the government. This challenge hindered effective collaboration during program life-span, as well as following the closure of programs.

P1 “one of the biggest factor of sustaining the program is to develop budget, relevant budget to that program … And also timely release of funds for the activity”

Availability of commodities: The challenge of lack of or non-availability of commodities was expressed by most participants as a common experience affecting sustainability of the MNCH programs in the State.

P4 “… you cannot provide any intervention without commodities, so provision of, continuous provision of commodities to the health facilities is very very important …”

Attitude of health workers: Several participants at both SMOH and Gar community mentioned this as a challenge to sustainability. Some however recommended that training and re-training of health workers could go a long way in remedying the situation.

P6 “so if somebody is lazy … and you don’t have documented things … responsibility here … in is that we should be dedicated to our work…”

Evaluating MNCH interventions for sustainability

Assessing MNCH interventions: Most respondents did not make tangible contributions to this theme. However, those that responded initially spoke about the routine assessment or evaluation of programs or interventions which are implemented with the support of partners, and which is usually undertaken either mid-term or at the end of the project/program.

Criteria for assessing sustainability of MNCH interventions: Although most respondents did not contribute to the theme on assessment of sustainability, 2 respondents demonstrated some insight.

P4 “…we assess that … looking at the demand and the supply side … if the commodities are always there … people are demanding for it …”

Other factors for assessing sustainability of MNCH: A suggestion regarding other factors or modalities which can be employed for assessing sustainability is how ‘cost-effective’ the intervention is.

Comparing MNCH programs: One participant compared programs implemented within the Gar community and remarked that availability of commodities (in particular ACTs) was responsible for the higher level of acceptance the malaria program received compared to other programs where there were no commodities.

Recommendations on sustainability of MNCH programs

Involvement of all stakeholders

Emphasis here was on mobilization of stakeholders and the need for as many stakeholders in health at all levels to be effectively involved not only in planning, but implementation of programs and interventions.

P6 “…we cannot just fold our arms or our hands waiting for somebody from somewhere to come and help us we will be involved right from the grassroots from the tertiary level to the grassroots to be involved in all aspects of activities and interventions so that we help our communities …”

Strengthening government-community linkages: Another recommendation called for greater recognition and “ties” between the government on the one hand and the community structures on the other hand.

P7 “…we are feeling this that State government, State House of Assembly, the Executive, even Ministry of Health, let them know the importance of WDCs, if they know the importance of WDCs, they should support us, … WDCs will be giving the support to the facilities, … the activities of health sector will improve from the grass-roots to the higher level”.

Provision of budget line and timely release of funds: Most participants felt that budgetary provisions known as ‘budget line’, and more regular release of budgeted funds, is an important recommendation for sustainability of these MNCH interventions and programs.

P4 “…that maternal, newborn and child health issue is a very big issue, it requires so many things and ehm and involves money …”

P12 “… Government to commit resources…”.

4. Discussion

The study sought to explore the perspectives of sample stakeholders on what the major influences promoting or challenging sustainability of MNCH programs in the Bauchi State are, with a view to not only enriching the literature regarding the sustainability of donor supported public health interventions and programs (especially in MNCH) in this setting, but hopefully inform and influence policy towards improving on sustainability of these high-impact low-cost interventions as well.

Understanding the concept of sustainability

Findings from the interviews and FGDs indicated a convergence in respondents’ definitions of sustainability, as well as the importance they attached to it, which aligns with the available literature, with the terms ‘to continue’ ‘good things’ or ‘beneficial things’ being a common response suggesting that the basic meanings people give to the concept of sustainability are universal.

Use of the qualitative approach added value to the finding, because it showed that participants had appreciation for the different levels of actions for sustainability, which corresponds to Bossert’s [14] contextual factors (signifying political, economic, legislative, administrative, infrastructural, socio-cultural factors) in his review of quantitative studies that conceptualized sustainability.

In the same manner, participants’ understandings of sustainability planning, elicited views which are comparable to Bossert’s [14] framework that acknowledges project or funding organization’s characteristics as important to sustainability planning.

MNCH interventions supported by donor partners

Exploring the knowledge of what MNCH programs participants were aware of (generally and within Bauchi State), allowed a comparison that showed high degree of awareness among virtually all participants, with most repeating the same examples. Although Edvardsson et al [15] and Amo-Adjei [18] both explored the perspectives of participants on sustainability, while Middleton et al [16] and Okereke et al [19] explored stakeholders’ perspectives on other subjects, none of the works specifically explored the knowledge of participants on MNCH interventions. The findings from participants’ responses however, are consistent with known MNCH services recommended by the UN Global Strategy for Women’s and Children’s Health [4].

The findings also indicated that respondents were mostly not satisfied with their lived experiences of how sustainable donor supported MNCH programs have been. Although these experiences tended to be similar, their dissatisfaction was attributed to different factors, including government’s poor performance. This finding, although in regard to MNCH programs, compares with Amo-Adjei’s [18] findings in which one of the two main strands of views on the sustainability of the Ghanaian National TB Control Program referred to as the ‘pessimists’, expressed their lack of confidence in the existing program being sustained “…so long as much of the operational funds were derived from external sources” [[18], pp. 1], views largely based on their past experiences of TB control.

Factors that promote and challenge sustainability

The value of these findings which explored participants’ views on the ‘why’ and ‘how’ of the sustainability of donor supported MNCH interventions in Bauchi State take on more significance when we consider that these views are not only those of health professionals (as in the Edvardsson et al [15] study), but include other stakeholders such as government officials and community members [16,18,19]. Analysis of participants’ responses highlighted the three most important factors capable of promoting the sustainability of these interventions within this setting as, a high level of community involvement and engagement, a high level of government commitment and political will, and the presence of a budget line and adequate release of funds.

Much of the conceptual frameworks proposed in the literature are agreed that three important domains around which the sustainability of public health [and MNCH] programs and interventions must rotate are:

- Factors around the project design and implementation

- Factors to do with the organizational characteristics of the local organization implementing the project/program

- Factors to do with the environment within which the project/program is to be implemented [5,12,14,17].

Shediac-Rikzallah & Bone [5] specifically recommended that sustainable programs must be community-centered, meaning the processes of determining ‘what’ projects or interventions to be implemented, ‘how’ to be implemented, ‘by whom’ within the community, are best done in a participatory manner that ensures community involvement, engagement, ownership and empowerment. The framework also acknowledges that the political, economic and policy factors, as elements of the environmental context, must be explored to secure governments’ commitment and funding.

Other important findings recognized as challenges to sustainability of public health interventions particularly in low- and middle-income countries, are non-availability of essential life-saving commodities and [shortage of and] poor attitude of health care workers [9,11]. According to Shediac-Rizkallah & Bone’s [5] sustainability framework above, these are elements of the weak health systems that must be strengthened in ensuring sustainability.

Evaluating MNCH interventions for sustainability

The initial responses suggested that participants’ perspectives were limited either by a low level of understanding of the concept of assessing or measuring sustainability, or by language challenges. It is significant to note here the usage of qualitative approach to explore peoples’ understanding of a quantitative phenomenon. While none of the literatures reviewed explicitly explored stakeholders’ views and understandings of how to evaluate or assess sustainability using in-depth interviews, several proposed conceptual frameworks with domains to aid understanding and evaluation of sustainability of public health interventions for the purposes of comparison [5,6,14,17]. Schell et al [13] actually combined a review of the literature with the concept-mapping method to develop domains and categories for evaluating and comparing the capacities of programs for sustainability.

Recommendations on sustainability of MNCH programs

Findings from this theme further explored the ‘what’ and ‘how’ of participants’ views and perspectives regarding the future of the MNCH programs in the State, as well as reinforce views about the major influencers of sustainability of MNCH programs in this setting. Although several literatures contain recommendations for sustaining MNCH interventions at national and sub-national levels [4,5,12,13,14], with which the findings of this study are consistent, a major contrast remains the absence of an explicit exploration of perspectives of participants for their recommendations on sustainability. Since no literature was obtained specific to this setting or context, which explored stakeholders’ perspectives regarding the sustainability of donor supported MNCH interventions, no recommendations on same are available for comparison with research findings.

5. Conclusion

Public health has been challenged for decades with the seeming inability of the world’s poor countries and health systems to sustain gains from international donor support programs aimed at reducing particularly the deaths of millions of children under five and hundreds of thousands of women of reproductive age [4]. At national and sub-national (States) levels, while new opportunities for support exist, especially with programs and interventions that focus on reducing mortality and morbidity in the regions/states with the highest burdens, it is imperative that new initiatives and actions that support sustainability of these MNCH interventions and programs justify the investments. This study has utilized the qualitative approach to explore the perspectives of key stakeholders involved in the day to day management of some of these MNCH interventions in Bauchi State, Nigeria, to explore the participants’ understandings of the concepts of sustainability, highlight important influences capable of promoting and challenging the sustainability of these [MNCH] interventions, as well as make useful recommendations for public health practice, policy and research, while filling a major gap in the public health sustainability literature by providing empirical accounts from this setting.

Acknowledgements Including Declarations

This article is based on my dissertation work submitted to the University of Liverpool in 2016 in partial fulfillment of the requirements for the degree Master of Public Health at the University of Liverpool.

Ethical Approval

Ethics approval was sought and obtained from both the University of Liverpool (UoL) Ethics Committee as well as the SMOH Health Research Ethics Committee.

Funding

None.

Competing Interests

None declared.

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