‘The stars seem aligned’: a qualitative study to understand the effects of context on scale-up of maternal and newborn health innovations in Ethiopia, India and Nigeria

Government willingness to collaborate with development partners and implementers

Interviewees suggested the governments in the three settings were open in principle to collaborating with development partners and implementers, and hence responded positively to innovations that align with their national plans, priorities and political thinking. Interviewees observed the Ethiopian government’s willingness to work with development partners and implementers that supported its aims within health sector programmes: ‘…the government has keen interest to work with any partners and to collaborate with them…to improve MNH in the country…’ said one, from a civil society organisation. Similarly, many northeast Nigerian states welcomed external partners bringing funding for MNH and other health programmes; Gombe, for example, was described as having an ‘open door policy’ to such programmes. Interviewees expressed high expectations about the Uttar Pradesh state administration that came into power in 2012, with the young and energetic new state First Minister’s openness to new ideas and working with development partners and their implementers. Despite these signs, the state government was said to be living in the shadow of the prior regime which was less open to collaboration: ‘…the government sector is still paralysed with apathy, lethargy, lack of ideas…’ said an interviewee from a civil society organisation.

Government responsiveness to civil society

According to our interviewees, government responsiveness to civil society also influenced externally funded implementers’ efforts to catalyse innovation scale-up since most implementers were civil society organisations, and across the three settings the situation was changing. The Uttar Pradesh state administration was responsive to civil society, which, an academic interviewee felt was beginning to be viewed as a ‘force of change’. Interviewees in Nigeria noted that stronger democracy meant an increasingly active civil society had influenced the allocation of resources; for example, CSOs advocated successfully for free maternal and child healthcare, leading to a bill being passed: ‘As democracy becomes entrenched, people are beginning to make demands on government and as people make demands, government wants to show results…’ said an interviewee from a multilateral organisation. In both Nigeria and Uttar Pradesh our respondents pointed to organised networks of CSOs working together to influence policy decisions and in many cases they had been successful. In Ethiopia where civil society was less established, CSOs were also described as having some influence on government; one interviewee suggested: ‘civil society organisations can show strategic directions to policy implementation…they can also convince [the Ministry of Health] with evidence about their innovations to be taken up and delivered at scale…’.

Evidence-based decision making

Our respondents suggested that the extent to which governments based policy decisions on evidence was an important consideration for scale-up. In practice when externally funded implementers had presented evidence demonstrating the effectiveness of their innovations this had tended to have limited influence on government thinking. A Nigerian interviewee in national government captured the problem of politics shaping decision making: ‘The ideal situation is that evidence from research, pilots, or practice should influence government’s decision to shape policy. [But] in a country like Nigeria…people want to score cheap goals for political reasons’. Similarly, in Uttar Pradesh, a civil society interviewee reflected: ‘…policies aren’t always based on evidence - sometimes huge decisions are made within an hour!’ In all three settings, ministers of health and state chief ministers tended to dominate decisions: ‘whims of the power centres’ as an academic interviewee in India put it. Nigerian state governors and other high ranking officials were reported as being motivated by ‘political capital’, as a national government interviewee reflected: ‘When an individual is appointed or elected into political offices his associates see it as an opportunity to influence things and get favours. And because he wants to please his ring of friends and associates that makes decision making not quite representative’.

Turnaround of government officials

Turnaround of officials at all levels undermined efforts to catalyse scale-up as reshuffling and attrition was constant across the three settings - ‘fickleness in the entire system’ as an Indian civil society interviewee observed. This made securing government agreement transitory; new officials were often unwilling to accept their predecessors’ decisions to scale-up innovations. One key informant noted: ‘…once your idea has got the desired approval the person may have changed’. In Uttar Pradesh and Ethiopia our interviewees reflected on the limited time a new leader or official had in which to learn their job. Poor institutional memory retained by the system when individuals leave, and outgoing parties’ unwillingness to share knowledge with new administrations, were related factors.

Bureaucratic government institutions

Bureaucratic institutions were also reported as a barrier to scale-up. Complex, lengthy government approval processes undermined or delayed decision making and slowed or stalled the implementation of innovations at scale. A key informant in India observed: ‘Right from the NRHM [National Rural Health Mission] directorate to the planning commission there are tedious processes to get approvals, once approvals are made there are bureaucratic delays…’. Indeed, some procedures became progressively complex; a corruption scandal surrounding the use of NRHM (now known as the National Health Mission) monies prompted the incoming Uttar Pradesh Government to route financing through the Treasury to strengthen checks and balances. Ethiopian procurement and contracting rules were also depicted as constraining the adoption of new commodities or innovative practices: ‘They can’t do things in certain ways because the government rules are very rigid and constraining…’ said a representative of a donor agency.

National policy frameworks

The high priority given to MNH in Uttar Pradesh and Ethiopia was enshrined in policy frameworks which our interviewees described as enabling MNH innovation scale-up. The federal government of India’s NRHM was a positive policy environment bringing with it substantial funding for state governments’ rural primary healthcare programmes, including MNH programmes. The new Uttar Pradesh state administration in combination with the NRHM was seen by interviewees as an important policy window for externally funded implementers to put forward innovations that align with the state’s aims: ‘The stars seem aligned in terms of the [policy] environment!’ one interviewee from a donor organisation exclaimed, while another, from a multilateral agency, reflected: ‘It’s important that institutions capitalise on this mood’. Ethiopia’s prioritisation of rural primary healthcare was embodied in its national flagship programme – the Health Extension Program (HEP) and national health plans including the Health Sector Development Program IV 2010/11-2014/15. The Ethiopian Government was described as receptive to externally funded MNH interventions that align closely with national plans and priorities, as a civil society organisation representative explained: ‘…government policies and programmes are very supportive to our programme…this is an encouraging issue for this organisation to expand its interventions…’. In contrast, rural primary healthcare, including MNH, struggled for policy attention in Nigeria: ‘What’s now happening is there’s erosion of primary healthcare,’ said a state government interviewee. The problem stemmed less from Nigerian economic resources, and more from how resources were allocated. Health was not on the executive list in the 1999 Constitution; at the time of the interviews it was not considered a priority sector and competed annually for funding: ‘There’s a lot of politicking and jostling for a piece of the cake…you struggle for monies to come to maternal and newborn health,’ a researcher said. State health departments therefore had limited finances to divert to scaling external programmes.

Economic resources and global and development partners’ influence

India’s economic growth together with the NRHM substantially increased Uttar Pradesh’s resources for rural healthcare including MNH. Reductions in external aid receipts changed relationships between donors and the state government, with the former increasingly adopting technical assistance rather than funding roles which gave them less influence on state policies, and made it crucial for externally funded programmes to closely align with Uttar Pradesh’s priorities. A government interviewee suggested: ‘…ideas that are working within the government framework have greater potential to be scaled-up. Working in oblivion doesn’t help…’. In Ethiopia, domestic resources were more limited: ‘A big barrier to scale is resources and continuity of resources’ as one donor representative noted. While the Ethiopian Government maintained strong control over its policy priorities, substantial external aid was required to support its health programmes and global priorities such as the Millennium Development Goals (MDGs) had shaped Ethiopia’s health programmes. Interviewees also reported that the publication of the 2011 Demographic and Health Survey revealed disappointing improvements in neonatal and maternal mortality against MDG targets which reinvigorated the Government’s efforts in MNH, and externally funded implementers saw this as an opportunity to promote their MNH innovations. An interviewee from the government observed that at the time of the interviews: ‘We are still lagging behind the MDG targets…there will be no change in priority until the MDGs are met in the coming three years - MNH will continue to be our top priority…’. In northeast Nigeria, while state governments commonly support programmes in principle, they were not always backed by financial resources: ‘…a lot of rhetoric – they don’t put their money where their mouth is…,’ noted an academic researcher. One reason for state governments’ limited financial support for rural healthcare was donor attention on this issue: ‘everything is seen as if it has to be donor-funded,’ said a multilateral agency representative. As a consequence, resources were vulnerable to shifting global priorities; HIV, for example, competed with MNH for funding and attention.

Influence of powerful country actors

Powerful actors also influenced the introduction of certain MNH interventions in Nigeria. Professional medical associations opposed community health workers dispensing the drug Misoprostol to prevent and treat postpartum haemorrhage: ‘…they have knowledge, power, they think they know what to do…so relinquishing power was a major problem for them,’ said one academic researcher. While traditional rulers had no formal role in government decision making in reality their influence was substantial. Individual rulers often resisted - although sometimes supported - ‘western’ health interventions making it difficult to introduce them in some states. Family planning, which was often conflated with MNH, was particularly controversial since many people believe it contradicts Islamic teaching and hence traditional leaders can oppose it. These problems appear to be intensifying, as an interviewee from a donor organisation clarified: ‘…all the social pressure at this point is to regress to a more conservative, historical set of behaviours. Everything we are talking about involves some degree of modernisation and the cultural current is absolutely against that at this point’. Nevertheless, interviewees noted changes in federal government’s commitment to MNH in the form of new funds, and some state governments introduced free MNH services. One reason was the government’s attitude towards evidence, coupled with strong civil society advocacy and greater media attention on maternal and child mortality-related issues. A 2008 report presented at a public meeting highlighted high maternal mortality rates in Nigeria which attracted officials’ attention, and data on Gombe pressed the state government into acting. As one national government representative remarked: ‘Any responsive government will respond to such pressure to look responsible’.

Information sharing and coordinated communication with government

Poor harmonisation undermined scale-up in different ways. It weakened government strategic oversight of external programmes making it difficult to coordinate and deploy externally funded innovations at scale resulting in duplication and programmatic gaps. Interviewees described limited information sharing as a missed opportunity to strengthen innovation design by building on learning derived from programmatic experiences, as a civil society interviewee captured: ‘People in India are not combining their expertise…instead of wasting time reinventing the wheel we really need everyone to come together…’. Further, donors and implementers competing for attention made it difficult for government to make informed decisions about scaling-up: ‘…it’s our moral and ethical duty to work together…we have to go beyond our little thing and make sure that we’re asking for common asks that are based on evidence…’ a civil society interviewee from India suggested.

Embracing donor coordination mechanisms

Many interviewees agreed these problems could be mitigated through donors and implementers working through government-led partner coordination mechanisms, including the Technical Working Group in Ethiopia, the Health Partners’ Forum in Uttar Pradesh and Nigeria’s Maternal and Newborn Child Health Core Technical Committee. In Ethiopia interviewees were most positive about their government’s efforts to coordinate donor programmes, with the Technical Working Group emerging as an important vehicle for achieving this: ‘The government is very good at Balkanising [separating] us – there is very little overlap…’ according to one interviewee from a donor agency, while a government interviewee said: ‘All plans are discussed with partners and we put together an action plan - all the bad and good experiences are discussed…’. An interviewee from a multilateral development agency in India, however, complained about limited donor engagement in the Uttar Pradesh mechanism: ‘Though this Health Partners’ Forum has potential it’s underutilised…’. The Nigerian government and key development partners, responding to the International Health Partnership, signed a Compact on Health in 2011 which strengthened commitments to harmonising health programmes under the National Strategic Health Plan. Interviewees reported that this had stimulated better coordination and represented a more conducive environment for scale-up: ‘Donors have a forum where they meet regularly and integration among donors has improved over the years…but there’s still a lot to be done…,’ said one, from a civil society organisation.

Health infrastructure

Our interviewees cited health infrastructure as an important barrier to scaling innovations. Rural health posts were depicted as very basic: they lacked water and electricity, sanitation and telephones, and were crumbling and unhygienic, which made it difficult to prevent infection. According to an interviewee from a multilateral development agency in Ethiopia: ‘Imagine a health centre without water, sanitation and power for pregnant mothers to come and deliver in…’. Interviewees commented that it is difficult to scale-up innovations through the lowest level rural health clinics: ‘In smaller health clinics the conditions are so bad this project may not in fact work very well…until the supply side is straightened out I think [this project] is bound to fail,’ said one implementation grantee in India. Indeed, poor services undermined confidence among potential beneficiaries – representing a further barrier to scaling facility-based innovations. An Ethiopian government interviewee said: ‘An unsatisfied client is unlikely to come back…’, while a donor said of Nigeria: ‘…when you create demand and there’s no supply then you have people who are disillusioned - people who feel betrayed are not willing to access the system anymore’.

Human resources

Government efforts to expand the health workforce by recruiting and training community level health workers were significant, namely Accredited Social Health Activists (ASHAs) in India, Health Extension Workers (HEWs) in Ethiopia and Junior Community Health Extension Workers and Community Health Extension Workers in Nigeria. Despite this, at rural primary healthcare level in the three settings, there remained staff shortages, poor training, problems of staff attitudes, high workloads and unsatisfactory incentive systems. Limited girls’ schooling in northern Nigeria and high illiteracy among women in Uttar Pradesh were reported as underlying shortages of women health workers in those settings, which an interviewee from an implementing grantee explained was a serious problem: ‘Sometimes women don’t want to go to a delivery facility because there are only men there…’. This was a critical barrier to scale-up, as many of the MNH innovations described by interviewees related to strengthening existing healthcare workers’ capacities and expanding their roles: ‘…the whole system’s a shambles – how do you scale-up without people?’ asked an academic in India.

Interviewees reported that health workers in the three settings were not unwilling to accept innovations, provided they helped them to achieve their tasks and did not place an additional burden on them. Nevertheless, health workers’ attitudes had been a barrier to scaling community-based innovations. An interviewee in Nigeria recalled health workers speaking to patients rudely, disregarding their fears and preferences and withholding care, while an interviewee from a multilateral agency in Ethiopia echoed: ‘If I come with my labouring wife at midnight to a health facility and he/she says “no, we are asleep, come in the morning”, why do I come to him/her again?’. In Nigeria and Uttar Pradesh community health workers were often recruited through family connections rather than based on qualifications or ability. ASHAs were selected through the panchayat (local self-government) system: ‘…most [frontline health workers] belong to the family of influential people in the village – or as we say the dominant castes’, which influences attitudes to low caste families: ‘Contamination of their caste system virtues, mixing up with other castes [is a problem for them],’ said an implementation grantee. High workloads and unsatisfactory incentive systems reinforced these problems. Workloads increased as each additional donor programme added new tasks and required new procedures: ‘Every new programme…you have a new set of forms…that kinda adds a lot of workload…’ explained an implementation grantee in India. In Nigeria a civil society interviewee said: ‘You see one health worker conducting twenty to thirty deliveries a day - it’s too much for her!’. Workloads for Ethiopian HEWs posed a problem as they received a limited stipend and inevitably juggled their roles with economic and household activities, especially during peak agricultural seasons: ‘They can be burned out easily’ observed a key informant. Poor incentives in northeast Nigeria were linked to rural health worker retention: ‘…retention becomes a problem - they’ll gravitate to the city where they have money and access to services…,’ said a civil society interviewee. In Ethiopia, health staff receiving training through donor programmes commonly used this to seek better paid posts in urban areas: ‘Training is not a solution to problems we have!’ said a civil society representative.

Logistics and commodity supply

Weak logistics and commodity management systems in the three settings resulted in uneven continuity of supplies of essential drugs, vaccines, delivery kits and other consumables in lower level rural clinics, which interviewees agreed represented substantial barriers to scaling-up innovations that depend on the distribution of commodities. A bilateral donor in Nigeria described the problems stemming from interrupted commodity supply: ‘You can get people excited about a commodity and they will be willing to use it, but if the chain of supply stops, you are really disrupting the process and creating more problems’. Lack of equipment, such as refrigerators as well as training to use and maintain equipment were related problems. A researcher in India said: ‘The majority of equipment even if installed is either not working, or there’s a lack of skilled operators who can handle the equipment’.

Health systems governance and information systems

Health systems governance and health information systems were also described by our interviewees as barriers to scaling MNH interventions. Fragile management and supervision systems existed both within health facilities and sub-national health departments. Poor access to and synthesis of information undermined local level managers’ decision making and eroded health workers’ motivation to record activity data, as an interviewee from a multilateral agency in India explained: ‘It’s all one way traffic, collection of information happens, it’s fed in…it’s of no use to the supervisor who collects it’. Limited technical capacity of managers undermined their ability to offer effective supportive supervision, and systems to ensure accountability for performance were weak: ‘No one is held accountable for maternal deaths,’ remarked a civil society representative in Nigeria. Weak monitoring systems were reported as undermining accountability and decision making, while limited training on data collection and recording led to inaccurate and missing data: ‘…we find funny figures! The figures are quite inconsistent…’ said a civil society interviewee in Ethiopia, while attempts to introduce electronic systems in the three settings were nascent and undermined by limited electricity supply and lack of computer training.

Financing

Inadequate funding was described by interviewees in the three settings as a problem underlying many health systems weaknesses: ‘I don’t think there’s any other barrier or constraint than funding,’ a civil society representative in Ethiopia observed. As discussed earlier, overall domestic resources were not necessarily the critical problem in India and Nigeria, and there were substantial donor contributions to support health programmes in Ethiopia: the problem stemmed from the allocation of resources across different sectors, and between urban and rural, tertiary, secondary and primary healthcare, and between MNH and other health priorities. Additionally, flows of finances through the system were commonly delayed or interrupted. The non-payment of healthcare workers’ salaries was cited by a donor interviewee as common in Nigeria: ‘If you look at the Federal budget in Nigeria there’s a lot of money that starts at the top of the system – that’s not a small budget. But most facilities see nothing. Many of them don’t have their staff salaries paid…’. This inevitably undermined the motivation and therefore the retention of health workers.

Education and awareness of health issues

Respondents argued that communities’ limited awareness of health issues and services undermined their willingness to use MNH interventions and that illiteracy and low levels of education, especially among girls and women, underlie this. A civil society representative in India linked poverty and illiteracy with a lack of sense of entitlement: ‘…when we talk of maternal health we talk of women who are very poor, illiterate, who come from marginalised society. I think we fool ourselves, we’re romanticising, when we think those women are actually going to come out and ask for accountability’. Nevertheless, some interviewees suggested communities rather than the health system were incorrectly blamed for problems of uptake: ‘No community is so dumb as to not understand its own benefits’ said a professional association interviewee in India.

Traditional health-related beliefs and practices

According to our interviewees ‘traditional’ health-related beliefs and practices among rural communities tended to be responsible for the slow adoption of new ideas: ‘…traditional beliefs and some cultures are barriers to people not seeking care…demand creation is a serious challenge…,’ explained a civil society interviewee. A common discourse in rural Ethiopia was lack of control, with health being determined by god, illness being caused by the evil-eye and childbirth being constructed as a natural rather than medicalised event. Some communities were reported as not forming ties with newborns until a certain age due to high infant mortality. Reluctance to use facility-based services was observed by interviewees in Ethiopia and northeast Nigeria reflecting a preference for secluding newborns; women in northeast Nigeria were expected to demonstrate their strength by delivering at home, and birth-related ceremonies in Ethiopia reinforced the preference for home births, as a government interviewee explained: ‘Birth in this country is ceremonial. There’s a so-called porridge ceremony…they don’t want to miss that and health facilities can’t provide that’.

Hegemonic gender relations

Hegemonic gender relations reinforced these issues; across the three settings men typically controlled household spending and health decision making, which was exacerbated by girls and women’s low education levels and early age of marriage, and in northeast Nigeria, polygamy. Such power relations were described by interviewees as highly engrained making change a slow process. A civil society representative in Nigeria explained: ‘…men see women as property; he dictates what needs to be done…’. Hence, women needed their husbands’ permission before seeking medical attention outside their homes, and had to ask their husbands for money to do so. A civil society interviewee in Ethiopia said: ‘…males have a dominant role to decide on…household service seeking behaviour including MNH services…’. Further, male healthcare providers, and indeed transport workers such as taxi drivers, were not readily accepted by many husbands. These factors represented major constraints to innovation scale-up, especially facility-based innovations.

Heterogeneity

Substantial heterogeneity was also reported within each of the three settings which made it difficult to scale-up innovations developed in one location to others without adaptation. Interviewees described local variations in religions, ethnicities and castes, climate, health problems, health-related behaviour and health systems capacity. The northeast states of Nigeria were depicted as very heterogeneous by a national government interviewee: ‘Every community is unique…even when they have the same structure they still have their own peculiarities’. Similarly, in Ethiopia an interviewee from a multilateral agency explained: ‘…Ethiopia is a big geography…there are pastoralists, agrarians, and people living in different regions with different needs…so there’s no one single solution for all…’.

Geographical distances

Interviewees cited geographical distance as a barrier to scale-up; low population densities across wide areas in Ethiopia and northeast Nigeria, especially arid areas inhabited by pastoralists, made uptake of interventions difficult, as a professional organisation interviewee explained: ‘…community groups who have access to roads, telecommunication and electric power usually accept and use innovations more than those who don’t…’. Limited public and private transportation, poor roads, villages lacking vehicular access, difficult terrain and climate posed difficulties for some communities seeking healthcare and health workers reaching some communities. In Nigeria an implementation grantee explained: ‘During the rainy season it’s very difficult to access some of the communities; it’s very dangerous, especially where there are no bridges’. A common problem experienced by Ethiopian HEWs was their ability to travel to remote households and health posts on foot. Uttar Pradesh’s vast population - over two hundred million people - and geographical size posed particular barriers to scale-up as externally funded implementers typically operated within a handful of districts each representing two to three million people. An civil society interviewee summarised: ‘Uttar Pradesh has its own special set of problems – a huge population, I think huge percentage living under the poverty line…it’s huge…’.

Poverty

Rural poverty and unemployment also inhibited scale-up. According to our interviewees, costs of transportation and receiving healthcare services could be prohibitive – despite MNH services being purported as free to users in the three settings: ‘Poverty, poverty, poverty!’ exclaimed an implementation grantee in Nigeria. An interviewee in India quoted a study that showed that despite institutional delivery being free, each woman paid on average an equivalent of US$200 in informal out-of-pocket costs. A Nigerian civil society organisation representative lamented: ‘Health expenditure per family is about 65% of their income…no wonder children are malnourished, no wonder nothing gets done, no wonder children aren’t going to school. They are spending more than half of what they earn on health - that’s not fair, that’s a big barrier’. In Nigeria and Ethiopia rural communities’ incomes were also very seasonal; particular hardship during certain parts of the year made it difficult to seek healthcare.