Evaluation of the Progress and Recommendations Towards Achieving Sustainable Development Goals Target in Nigeria

An improvement in mother and child health has shown positive impacts on health outcomes. A shift in increasing the rate of child survival has become a global health priority and can attest to the substantial progress in reproductive, maternal and child health over the past two decades(1).  Across countries worldwide, major accomplishments have been made in decreasing child mortality and premature deaths(1). In 2015, children under-5 mortality rate (U5MR) was 43 deaths per 1000 livebirths, which reduced by 44% and the neonatal mortality rate (NMR) was 19 deaths per 1000 livebirths, with a 37% decrease globally since 2000(1). This translates to 5.9 million under-5 deaths and 2.7 million neonatal deaths in 2015(1). Though great strides were made universally, the Millennium Development Goal (MDG) to reduce U5MR by two-thirds from 1990 to 2015 still fell short. Of the 195 countries, worldwide, 57 met or exceeded the target set by MDG 4, of which 19 were in Africa(2).

2016 marked the implementation of the Sustainable Development Goals (SDGs). SDG 3.2 set the target to reduce U5MR to 25 per 1000 livebirths, NMR to 12 per 1000 livebirths and end preventable newborn deaths in countries worldwide by 2030(2). Among all 195 countries estimated post MDG era, 59 have met the SDG 3.2 U5MR target(3). Sub-Saharan Africa continues to maintain the highest U5MR with 84 deaths per 1000 livebirths and NMR remains high with 29 deaths per 1000 livebirths in 2015(1). Sub-Saharan Africa holds the top ten countries with the highest U5MR, collectively accounting for 60.4% (3.6 million) of global children under-5 deaths(4). However, within countries in sub-Saharan Africa, the U5MR in 2015 ranged from 16 deaths per 1000 livebirths-Botswana to 135 deaths per 1000 livebirths-Central African Republic, with large disparities among regions with the highest and lowest child mortality rate(2).

In the past 25 years, Nigeria has shown progress and challenges in improving its children’s health. Almost half of the U5MR globally in 2014 occurred in five countries with Nigeria accounting for 13% and together with India (21%) constituted for more than one-third of deaths in children under-5(5). Nationally, U5MR reduced by 38% from 1960 to 2013, declining from 184 deaths(6) to 116 deaths per 1000 livebirths(7), but it still accounted for 14% of child death worldwide in 2013(8). The state-level difference in U5MR in 2013 was 139, showing major gaps with rates ranging from 70 deaths per 1000 live births in Lagos, Edo and Oyo to 209 deaths per 1000 livebirths in Zamfara(8). Despite large progress in the under-5 survival in Nigeria, great disparities persist statewide, with states in the North-East and North-West region facing higher U5MR in 2013 than states in the southern region. Seven northern states in 2013 reported U5MR above 150 deaths per 1000 livebirths comparable to national rates of countries with the highest ranks of U5MR(8). In 2015, similar inequality patterns in U5MR presented in other geographic areas. Nigeria had a national U5MR of 108 deaths per 1000 livebirths in 2015(7), however, at the local government (LGA) level U5MR ranged from 55 deaths per 1000 live births in Osun LGA of Osogbo to 215 deaths per 1000 livebirths in Bauchi LGA of Ningi(2).

The trend of neonatal mortality in Nigeria has been significantly higher than that of the world for the past two decades. The NMR in 2000 was 49 deaths compared to 31 deaths worldwide(7) and 41 deaths per 1000 livebirths in Africa(9). In 2013, the estimated NMR in Nigeria showed a 20% decline from 2000 with an NMR of 36 deaths per 1000 livebirths(6, 7) however, still high, it represented about 54% of all infant mortality in the country(10). Approximately two-thirds of the neonatal deaths globally in 2014 occurred in 10 countries with Nigeria accounting for about a tenth(5).  In 2015, Nigeria came in second to India with the largest neonatal deaths(6) and according to the 2017 UN Inter-agency child mortality report, sub-Saharan Africa accounts for 38% of the global NMR with Nigeria representing about 9% of that(11). Like U5MR in Nigeria, burden of neonatal deaths is unevenly distributed across the country, showing variations in the trends of NMR across the geopolitical regions(10). In 2013, the highest NMRs were reported in the North-Western region with 42 deaths compared to the South-Southern region with 31 deaths per 1000 livebirth(10). There was also rural and urban difference present with more deaths happening in the rural and northern regions(10). Neonates born to mothers in the urban regions were more likely to survive compared to their counterpart in rural regions(6, 10). This can be attributed to rural areas dealing with environmental factors like inaccessibility to clean developed water source, insufficient sanitation facilities, and limited access to health and social services(6).

The rate of child survival in Nigeria is more evident in children under-5 than neonates, with similar trends being seen in other countries in sub-Saharan Africa. Governmental and international agencies focus on, and targeted funding towards post-neonatal interventions could account for this trend(6). Factors impacting the U5MR in Nigeria include ongoing violence in the northern region, proximity to healthcare facilities and transportation access in rural areas, healthcare cost, availability and trust in medical providers, accessibility of medical supplies, inadequate facility infrastructure(8), cultural beliefs and practices(8, 10). Factors linked to high NMR include greater risk for neonatal death in women with no education than those with a secondary education or higher(10). Births to mothers younger than 20 years or older than 35 years are more likely to experience neonatal death than those aged 20-35 years(10). Rural women are less likely to participate in antenatal care, due to limited access to health facilities, decreasing the likelihood of detecting abnormalities in the early stages of pregnancy(10). Child’s sex, wealth status, birth order and interval also influence NMR and U5MR in Nigeria(6).

To fast-track Nigeria’s progress towards attaining the SDG 3.2 target, the nation’s top priority is improving and expanding the availability, accessibility, and affordability of primary healthcare services, increasing health coverage and quality of services rendered(12). To achieve this, the government has executed the National Insurance Scheme with a focus on the reduction of infant and maternal mortality by establishing primary health centers across each LGA to improve access to healthcare(12). Also, launching the Tertiary and Public Primary Pupils Social Health Insurance Program to deliver health services to children from middle and lower-income socioeconomic backgrounds(12). Medical providers are given special incentives, and amenities to provide health services in rural communities, with updated medical equipment and affordable medications(12). With plans to expand to a more comprehensive program utilizing e-health mechanism to connect specialized hospitals to rural communities through mobile telemedicine to increase access and quality of services provided(12). In addition, the advancement of healthcare infrastructure under the Health Systems Development Program will increase in funding for equipment, upgrading health facilities and enlisting first-class health specialists(12).

More sub-national government health policies and programs are now implementing interventions to reduce maternal and child morbidity(12). Kaduna state now offers free healthcare to pregnant women and children under 5, Yobe state has invested additional funding for the School of Health Technology and College of Nursing and Midwifery and Ebonyi state has released N2.1 Billion in grants to six rural and mission hospitals to improve maternal, newborn and child health(12). Integration of the SDG costs in the annual 2016 and 2017 budgets was implemented with the intention to maintain it onward(12).  Furthermore, states now recognize the need for adequate data when planning their health development strategies so, the Health Management Information Systems are now being deployed to improve health data collection, organization and reporting in most states, and SDGs data mapping, monitoring and evaluation to keep track of process being made(12).

To achieve Nigeria’s National Health Bill enactment in 2014 to save over 3 million lives of mothers, newborns, and children under-5 by 2022(8) and SDG 3.2 target by 2030(1) are very ambitious goals and hangs on the successful execution of the interventions being implemented in Nigeria and a consistent and substantial decline in U5MR and NMR. Recommendations on advancing the progress towards these goals are to address the health inequalities statewide and within LGAs, accessing the regions and rural areas with high U5MR and NMR and addressing risk factors, intervention coverage, and other area-specific variables influencing U5MR and NMR. Preventive programs like contraception and family planning needs for adolescents, women and partners, improved antenatal and postnatal care, access to clean water and sanitation, and reduction in malaria, pneumonia, and diarrhea incidence, will aid in child survival efforts(4, 8). Policies and reform programs that can effectively reduce the U5MR and NMR in Nigeria currently exist but by strengthening the implementation, honouring continued care, consistent funding, increased resources, and accountability, Nigeria has the capacity to drastically stop the preventable mortality of children(13).

Overall, Nigeria has high hopes in charging the narrative with policies and plans in place to attain the SDG 3.2 target. In 2016, the U5MR was 104 deaths and NMR was 34 deaths per 1000 livebirths showing little difference from 2015(U5MR:108 deaths; NMR:35 deaths)(7). At this pace, a steady decline in U5MR and NMR at double the rate of MDG 4 is required to attain the SDG 3.2 target by 2030(2).

References

1. The Sustainable Development Goals Report 2017. New York: United Nations; 2017.

2. Golding N, Burstein R, Longbottom J, Browne AJ, Fullman N, Osgood-Zimmerman A, et al. Mapping under-5 and neonatal mortality in Africa, 2000–15: a baseline analysis for the Sustainable Development Goals. The Lancet.390(10108):2171-82.

3. Section UDaA. Progress for Every Child in the SDG Era. New York: UNICEF, Division of Data RaP; 2018.

4. Liu L, Oza S, Hogan D, Chu Y, Perin J, Zhu J, et al. Global, regional, and national causes of under-5 mortality in 2000-15: an updated systematic analysis with implications for the Sustainable Development Goals. Lancet (London, England). 2016;388(10063):3027-35.

5. Levels & Trends in Child Mortality Report 2014. UN Inter-agency Group for Child Mortality Estimation; 2014.

6. Morakinyo OM, Fagbamigbe AF. Neonatal, infant and under-five mortalities in Nigeria: An examination of trends and drivers (2003-2013). PloS one. 2017;12(8):e0182990.

7. The World Bank Data: The World Bank Group; 2018 [Available from: https://data.worldbank.org/indicator/SH.DYN.NMRT?end=2013&page=4&start=1960.

8. Wollum A, Burstein R, Fullman N, Dwyer-Lindgren L, Gakidou E. Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000–2013. BMC Medicine. 2015;13(1):208.

9. World Health Statistics data visualizations dashboard: World Health Organization; 2017 [Available from: http://apps.who.int/gho/data/view.sdg.3-2-data-reg?lang=en.

10. Akinyemi JO, Bamgboye EA, Ayeni O. Trends in neonatal mortality in Nigeria and effects of bio-demographic and maternal characteristics. BMC pediatrics. 2015;15:36.

11. Levels & Trends in Child Mortality Report 2017. UN Inter-agency Group for Child Mortality Estimation; 2017.

12. Implementation of the SDGs: A National Voluntary Review. Nigeria: Federal Republic of Nigeria, (OSSAP-SDGs) TOotSSAttPoS; 2017.

13.  Saving Newborn Lives in Nigeria: Newborn Health in the context of the Integrated Maternal,  Newborn and Child Health Strategy. Abuja: Federal Republic of Nigeria Ministry of Health; 2011.