Developing equity-focused interventions for maternal and child health in Nigeria: an evidence synthesis for policy, based on equitable impact sensitive tool (EQUIST)

Introduction Among the most critical health systems components that requires strengthening to improve maternal, newborn and child health (MNCH) outcomes in Nigeria is the concept of equity. UNICEF has designed the equitable impact sensitive tool (EQUIST) to enable policymakers improve equity in MNCH and reduce disparities between the most marginalized mothers and young children and the better-off. Methods Using the latest available DHS data sets, we conducted EQUIST situation and scenario analysis of MNCH outcomes in Nigeria by sub-national categorization, wealth and by residence. We then identified the intervention package, the bottlenecks and strategies to address them and the number of deaths avertible. Results EQUIST profile analysis showed that the number of under-five deaths was considerably higher among the poorest and rural population in Nigeria, and was highest in North-West region. Neonatal causes, malaria, pneumonia and diarrhoea were responsible for most of the under-five deaths. Highest maternal mortality was recorded in the North-West Nigeria. Ante-partum, intrapartum and postpartum haemorrhages and hypertensive disorder, were responsible for highest maternal deaths. EQUIST scenario analysis showed that an intervention package of insecticide treated net can avert more than 20,000 under-five deaths and delivery by skilled professionals can avert nearly 17,000 under-five deaths. While as many as 3,370 maternal deaths can be averted by deployment of skilled professionals. Conclusion Scaling up integrated packages of essential interventions across the continuum of care, addressing the human resource shortages in rural area and economic/social empowerment of women are policy recommendations that can improve MNCH outcomes in Nigeria.


Introduction
In Nigeria maternal and child health outcomes remain unacceptably poor, largely due to the weak health systems. Consequently, maternal and child health status in the country remains one of the worst in Africa and has not improved substantially, and in some areas of the country, has worsened over the past decade [1]. There exists a wide variation in maternal mortality ratio (MMR) across the six Nigeria geo-political zones, with the northern zones generally having worst maternal, newborn and child health (MNCH) indicators than the southern zones [1]. With the population of up to 186 million, Nigeria has about 2.5% of the population of the world and 10% of all maternal and under-five deaths, translating into more than 50 000 maternal and more than 1 million newborn, infant, and child deaths annually [2][3][4]. Nigeria loses 2,300 under-five year olds and 145 women of childbearing age every day, making the country the second largest contributor to the under-five and maternal mortality in the world [1]. Many of these deaths which occur during pregnancy, labor and delivery are preventable, but the coverage and quality of health care services in Nigeria continue to fail women and children [1].
Kana and co-workers, who reviewed maternal and child health interventions in Nigeria from 1990-2014, noted that since documentation of national MNCH statistics began in the early 1990s in Nigeria, poor MNCH indicators have been a recurring public health challenge [5]. Available reports have shown that more than a quarter million neonates die in Nigeria each year, representing about 700 neonates per day [6]. In Nigeria, a number of factors have been strongly linked with high mortality of neonates including mother's age, maternal illness, lack of antenatal care, low birth weight, birth asphyxia and prematurity [7,8]. Annually, up to 529,000 maternal deaths are recorded globally, and of this number, about 52,900 Nigerian women are estimated to die from complications associated with pregnancy, making the risk of a Nigerian woman dying from pregnancy and child birth to be 1 in 13 [9]. HIV/AIDS (5%), Malaria (11%), obstructed labour (11%), unsafe abortion (11%), toxaemia/eclampsia/hypertension anaemia (11%), infection (17%), and haemorrhage (23%), are responsible for most of the maternal deaths in Nigeria [2][3][4]. Also contributing to the high maternal mortality in Nigeria are socio-economic factors including: lack of awareness about complications in pregnancy; need to seek medical intervention early; lack of transportation to the health facilities where maternal healthcare can be provided; inability to pay for services, etc. [2,4,9,10]. The use of insecticide treated bed-nets increased from 8% in 2008 to 50% in 2013, but malaria contributes some 30% to childhood mortality [4]. AIDS, lower respiratory tract infections and diarrheal diseases are among the leading causes of years of life lost [9]. Since 2009 the Boko Haram group has led an insurgency that has seen thousands killed and led to severe humanitarian and health crises in particular in the North-East and North-West regions of Nigeria.
Among the most critical health systems components that requires strengthening to improve MNCH outcomes in Nigeria is the concept of equity. The importance of equity consideration in evidenceinformed policymaking and interventions to improve MNCH in Nigeria cannot be overstated. Findings from a number of studies from low and middle-income countries (LMICs) have consistently shown that interventions leading to decrease in maternal and child mortality are accompanied by increased inequity in health outcomes between the rich and the poor [11][12][13][14]. Based on these findings, the United Nations Children's Fund (UNICEF) is strongly promoting an "equity-focused" approach in which health interventions are targeted at the poorest and the underserved population, rather than the "mainstream approach" where scaling-up of health interventions favours the wealthier population [12]. UNICEF is also currently advocating for equitable investment in health interventions in LMICs targeting MNCH since practical, high-impact and low-cost health interventions, extended to the most deprived and marginalized populations have the potential to avert more maternal and child mortality more costeffectively [14].
As part of her effort to support the global campaign on equity focused investment in health interventions, the UNICEF developed an online equitable impact sensitive tool (EQUIST) to enable the MNCH policymakers and other stakeholders improve equity and address health disparities between the most marginalized and wealthier populations [15,16]. EQUIST helps policy makers select strategies that balance the principles of equity, effectiveness and efficiency by leading them through a logical process to identify the most rational and cost-effective solutions for their context [17]. The purpose of this evidence synthesis for policy is to use EQUIST to provide reliable evidence, on equity-focused interventions and recommendations that will inform policy development to improve MNCH outcomes in Nigeria.

Setting
Nigeria has a total area of 923,768 km 2 and is located on the Gulf of Guinea of West Africa and lies between latitudes 4° and 14°N, and longitudes 2° and 15°E. The country is divided into six geopolitical zones including North-West, North-Central, North-East, South-West, South-East and South-South and comprises 36 states and the Federal Capital Territory, Abuja as the capital [18]. The states are divided into 774 local government areas (LGAs). With approximately 186 million inhabitants in 2016, Nigeria is the most populous country in Africa and the seventh most populous country in the world [19]. Being the most populous country with high fertility rate, Nigeria has thirdlargest young population in world, after India and China, with up to 44% of the population under 15 years of age [20]. Nigeria is the largest economy in Africa, with a GDP greater than USD 500 billion and steadily grew to over 7 percent per annum between 2005 and 2014, but this growth has been slower in 2015 [21]. Ironically, poverty is still pervasive in Nigeria, where recent figures indicate 68% of the population lives on less than US$1.25 a day [20].
The Nigeria health profile is shown in Table 1. Great disparities in health status exist, across the states and geopolitical zones of the country and disease aetiology is linked to social determinants such as socio-economic status, education, gender inequality, as well as poor access to water, sanitation and hygiene [20]. Health care delivery in Nigeria is a concurrent responsibility of the three tiers of government in the country (federal, state and LGAs), as well as the private sector.
Nigeria health systems was ranked 187 th in the world in 2000 [22] but within the last 15 years, various health indicators have shown steady, albeit slow, improvement.

EQUIST situational analysis
We used the 2013 DHS data sets for Nigeria which are the latest preloaded in EQUIST to perform both situational and scenario analysis.

EQUIST scenario analysis
We performed EQUIST scenario analysis for the North-West region of Nigeria. First, we assessed the main epidemiological causes of underfive mortality and maternal mortality in the region (prematurity and asphyxia). Second, we identified interventions considered as priorities that can address the epidemiological causes of under-five and maternal mortality, grouped in "packages" under family care practices (ITN ownership and use), preventive services (DPT3 immunization), and curative services (delivery by skilled professionals). Third, we determined the major possible bottleneck (geographical accessibility) that can constitute potential impediment to the identified intervention. We assessed the severity, how they affect utilization of the intervention packages and coverage and the strategies to address them. Four, we analysed the enabling environment that can facilitate the strategies for addressing bottlenecks from the perspective of the health systems building block components (task shifting, redeployment/relocation existing staff, non-facility service provision, lay/community health worker service delivery, contracting out). Five, we performed impact analysis to determine the number of avertible under-five and maternal deaths.

Outcome of EQUIST situational analysis
The result of the Nigeria EQUIST profile analysis showed that underfive mortality rate was highest in the North-West region (149/1000 live births) and the mortality figure was more than double the number obtained in the region with the lowest under-five mortality in Nigeria is presented in Table 2 The lowest national percentage of ITN coverage was recorded in North-East (10%) and North-West (11%) which were below the national average (13%). Also, the lowest coverage for immunization was also recorded in the North-East (21%) and North-West (14%) which were below the national average of 38%. The percentage coverage for delivery by skilled professional was lowest in both North-East (18%) and North-West (11%) with the national average at 28% and the South-West, South-East and North-Central regions recording the highest percentage of 27% ( Table 2).   deliver essential MNCH services [35]. It is a well-established fact that the health sector is skilled-labour-intensive and the increase in health workforce is very crucial to the overall improvement in the performance of the health systems. In this domain, emphasis must be placed on territorial equity in order to address the human resource shortage in rural areas, where the poorest people live but which still harbour the greatest health risks [31]. Underfunded investments in MNCH are part of the impediment towards the implementation of feasible and cost-effective interventions targeted at reducing maternal and child mortality [36,37]. Interventions that have been proven to be very effective are often lacking in LMICs, there is therefore the need for increased investment in health system infrastructure, capacity enhancement of health workers, and patient enlightenment for these are critical to improving health outcomes for mothers and newborns [38]. In order to address the insufficiently diversified and autonomous financing of health, it is important to invest the growth dividend in health and explore other avenues to raise additional resources to fund the health sector [31].  [44]. In Nigeria, private maternity care was the preferred place of delivery because of the problems associated with public owned hospitals including low quality of facilities, absence of staff, poor perceived quality, long waiting times, and high costs [40]. It is therefore imperative for the enactment of policies that will facilitate the engagement of the private sector to increase accessibility to reproductive and child health care [39]. The to follow a universal coverage model that exists elsewhere, but rather to design one that is adapted to the needs of the region and evolves as progress is achieved [31]. In Africa, irrespective of the existence of multi-ethnic, cultural, tradition, lingual and religious diversity and differences, there is still a very strong social bonding which manifests in the establishment of homogenous social groups. In Nigeria as in many other African countries, any health insurance scheme that is anchored on social bonding culture of the population is most likely to succeed. This is important because available reports have indicated that the so-called formal health insurance scheme has not really worked in most of the African countries [46][47][48]. Of all the types of health insurance schemes, the Community-Based Health Insurance achieving success [53]. Because much of the burden of maternal and child mortality and ill health is concentrated among the poorest populations, the highest mortality is observed among the marginalized and poor, who frequently reside in remote and rural areas with limited access to health care services [53,54]. In a recent fact sheet on reducing mortality among children [55], the WHO calls on member states to address health equity through universal health coverage so that all children irrespective of status (whether among the rural or poorest population) are able to access essential health services without undue financial hardship.

Outcome of EQUIST scenario analysis
Policy option 6: improving the status of women through economic empowerment and making their health well-being an utmost priority.
Empowerment of women through access to health and education will not only reduce maternal and child mortality but will also facilitate the reduction of the fertility rate. Creating opportunities for women to be economically and socially empowered will enable them to lead meaningful careers and earn resources to adequately take care of their health. Accessibility to healthcare is one of the bottlenecks highlighted by the EQUIST analysis and this can be partly addressed by economically empowering women. This is because a woman who is economically empowered will have the resources that will enable her seek adequate healthcare. According to Santi and Weigert [31], the demographic dividend would have increased considerably if women had greater access to education and health and the goals to be achieved are the reduction of fertility and procreation risks, increase of the average age of marriage and the introduction of women into the labour market [31]. In an earlier report, UNICEF argued that helping governments provide a quality primary school education, a UNICEF priority, will benefit maternal and infant health particularly education for girls [56]. UNICEF also noted the following [56]: (i) educating girls for six years or more drastically and consistently improves their prenatal care, postnatal care and childbirth survival rates; (ii) educating mothers also greatly cuts the death rate of children under five; (iii) educated girls have higher selfesteem, are more likely to avoid HIV infection, violence and exploitation, and to spread good health and sanitation practices to their families and throughout their communities. In a recent report by the United Nations Foundation (UNF) [57], on private sector action for women's health and empowerment, a call was made for the recognition of the centrality of gender equality and the health and rights of girls and women as emphasized in SDG 5.

Conclusion
As the knowledge of the importance and application of EQUIST is not yet wide-spread in Africa [29], the present study is the first attempt to use the tool to provide an evidence synthesis for policy on equity-focused approach to health interventions to improve MNCH in Nigeria.  Interventions leading to decrease in maternal and child mortality is accompanied by increased inequity in health outcomes between the rich and the poor.