Charting the Course: Reducing Neonatal and Under-5 Mortality by 50% in Ekiti State

In August 2020, I assumed office as Commissioner for Ekiti State Ministry of Health and Human Services , Nigeria, following extensive discussions with Dr. John Kayode Fayemi, PhD. on the strategies necessary to reform the state's health sector. When His Excellency, Mr. Biodun Abayomi Oyebanji , requested that I remain in this position in 2022, we reviewed the sector’s performance over the preceding two years and mapped out priorities for his administration.

In 2020, the health system's performance in Ekiti was concerning. Despite high coverage of selected interventions, health outcomes remained suboptimal and lagged behind other southwestern states. For example, Penta 3 immunization coverage was 86%, yet neonatal and under-5 mortality rates stood at 42 and 95 per 1,000 live births, respectively, according to the 2019 Nigeria Demographic and Health Survey (NDHS). This meant that one in 24 infants died within the first month, and one in 11 children died before their fifth birthday. The system faced multiple challenges, including workforce shortages, inadequate commodity supplies, substandard infrastructure, and limited financing.

?From the outset, it was clear that urgent reforms were required. At our first sectoral retreat, I outlined a vision to reduce neonatal and under-5 mortality by 40%, securing the commitment of staff to achieve this ambitious goal. We then embarked on the task of building a resilient and sustainable health system.

?Today, following the release of the 2024 NDHS report, I am proud to report that we have halved neonatal, infant, and under-5 mortality rates, reduced teenage pregnancy by 36%, decreased unmet need for family planning by 30%, and increased facility deliveries by 14%. In effect, we have surpassed every single target we laid out four (4) years ago.?

Several key strategies contributed to these achievements:?

1. Lead by Example – I believed that transformational change required strong leadership. By personally chairing meetings, conducting random facility visits, and reviewing outgoing documents, I set the tone for accountability and performance. This hands-on approach motivated the entire team to stay focused, celebrating successes together while addressing underperformance.

2. Harnessing Data for Action – Effective decision-making relied on data. In addition to formal data sources like DHIS2, SORMAS, and Ulerawa, we established a citizens’ engagement platform through WhatsApp, allowing real-time issue tracking, particularly in hard-to-reach communities. Regular data reviews with the team ensured we could rapidly interpret information and implement targeted solutions.

3. Weekly Performance Management Meetings – Weekly meetings with key stakeholders, including permanent secretaries, executive secretaries, directors and program leads, allowed us to track progress and solve emerging challenges. These gatherings fostered a culture of accountability and urgency, aligning individual efforts with the sector’s overarching goals. There’s a lot more to say about this, but I plan to delve deeper into the science behind these meetings in my upcoming book.

4. Support from Leadership – Strong political leadership was instrumental. Both Dr. Fayemi and Governor Biodun Abayomi Oyebanji provided critical support. Governor Oyebanji, served as our chief advocate, engaging directly with key stakeholders to advance our goals. In one instance, I recall him leading from the front and personally calling all nine (9) members of the Ekiti State Caucus of the National Assembly, to commit to our innovative solution to increase the fiscal room to recruit skilled health workers to the state. His active involvement in health advocacy played a crucial role in our success.

?5. Implementing Context-Specific Interventions – Tailored solutions made a significant difference. For instance, our Ulerawa health insurance program was designed to incentivize service provision and quality through case-based reimbursement. Additionally, decentralizing emergency operations and establishing rapid response teams at the local government level enhanced our disease surveillance and outbreak response. This simple but highly effective solutions have now been replicated in other states and it contributed to us earning the award of the best performing state in disease surveillance, for two (2) consecutive years. We also invested in a number of input related interventions that contributed to our performance. For instance, we established our drug management agency, revitalised our health centres, and trained over 3,000 health workers.?

6. Partnerships – Ekiti is often considered an orphan state. In my first year in office, I was surprised to learn that the World Health Organisation (WHO) and UNICEF were the only development partners supporting the state. We aggressively built our partnership portfolio over the years. By demonstrating results, maintaining fiscal fidelity, and ensuring accountability, more development and implementing partners felt comfortable working with us. I am particularly grateful to Christoph Kurowski , Mary Boyd, Sanjana Bhardwaj , Olufunke Fasawe , Olumidé O. Elegbe , Chikwe Ihekweazu , Ifedayo Adetifa and Fatima Zanna who went out on a limb with their organisations, to trust and invest in Ekiti even when we weren’t considered a priority state.

On this occasion of my fourth anniversary in office, it is heart-warming to see how far we have come and how these strategies not only improved health outcomes but also laid the foundation for a more resilient and sustainable health system in Ekiti State.

A big shout out to my pillar Temi Filani .

As always, I am grateful to God for the wisdom and insight to manage and lead a health system that caters to 3.8million persons.