Financing Maternal and Newborn Health (MNH) Care: The Costly Yet Crucial Investment for Nigeria's Future

The cost of delivering an integrated package of patient-centered, respectful maternity care, as recommended by the World Health Organization and crucial for women and their children (unborn and newborn), is not cheap. Insufficient funding remains a critical bottleneck in our system, significantly impeding our efforts to provide essential care. However, we cannot achieve a truly integrated service package without adequate financing investments and coordinated delivery for Maternal and newborn health.

One often evaded aspect of delivering high quality MNH services in the public health discourse is the actual cost. The most common reaction to the cost issue is to unpack the mortality drivers and design programs targeting one or a few of the drivers. This is completely understandable given that resources are scarce, and the assumed cost of upgrading the healthcare system to the standard where we deliver a holistic package appears daunting. Donors supporting the government choose aspects of delivering MNH care that the data shows will give the highest “Return on Investment” or are the lowest hanging fruits, likely to address the biggest drivers of mortality. But is this the best approach when we consider the challenges of MNH morbidity and mortality from a societal and patient perspective? This approach, often called the verticalized programming approach, has, for many years, had some results but not enough to bend the curve on reducing maternal and newborn mortality in most countries; why do we continue to pick and choose?

Despite the multiple government projects and initiatives to deliver free MNCH services through various means – free Antenatal care, free delivery services, and outreach programs like the MNCH weeks, the cost of accessing services to the patients continues to be a major barrier for seeking healthcare services on time or accessing the available services. Many women are still required to buy the supplies they need for childbirth when going to the facility for delivery or are required to make deposit payments for services. In some cases, women bring their own water, infection control supplies (such as bleach), gauze, and other basic items used in health facilities for their delivery. Poorly funded healthcare facilities that lack essential equipment, medications, and personnel make it even more difficult to provide integrated care effectively. With all of these barriers, it is no wonder that women are not choosing to deliver in our facilities and that mortality rates remain high.

In the recently published Exemplars in Global Health article, ?countries that have successfully improved health outcomes at a population level and for primary healthcare, of which MNH is a fulcrum, have done a couple of critical things along with strong political will and leadership - ?1) taken an integrated service delivery approach rather than vertical programs, 2) substantially increased domestic financing for primary healthcare by increasing government’s spending on healthcare or identifying innovative financing mechanisms including community-based financing, and 3) Alignment of stakeholders and government toward a common goal and targets with robust mechanisms for measuring performance and progress. Nigeria’s annual total health expenditure on Primary Healthcare per capita is about $35; more than 70% of this cost is borne by the patients who pay out of pocket for services.

So, in simple terms, what are the main cost drivers for maternal and newborn care?

The major cost drivers of maternal and newborn care are the commodities (drugs, diagnostics, and supplies), the cost of the health workforce (we have to pay for doctors, nurses, midwives, pharmacists, and specialists, but we also need to pay for the operations staff – finance, logistics, administrative ), and other costs like emergency response where there is a need to evacuate patients or transport patients to more specialized centers. Of course, there are other critical costs for service delivery, which include the availability of infrastructure for service provision, i.e., physical buildings and space for delivering the services, as well as supporting infrastructure for data management, communication, and general information systems.

In 2012, the Guttmacher Institute released a detailed analysis of the cost of maternal and newborn health services for developing countries where they identified that at the time, the estimated spend on MNH care was around $ 11 billion (22% on Antenatal Care and 78% on delivery and postnatal care)[1]. This report identified the unmet need for MNH care. It is estimated that countries would need to spend at least $24.1B annually for MNH care, more than double the current spend, to achieve the level of improvement in health outcomes that we desire as a global community. At this increased level of spending, the estimated reductions in maternal and newborn deaths were 57% and 42%, respectively. A similar study that looked at the cost of pregnancy and delivery in the United States from insurance claims records also identified the average cost associated with pregnancy, childbirth, and post-partum care was $18,865 ranging from an average of ~$14K for vaginal delivery to ~$26K for cesarean section.

While this might seem like a substantial cost to the healthcare system, not adequately spending on healthcare services for MNH care results in morbidity and mortality, which have significant societal costs. Another modeling study by the Commonwealth Fund found that “the projected cost of maternal morbidity for all births in 2019, from conception through age 5, was $32.3 billion” for the US. The authors also noted that this was largely an underestimation of the actual toll of maternal morbidity and mortality on the US society (see figure below). Further breakdown of these costs showed that 74% of this financial burden was associated with child health complications (two-thirds of which are incurred in the first year of life), while of the 26% associated with maternal complications, the main health outcomes drivers of the costs were lost productivity (84%), caesarean section (11.4%) and hospital stay before, during or after childbirth (5%)[2]. While we don’t have similar service utilization data analysis specific to Nigeria, what is key and universal is that maternal and newborn morbidity and mortality places a high financial burden on society, and the cost of preventing these complications and poor outcomes is a worthwhile investment. For example, the health of mothers and their children goes beyond one generation. Not only do mothers provide care for their immediate offspring, but these mothers, if kept alive, go on to become grandmothers who also provide care to the offspring of their children, enabling more women to remain in the workforce and not have to choose between the ever-growing cost of childcare and their jobs.

Solutions?

Having established that delivering an integrated MNH service is not cheap but has high returns on investment for society and our overall well-being, how can Nigeria turn the tide?

1.????? The national and state governments must reprioritize maternal and newborn health funding. Reprioritizing MNH care must be demonstrated by increased funding allocations to MNH service delivery, which includes the major elements required – consistent procurement and distribution of essential drugs, equipment, and supplies for facilities to deliver high-quality care; recruitment and adequate compensation of health workers (appropriately skilled health workers), and strengthening of emergency response (referral system, blood services, and surgical interventions). As a matter of urgency, Nigeria needs to determine the cost of delivering an optimal package of MNH services (ANC, delivery, and postnatal care) to inform the allocation of resources for the care of mothers and newborns. Given that over 60% of Nigerians are multi-dimensionally poor, governments at national and state must be deliberate about allocating adequate resources to cover women and mothers who are poor at the very least. Government funding should cover MNH services fully. The Government can do this by expanding health insurance schemes, expanding coverage of subsidized health insurance premiums for the poorest segments of the population, and expanding the benefits packages of health insurance schemes to cover comprehensive MNH services. States should also support Community-based Organizations through grants to work with local communities to develop community health funds administered by the local communities to cover MNH care for mothers and children who access services in their local communities. This community-driven microfinancing approach could enhance ownership and relieve women and their families of the financial hardships associated with pregnancy, childbirth, and postnatal care.

2.????? Leveraging private sector financing to improve health infrastructure for MNH service delivery. The delivery of basic and emergency maternal and newborn care in Nigeria is hindered by inadequate infrastructure and essential equipment. The government or donors may find the costs prohibitive to address. Instead of seeking easy solutions, we must actively pursue innovative financing mechanisms with the private sector to invest in facility infrastructure and equip them with the necessary technologies for MNH services. With over 70% of healthcare spending in Nigeria currently being out of pocket, we must find ways to optimize the utilization of these funds in the system. We need to attract private sector investments to significantly improve primary healthcare facilities and infrastructure, including providing essential antenatal and delivery equipment, access to electricity, water, and referral transport. Encouraging private stakeholders (corporate investors and healthcare providers) to participate in public health programs through beneficial contracts or partnerships will ensure alignment with public health goals and private business interests.

3.????? Innovative financing mechanisms like Development Impact Bonds for MNH or blended finance models. Development Impact Bonds would entail private investors investing in major health sector projects to improve maternal and newborn health services, and these investments are repaid by the Government based on the achievement of specifically defined MNH outcomes. This could be one way to maximize the development financing from multilateral financing institutions like the World Bank to build the necessary infrastructure and optimize the health workforce. Blended financing models combine government, private, and donor funds to attract private sector investments, thereby increasing funding and investment in MNH. In addition to innovative financing mechanisms, performance-based financing models should be reconsidered to drive value-based care for MNH. If providers (health workers and care systems) are paid for services based on performance targets, this would incentivize higher quality care and efficient use of resources.

4.????? Refocus on integrated service delivery for MNH and longer term donor funding support. The argument for vertical or narrow-focused programs that aim to tackle single mortality drivers or focus on commodities or specific diagnostics as single interventions is that there are not enough financial resources to meet the need, so narrowing the focus on where the biggest gains are is an economically viable option. But is it? If we prevent one mortality driver by investing in building the capacity to manage that one condition and providing the drugs required for that condition, yet the same health workers cannot adequately manage other drivers of mortality, have we solved the problem? Understanding that donors and government may not have adequate resources to cover the full integrated package, we need stronger coordination and alignment of available resources towards a common goal. This coordination needs to happen at subnational and national levels and is in line with the current administration's Sector Wide Approach (SWAp) to improve Aid alignment. We need donors to commit to longer-term financial support for integrated MNH programs rather than addressing some aspects. This would provide stability and predictability in funding, which is essential for sustained program success.

5.????? Sustainable commodity financing through integration into existing PHC programs, including the BHCPF, Drug Revolving Funds (DRFs), and public-private sector partnerships. Commodity unavailability and persistent stockouts are among the biggest challenges to delivering adequate MNH care. Most facilities are stocked out of essential drugs and supplies, and patients have to bear the cost of these products to receive care. Most commodities and supplies are purchased in the private sector from pharmacies and patent medicine vendors. This process is highly fragmented and poorly regulated, leading to significant price and quality variations for essential MNH commodities. Within the context of Networks of Care, one approach to solving the commodity financing issue could be entering into agreements with pre-selected private sector pharmacies to negotiate product prices and margins both for the health insurance schemes that reimburse them for providing drugs and supplies for enrolled patients, but also for patients who pay out of pocket to reduce the cost to the patients.

6.????? Investing in expanding the knowledge of and access to modern contraceptives and other sexual and reproductive health services. Investing in access to modern contraceptives can lead to at least a 30% reduction in maternal mortality. Some of the risk factors for maternal morbidity and mortality are related to the number of deliveries and the frequency/timing between pregnancies. Therefore, it is undeniable that investing in access to modern contraceptives is a cost-effective measure for reducing the cost of MNH (maternal and newborn health) care over time, enabling the available resources to cover much-needed care for the population. Nigeria urgently needs to reinstate its annual funding commitment and budgetary releases to procure modern contraceptives and implement its costed implementation plans.

[1] Singh S, Darroch JE and Ashford LS, Adding It Up: The Need for and Cost of Maternal and Newborn Care—Estimates for 2012, New York: Guttmacher Institute, 2013, <https://www.guttmacher.org/pubs/AIUMNH-2012-estimates.pdf>.

[2] So O’Neil et al., The High Costs of Maternal Morbidity Show Why We Need Greater Investment in Maternal Health (Commonwealth Fund, Nov. 2021). https://doi.org/10.26099/nz8s-4708