Agenda setting and community sensitization in MCH
The changes in policy and programme environments that help to keep MCH on the political agenda included changes at the federal level, influences in Anambra state, and events in other states of the country that include Anambra state. From the mapping, a total of 14 events were implemented of which 2 were at the sub-national/state level and 12 were at the federal level. As shown in Box 1, key advocacy organisations and individuals included health professional groups, the media, civil society organisations and NGOs with similar objectives coming together informally for MCH issues, powerful individuals, and policymakers. The nature of their engagement included organizing demonstrations, workshops, symposiums, town hall meetings at the national level, individual meetings, press conferences, and engagements with media as shown in box 1.
Despite remaining national and international priority, sustaining citizens’ interests, political and financial commitment to MCH services in Nigeria often requires effective advocacy efforts. We found that key outcomes of advocacy included financial commitment, political involvement, policy enactment, and implementation as shown in Box 1. Specifically, the outcomes included the reactivation of the Midwives service scheme (MSS), which was in place before the advent of SURE P/MCH, appropriation of the Basic Health Care Provision Fund (BHCPF) in the 2018 national health budget, signing of a declaration by participating organizations calling for action by the Government to address among other things, maternal and neonatal death and declaring them a priority and leading to the federal government setting up a task-force to speed up the reduction of maternal deaths with a target to increase funding for family planning services from US $3million to US $4million, from 2018, media sensitization on accountability for health funds. Other outcomes included prioritization of Reproductive, Maternal, Newborn Child, Adolescent Health plus Nutrition (RMNCAH+N). Also, the World Bank Approved US$500 Million to improve MCH, achieve the ‘Saving One Million Lives’ Goal (a high-impact reproductive and child health and nutrition interventions) whose operation was expected to last from August 1, 2015, to December 2019 [34]. It is important to note that although the World Bank offers packages, advocacy enabled the government to agree to seek those packages and use the funds correctly.
There was raised awareness and ‘education’ of the State governor about the significance of health issues through advocacy. According to one of the respondents, “Advocacy is a powerful tool because most of these people, they are not health workers, the governor is not a medical doctor, so it is not like he doesn't know, but when you come to him as an advocate and you can give him facts, looking at indices and looking at what is on the ground, telling him the gaps and everything, he will understand and he will quickly key into it". (Policy Maker State)
Some civil society organizations (CSOs) in Nigeria alluded to having achieved a lot for MCH by advocating government and other relevant stakeholders: “Our organization appreciates the nature and importance of advocacy and that is one of the cardinal things we do with very good results. Like we advocate the government, and the State governors especially the governors’ wives in some states because many are interested in knowing what is happening in their state” (Professional Group, National). Different actors were targeted differently in different states, for instance, in some areas “governors’ wives” were targeted since they seemed to act as knowledge brokers to other elite decision-makers.
Multiple factors impact the potential of advocacy to generate change [35] in MCH policies such as, the topic, the political time and the socio-economic context, and the type and coalitions of organisations involved in the campaigns but some respondents felt they could have a direct impact, for example, in the case of Nigeria Every New Born Action Plan (NIENAP). A respondent noted that “UNICEF was interested in maternal and child nutrition and when the benefit package was developed, it didn’t have anything on nutrition because they wanted a slim benefit package, but there was this targeted advocacy to the Minister of Health and the Minister of Finance and eventually it was agreed to add nutrition to the benefits package” (Policy Maker, National). The individual who represented UNICEF was able to convince the ministries of health and finance of the importance of MCH and thus conferred international legitimacy, credibility, power, and recognition as mechanisms through which advocacy worked on this occasion. Another example was the passage of the State Primary Health Care Development Agency bill in Anambra state. This led to Anambra State releasing their counterpart fund for the Basic Health Care Provision (BHCPF), and accessing the main fund from the Federal Ministry of Health for the delivery of the Basic Minimum Package of Health Services, including basic emergency obstetric and newborn care (BEmONC) in 2019. The persistence of the CSOs and the timing/message convinced the governor to take this forward. This was captured by a respondent thus:
“…… we championed it and paid advocacy visit to the house of assembly and the commissioner for health then and the governor took it upon himself to send the bill as an executive bill to the house of assembly. And after advocating to even the ministry of justice and other line ministries, it was passed. And then we persevered and after some time, the State Agency was inaugurated and members were appointed and inaugurated immediately and they moved into action” (CSO State).
According to the respondents at the sub-national level, where some groups like the CSOs kept advocating and checking the budgets and releases to the MNCH sector, advocacy has also led to an increase in funding for MCH at the sub-national level, for example, the increased package of health services for mothers and children in the current Basic Healthcare Provision Fund (BHCPF) was due to advocacy and the increased releases in budget funds at the state level was also attributed to advocacy by some groups. The release of their counterpart funding for the BHCPF was also due to better awareness of the value of social sector investments and possibly the ability to demonstrate visible political gains (which will help them get re-elected). Advocacy is an explicit aim in some local NGOs as this participant explained “advocacy has always been an integral part of our programme management. Over the years the state government has tried to increase the budget from what it used to be up to where we are now as the elections are just by the corner… And so I can say that the increase in the budget was as a result of that advocacy and the subsequent advocacy that happened in the past. So eventually, the 2018 budget for health was increased” (NGO State)
Contextual factors and mechanism of advocacy in MCH
The key contextual influences which determined the effectiveness of advocacy measures for MCH include the political cycle (given the change that comes with MCH interventions with a change in government), availability of evidence on the issue, networking with powerful and interested champions, and alliance building in advocacy.
Spatiotemporal Factors: Timing and the Political Cycle in Nigeria:
Change in government can determine the sustainability of an MCH programme. For example, the change in government led to the termination of the SURE-P and a change in the direction of MCH policy as explained by one of our respondents. “One of the biggest problems in Nigeria has been issues of governance and policy inconsistency, and these inconsistencies are coming by the cycle of democratic governance in Nigeria. So, when you change the government, their priorities automatically change, their attention changes and so their political economy shapes what you are doing, and the politics around what you are doing” (Development partner).
At the sub-national/ State level, the change of power at the national level also led to a changed direction. This was captured by a respondent thus: “actually, you know that most times the government policy comes and if there is somebody that is driving it and that person goes out, the person that comes in though he will inherit assets and liability, may not be interested in that programme. He will look for the one that he will initiate” (CSO State level). On the other hand, change in the political cycle can create opportunities for advocacy., When a new government has a vision in some areas in health, decision-makers are more likely to listen to the advocates because “they are liable then and can listen to suggestions and are more willing to impress the people” (Media State level).
It was also noted that to be more effective, advocacy needs to be timely, strategic, and sustained. It is needless starting advocacy when it is known that the tenure of the government is going to end soonest because it is going to be a waste of resources. According to a respondent, advocacy “has to be well-timed. For instance, if I’m working in a state and I know the governor is completing his tenure in 2 months, I will have to wait for the incoming one…..it will be a waste of resources if I’m going to advocate……it means my advocacy is not well-timed if I do so. I will rather wait until the new governor comes in because in any transition you need to be mindful of how you invest in advocacy” (Development partner).
The Role of Evidence: Knowledge Production and Brokerage in MCH:
The availability of credible and convincing evidence is the key to successful advocacy. For example, evidence was identified as significant in the implementation of the free MCH services in Anambra State. Powerful videos of graphic images used for advocacy triggered a sense of sympathy, fear of civil unrest/media coverage) which then contributed to better responses to the MCH issues by the government. As noted by a respondent, “When we visited the governor, we showed him videos of how people were delivering with some people putting herbs inside somebody’s body parts, by jumping on somebody’s tummy to push out the baby. All these things have been captured by the videos, and how people died, and so on” (Health Professional Group). Thus the policy champions relied on their reputation of having extensive experience in maternal health and used critical incidence events to emphasize maternal mortality to convince the Governor to support the free MCH services in that state.
Several respondents buttressed how evidence can either enable or constrain advocacy. If the person advocating has compelling evidence such as ugly incidences of what happens during child delivery or health service utilization, this can make advocacy effective. For example, one of the respondents noted: "if you are going to advocate, it means you advocate on a piece of very firm information and evidence, so if you are advocating on faulty evidence, even if someone listens to you, it may not sound very convincing to attract investment or political will to it” (Developing partner). Another respondent noted: “Of course, there is no way that you can do any policy without evidence. For us, you must have evidence to back up our claims and in fact, sometimes we do peer learning of what has worked in other countries” (CSO National). Such evidence used included what advocates have produced themselves using their data and also as “knowledge brokers” sharing relevant academic data with the decision-makers as one respondent noted, "If you want the government to put in one naira, you have to tell them what that one naira will achieve based on the data you have” (NGO, National).
On the other hand, you can have negative effects when there is no concrete evidence or when evidence is biased or skewed. A key constraint is that people engage in advocacy when they are not adequately informed. As noted by a respondent: It’s a big challenge just like what is happening now, the civil society groups advocating for the implementation of Basic Health Care Provision Fund (BHCPF), so a good number of them do not understand the dynamics of the scheme, so the advocacy is misaligned” (Policy Maker, National).
Networking with Powerful and Interested Champions:
Another key contextual influence, which determines the effectiveness of advocacy measures for MCH is engaging key people and elite authorities. Strategic engagements with stakeholders like the minister of health, minister of national planning and minister of finance, legislators, chairman Senate committee on health and chairman house of representative on health and the wife of the Governor after the suspension of funding to SURE-P MCH facilitated the process of sustained concern on MCH both at the national and sub-national level. The different manifestations of their power and influence included the control of resources (the Ministers) policy influence (Governor’s wife, the legislators) and this helps explain specific mechanisms, which these contextual factors triggered. In the words of one of the respondents, “It was because the first lady (Governor’s wife) was there, and that was a very big driving force and based on that it has succeeded, and we also once in a while have meetings where we invite the wives of the governors……It was the first lady that we used on this occasion and that was also part of the reasons why the project was moving” (Development partner).
Also, the strategic engagements with these stakeholders like the minister of health, minister of national planning and minister of finance, legislators, chairman Senate committee on health, and chairman house of representative on health may have resulted in the increased budget to health. For example, (figure 1) shows that there has been an increasing budget for health since 2016. The Capital items within the approved budget range from the provision of vaccines, rehabilitation of hospitals and primary health centers, to the purchase of medical equipment, family planning and reproductive health commodities, interventions in the control of HIV and other diseases, nutrition-related interventions as well as counterpart funding to leverage specific international donor programmes within Nigeria's health sector [36]
Alliance Building in MCH Advocacy:
Group interest and willingness to undertake advocacy on the matter is an important contextual influence on advocacy and a major driver of advocacy activities. Alliance building emerged through a sense of common will, need, and a goal that affects everything that the CSOs and other advocates do. These are examples of mechanisms that a group/collective brings. According to a respondent, “the fact is the passion, coalitions are formed based on passion. So, the first is the passion that drives the coalition, the second is the ability and the capacity of the coalition and then the unity of purpose. They must have a common vision to be able to achieve any result as a coalition” (CSO National)
Determinants of effective advocacy processes
Effective advocacy processes involve alliance brokering (to gain more influence), building relations with media (for adequate dissemination of advocacy agenda and result), champions/influencers (to maximize result), effective mobilization of citizens (for demand creation) and using relevant evidence.
Alliance Brokering to Increase Influence:
Forming groups is one of the important advocacy processes that can be effective as evidenced by the comment from one of the leaders of a national organization in Nigeria, “we operate like a big NGO we work with UNICEF, USAID, PATHFINDER to mention but a few in the areas of maternal health” (Professional Group). It was noted during the interviews that when groups come together, they tend to create a common objective and have a composite position in advocating the government or partners. But when parallel advocacy is done sometimes, it creates much distraction. It was stated that the coalition works better through collaboration, instead of one organization going for it: “advocacy is better when groups of people come together and have a common vision and through coordinated activity, meet the right people and are given the audience, then they are more likely to achieve their aims. Another thing is having the right person amongst their midst to influence the policy-makers” (Media National). Although when messages are repeatedly emphasized from different angles and organisations, this can also be an effective tool to consolidate agenda-setting by a sense of social consensus.
The Media: Supporting and Engaging in Advocacy
A good relationship with the media, which ensured a wider reach and possibly translation of complex messages was an important enabler for the advocacy process by holding public events and disseminating research evidence. Most of the respondents acknowledged that it is difficult to do advocacy without talking with the media as one of our respondents explained: “we have a relationship with the press and media which is very good, you can't do advocacy without talking with the media….. well, most of the activities carried out especially when they concern international health week and all that, the media is usually carried along, immunization days, maternal and child health week, the media is usually involved,” (Policy Maker, State). This was also echoed by a media expert: “They call the media when they’ve set the time for the advocacy visits………..So, it wasn’t just “we have an event, come and cover”…… they insisted that the media stay all through with them and I think that’s one time, the media, without knowing it, actually helped in building the message”. (Media National). Therefore, the media is valued as a key actor in creating an atmosphere of social consensus [37] and concerns that are crucial in supplementing advocacy efforts.
However, this can at times be a double-edged sword since a negative relationship with the media can adversely affect advocacy. One respondent notes that “one of the challenges we also face in this advocacy is that the media sometimes does not even help when you are not in good standing with them……. the media do not represent those issues the way they are and they don’t give it the appropriate terms” (CSO National). Misrepresentation and simplification of media messages can constrain advocacy efforts. For example, one respondent noted that a lot of media people did not understand the Basic Health Care Provision Fund and felt it was the magic bullet to the provision of comprehensive health care and therefore reflected it like that to the populace (Policy Maker State). Another respondent noted that some media practitioners also misinterpreted the 15% budget allocation health considering it to be too small given the percentage (Policy Maker, National). It took the intervention of the policymakers to rectify this misconception.
The media itself also directly engage in advocacy work. In one instance, for example, a symposium on the role of the media in advocating for increased health sector budget for MCH in Nigeria was organized by one of the media organizations, the Health Writer’s Association of Nigeria (HEWAN) and a respondent noted the outcome of this activity was that the media promised more commitment to reporting MCH issues. Also, the 10th quarterly CS-Media forum (overcoming the effect of the recession on maternal health) was held by another media organization, the Development communications network, which brought together health writers, reporters, and civil society organizations to address the effect of the recession on maternal health in Nigeria. A respondent noted that the outcome of the event was that “the participants agreed to use their various medium to sensitize the need for pregnant women to patronize only registered maternity centers and hospitals headed by qualified personnel, also to adhere to medical advice given on nutrition to prevent complications before and after pregnancy” (Media National).
In another instance, a media conference on Maternal, Newborn, and Child Health was organized by the Africa Media Development Foundation with participants drawn from the media, government, development partners, NGOs, and CSOs. The conference was aimed at drawing the attention of media practitioners to understand their roles in reducing maternal and child death rates especially in Nigeria. These efforts increased the awareness of key stakeholders to MCH issues.
Several respondents noted specific examples of effective advocacy:
“There are some advocacy activities we directed at MCH issues. One was about, the Basic Health Care Provision Fund into the budget and having it released as well. (Media State)
“There is another advocacy that is on asking for improved funding for health generally to meet up the 15% Abuja declaration” (Media National),
"We have seen cases where some line items have been removed from the budget or the funding being cut, but because of our advocacy, those funding were returned and received their appropriate attention”. (CSO State)
Use of Champions, Influencers, and Spouses: Leadership and Elite Gendered Power Dynamics in MCH:
The use of champions and influencers in the advocacy process was considered by our participants as an enabler. Once an advocacy issue is identified, those that have the capacity, ability, and passion to drive those issues and their strengths are identified and are used to reach out to the MCH policy-makers and implementers. For example, according to a respondent, "there was a need to increase the minimum service package for mothers and children in the new Basic Health Care Provision Fund and, the wife of the President was approached and she led the advocacy that resulted in that increased package” (CSO National). An influencer could be somebody who can influence the decision of another person. A policy champion is usually a powerful individual at the national level (and or state and community levels) and having good connections with different actors and stakeholders including donors and development partners [38]. The policy champion is capable of disseminating, advocating and mobilizing support, and resources. Furthermore, the person can actively facilitate placing problems onto the policy agenda. In the words of one respondent “you need to have like champions that can mount pressures on government as it is usually difficult for civil servants to say certain things to the government… so you need people like the traditional leaders of the town, the chairmen of ward development committees at the local level” (Policy Maker, State). Respected members of society may vary, for instance, between Northern territories in Nigeria where “traditional leaders are members of the elite and so command the respect of political office holders” while in other areas such as Lagos and Benue, community committees are more likely to have influencers members [39]
In MCH, spouses of elite politicians seem to have an important role in brokering policy impact. For example, at the sub-national level (Anambra state), advocacy specifically helped in the entrenchment of MCH on the political and financial agenda. A case in point is related to the activities of the wife of the State Governor. With the backing of the state and local governments, she toured all the primary health centres in the state noting the deficiencies and advocating for safe delivery practices for pregnant women. She further requested the State Governor to provide more funds for MCH. The outcome according to one of the respondents was “the distribution of maternal delivery kits (MAMA KIT) to pregnant women present and the request to the executive governor of the state to provide more funds for MCH services which he did” (Policy Maker, State). Also, the mapping showed that she (Governor’s wife) facilitated the passage of the State Primary Health Care Development Agency bill and the release of counterpart funds for the Basic Health Care provision Fund in Anambra state in 2018 for the provision of basic minimum health package.
In another instance, an advocacy meeting on reproductive health was held by the office of the wife of the President of Nigeria to explore how to reduce the high rate of maternal and child mortalities, and child malnutrition in the country. The participants included staff of the Federal Ministry of Health, UNICEF, wives of the 36 state Governors, and the NPHCDA. According to a respondent, the outcome of the meeting was that the Minister for Health pledged Government’s support to the wife of the President’s programme on reproductive health and the Governors’ wives committed to partner with the President’s wife in implementing programmes to reduce maternal and child mortality in their respective states. Another respondent noted that: “Yes, we had cause to use champions at the community level to mobilize citizens, state-level…… we used role models that can bring attention to all these issues……some were governors’ wives, parliamentary aspirants” (NGO National). In a society where males have for long dominated public power, the emerging gendered aspect of policy is illustrated in MCH by the explicit role of female spouses. In this policy area, a power shift seems to occur with elite women being recognized and targeted as respected change agents.