Tackling barriers to health facility attendance in Northern Nigeria
Understanding why women and their children do not attend health facilities is crucial in order to improve programmes that seek to tackle undernutrition and ultimately broaden their reach.
Experience from northern Nigeria shows that by embedding research capacity in a large maternal, newborn and child nutrition project can lead to improvements in the design and implementation of interventions. Furthermore, this research can inform advocacy to promote government action.
The UK Department for International Development (DFID) funds the Working to Improve Nutrition in Northern Nigeria (WINNN) programme, which is seeking to improve the nutritional status of over 6 million children across five states (Kebbi, Katsina, Jigawa, Zamfara, and Yobe). WINNN provides micronutrient supplementation for pregnant women and children under five years through Nigeria’s biannual Maternal, Newborn and Child Health Week Campaign (MNCHW).
MNCHW is a platform for essential interventions in the absence of strong routine primary health services. However, a common challenge in the effective implementation of MNCHW is that many women and children are not visiting facilities during MNCHW to benefit from the services available.
How can problem-led research design help?
The independent Operational Research and Impact Evaluation (ORIE) component of WINNN found that women’s attendance to health facilities is affected by:
- Lack of knowledge amongst communities about the programme, the services available and their health benefits
- Confusion and competition between MNCHW and immunisation campaign days
- Limited number of facilities providing MNCHW services.
From these findings, ORIE recommended:
- Share messages in the appropriate form, and through the right channels. For example, community volunteers and religious leaders could motivate men to encourage women to attend MNCHW, and the development and communication of messages that are appropriate for particular audiences (e.g. in local dialect) and that include details of the health benefits of MNCHW interventions, as well as their dates and location.
- The national MNCHW strategy should be adjusted to focus on delivering a simple set of interventions that do not require highly skilled staff. This change would allow an increase in the number of health facilities and outreach posts through which MNCHW is delivered.
Increasing community awareness
Following this research, WINNN made adjustments to the MNCHW strategy to increase awareness and acceptance amongst communities. WINNN has tested new messages to more clearly explain what the services are that MNCHW offers and their benefits. It is also engaging and recruiting community volunteers, community dialogue and places of worship to improve understanding. The challenge is now to reach poor households where up to 50 per cent of children, many of whom need the interventions the most, have been missed by MNCHW.
Improving access to facilities
WINNN shared findings during a review of the Nigerian Government’s MNCHW guidelines. MNCHW services are now present in all eligible health facilities, which have risen from two health facilities per ward. Subsequently, revised guidelines have been shared with all states and were used in the most recent rounds of MNHCW, which began in November 2014.
Funding from government now needs to be significantly increased to ensure that the services can be improved and maintained. Alongside this, the release of funds needs to happen more quickly to ensure services can be provided.
WINNN’s implementation of ORIE recommendations and the roll out of new national MNCHW guidelines should continue to be monitored and documented to see if more people attend MNCHW, including those in most need.
The experience of WINNN and ORIE suggests that embedding research capacity in a service delivery programme can provide useful and timely evidence for ongoing learning to strengthen implementation and advocacy efforts.