Evaluation of Maternal Health Accountability in Nigeria

Total Awarded: $2.2 million
Duration: 2013 - present
Total Grants: 7
Geographic Focus: Nigeria

Background

In 2013, MacArthur began funding a portfolio of seven grantees working to increase government accountability for maternal health in Nigeria. Since then, grantees have been employing a combination of four accountability strategies—budget analysis, community mobilization, legal approaches, and maternal death audits—to address this issue at federal, state, and local levels in 12 Nigerian states and the Federal Capital Territory (FCT).

At the same time MacArthur hired EnCompass, LLC to assist the Foundation in refining the portfolio's theory of change and evaluate progress toward the portfolio's intended results. EnCompass also provided technical assistance to each portfolio grantee in order to build their individual and collective capacity for monitoring, evaluating, and learning from their work.

In 2014 EnCompass conducted a baseline evaluation that examined the maternal health landscape in Nigeria before grantees began implementing activities, as well as a midline evaluation in 2015 to assess the portfolio's progress and identify strategies for amplifying grantee-level and portfolio-level effectiveness. In 2017, MacArthur provided its final round of 3-year awards to each of the 7 grantees in order to consolidate gains that had been achieved over the course of the portfolio's implementation period.

What We Evaluated

In 2016, the Foundation commissioned EnCompass to conduct an endline evaluation of the portfolio with two purposes in mind: to provide evidence to share with the maternal health field on which accountability areas—and which interventions in each area—have shown to hold the most promise for building government accountability for maternal health in Nigeria; and to enhance the sustainability of the organizations  by providing information that identifies areas in which grant activities should continue to focus.

The evaluation used a mixed-methods design, including individual and group interviews and focus group discussions with key stakeholders, analysis of grantee monitoring data, and a desk review of relevant documents, such as findings from the 2013 and 2015 evaluations.

What We Learned

The evaluation surfaced key findings related to the four accountability strategies employed by grantees:

• Data collected on budget analysis reveal that, although this strategy is slower to show concrete progress in increasing budgets, it is nevertheless an important pathway for continued focus. This pathway faces several hurdles related to slow bureaucratic processes, competing priorities for health allocations, and the impact on overall government budgets in times of economic fragility. However, there has been progress in government stakeholders' understanding of the importance of maternal health issues and beginning to prioritize maternal health in their budget-planning processes. Government stakeholders at federal, state, and local levels are using evidence produced by CSOs to make decisions about funding related to maternal health. Coalitions of government stakeholders and CSOs such as Accountability Mechanism for MNCH in Kano State (AMKASS) and Maternal, Newborn, and Child Health Programme (MNCH2), also provide a promising model of government–CSO collaboration that should be expanded in the future.

• Findings related to CSO mobilization indicate that this strategy has proven to be an effective way of holding the government accountable for maternal health over the grant portfolio's lifetime. CSOs have increased collaboration and formed more CSO coalitions since baseline, expanding the platform for raising awareness and progress on maternal health and government accountability for maternal health.

Maternal death audits, which are in-depth systematic reviews of maternal deaths to determine the underlying factors that contributed and to prevent similar future deaths, have had the most concrete evidence of progress in holding government accountable for maternal health. This accountability strategy shows great promise for the future, as it has produced clear evidence on the quality of maternal health services in facilities and has led to improvements in health facility infrastructure and services. Maternal death review committees have been institutionalized in state-level government policies.

• The evaluation confirmed that taking a legal approach was not as successful a strategy; the number of maternal death or injury cases has not increased substantially over the 3-year grant period. The barriers to litigation (including religious and cultural factors that hinder community members from bringing cases to court, slow litigation processes, constitutional barriers, and lack of expertise and financial incentives for lawyers to take on these types of cases) were too great to make progress. As a result, grantees sought other pathways to advance government accountability for maternal health through non-judicial mechanisms of redress. By acknowledging these limitations, paralegals and other community-based stakeholders are providing citizens with an alternative to seek redress and, therefore, a path forward for using legal approaches to increase accountability for maternal health in Nigeria.