Insufficient funding undermines ‘free maternal care’ policy in Kano

On a quiet, frigid Sunday afternoon, Zainab Bala, a 24-year-old entrepreneur well into the third trimester of her second pregnancy, told the three women gathered in her home in Kano that she thought it was time to go to the hospital. She was taken to the Murtala Mohammed Hospital posthaste. Her husband, Mr Bala, also joined them in the clinic.

It took a while before the providers attended to Mrs Bala. When they did, a midwife handed a list to her husband to purchase the standard items required for conducting a delivery: surgical gloves, sutures, surgical blades, sanitary pads and detergents for cleaning.

Mr Bala argued that maternal services should be free in the state’s general hospitals and, therefore, he would not buy anything. He was adamant that the midwife was trying to cheat him until other men told him that they had all bought the same items for delivery.

This type of misunderstanding happens regularly between health workers and patients in Kano public hospitals, PREMIUM TIMES learnt.

Free Maternal Care

The Kano State Government has a Free Maternal Health Care Policy, a plan that covers the costs of delivery and postnatal services in all secondary and tertiary health facilities but out-of-pocket spending is still common. Initiated in 2001, the policy targets every pregnant woman in Kano with a full benefits package covering antenatal, delivery care, and postnatal care.

The services involved in the free maternity care programme include free antenatal care (including card and antenatal drugs), free vaginal and assisted vaginal delivery (forceps and vacuum), free caesarean section (elective and emergency), free post-abortion care services, free management of ectopic and free laparotomy for obstetric complications.

Other programmes in the state that positively impact maternal health care are free treatment for children under five and free vesicovaginal fistula repairs.

How successful is the policy implementation?

Successive governments have maintained the policy so as to eliminate out-of-pocket (OOP) payments and enhance the utilisation of maternal health services.

However, a PREMIUM TIMES investigation has shown that inadequate planning and financing of the “free” maternity policy has resulted in overstretched facilities, overworked staff and dissatisfied clients.

Our findings also reveal that, due to the policy’s insufficient funding, out-of-pocket spending remains the popular method of financing maternity services in public hospitals in Kano.

“My husband spent more than N40,000 on the delivery that day,” Mrs Bala told PREMIUM TIMES in May.

Due to endemic poverty in many parts of Nigeria, including large parts of Kano, many families cannot afford medical care. Women, in particular, often struggle to pay for costly treatments, which could lead them to forgo lifesaving prenatal and postnatal care.

The leading barrier to healthcare for Nigerian women and children is the money for treatment. More than half of women reported that getting money for treatment was a severe problem in accessing health care, the Kano government said.

This was why the Kano government initiated free maternal care in all public secondary health care facilities of the state in 2001.

In May 2023, the Kano State Assembly passed the Free Maternal and Child Healthcare (FMNCH) Bill into law. This made the state the first in Nigeria to enact the law, a move that received wide commendation. The law is also supposed to provide access to quality health services for women and children.

While many residents applaud the efforts, patients and health providers said much more needs to be done, especially about funding.

“What the government provides is not enough to cater for a third of the patients going to Murtala Mohammed Hospital,” said a senior official at its Department of Gynaecology and Obstetrics.

“Most times, the medical items they provide to serve for a month don’t go beyond seven days,” said the official who agreed to speak off the record because of civil service rules on press interviews.

Residents continue out-of-pocket spending

Two days after giving birth to her second child in May, Hafsat Auwal woke up cheerful. By the standards of a woman recovering from childbirth while caring for a toddler, she was said to be feeling energetic.

But by the next morning, Ms Auwal began feeling intense fatigue, an aching back and a headache that did not respond to “ibuprofen.”

As the day wore on, her head and back pain became excruciating, and she had trouble catching her breath. Her family took her back to Murtala Mohammed Hospital, where she gave birth. At the hospital, it was a busy Monday afternoon when Mrs Auwal was wheeled into the high-risk cases area.

“It was an emergency case, and we spent more than N100,000,” Mr Auwal told PREMIUM TIMES.

Such costs of postpartum treatment were supposedly covered by the state government under the Free Maternity Act. “It’s unforeseen, and we had to get these items before they even attended to her,” Mr Auwal said.

For many people, access to lifesaving maternity treatments and medication is not available. Patients continue out-of-pocket payments – spending pushing households below the poverty line.

Recently, the President of the Nigerian Medical Association, Uche Ojinmah, said the rising costs of healthcare were pushing Nigerians deeper into poverty.

“Nigeria should develop a health sector development bank to help the local pharmaceutical industry,” Mr Ojinmah said.

In 2022, the World Health Organisation (WHO) estimated that about 80 per cent of Nigeria’s population has fallen into poverty as they struggle to pay hospital bills.

Our story, based on on-the-ground reporting and interviews with multiple sources, including families and health providers, shows that despite a law to the contrary, the Kano State Government’s underfunding of healthcare means that out-of-pocket spending remains the main method of financing maternity services in public hospitals in Kano.

Aside from patients incurring out-of-pocket payments, PREMIUM TIMES found that some problems associated with the free maternal policy are patients having to wait for long periods during antenatal care, verbal abuse by some health workers, bad outcomes such as the death of infants and complications attributable to health workers’ negligence, and difficulty in accessing drugs and ultrasound.

‘Poor maternity care’

Some residents said although maternal care is free, they found the services to be below standard. One such person was Hannatu Abubakar. Her malcontent was understandable. In 2022, the 26-year-old lost her child to “medical negligence” at the Nuhu Bamali Hospital in Kano.

“We accessed the free maternal healthcare for the birth of my first child, and the baby died due to the negligence of the nurses,” Ms Abubakar said. “It is better to pay than to experience that again.”

Now, Ms Abubakar is pregnant again and is in her third trimester. She’s been receiving antenatal care at a private clinic, and providers have informed her about a caesarean section plan.

“I will pay any amount for good maternity care,” she told PREMIUM TIMES in May.

However, only a few women are as financially buoyant as Ms Abubakar. Thousands of women rely on the state’s public hospitals for maternal services, and many share their discontent with prolonged waiting time during antenatal care in facilities offering free maternal health services.

Overstretched facilities

At Abdullahi Wase Hospital in the state, Rabi Ibrahim feels that the facility is understaffed and overcrowded, making the free maternal services ineffective.

Ms Ibrahim, a resident of the Panshekara area of the state, delivered her three children in public hospitals. The 37-year-old said she had all the children through caesarean section, the first being in 2012.

“I had my first child here, and we paid for delivery and postnatal care. It’s difficult to access the so-called free maternal services when you look at the number of women coming here,” Ms Ibrahim said, adding, “We always have to buy even the most basic things for delivery such as gloves.”

Hafsat Abdulmumin, 41, has similar concerns. She delivered a baby girl at Murtala Hospital in April via Caesarean Section. Ms Abdulmumin was on admission for three days, and her family spent N109,000 purchasing the medical items needed for her surgery.

Ms Abdulmumin said aside from the bill, “the waiting period is unnecessarily long.” She said that because the hospital is understaffed, “patients, especially those on admission, don’t get the care they deserve.”

The official of the Murtala Hospital conceded Ms Ibrahim and Ms Abdulmumin’s points but said it was “beyond our control.”

“The hospitals are understaffed, and people are coming here in large numbers, partly because primary health care centres in rural areas are not functional. Therefore, we received patients from all parts of the state coming to the city for maternity care.

“Even if the staff are determined to do their best, they can’t handle the services promised,” said the official, who said he wasn’t authorised to speak to journalists.

“The hospital gets more than 70 – 80 patients a day, most of them receiving antenatal care, while a few come for immunisation.”

Since the Kano state free maternity service provision removed user fees, data shows an increase in the number of patients receiving maternal services (Antenatal Care, delivery, and caesarean section).

However, researchers said there has yet to be a significant corresponding increase in human resources for health. The state had a ratio of one doctor to 11,500 persons as of 2023.

“This is another major constraint of free maternity services in the state and it compromises the quality of maternity services in the state,” Hadiza Galadanci, a professor of gynaecology and obstetrics, said in a reproductive health article.

There are 1,183 health facilities across Kano’s 44 Local Government Areas (LGAs). Of this number, 1,142 are primary healthcare centres, 97 per cent of the total. Most of them struggle to provide basic healthcare to people, especially in rural areas; therefore, most patients go to general hospitals in the city centre.

PREMIUM TIMES contacted Kano State Health Commissioner Abubakar Labaran for comment, but he has not responded. Mansur Nagoda, the Executive Secretary of the Kano State Health Management Board, also said he would get back to our reporter when contacted over the telephone. He was yet to do so as of the time of this report.

Maternal and child mortality remains a significant public health problem in Kano and Nigeria in general. In 2020, the latest year for which data is available by WHO, Nigeria recorded extremely high maternal deaths at 1,047 per 100,000 live births, ranking third in Africa behind South Sudan and Chad.

Women in the poorest households bear the brunt of most of these deaths. They are the least likely to access lifesaving obstetric services. According to the WHO, almost all maternal deaths are preventable with the use of quality obstetrics services.

In her research article titled, “Programmes and Policies for Reducing Maternal Mortality in Kano State, Nigeria,” and published by African Journal of Reproductive Health, Ms Galadanci said, “eclampsia is one of the major causes of maternal death in Kano State, although case fatality rate for eclampsia has reduced significantly with the introduction of magnesium sulphate in the treatment of eclampsia especially in the tertiary health facilities.”

Other major causes of death are postpartum haemorrhage, anaemia and puerperal sepsis, according to the researcher.

Underfunded Health Sector

Although the Kano State Government has increased its budgetary allocation over the years, experts believe it still needs to do more.

About N144 billion was allotted to the state’s health sector in the last five years.

The government’s total health expenditure was put at N10.5 billion in 2020; N10.7 billion in 2021; N33 billion in 2022; and N39.1 billion in 2023.

Out of the N437 billion budgeted for 2024, the government earmarked N51 billion for its health sector (11 per cent).

This falls short of the commitment in the Abuja Declaration, which Nigeria and 43 other African countries signed in 2001. The pact commits governments to spending at least 15 per cent of annual budgets on public health. The Nigerian government and the sub-unit Kano government have yet to achieve this.