Nigeria Subsidy Reinvestment and Empowerment Programme (SURE-P): Maternal and Child Health Initiative

In Nigeria, more than one in 10 children will not survive to see a fifth birthday, and nearly one in 20 women will die in childbirth. In collaboration with the Government of Nigeria, researchers evaluated a program that aimed to save the lives of mothers and their babies by improving access to reliable health services and increasing the demand for these services.

In many developing countries, pregnant women and infants are at risk of dying from often-preventable disease and complications related to pregnancy and birth. Prenatal care, midwife assistance and proper health facilities all help improve survival rates and ensure healthy births, but even such basic services are often not available or accessible to women in Nigeria. 

Context

Nigeria, Africa’s most populous country, cut maternal and infant and child mortality by half between 1990 and 2008. Still, with an estimated 36,000 women dying annually in pregnancy or during childbirth Nigeria accounts for 13 percent of the world’s maternal deaths. Reasons include a shortage of trained midwives, low quality health clinics, high costs for patients, and low awareness of the importance of prenatal care and giving birth with a midwife or another trained health worker. The Government of Nigeria has been introducing reforms to improve health care. The evidence gathered from this impact evaluation can help policymakers in future maternal-child health care planning.

Intervention and Evaluation

The Government of Nigeria’s SURE-P Maternal and Child Health Initiative (SURE-P MCH), which ran from 2012 through 2014, and was designed to improve health care for pregnant women and their babies. There were two main components:

1. Improving the supply of services. This included training and placing midwives and community health extension workers in 1,000 previously under-staffed health facilities; training tens of thousands of village health workers to act as a liaison between pregnant women and primary health facilities; and upgrading facility infrastructure and providing drugs and commodities.
2. Improving the use of services. This included cash transfers for pregnant women who registered at a participating primary healthcare center, got health check-ups while pregnant, delivered at a health center, and took their baby for the first series of vaccinations. Women received cash each time they meet one of the conditions, up to a total of about US$30. An informational campaign was also carried out on the availability and benefits of maternal healthcare.
3. As part of the move to improve services, the program included a component to measure the impact of financial and non-financial incentives (clocks, uniforms and other items) on midwife retention.

The program was active in 1,000 public primary healthcare facilities spread across Nigeria’s 36 states and the capital region of Abuja.

Evaluation

The impact evaluation measured the overall program’s effect on the health of women and infants, testing whether monetary or non monetary incentives are better for encouraging midwifes to stay on the job, and measuring the impact of conditional cash transfers on women’s use of health services.

1. Because the health program was not randomly assigned when rolled-out, researchers used the quasi-experimental difference-in-differences method to match program areas with non-program areas to measure impact of the overall health program.
2. To measure the impact of incentives on retention of midwives, the evaluation used cluster level randomization – at the health facility level – to randomly assign midwives to one of four groups. One group qualified for financial incentives, one group qualified for non-financial incentives, one group qualified for both, and the control group receives no incentives.
3. To test the marginal impact of conditional cash transfers within the broader program on women’s use of skilled birth attendants and prenatal and antenatal check-ups, researchers randomly assigned health facility clusters to one of two groups. One group offered cash transfers to women who meet one or more conditions, while the other was the control group and did not offer any conditional cash transfers.

Surveys collected data from recent mothers and their households, midwives, health facility managers, and other local leaders.

Policy Impacts

Nigeria introduced a program in 2009 to improve the availability of midwives at health clinics. Retentions, however, was a problem, and the SURE-P health initiative was designed with that in mind. The results of this evaluation are feeding into policymaker discussions on what steps can be implemented to boost retention of skilled midwives, while encouraging women to use health services.