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Experiences with Universal Health Coverage of Maternal Health Care in Ondo State, Nigeria, 2009-2017.

I am pleased that the theme of this maiden conference of the Association of Feto-Maternal Medicine Specialists of Nigeria (AFEMSON) is the reduction of maternal and perinatal mortality. Practising in our setting can be particularly challenging due to the weak health system which leads to frustrating outcomes, with high rates of avoidable maternal and perinatal morbidity and mortality. For practitioners of fetomaternal medicine to deal with this as a major public health concern, the focus should not just be some cold statistics, but rather it must be addressed as a true everyday human story and societal tragedy.

In a recent publication (1), Elliot Main, a Stanford Professor of Obstetrics and Gynaecology, and founder of California Maternal Quality Care Collaborative was reported as saying: "When you've had a maternal death, you remember it for the rest of your life - all the details" Perhaps, practicing in our setting (like in most low and middle income countries) you may not remember "all the details" because of regularity of occurrence. However, I am sure that each of you, frontline practitioners here gathered, has had a few unfortunate human angle stories - details of which get imprinted in your memory for the rest of your life.

In my practice, I also had my own experiences, which were part of the reasons that I decided to temporarily set aside the practice of clinical medicine to get involved in top policy formulation for health and overall societal development.

As reported by Olu Obafemi (2) in his recent publication of my experiences:
"Those days I will tell people that I could never forget the cry of a
woman when she loses her child at night, because at a stage, I was
living within my clinic. It was harrowing, especially at night, between
1-2am."


As Governor of Ondo State, southwest Nigeria for 8 years (2009-2017), working with other stakeholders, we proved that even in resource-restricted settings like Nigeria, it is possible to achieve positive outcomes in terms of systematic reduction in maternal and perinatal death mortality. The Centre for Strategic and International Studies (CSIS), in its publication on the first year of ABIYE (3), succinctly encapsulated this by saying "With leadership, progress is possible."

Specifically, under my leadership as Governor of Ondo State, we commenced a unique Abiye maternal health program that offered free maternal and child health services to pregnant mothers and children less than five years old (including sophisticated referral care) that brought maternal and child health care to the doorstep of every citizen in the state. The consequence was a significant reduction in maternal mortality in the state, enabling the state to achieve the target of Goal-5 of the Millennium Development Goals. But this was not achieved without some noteworthy challenges. The purpose of this presentation therefore is to describe the philosophy that led us to focus on the delivery of free maternal health care, to summarize the methods and challenges in its implementation and to make recommendations on ways to build political will for improved delivery of maternal health care and the reduction of maternal and perinatal mortality in Nigeria. I believe that the recommendations made will be useful for policymakers elsewhere to understand the social context of health care and to prioritize the delivery of maternal health care as a social justice and human rights requirement of citizens.

Introduction

From the onset, let me make it clear that I am a firm believer in Universal Health Coverage (UHC). According to the World Health Organization (4), UHC implies that "all people and communities can use the promotive, preventive, curative, rehabilitative, and palliative health services they need of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship". This is based on the principle that everybody should receive the health that he or she needs (not what he/she can afford) without catastrophic spending.

For me, UHC is a moral, socio-economic and political imperative, and is in line with the United Nations constitution of 1948 which spells out clearly that "the enjoyment of the highest attainable standard of health is one of the fundamental rights of human beings."

The 58th World Health Assembly of 2005 encouraged countries to embrace a transition to UHC. The immediate past Director General of the World Health Organization (WHO), Dr Margaret Chan put it succinctly when she said that "Universal Health Coverage is the ultimate expression of fairness" (5). The first African Director-General of the WHO, Dr. Tedros Adhanom Ghebreyesus, has also pledged to put UHC at the "center stage" of his administration.

In Nigeria, a Presidential Summit on UHC was convened in 2014, which recommended the acceleration of work towards attainment of UHC. However, UHC as a goal cannot be achieved overnight. It requires considerable financial commitment and political will. The UK National Health Service budgeted more than [pounds sterling]100 billion for the purpose in 2015. In a recent Chatham House roundtable discussion on The Political Economy of Universal Health Coverage (6), the point was made that from experience, it is healthy citizens that create the wealth of nations and not the other way around. It is evident therefore that we cannot wait until we become "prosperous" as a nation before we implement UHC. It has to be part of our developmental aspiration to achieve UHC in order to move towards national and global prosperity. Movement towards UHC must be incremental and strategic for its full effects to be attained.

Since matching resources with health needs will always be a continuous exercise, setting priority becomes unavoidable. Every nation moving towards UHC will require an irreducible minimum of health benefit package. Most will start from the most cost-effective interventions like immunization and the need of the most vulnerable groups such as maternal and child health.

Imperative of maternal health for universal coverage

Maternal health is doubtlessly a cost-effective intervention. Beyond the economic dictates of investment in it, maternal health is a moral imperative. Giving birth is a process of perpetuating the human race. It is a divine instruction. Genesis 1:28 states: ".... be fruitful and multiply and replenish the earth..."

Our shared humanity and fundamental interest makes it incumbent on society to consider maternal health as a shared responsibility of all. Women should not be allowed to die while giving life, or as one of the popular anecdotes of ABIYE, "Pregnancy should never again be a death sentence." Put differently, the renowned founder of Safe Motherhood Initiative, former FIGO President, Professor Mahmoud Fathalla (7) once said:
"Maternity is not a disease; it is a means by which the human species
is populated. Society has more of an obligation to prevent maternal
deaths than to prevent deaths from diseases...Maternal mortality should
not be lumped together with, and ranked against other disease problems".


Clearly, this was an eloquent case made for the prioritization of maternal health and for public funding of maternal healthcare. It is critical that increased public expenditure is emphasized as a veritable form of universal health coverage.

A recent publication titled "Thinking Public" by the WHO (8) concluded that "public financing is central to making progress towards Universal Health Coverage (UHC)." Prof. David Heyman, Head of Global Health Security, Chatham House succinctly captured this by saying "by its very nature, Universal Health Coverage creates a larger role for the state in ensuring a free health financing system that market alone cannot provide. Markets cannot be effective drivers of heath care." Unfortunately, this is what the United States is learning the hard way by the controversies currently surrounding its healthcare system. This is perhaps why the United States is the only high income country in which maternal mortality rate has been on the increase. Maternal mortality rate is reported to have risen by approximately 26.6% in the USA from 2000 to 2014 (1).

The important question is whether this dismal picture could be the consequence of the promotion of market forces over public funding of health care? This is yet to be ascertained, but more comparative analysis in the coming years will resolve the question.

The situation in Nigeria has equally been depressing. While there was a decline in global maternal mortality rate (MMR) between 2000 and 2015 with many countries meeting the MDG 5 target, it is evident that MMR may have increased in the country. The WHO estimated Nigeria's MMR as 814 per 100,000 live births in 2015 (9), an increase of 30% from the 2010 figure of 630 per 100,000 live births. In contrast, the 2014 Nigeria Demographic and Health Survey (NDHS) reported a figure of 576 per 100,000 live births (11), an increase from the 545/100,000 live births reported in 2008 (12). Whichever figure is used, maternal mortality rate is extremely high in Nigeria when compared with other countries.

Since the landmark Zaria Maternity Survey in 1985 (13), successive Nigerian governments at both the national and sub-national levels have adopted the major international recommendations on prevention of maternal mortality. These include the Safe Motherhood Initiative, Millennium Development Goals (MDGs), the Sustainable Development Goals (SDGs), and the Midwives Services Scheme (14), among several others.

Unfortunately, these programs have had limited success in the country due to multiple factors including health system weakness, the lack of consistent and sustained political will to address the multiple problems of the health system, inappropriate deployment of available human and financial resources as well as poor monitoring and evaluation. The consequence has been that Nigerian women continue to die in child birth essentially from preventable causes. Some who are likely to make it are held hostage or "prisoners" in hospitals (including government hospitals) for inability to settle bills.

In Ondo State, we decided on assumption of our administration in February 2009 to do things differently. We met a poorly funded, inadequately equipped, and poorly staffed health infrastructure. It was therefore not surprising that the NDHS report of 2008 (11) showed that Ondo state had the worst maternal and child health indices in the south-western zone of the country. It was also the only state in the zone and one of the few nationwide without a state-owned teaching hospital for undergraduate and post-graduate training of health workers.

Therefore, we decided from the onset to overhaul the healthcare system and remove financial barriers that limit the access of pregnant women and children under 5 to evidence-based health care. We therefore put in place the ABIYE programme (Safe Motherhood Programme) which was essentially about:

(i) Improving the supply and demand side of services;

(ii) Removing financial barriers completely; and

(iii) Tracking every pregnant woman from conception until delivery

Eight years down the line, with all sense of modesty, ABIYE remains arguably one of the most successful healthcare initiatives in the developing world.

The Gains of ABIYE

Hospital utilization and effects on maternal mortality

ABIYE was piloted in Ifedore Local Government of Ondo state in October 2009. Within the first year, there was a phenomenal increase in the number of registrations for antenatal care and hospital deliveries. After the first year, the programme was scaled up to cover the entire 18 Local Government Areas of the State.

After two years of the programme, an Impact Evaluation conducted by the Institute of Public Health, Obafemi Awolowo University (OAU), Ile Ife, in partnership with the Bill and Melinda Gate Foundation (15) noted the following findings: 1) increased facility utilization by 69.6%; 2) increased proportion of deliveries taken by skilled attendants from 43.3% to 69.6%; and 3) reduced maternal mortality rate by 31%.

The Mother and Child Hospitals located in the cities of Akure and Ondo were commissioned in February 2010 and November 2012 respectively. To date, they remain among the busiest and most impactful maternity centres in the country. The identical mission statements of the two hospitals at inception was "to run integrated maternal and child care facilities fully poised to offer qualitative and critical interventions when required, free of charge irrespective of ethnicity or social status of patients". Data collection was in-built into the processes of monitoring the performances of the hospitals from the very beginning.

As at mid-2016, the Mother and Child Hospital Akure (MCHA) had registered a total of 139,368 patients. Out of this figure, 59,478 were antenatal patients, while 79,890 were children under 5 years of age. Total deliveries were 36,713 out of which 30,193 were vaginal, while 6,520 (17.75%) were by Caesarian operation. A facility-based 5-year audit of maternal mortality ratios at the MCHA showed a reduction from 708 per 100,000 live births in 2010 to 208 in 2014 - a decline by nearly 70% (16). What was perhaps most impressive was that contrary to what is generally believed, the average cost of care per patient was reduced by almost 50% during the same period, due to the cost saving methods that were put in place. This finding suggests that providing affordable and qualitative care for women would enable them access care before complications set in, thereby reducing the cost that would otherwise have been attributable to the management of severe complications.

The Mother and Child Hospital in Ondo City also witnessed similar salutary experiences. An assessment in mid-2016 showed that the hospital recorded a total registration of 47,032 pregnant women, out of which 19,842 were women attending antenatal care, while 25,190 were children under 5 years of age. Total deliveries were 11,600 comprising 8,872 vaginal births and 2,728 (23.5%) caesarian sections. The Hospital was also accredited for post-graduate residency training in Obstetrics and Gynaecology by the National Postgraduate Medical College of Nigeria and the West African College of Surgeons.

In efforts to build greater accountability for maternal health implementation throughout the state, we established Maternal Death Surveillance and Response (MDSR), while the Confidential Enquiry into Maternal Deaths in Ondo State (CEMDOS) was signed into law in May 2010. It mandated the reporting and compulsory investigation of circumstances surrounding all maternal deaths, irrespective of where they occur. According to the 2015/2016 preliminary report of CEMDOS, Ondo State witnessed a 70% reduction in maternal mortality rate from a baseline of 545 per 100,000 women of reproductive age (NDHS 2008) to a verifiable 170 per 100,000 in May 2016.

Health systems strengthening

The improved health care system in Ondo state has been eloquently summarized by Richard Downie, Deputy Director and Fellow with the Center for Strategies and International Studies (CSIS) Washington Africa Programme and a consultant for the CSIS Global Health Policy Center, when he said "Ondo State has established a functional and efficient health system that is responsive to the needs of its population" (17). Apart from the improved maternal health outcome, free maternal services in Ondo state resulted in overall health systems strengthening. All the major elements of the building blocks of health system recommended by the WHO were improved during the period. These include infrastructure development; human resources for health; information management; medicines, vaccines and commodities; financing; and leadership and governance.

Infrastructural development

A number of Primary Health Centres and 18 secondary health facilities were renovated and made functional, while the Mother and Child Hospitals in Ondo City and Akure were built and equipped to provide tertiary level care.

Additionally, an edict establishing the University of Medical Sciences was passed into law in December 2014. This became the first full-fledged University of Medical Sciences in Nigeria, approved by the National Universities Commission for the training of health personnel in April 2015. This was to take advantage of the other facilities put in place in the same location at the Medical Village in Ondo City, including the Mother and Child Hospital, Trauma and Surgical Center, the Gani Fawehinmi Diagnostic Centre and the Kidney Centre. The facilities in the Medical Village were later accredited for Postgraduate training in General Surgery, Orthopedic Surgery, Anesthesiology and Radiology even before the take-off of the University. Our aim was to ensure the sustenance of human resources for health in the state for the effective running of the health institutions in perpetuity.

Human resources for health

Hundreds of Doctors, Nurses and Midwives were recruited into the State workforce. The number of consultants in the state increased from 4 in 2007 to more than 70 (including eight consultants in Obstetrics and Gynecology). High quality and consistent delivery of effective services were assured through proper incentivization, the use of appropriate protocols and algorithms, and task shifting. Emphasis was also placed on staff training and re-training both locally, and internationally through partnership with Iowa State University.

Health information management

Improved data consciousness (for proper planning and in-built accountability) due to our intervention has positively impacted the health system leading to a very robust digitally-driven health management information system. This has enabled the development and implementation of policies based on evidence. As an example, the first CEMDOS report in 2012 showed that over 90% of maternal deaths were linked to mismanagement or delayed referrals by unskilled faith-based or traditional birth attendants (TBAs). This led to the development of AGBEBIYE (Safe Birth Attendant) programme designed to incentivize through cash, training in uptake of alternative vocation, with and start-up microfinance for TBAs to refer pregnant women to designated public facilities and ensure delivery at such facilities. The TBAs are therefore given dignified exit out of the trade in provision of maternity services. The programme started in February 2014. By December 2015, there had been 14,802 referrals of pregnant women by TBAs to Public Health facilities. Out of these, there were 29 sets of twins, 13 sets of triplets and one set of quadruplets.

Medicines, vaccines and commodities

We also established a policy on transparent procurement and drug package system, which ensured accountability, cost control and reduction of waste. Essential drug list now includes generic drugs, which are regularly updated.

In Nigeria, the use of modern methods of contraceptives is still very low. In 2012 for example, while in the developing world, 57% of married women use modern contraceptives, only about 10% of women used contraceptives in Nigeria. By contrast, in Ondo State, the contraceptive prevalence rate rose from 15% in 2009 to 31% in 2012.

Similarly, there has been increased immunization coverage in the State since 2009. Indeed, Ondo State won the only two editions (2013 and 2014) of the Bill and Melinda Gates Leaderships Award on Polio Eradication by States in the country. Primary health care received a new fillip which resulted in the State ranking first in 2014 under the assessment of the Primary Health Care Under One Roof (PHCUOR) policy established by the Federal Ministry of Health. It's on record that the proportion of deliveries in Ondo State has shown progressive increase in patronage of Primary Care facilities from 57.3% in 2013 to 68.7% in 2015.

Financing

The commitment of Ondo State to public financing and our drive towards Universal health coverage ensured an increase in percentage of budget allocated to health from 2.9% in 2009 to 11% in 2014 (just a few points less than the prescription of Abuja declaration of 15%). We have also built an accountability mechanism that enables the tracking of expenditure and the efficient application of Results Based Financing mechanism in partnership with the World Bank.

It is clearly evident that sickness is one the most frequent causes of poverty in many developing countries. In turn poverty is one of the greatest health risks, and the most profound perpetuator of poverty. Van Gupta et al, (18) reported in a study of six emerging economies - Chile, Mexico, China, Thailand, Turkey, and Indonesia - that the adoption of universal health coverage accounted for the increase in economic growth in all the six countries in the early to mid-2000. WHO has estimated that every year more than 150 million individuals in 44 million households face catastrophic health expenditure as a direct result of health problems. About 25 million households or more than 100 million people are impoverished due to medical expenses.

It is important at the juncture to state categorically that health care financial protection generally precedes national prosperity. Indeed, only healthy citizens can engender national development.

Leadership and governance

As aptly stated by Dr Tedro Adhanom Ghebreyesus, the Director General of the World Health Organization in June 2017 "Universal health coverage is ultimately a political choice..." The modest success in Ondo State has earned us recognitions and accolades both nationally and internationally. These include the Olikoye Ransome-Kuti Award for Excellence in Public Health, Olatokunbo Lucas Institute of Public Health Gold Medal Award, the Bill and Melinda Gates Leadership Challenge Award, and several accolades from the World Bank, Centre for Strategic and International Studies (CSIS), and Chatham House, UK which strengthened our political will and commitment to do more in health governance. The documentation of comprehensive social safety and legislative framework currently being put together in partnership with UNICEF will also strengthen further governance and sustainability issues going forward.

Challenges

In view of our modest achievement in the maternal health sector during the period, we were often inundated with questions as to how we were able to overcome the associated challenges. The major challenges can be grouped essentially into three: 1) availability and management of financial resources, 2) attitude to public provision of health care, and 3) the persistence of harmful socio-cultural practices.

Funding challenge

Despite our gradual increase in health financing as percentage of total budget from 2.9% of total budget in 2009 to 11% in 2014, we still had substantial funding challenges. However, I wish to emphasise that funding is always a challenge in a bid to satisfy human needs. However, for me governance is about choices. The choice made is what informs prioritization. Moving towards achieving proper financing of Universal Health Coverage and the Sustainable Development Goals, referred to in a recent WHO publication as "the SDG health price tag" (4), will continue to demand political will, increased public funding, taxation, social health insurance reforms, and robust accountability mechanisms. Putting cost to care and institutionalising results based financing mechanisms helped us to mitigate some of the financial challenges in the State. It was of note that due to our cost saving measures, the cost of care (drugs and medical consumables) of the average pregnant woman from conception to delivery, irrespective of mode of delivery was about 5,000 naira (USD$16.6). When some overhead costs and exigencies are added, the total cost to care for 40,000 pregnant women per year was about 480 million naira (USD$1,594,685) (i.e. approximately 12,000 naira or USD$39.9 per parturient). This meant that one million taxable adults in Ondo State, out of a population of 4 million, were only required to pay about 40 naira (USD$0.13) each per month as additional tax or earmarked social insurance fee to enjoy quality maternal care. This is much less than what an average Nigerian spends on recharge card daily. This of course does not consider salary and emoluments of workers and capital expenditures like building etc. which in any case government is obligated to continue to provide. Thus, the reason for this simple computation (which will require elucidation in a more detailed form) is to let people know that we did not have to spend much in running the highly successful free safe motherhood program in Ondo State, and that opportunities exist for creative, continued funding initiatives using diverse mechanisms.

The national health bill 2014 prescribes the earmarking of 1% of Federal Government's consolidated revenue for primary health care which will essentially be expended through the National Health Insurance Scheme (NHIS). We do not wish to go into the merit and demerit or the performance or non-performance of the NHIS in this paper. Our point of interest is that the law requires government to come up with "essential health services" to be covered under the funding scheme. It is critical to point out that maternal and under-5 health care service delivery must be part of the package.

Incessant industrial actions

One worrisome trend that really gave the State nightmares was the incessant strike actions embarked upon by different cadre of health professionals. Each time public hospitals close down those who cannot afford the use of private health facilities suffer the dire consequences. One strategy we developed to mitigate the negative impact of this challenge was to formally co-opt some private sector practitioners to offer free or highly subsidized care, after which they are reimbursed by the state government. One can understand the need (and compulsion) to stand up against injustice like inadequate emolument, irregular payment, and occasional insensitivity of government etc. However, as a medical practitioner, I passionately believe that each time we turn our backs on our patients, we take something away from the dignity of our profession. We must think deep and come up with some innovative ways to seek redress. We must also for the sake of our patients and the dignity of our profession, think of ways to redress the malignant issue of inter-professional squabbles and rivalry in the health sector.

Harmful socio-cultural and traditional practices

Although, we were able to increase the demand for maternal health services through efficient and cost-effective service delivery, some of our people still continued to patronize traditional birth attendants, faith-based attendants and all manners of unskilled workers. Our Agbebiye programme has been able to largely address this challenge, but much more remains to be done.

Recommendations

Arising from this presentation, I posit that maternal health must be a shared responsibility as epitomised by the theme of this conference, if what we achieved in Ondo State is to be scaled up for effective implementation throughout the country. The shared responsibility mantra is in line with the Global Strategy for Women, Children and Adolescent Health (2016-2030) which specifically prescribes "a multi-sectorial approach" and facilitation of "cross sector collaboration" for the implementation of effective maternal health care. Reducing preventable deaths of our women and children surely requires all hands to be on deck. Governments, political leaders, health care providers, civil society and non-governmental organizations, professional Associations, academics, nutritionists, climate change experts and social advocates and all must be involved.

Yes, climate change. Researchers at the Johns Hopkins School of Public Health (19) report that by choosing one fewer child (improved maternal and child care ultimately lead to smaller families), an individual would reduce his or her annual carbon footprint by 58.6 metric tons. This is a much higher impact than getting rid of cars which would only reduce a person's annual carbon footprint by 2.4 metric ton (Global Health Now, John Hopkins).

Finally, I would like to reiterate that investment in maternal health care (and indeed Universal Health Coverage) must be driven by strong political will and commitment. We must all learn to hold our political leaders to account. Let's move away from the mortar and brick approach as the hallmark of performance; let the benchmark performance of our political leaders in health outcomes be the ultimate indicator of success in social governance. Let's think of effective ways to make these indices resonate with the grassroots. With time, electoral appeal will carry with it evidence of ability to implement strategic health policies and programmes. Then and only then will we be able to get more commitments from our political leaders.

Conclusion

I wish to conclude this paper by drawing attention to the four key messages of Universal Health Coverage Initiative as recommended by the Elders chaired by Kofi Annan. These include that:

* Universal Health Coverage UHC is the best way to achieve the health Sustainable Development Goals;

* Universal Health Coverage delivers substantial health, economic and political benefits across populations;

* Women, Children and Adolescents must be covered by Universal Health Coverage as a matter of priority; and

* Public financing is the key to achieving Universal Health Coverage.

Our experiences in Ondo State suggest that universal health coverage of maternal health can be achieved through delivery of free health services, and that this is a feasible approach even in resource-poor settings. I commend this to advocates and health policy implementers at national and sub-national levels in sub-Saharan Africa.

Acknowledgement

This keynote address was delivered by Dr. Olusegun Mimiko at the Maiden Scientific Conference of the Association of Feto-maternal Specialists of Nigeria (AFEMSON) on the theme "Reduction of Maternal and Perinatal Mortality" in Lagos on July 22., 2017. Dr. Mimiko is a medical doctor and is the immediate past Governor of Ondo State, one of the 37 States in Nigeria.

References

(1.) ProPublica. The last person you'd expect to die in childbirth - based on the experiences of Elliot Main. May 12, 2017. https://www.propublica.org/.../die-in-childbirth-maternal-death-rate-health-care-system

(2.) Mimiko's Odyssey, A Biography of Revelations, Olu Obafemi, 2017.

(3.) Centre for Strategic and International Studies (CSIS), in its publication on the first year of ABIYE

(4.) WHO. What is universal coverage? Accessed from www.who.int/health_financing/universal_coverage_definition/en/. August 17, 2017.

(5.) Chan Margaret: My decade at the WHO: dirty fights and steps toward universal coverage. https://www. statnews.com/2017/06/20margaret-chan-who-director-general/.

(6.) Chatham House. The political economy of universal health coverage. Centre on Global Health Security, Universal Coverage Policy Forum, June 6, 2017. http://www.chathamhouse.org/event/political-economy-universal-health-coverage. Accessed July 31, 2017.

(7.) Fathala M. On safe motherhood at 25 years: Looking back, looking forward. Published by Hands on for Mothers and Babies. www.handsonformothersandbabies.org 2012. www.birgmingham.ac.uk/Documents/heroes/on-safe-motherhood-fathalla.pdf.

(8.) WHO. Towards UHC: thinking public. www.who.int/health_financing/documents/towards-uhc/en/

(9.) World Health Organisation. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva, Switzerland: World Health Organization, 2015.

(10.) National Population Commission [Nigeria]. Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission, Federal Republic of Nigeria and MEASURE DHS+ ORC Macro.2009

(11.) National Population Commission [Nigeria]. Nigeria Demographic and Health Survey 2008. Abuja, Nigeria: National Population Commission, Federal Republic of Nigeria and MEASURE DHS+ ORC Macro.2009

(12.) Harrison K. Childbearing, health and social priorities: a survey of 22,774 consecutive hospital births in Zaria, northern Nigeria. BJOG 1985; 92 Supplement 5, 1-119.

(13.) National Primary Health Care Development Agency. The MDG-DRG funded Midwives Services Scheme: Concept, Process and Progress. 2nd edition. Abuja: NPHCDA, 2012.

(14.) Mimiko O. Mobilising resources for achieving MDG-5: the Ondo state example. Paper presented at the 2nd Annual Safe motherhood lecture organized by the Women's Health and Action Research Centre (WHARC), Abuja. FCT. 2010.

(15.) OAU evaluation of Abiye program

(16.) Oyeneyin LO, Akintan AL, Aderoba AK and Owa OO. Maternal mortality ratio in a tertiary hospital offering free maternity services in South-west Nigeria: A five-year review. Trop J Obstet Gynaecol 2017; 34: 112-5.

(17.) Downie R. US Centre for Strategic and Int'l studies lauds Ondo government for functional health care system. Accessed: http://www.richievoice.com/2016/09/us-centre-for-strategic-and-int-studies-html. August 25, 2017.

(18.) Gupta V, Kerry VB, Goosby E and Yates RN. Politics and universal health coverage - the post-2015 Global Health Agenda. New Engl J Med. 2015 (Sep 3); 373: 885-889.

(19.) John Hopkins University. Climate change and measurable impact. Johns Hopkins Bloomberg School of Public Health Global Health Programn2016. Accessed from: https//www.globalhealthnow.org/topics/climate-change. August 27, 2017.

Olusegun Mimiko

Former Governor, Ondo State, Nigeria (2009-2017). 1, Mimiko Street, Ondo City, Ondo State, Nigeria

(*) For Correspondence: E-mail: segunmimiko@gmail.com
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Title Annotation:COMMENTARY
Author:Mimiko, Olusegun
Publication:African Journal of Reproductive Health
Date:Sep 1, 2017
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