By Nnenna Ibeh
When 27-year-old Emmanuella Okoli graduated from Midwifery College, and landed a job with a Nigerian government health agency three years ago, her top concern was the pay.
She had grown tired feeding off her mother who sent in cash and food regularly. But 14 months with the National Primary Health Care Development Agency, a Nigerian government department in charge of emergency maternal health scheme, the salaries suddenly stopped coming – two months first, later six months at a stretch.
“The last payment we received was August salary,” Ms. Okoli told PREMIUM TIMES in January. “We were paid our August 2014 salary in September 2014. They paid us June, July in the first week of September and then paid August towards the end of September.”
On days she could not borrow her transport bill to the office, Ms. Okoli trekked over four kilometres to get there. “Most times, I live on the money I borrow from people here in Delta and some of my colleagues whose parents can afford to send money to them,” she said.
Ms. Okoli was drafted in as part of an emergency team to help roll back Nigeria’s notorious maternal death record, to meet the globally-adopted Millennium Development Goals, MDG, whose key targets is reducing pregnancy and childbirth-related deaths by 75 per cent by 2015.
A 2014 World Health Organisation report said Nigeria lost about 40, 000 women during childbirth in 2013, second only to India.
The risk of a woman dying as a result of pregnancy or childbirth in Nigeria is about one in 15, as opposed to one in 5,000 in developed nations, Chris Akani, the Provost, College of Health Sciences, University of Port Harcourt, said in January.
Yet, Nigeria’s drive to reduce that number has been hampered by several factors, among them a failure by authorities to pay health workers, provide quality work conditions, accommodation for staffers, basic amenities such as electricity or water.
Ms. Okoli and thousands of her colleagues are victims of such failure.
Chinwe Opara, 29, who serves as a midwife in Ogun State, told PREMIUM TIMES that despite her job, she is still supported by her mother who also sends in money.
“My parents worked so hard, trained me in school for three years with all hope that I’ll take care of them but this is what they get in return,” Ms. Opara lamented recently.
The MSS programme
The NPHCDA’s Midwives Service Scheme employs over 7, 000 midwives. The scheme was implemented in 2009 as a MDG-backed project that recruits new graduates from Schools of Midwifery, unemployed midwives and retired but able midwives for deployment to health facilities in rural communities for a one-year community service. The service is mandatory for the new graduates as a prerequisite for licensing to practice in Nigeria.
Between 2013 and 2015, the programme received N1.5 billion, according to federal budget office.
Under the terms of conditions of their employment, Ms. Okoli and her colleagues are to be paid N20, 000 monthly, to be augmented by allowances from the state and local government area to which they are deployed.
They were given one year contracts, renewable on satisfactory performance and readiness to reside in the community of deployment.
The midwives are also expected to show willingness to conduct outreach and home deliveries and denounce any other appointment or formal training during the one-year period.
But many states and local government have for months and years refused to fulfil their commitments.
In Kiyawa Local Government Area, Jigawa state, a midwife identified only as Mariam, said she was yet to receive her September allowance.
“We were paid our August salary in September, so that of September, October, November and December is what we are begging for them to pay us,” Mariam told PREMIUM TIMES in January.
While the Jigawa State government has regularly paid its N30, 000 monthly allowance to the midwives and N20, 000 for the Community Extension Health Workers under the same service scheme, Kiyawa Local Government Area has never paid a kobo.
Midwives in Bwari Area Council of the Federal Capital Territory said the last time they received their LGA allowance was in the first week of January and that was for July, 2014.
The FCT midwives told PREMIUM TIMES that since 2009 when the scheme was launched, the FCT has never paid any allowance to them. They said when they approached the FCT authorities, they were promised their money “in less than no time”.
The story is the same in almost every other state. With the NPHCDA refusing to pay salaries, the midwives cannot rely on the states or local governments as stipulated in their employment letters.
Besides payments, midwives say the government has done very little to ensure the success of the programme. They complain about the lack of basic amenities such as electricity, accommodations, and water at their health centres.
Ms. Okoli said initially they were given one or two trainings, but not anymore. She said attempts to reach her focal person to find out why trainings were cancelled were fruitless.
A visit to some facilities in the FCT revealed that Primary Health Centres in Bwari, Gwagwalada and Abaji do not have access to water or even boreholes. The midwives said the absence of potable water put them and their work at risk, especially as they handle new-borns.
Of great concern
The Vice President, National Association of Nigerian Nurses and Midwives, Margaret Akinsola, told PREMIUM TIMES that issues surrounding allowance of the young midwives have become a thing of great concern for the association.
“Of course, we are aware and we are working on making sure they get their remuneration as at when due and also cancel this issue of dividing it by three different fractions – whereby part is to be paid by the federal government, another by the state government while the other is paid by the local government. We want to put a stop to that,” Ms. Akinsola said.
She said aside the allowances, the association was working on ensuring that there was definite channels through which the midwives can get their remuneration. She urged the government to act to discourage qualified midwives leaving the country in frustration.
“In those days, immediately you finish from the School of midwifery, even if you are basic midwifery holder – with the three years basic training for midwives – once you are out, you will be absorbed into the system, that’s job security.
“Day in day out these people get better jobs and leave the country, these people are not being treated well. Because if we are meeting the needs by 97 per cent in training these midwives then where are they? Are outside the country? Are most of them retired? Are we really absorbing them as we should?” she asked.
She said the association provided quality training for the 5, 000 to 7, 000 midwives under the MSS in 2013, and is now pushing to ensure midwifery science is made a course in Nigerian universities before 2020.
The management of the midwife scheme is so poorly coordinated that offers for vital trainings are often not taken advantage of.
In August 2013, during the launch of Voluntary Obstetricians Scheme, the Society for Gynaecology and Obstetrics of Nigeria promised to mentor midwives on the MSS through a memorandum of understanding with the NPHCDA.
Speaking to PREMIUM TIMES, the president of the society, Brian Adinma, said although the VOS has commenced, it was yet to be rolled out to the states due to delay by the NPHCDA to endorse guideline developed for the scheme.
Mr. Adinma, a professor of Obstetrics and Gynaecology, said the endorsement would enable SOGON disseminate the VOS to members in all sectors.
“But, we are having some bottlenecks from the National Primary Health Care Development Agency – you know they are having some monetary problem there – so the decision I have just taken is to take on the guidelines and move in ourselves. You know it is their facilities we are supposed to make use of under the MSS,” Mr. Adinma said.
He said although the agency was yet to endorse the guidelines for roll out, SOGON, through the VOS, will have to re-strategize to incorporate the scheme’s guidelines into the states at least before early February.
Mr. Adinma also thinks the agency is lukewarm about the VOS due to its inability to pay its midwives.
“Salary is a fundamental right of anybody who is working, if somebody is not paid salary what anybody can do is, appeal or taking any other measure towards making the people to pay. But I believe, if inspite of the salaries not paid they are working, they should allow us come in, when we do, and then we can make our very strong recommendations,” he said.
NPHCDA’s and states’ defence
The Head, Monitoring and Evaluation, Bwari Area council, FCT, Yakubu Makka told PREMIUM TIMES they had revenue shortfalls, and that once that was sorted they (midwives) would be paid.
“Ask them, have the states paid them? When we did not have this financial problem, we were paying them immediately we pay our staff. They are not the only people we pay, we have corper doctors and pharmacists; we pay N2 million every month as allowance,” Mr. Makka said.
He also said a committee had been set up to look into the councils’ financial issues in order to seek ways of ameliorating the plight of staff.
The Executive Secretary, FCT Primary Health Care Board, Rilwanu Mohammed, in a text message to PREMIUM TIMES, claimed he knew nothing about the owed benefits.
The Executive Director of NPHCDA, Ado Muhammad, said the noncompliance of the states to the signed agreement was a major issue in the delay of the midwives allowances. He said it was expected that after two years of implementation, the states would take ownership of the scheme while the agency supports with monitoring and retraining, among others.
He said the agency was also discussing with the states to ensure the midwives are absorbed and other needs taken care of, where possible.
“60 per cent of the challenges – water, power – of the health sector is outside the control of the sector, however, health sector is collaborating with the states and local government areas to make that happen,” he said.
On midwives leaving the country for better jobs, Mr. Muhammad said, “These are exceptional cases but however, the agency will continue its advocacy to the states to absorb and retain the midwives in the country.”
The agency’s boss said the midwives would also be deployed to locations where they are needed and where adequate incentives with update allowances will be made available.
“The midwives are adding value to the health sectors. Because we expect that as we pay their allowance from the centre, the state will also complement by paying or providing accommodation. But what we’ve realized is that some states are meeting their obligation while others are not,” he said.
Like her colleagues who are leaving Nigeria for better midwifery jobs abroad, Ms. Okoli said she would not hesitate to jump at any opportunity she gets to leave Nigeria for the US or the UK.
The case for SURE-P
Comparing NPHCDA’s scheme to the Subsidy Reinvestment and Empowerment Programme (SURE-P) midwives programme, Ms. Okoli said the MSS midwives are receiving a worse treatment.
The SURE-P Maternal and Child Health Programme (SURE-P MCH) was implemented in 2012 when it became evident that the MSS had helped in reducing maternal and new-born deaths especially in rural communities of the North East.
“The MSS has been on ground for so many years before the commencement of SURE-P MCH, and SURE-P midwives are paid regularly and up to date, there is always trainings organized for them at one point or the other and they are also provided with all they need to work. On the other hand, we the MSS who have been on ground since are totally being neglected,” Ms. Okoli said.
Two midwives under the SURE –P scheme in Dutse Alhaji Primary Health Centre, Bwari Area Council, FCT, confirmed Ms. Okoli’s claims. The midwives, who spoke under anonymity said they have been paid their salaries till date.
In contrast their counterparts in Duste Markaranta Primary Health Centre, under the MSS scheme, are yet to receive their allowances.