• Users Online: 261
  • Print this page
  • Email this page

Table of Contents
Year : 2021  |  Volume : 26  |  Issue : 1  |  Page : 44-49

Implementation of a Free Maternal and Child Health Programme in a Nigerian State

1 Government House Enugu, Nnamdi Azikiwe University, Awka, Nigeria
2 Department of Community Medicine, College of Medicine, University of Nigeria, Enugu, Nigeria
3 Department of Physiology, Nnamdi Azikiwe University, Awka, Nigeria

Date of Submission05-Jul-2020
Date of Decision22-Aug-2020
Date of Acceptance14-Sep-2020
Date of Web Publication21-Oct-2020

Correspondence Address:
Arthur Idoko
Department of Community Medicine, College of Medicine, University of Nigeria, & Enugu State Agency for Control of AIDS (ENSACA), 3/41 Kingsway Road, GRA Enugu.
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_44_20

Rights and Permissions

Background: The Government of Enugu State as a policy response to reduce maternal and child mortality and morbidity in the state introduced the Free Maternal and Child Health (MCH) programme for all pregnant mothers and under-5-year-old clients in public health facilities across the state in 2007. Materials and Methods: Forty-three health facilities, 487 clients of the public health facilities, 43 health facility workers, and 8 directors of the State Ministry of Health and the State Hospitals Management Board were randomly selected through a multistage sampling technique involving stratified sampling techniques. Various instruments, namely pretested structured questionnaire, in-depth interview, and document review, were used to elicit data for the appraisal of the programme in terms of concept, policy and plan, implementation, management, and outcome. Data obtained were analyzed and variables tested for significance. Results: Our findings indicate that more than 60% of the clients are aware and utilize the free MCH programme. There was an overall reduction in maternal deaths, and an increase in the number of deliveries in public facilities since inception of the programme in the state. There was also a significant improvement in the MCH service uptake and high clients’ satisfaction. Major setback was inadequate supportive supervision. Conclusion: There is a huge need for increased awareness creation regarding the programme to enhance utilization, especially in the rural areas. Comprehensive baseline data of the health indices of the affected population are paramount to any future comprehensive programme assessment and are hence recommended.

Keywords: Child, Enugu state, free, healthcare, maternal, programme

How to cite this article:
Uzor F, Idoko A, Nwobodo E. Implementation of a Free Maternal and Child Health Programme in a Nigerian State. Int J Med Health Dev 2021;26:44-9

How to cite this URL:
Uzor F, Idoko A, Nwobodo E. Implementation of a Free Maternal and Child Health Programme in a Nigerian State. Int J Med Health Dev [serial online] 2021 [cited 2021 Jan 20];26:44-9. Available from: https://www.ijmhdev.com/text.asp?2021/26/1/44/298786

  Introduction Top

The past 15 years witnessed major declines in child and maternal mortality and progress in the fight against human immunodeficiency virus, tuberculosis (TB), and malaria in developing countries following the Millennium Development Goals programme.[1] The follow-up Sustainable Development Goals have also come with its own component of maternal and child healthcare providing good prospects for healthcare delivery in the developing world.

Maternal mortality rate in Nigeria was put at 814 per 100,000 live births in 2015 with a wide variation across the different regions of the country (165 in south west to 1549 in north east). The north east region in essence contributes 75% of the deaths.[2]

A number of studies reported that traditional birth attendants as opposed to skilled health worker manage more than 50% of all deliveries in Enugu State.[3],[4],[5],[6]

Nearly 45% of Nigerian women and 75% of women from Northern Nigeria give birth in their homes with the assistance of traditional healers.[2] Contributory factors to this are the delays in accessing healthcare which include ignorance/delay in decision making, delays in access roads and good transportation network, and delay in the availablity of appropriate competence and equipment at available health facility.[3],[4],[5],[6]

The Government of Enugu State introduced a free maternal and child health (FMCH) care programme in January 2008. The programme was designed to be a joint venture of the state and its 17 Local Government Areas (LGAs) making joint contributions to offsetting the bill of free health services for all prospective mothers and under-5 aged children in the state.

Included in the health package of the FMCH programme is maternal health (antenatal care (ANC) 12–40 weeks, including routine laboratory investigations and drugs, and all deliveries such as safe delivery, basic emergency obstetric care (EOC), comprehensive EOC, postnatal care up to 6 weeks) and child health (malaria, acute respiratory infections, diarrhoea, growth monitoring, nutritional supplement, health education, de-worming, and febrile convulsions). These packages are to be offered on the basis of the Minimum Service Package. The target groups for the FMCH programme of the State are pregnant women and children who are under the age of 5 years.

The aim of this study was to identify what is working well as well as negative implementation issues/gaps as perceived by the users and implementers of the free maternal and child health programme to provide the basis for improvement plans for the current and future health programmes in the state. We asked some questions and developed pairs of hypothesis in order to achieve the objectives:

  • Are the target beneficiaries of the programme aware and utilizing the FMCH service?

  • Are the health facilities or service delivery points for FMCH service adequate in terms of numbers and skills of providers, equipment, and commodities and of the guidelines to ensure standardized service delivery?

  • Are there gaps in implementation of the FMCH implementation in the state?

In addressing these questions, we hypothesized that 70% of pregnant women between the ages of 15 and 49 are aware of and utilizing the FMCH services; that health facilities or service delivery points for FMCH service is adequate; and that there are no gaps in implementation and practices.

  Materials and Methods Top

Study area

This study was conducted on Enugu State, South East Nigeria. Enugu State shares boundaries with Benue State to the North East, and Kogi State to the North West, Anambra State to the South West, Ebonyi State to the South East and Abia and Imo States to the South South. Enugu State has a population of 3,100,000. There abound also numerous private hospitals and health facilities.[7]

The service delivery points included for the implementation of the programme are district hospitals, subdistrict hospitals, cottage hospitals, health centers, and health clinics.

Study design

This is a cross-sectional descriptive study where data are collected from attendees to health facilities who meet the criteria for participation as well as from staff at the various facilities.

Study population

Women not less than 6 weeks pregnant and within 42 days post delivery attending antenatal or postnatal clinics in the designated health facilities were participants in the study. Only ANC attendees and mothers bringing their under-5 children to the health facility were eligible for the survey.

Study instrument and data collection

The instruments for this study consisted of a pretested interviewer administered questionnaires to ensure uniform answers. This questionnaire was administered to attendees to the health facilities that meet the criteria for participation and willing to participate in the study. On the other hand, on-the-spot interview was conducted with staff at the facility at the time of visit until sample size was achieved. Data collectors were trained on the process of data collection and were also involved in the pretesting and questionnaire revision. The secondary data were sourced from journals, books, and extracts of reports of the Ministry of Health, the State Health Board, the health districts, and health facilities in respect of commodities, equipment, and manpower dispositions which were all analyzed.

Ethical considerations

Ethical approval was secured from the Ethics Committee of the Enugu State Ministry of Health. Free verbal and informed consent was sought and instruments administered to consenting respondents. In the unlikely event, some sort of information was sought from children under-5 years of age, and free verbal and informed consent was sought from the parents. All aspects of the questions were explained to the respondents prior to administration of questionnaires.

Sampling technique

Sampled facilities and subjects in this study were selected through a multistage sampling method involving stratification.[3]

Enugu was stratified into seven zones based on the seven health districts of the state. The sample sizes of the facilities are expected to cover the component LGAs of each of the seven health districts of the state to allow for fair representation. A total of 18 primary health center (PHC) facilities and 18 secondary health facilities in the 7 districts were sampled. In each of the health facilities, at least one skilled staff was interviewed. The target numbers of policy makers of four out of a possible eight directors were interviewed to obtain a wide range of opinion on the programme implementation. A total of 400 clients of the FMCH programme were interviewed. The summary of the samples are: Facilities staff, n = 463; FMCH clients, n = 429; policy makers, n = 4; managers of the programme, n = 4. Policy makers and managers of whom are members of the FMCH Steering Committee.

Statistical analysis

The transcripts of the interviews and the analysis of the questionnaires from the clients, health workers (implementers), managers, and the policy makers were compared between and among themselves and also with the previous related data. The statistical tools include Epi-info and SPSS. Variables were tested for significance and correlation using the Fischer and Pearson’s rank correlation methods, respectively.

  Results Top

The results of the findings in respect of the level of awareness of the availability of the FMCH programme in the state are summarized in [Table 1]. The table shows that both urban and rural women are aware of the availability of the FMCH programme of the state. There is a slight difference in the level of awareness of the availability of the programme between the women resident in declared urban vs those resident in the rural areas of the state. The level of awareness of FMCH programme among rural women interviewed in the course of this study shows a level of just over 60%. In contrast, the level of awareness of the FMCH programme among women resident in the urban area is 80%.
Table 1: Utilisation and awareness of the FMCH programme

Click here to view

Similarly, the level of utilization of the FMCH programme among the two groups of clients shows a higher level of utilization in the urban area (80%) compared to the rural area (<60%). In general, there is a statistically significant (P < 0.05) difference in both the utilization and awareness of the availability of the FMCH programme among prospective rural and urban MCH clients. Among the facility staff interviewed, there is 40% level of understanding of the MCH guideline by staff at the PHC facilities that are mostly in the rural areas. At the top-level hospitals, 80% were reported to having a working understanding of the document. The availability of drugs for the FMCH service is poor at levels of 60 and 25% for the secondary hospitals and the PHC facilities, respectively [Table 2].
Table 2: Perception of facility staff officers in charge of health facilities on FMCH implementation

Click here to view

The sampled health facilities from each of the zones surveyed indicate a substantial level of infrastructural support. For instance, all the district hospitals have water and power supply, alternative power source, and basic EOCequipment [Table 3]. The level of equipment/facilities available for MCH services in the district hospitals is not replicated in all the secondary health facilities surveyed. Only about 11% of the secondary healthcare facilities have any EOC equipment and none of PHC facilities has the EOC equipment (although EOC is not supposed to be offered in any PHC facility according to the national policy on health).[8] All the health facilities have at least a skilled staff in attendance for maternal and child health clients.
Table 3: Availability of supportive infrastructure across the different health facilities

Click here to view

In general, all the district hospitals offer the full range of MCH services and reported to having the equipment, skilled staff, and capacity to offer the services. In contrast, not all the secondary healthcare facilities surveyed are able to offer the full scope of the FMCH services [Table 3].

In respect to child health, all the service packages are available in all the categories of health facilities surveyed in the course of this study. All the 7 district hospitals and 36 secondary and primary healthcare facilities offer the full range and scope of the child healthcare services provided for in the FMCH benefit package of Enugu State as reflected with the skilled staff on call.

Integrated supportive supervision is a mechanism employed to assure compliance and attendance to duty by the health workers. The findings of this survey show that only 13% of the PHC facilities are supervised. This is of significance to compliance of facility staff to service standards with potential impact on quality of care and absenteeism rates of the staff; the secondary health facilities, however, appear to be better supervised with 87% reporting having supportive supervisory visits in the last month.

The clients in both the urban and rural areas report that the staff attitude to work and the quality of service were both good. The urban clients report a longer waiting time compared to the rural counterparts. The results of perception of the provision of the FMCH services in 43 public healthcare facilities reflect that the staff attitude to work was perceived as poor by 40% of the clients and waiting time is reportedly good or very good by more than 60% of all clients seeking MCH services in public health facilities [Table 4].
Table 4: Maternal/clients perception and satisfaction

Click here to view

From the available State Ministry of Health HMIS records, we found an increase in deliveries in public health facilities in the state from 2007 when the FMCH programme was instituted to 2010 with a commensurate reduction in maternal deaths [Table 5].
Table 5: Maternal death rates in public health facilities in Enugu state

Click here to view

  Discussion Top

In this study, the awareness/level of utilization of the free healthcare services offered was assessed. The perception of the recipients and staff/care givers as well as available services and supportive infrastructure at the different facility care levels was identified.

There is a relatively high level of awareness of the availability of the FMCH services in the state among the urban and rural clients at over 80% and 60%, respectively. The key means of information about the services is the radio and the TV and from relatives and members of the community. These findings are consistent with results from previous studies.[9],[10],[11],[12],[13]

The efforts of the healthcare staff in community mobilization is comparatively low with only an average of 13% of all clients learning of the services from them.

Many health seekers do not access healthcare in public health facilities due largely to the poor attitude to work of the public health worker.[9],[14],[15],[16],[17] This is confounding given the relatively higher level of staff in public health facilities and the free health service. The results of this investigation showed that many of the potential beneficiaries do not believe that the services are actually free; that the staff will be at the facilities to give the service; or that the quality of care is good enough. There are clear attitudinal issues affecting the uptake of the free service. This has been documented by other authors.[3],[18],[19]

The scope of the FMCH healthcare package might be an issue as regards the child healthcare package. For instance, there are no provisions for dental care, mental care, and surgical services for the under-5 child. It is not indicated what role the national social health insurance and private health insurance can play in the scheme.

There are as yet many unmet maternal and child health needs in the state, including specialized obstetric and neonatal care services.[20] The secondary health facilities do not have doctors in these specialties. The state understands that it might be too challenging to spread its lean health resources over the seven health districts to deliver a more comprehensive package of its FMCH programme to the entire citizenry. This study, however, throws up the need to explore other avenues of attracting specialists by the state government without necessarily employing more staff as a public–private partnership approach may present.

A majority of staff at facilities emphasized that advent of the free healthcare programme increased amount of work they do at duty point. They have a feeling that this has not proportionally reflected in their take home pay. A concern reflected in similar studies that had been conducted in the past.[10],[11],[21],[22],[23]

There had been a steady increase in the level of awareness, level of utilization of the facilities with a pooled total of over 70% among both the urban and rural clients. Beside the provision of the fund, we found that there are issues with fund management ranging from late disbursement which can have negative implications on the availability of service and drug replenishment at the service delivery points. The injection of donated drugs to the FMCH programme is probably a buffer for the funding gap. The Federal Ministry of Health and PATHS 2 are some agencies that have provided health commodities that are being applied in the FMCH programme.[24]

There is lack of regular monitoring and supervision of the healthcare staff by the State Hospitals Management Board and the State Ministry of Health to ensure staff attendance to work, compliance to guidelines and up-scaling of skills sets especially at the PHC where the bulk of potential users of this service reside (the rural poor). Our findings indicate a low level of supervisory visits to the PHCs relative to the secondary healthcare facilities at disproportionate rates of 13% vs 87%, respectively. There is no evaluation of the progress of the programme to determine whether there has been value for money or for strategic/service improvement planning.

Deliveries in public health facilities in Enugu State have increased since the commencement of the FMCH programme. This has also yielded a commensurate reduction in maternal deaths in public facilities. This further buttresses the fact that the free user fees has positively increased uptake of services. This is as reflected in similar studies.[25],[26],[27]


The study called for a lot of visits and travels to near and distant hospitals and health centers which demanded a lot of logistics and funding. However, the commitment of members and support from the ministry of health was quite helpful.

A number of staff in the facilities felt distracted from work by the interviews and collection of data, so were not readily cooperative. To this view, the interviewers were cordial explaining the gains and importance of the study even to them as health practitioners.

  Conclusion Top

The FMCH Programme in Enugu State is improving the health indices of the state in terms of reduction in maternal deaths and percentage deaths of deliveries. The number of deliveries at public health facilities has also increased tremendously since the inception of the programme.


The FMCH programme when adopted by other states in Nigeria would help improve healthcare access to the masses.

There is need for improvement in the supportive supervisory visits to healthcare facilities to encourage commitment to duty of staff and employees, improve on the job capacity building as well as adherence to global best practices.

Increased awareness creation regarding the programme is necessary, especially in the rural communities, to enhance utilization.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

From MDGs to SDGs WHO launches new report. Cited January 20, 2018. www.who.int/mediacentre/news/releases/2015/mdg-sdg-report/en/. [Last accessed on 2018 Jan 20].  Back to cited text no. 1
Fawole OI, Adeoye IA Women’s status within the household as a determinant of maternal health care use in Nigeria. Afr Health Sci 2015;15:217-25.  Back to cited text no. 2
Onah H, Eze L, Ikeako C, Iloabachie GC Factors associated with the use of maternal services in Enugu, south-eastern Nigeria. J Soc Sci Med 2006;63:1870-8.  Back to cited text no. 3
Olatunbosun OA, Edouard L The teaching of evidence based Reproductive Health in developing countries. Int J Gynaecol Obstet 2017;56:171-6.  Back to cited text no. 4
Ransome Kuti O Child health in Nigeria: Past, present and future archives of disease in childhood. Arch Dis Child 1986;61:198-204.  Back to cited text no. 5
Plante R, Malonfent R Reproductive health and work: Different experiences. J Occup Environ Med. 2017;40:964-8.  Back to cited text no. 6
Uzochukwu BSC, Okwuosa C, Ezeoke O, Onwujekwe O Free maternal and child health services in Enugu State, South East Nigeria: Experiences of the community members and Health care providers. Int J Med Sci Public Health 2015;2:158-70.  Back to cited text no. 7
Federal Ministry of Health. National Policy on Health. Abuja, Nigeria: Government of Nigeria; 2006.  Back to cited text no. 8
Harries J, Stinson K, Phyllis O Healthcare providers’ attitudes towards termination of pregnancy: A qualitative Study in South Africa. BMC Public Health 2009;20099:296.  Back to cited text no. 9
Burnham G, Pariyo G, Galiwango E, Wabwire-Mangen F Discontinuation of cost sharing in Uganda. Bull World Health Organ 2004;82:187-95.  Back to cited text no. 10
Witter S Service and population-based exemptions: Are these the way forward for equity and efficiency in health financing in low-income countries. Adv Health Econ Health Serv Res 2009;21:251-88.  Back to cited text no. 11
Belaid L, Ridde V An implementation evaluation of a policy aiming to improve financial access to maternal health care in Djibo district, Burkina Faso. BMC Pregnancy Childbirth 2012;12:143.  Back to cited text no. 12
Khim K, Annear PL Strengthening district health service management and delivery through internal contracting: Lessons from pilot projects in Cambodia. Soc Sci Med 2013;96:241-9.  Back to cited text no. 13
Okenwa K, Uzor F, Nwobodo E, Rogues A The District Health System. Health Issues. 2009 [cited January 20, 2018]. www.nas.org.ng. [Last accessed on 2018 Jan 20].  Back to cited text no. 14
Nwobodo E Reproductive health issue of the adolescent in Africa: Review and commentary in Nigeria. J Physiol Sci 2002;17:1-8.  Back to cited text no. 15
Idoko CA, Idoko CI, Chidolue IC Attitude of women in a Nigerian local government to reproductive health following health education intervention. Afr Health Sci 2019; 9:4.  Back to cited text no. 16
Idoko CA, Omotowo IB, Agunwa CC, Okeke C, Obi IE, Ndu AC, et al. Effect of health education on reproductive health knowledge of women in two local Government Ares, South East Nigeria, a cross-sectional study. Int J Med Health Dev 2017;22:130-7.  Back to cited text no. 17
  [Full text]  
Sagir VV, Aditi C, Samarasingha M, Sworoop TJ Maternal and child health services utilization in coastal Karnataka. J Young Investig 2009;19:15.  Back to cited text no. 18
Uzochukwu BSC, Onwujekwe OE, Akpala CO Did the Bamako initiative improve the utilization of maternal and child healthcare services in Nigeria? A case study of Oji River local government area in Southeast Nigeria. J Health Popul Dev Countries 2014;19:107-16.  Back to cited text no. 19
Engmann CM, Sedaf K, Charyl AM Transformative innovations in reproductive, maternal, newborn, and child health over the next 20 years. PLoS Med 2016;13: e1001969.  Back to cited text no. 20
Kajula PW, Kintu F, Barughare J, Neema S Political analysis of rapid change in Uganda;s health financing policy and consequences on service delivery for malaria control. Int J Health Plan Manage 2004;19:133-53.  Back to cited text no. 21
Bhayat A, Cleaton-Jones P Dental clinic attendance in Soweto, South Africa, before and after the introduction of free primary dental health services. Commun Dentist Oral Epidemiol 2003;21:1054-110.  Back to cited text no. 22
Walker L, Gilson L We are bitter but we are satisfied: Nurses as street-level bureaucrats in South Africa. Soc Sci Med 2004;59:1251-61.  Back to cited text no. 23
Technicalreportnew1-Health Policy Project. [Cited June 5, 2020]. www.healthpolicyproject.com>pubs>97_Nigeriahealth.  Back to cited text no. 24
Witter S Service and population-based exemptions: Are these the way forward for equity and efficiency in health financing in low-income countries. Adv Health Econ Health Serv Res 2009;21:251-88.  Back to cited text no. 25
Ridde V, Diarra A A process of evaluation of user-fees abolition for pregnant women and children under five years in two districts in Niger (West Africa). BMC Health Serv Res 2009;9:89.  Back to cited text no. 26
Ridde V, Morestin F A scoping review of the literature on the abolition of user fees in health care services in Africa. Health Policy Plan 2011;26:1-11.  Back to cited text no. 27


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Materials and Me...
Article Tables

 Article Access Statistics
    PDF Downloaded29    
    Comments [Add]    

Recommend this journal