You are here

  • Home
  • Archive
  • Volume 12, Issue 7
  • Insight into Nigeria’s progress towards the universal coverage of reproductive, maternal, newborn and child health services: a secondary data analysis

Article Text

Article menu

Download PDFPDF

Health services research
Original research
Insight into Nigeria’s progress towards the universal coverage of reproductive, maternal, newborn and child health services: a secondary data analysis
  1. Joy James Mafiana1,
  2. Xiping Shen2,
  3. Wenping Hu1,
  4. Xiaohui Wang1
  1. 1Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, Gansu Province, China
  2. 2Department of Statistics and Epidemiology, School of Public Health, Lanzhou University, Lanzhou, Gansu Province, China
  1. Correspondence to Dr Xiaohui Wang; wangxiaohui{at}lzu.edu.cn

Abstract

Objective This study investigated the progress towards the universal coverage of reproductive, maternal, newborn and child health (RMNCH) services in Nigeria after universal health coverage (UHC) adoption.

Design A descriptive observational approach was used based on secondary data analysis. Representative data generated from publicly accessible databases and reports were used to describe the coverage trend and estimate the absolute inequality. Analysis was conducted using Excel and the WHO’s Health Equity Assessment Toolkit software.

Setting The study setting is Nigeria.

Participants Aggregated health service coverage data of women aged 15–49 years and children under 5 years of age.

Outcome measures The outcome of interest is the level of coverage of RMNCH services in Nigeria and the difference in equity gaps among subgroups before and after UHC adoption.

Results The RMNCH index increased by 6.4% points with a difference of 33.7% points to attain the minimum 80.0% target. The widest inequality was by economic status with the difference ranging from 21.9% points (95% CI 10.1% to 33.8%) to 56.3% points (95% CI 51.5% to 61.2%), Absolute Concentration Index from 3.5% points (95% CI 1.6% to 5.5%) to 11.3% points (95% CI 10.4% to 12.2%), Slope Index of Inequality from 23.1% points (95% CI 11.9% to 34.2%) to 65.5% points (95% CI 62.6% to 68.5%) and population attributable risk from 9.3% points (95% CI 7.3% to 11.4%) to 31.2% points (95% CI 29.0% to 33.3%). Among the indicators, three doses of diphtheria–tetanus–toxoid–pertussis immunisation had the widest absolute inequality across the subgroups.

Conclusion The poor coverage of RMNCH services in Nigeria and persistent inequalities pinpoint the need to investigate further the country-level determinant of RMNCH service coverage. In addition, it emphasises the need to formulate effective policies focusing on marginalised groups and improving resource allocation to ensure sustainable service coverage.

  • public health
  • antenatal
  • health policy
  • community child health

Data availability statement

Data are available in a public, open access repository. The data underlying the results are freely available from the WHO Global Health Observatory data repository, United Nations Population Division, World Bank database, and UHC 2017 and 2021 global monitoring reports as cited in the study.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi-org.ezproxy.u-pec.fr/10.1136/bmjopen-2022-061595

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Strengths and limitations of this study

    • This study uses representative data to assess the progress towards the universal coverage of reproductive, maternal, newborn and child health (RMNCH) services in Nigeria, focusing on sustainability.

    • The assessment was conducted along with an inequality analysis to ascertain the subgroups and health programmes that require further interventions.

    • Due to data availability, the latest year reported in the study was 2019 (for the RMNCH service index, antenatal care of four or more visits and care-seeking for pneumonia) and 2020 (for family planning and three doses of diphtheria–tetanus–toxoid–pertussis immunisation).

    • The time points for comparing inequality before and after the policy adoption were limited to 2013 and 2018.

    • Also, the equity gap analysis excluded the subnational dimension due to limited data.

    Introduction

    Universal health coverage (UHC) is one of the targets underpinned in the United Nations (UN) Sustainable Development Goal 3 (SDG). It aims at ensuring access to health services for everyone.1 Reproductive, maternal, newborn and child health (RMNCH) is one of the essential health service components of UHC. It consists of four tracer indicators: family planning, antenatal care of four or more visits (ANC 4+visits), three doses of diphtheria–tetanus–toxoid–pertussis (DTP3) child immunisation and care-seeking for pneumonia.2 RMNCH encompasses health interventions involving women before and during pregnancy, newborns (within the first 28 days of life) and children under 5 years.3 Improving health service coverage of RMNCH is a global priority4; as reflected in the Millennium Development Goals (MDGs) for countries to reduce child and maternal mortality5 and subsequently in the SDGs.1

    To achieve UHC, it is imperative to monitor the progress of service coverage and understand the pattern of service delivery across the various subpopulations of the equity dimension. WHO and World Bank recommend a minimum target of 80.0% coverage of essential health services for countries striving towards UHC.6 Globally, RMNCH services have experienced substantial gain, and improvement has been seen in the health status of mothers and children.7 In 2017, the global estimate for maternal deaths was 211.0 deaths per 100 000 live births (295 000 deaths); this was 38.4% lower than the 342.0 deaths per 100 000 live births (451 000 deaths) reported in 2000.8 Likewise, the global under-5 and neonatal mortality rate fell to 38.0 and 17.0 deaths per 1000 live births in 2019 from 76.0 and 30.0 deaths per 1000 live births in 2000. This reduction was by 50.0% and 42.0%, respectively.9 Nevertheless, studies have shown that progress is uneven between and within countries with poor coverage in low-income and middle-income countries and huge disparities among subpopulations of the equity dimension.3 4 7 10 Correspondingly, a considerable gap exists between the health status of women and children in low-income and middle-income countries and that of high-income countries. It is important to note that 94.0% of the global maternal deaths in 2017 occurred in low-income and middle-income countries, of which the maternal mortality rate (MMR) in the least developed countries was 415/100 000 live births while high-income regions like Australia and New Zealand had an MMR estimate of 7/100 000 live births. Sub-Saharan Africa had the highest burden, accounting for over 66.0% (196 000) of the global maternal deaths.8 Likewise, low-income and lower-middle-income regions accounted for more than 80.0% of the 5.2 million under-5 deaths globally in 2019. Moreover, sub-Saharan Africa recorded the highest rate, with about 2.8 million deaths (53.3%).9 11

    Nigeria has a history of poor maternal and child healthcare.12 It is considered one of the countries with the highest maternal and child mortality rates in sub-Saharan Africa.13 14 In 2017, it accounted for 67 000 (23.0%) of the global maternal deaths,8 while 872 676 under-5 deaths occurred the same year.15 Nigeria has poor health indices for RMNCH services, with a high unmet need for family planning16–18 and a low ANC 4+ visits attendance.19 Also, it had the highest number of DTP unvaccinated and undervaccinated children in the world in 2017, accounting for about 4.0 million of the 19.9 million DTP unvaccinated and undervaccinated children.20 In addition, Nigeria recorded the highest number of under-5 pneumonia-related deaths in 2018, with 162 000 deaths.21 Despite Nigeria’s poor maternal and child health indices, studies have further highlighted the existence of inequalities among various subpopulations in the country.7 22–26

    Expanding coverage of RMNCH services is fundamental to attaining universal access to sexual, reproductive, maternal and child healthcare services as called for in the 2030 Agenda for Sustainable Development.27 Nigeria failed to meet the MDG target for universal access to reproductive health, improving maternal health and reducing child mortality.28 Thus, early tracking of its progress is crucial to identify if the country is off-track and highlight the need for intensified action to accelerate progress. Conversely, with just 8 years left to deliver on the SDGs, little is known about the progress towards attaining the UHC target for RMNCH services in Nigeria. Therefore, this study investigated the progress towards the universal coverage of RMNCH services in Nigeria by describing the coverage trends before and after UHC was adopted. Likewise, we analysed inequality and compared the equity gaps in RMNCH service coverage before and after UHC was adopted to ascertain where inequalities persist. This assessment will provide helpful information on the areas of success and shortfall. It will also identify priorities for further studies and provide relevant information to aid policy-makers in evaluating, prescribing and implementing evidence-based strategies towards achieving sustainable universal coverage of RMNCH services.

    Materials and methods

    Study design

    A descriptive observational approach was employed to investigate the progress towards the universal coverage of RMNCH services in Nigeria based on secondary data analysis.

    Study setting

    Nigeria is a lower-middle-income country29 located along the west coast of Africa, occupying an area of 923 678 square km.30 It is the most populous African country having an estimated population of 206.0 million citizens in 2020.31 As of 2020, Nigeria’s gross domestic product (GDP) was estimated at US$432.3 billion (current US$),32 making it the largest economy in Africa.33 Nigeria operates a three-tiered (federal, state and local government) federal system of governance and consists of 36 semi-autonomous states, 774 local government areas and a Federal Capital Territory in Abuja. It is further divided into six geopolitical zones: North-central, North-east, North-west, South-east, South-south and South-west, with over 350 ethnic groups and 500 local languages while English is the official language.34

    Nigeria runs a healthcare delivery system consisting of the public and private sectors. The public healthcare sector consists of tertiary, secondary and primary levels provided by federal, state and local governments. The federal government, through the Federal Ministry of Health, leads the development and implementation of specific public health programmes, while the state health ministries and local government councils manage the implementation of these programmes at their levels.34 The three tiers have substantial autonomy in allocating and utilising their resources. Healthcare in Nigeria is financed through the federal government and its parastatals, states and local governments, insurance companies and out-of-pocket (OOP) household payments.35 However, evidence suggests that households through OOP spending continue to be Nigeria’s primary health financing source.36 37

    Patient and public involvement statement

    Patients and the public were not involved in this study because it used secondary data that were publicly accessible.

    Data source

    Being a secondary data analysis, a description of the selection methods of participants, eligibility criteria and the study size was not required. We generated publicly accessible data from the WHO Global Health Observatory data repository,38–42 the United Nations Population Division31 43 and the World Bank database.32 44–50 The data for ANC 4+ visits and care-seeking for pneumonia obtained from the databases were supplemented with representative data reported in the UHC 2017 and 2021 global monitoring reports.51 52 These data sources publish datasets for different countries based on information generated from national health surveys (such as the Demographic and Health Surveys or Multiple Indicator Cluster Surveys), health facilities and administrative records. The recent data included in the study were based on data availability.31 51–54 Information on the datasets used in this study, the years report and sources is summarised in table 1.

    View this table:
    Table 1

    Sources of data

    Outcome measures

    The outcome of interest is the level of coverage of RMNCH services and the difference in equity gaps among subgroups in Nigeria before and after UHC adoption. The inequality assessment aligns with the WHO and World Bank recommendation for monitoring progress towards UHC along with an equity analysis because national averages can mask coverage variations among different subgroups.51 55 The RMNCH tracer indicators used in this study were defined according to their official UHC definition2 provided by the global monitoring framework, as shown in table 2.55

    View this table:
    Table 2

    Definition of outcome indicators

    Regarding the difference in equity gaps among subgroups, we compared the level of inequality before and after UHC adoption. The recent time points for comparing inequality were limited to 2013 and 2018 based on data availability. The coverage of the RMNCH indicators were disaggregated by economic status (from quintile 1 (Q1) to quintile 5 (Q5), with Q1 indicating the poorest and Q5 the richest), maternal education (no education, primary school and secondary education above (+)) and place of residence (rural and urban residence). Due to limited data availability, the subnational (geographical regions) dimension was excluded in this study.

    Data analysis

    The data were sorted and compiled with Microsoft Excel. Each variable was cross-checked for completeness and consistency. Descriptive analysis was conducted to show the sociodemographic characteristics and the level of service coverage each year. We described coverage trends for each indicator to ascertain the pattern of RMNCH coverage before and after UHC adoption. To determine the progress made towards attaining universal coverage of RMNCH services, a coverage index was computed using the methods in Hogan et al,56 the WHO,55 and the United Nations Statistical Commission2 reports. The index was constructed by compiling the indicators of RMNCH services into a geometric average. Following that, we calculated the difference between the RMNCH coverage index in the policy year (2015) and the latest year after the policy with data for all the indicators (2019). Second, the difference between the recommended minimum target (80.0%)6 and the recent RMNCH index after the policy was estimated. Additionally, the difference between the policy adoption year (2015) and the latest year with data after the policy for each of the indicators was determined. Likewise, the difference between the minimum coverage target and the latest service coverage for each indicator was calculated.

    We analysed absolute inequality using the WHO Health Equity Assessment Toolkit (HEAT). HEAT is a software application developed by the WHO, and it enables the interactive exploration and comparison of health inequalities.57 To determine the progress made towards equitable access to RMNCH services, the difference between the extreme groups of each equity dimension (economic status: Q5–Q1, educational status: secondary education (+)–no education, urban–rural residence) was measured and compared for all the indicators. Complex measures that consider all population subgroups were also used. The Absolute Concentration Index (ACI) and the Slope Index of Inequality (SII) were used to assess inequality in the economic and educational status dimension because they cannot be calculated for dimensions with two subgroups, such as the place of residence.57 At the same time, the population attributable risk (PAR) was calculated for all the dimensions. It was used to estimate the possibility of improving the national average of each indicator if all subgroups had the same level as the reference subgroup (Q5, secondary education (+) and urban residence).

    Results

    Sociodemographic characteristics

    The results in table 3 show some notable differences in the sociodemographic characteristics across the years. The result shows an increase in the total population and life expectancy at birth from 2010 to 2019. It also shows a decline in MMR (per 100 000 live births) and the under-five mortality rate (per 1000 live births). There was a fluctuating pattern in GDP (billion, current US$) growth, CHE per capita (US$), CHE as a percentage of GDP, GGHE-D per capita (US$), GGHE-D as a percentage of GDP, GGHE-D as a percentage of CHE, OOP per capita (US$) and OOP as a percentage of CHE from 2010 to 2019.

    View this table:
    Table 3

    Sociodemographic characteristics

    Progress in the coverage of RMNCH services sequel to UHC adoption

    Figure 1 shows the coverage pattern from 2010 (before the policy) to the latest year for each RMNCH service indicator. There was a fluctuating pattern across the years for all the indicators except family planning.

    Figure 1
    Figure 1

    Trend analysis showing the coverage of the RMNCH indicators relative to the minimum 80.0% target. (A) coverage of family planning services from 2010 to 2020. (B) Coverage of ANC 4+ visits from 2011 to 2019. (C) Coverage of DTP3 immunisation from 2010 to 2020. (D) Coverage of healthcare-seeking for children with pneumonia from 2011 to 2019. ANC, antenatal care; DTP, diphtheria–tetanus–toxoid–pertussis; RMNCH, reproductive, maternal, newborn and child health.

    Table 4 shows the progress towards universal coverage of RMNCH services in Nigeria after UHC adoption. Overall, the RMNCH index increased by a 6.4% points from 2015 to 2018 with a difference of 33.7% points to attain the minimum 80.0% target. Also, there was an increase in coverage for all the RMNCH indicators. The service coverage for DTP3 immunisation increased the most, while ANC 4+ visits had minor improvements. Regarding the coverage gap towards the minimum 80.0% target, family planning had the highest while ANC 4+visits and DTP3 immunisation had the least.

    View this table:
    Table 4

    Level of progress made towards the universal coverage of RMNCH services sequel to UHC adoption

    Comparison of equity gaps before and after UHC adoption

    Figure 2 shows the coverage of the RMNCH indicators across the equity dimension subgroups in 2013 and 2018. Coverage for all the indicators increased in each subgroup except ANC 4+ visits, in which the coverage for the richest (Q5), secondary school + and urban residents declined in 2018. The most considerable improvement was observed among the poorest group (Q1), women with no educational qualifications and rural residents.

    Figure 2
    Figure 2

    Coverage of the RMNCH indicators among the subgroups of the equity dimensions in 2013 and 2018 extracted from the WHO HEAT inequality analysis.57 HEAT, Health Equity Assessment Toolkit; RMNCH, reproductive, maternal, newborn and child health.

    Table 5 shows the coverage gaps by economic status, educational level and place of residence. The absolute inequality in all the equity dimensions for each indicator decreased from 2013 to 2018 except for care-seeking for pneumonia, in which inequality increased by educational status. Among the indicators, DTP3 immunisation had the highest absolute inequality across all the subgroups in 2013 and 2018, while care-seeking for pneumonia had the most diminutive. Across the indicators, the widest difference was by economic status, while the least was by place of residence. Likewise, the absolute inequality measured by ACI and SII tends to be higher by economic status except for DTP3 immunisation, where the inequality was greater by educational status. The indicators had the potential for improvement if the subgroups' inequalities were reduced (PAR) between 5.6% points and 31.2% points. DTP3 immunisation had the widest PAR for all subgroups (economic status: 31.2% points, educational status: 24.1% points and place of residence: 17.6% points). In contrast, family planning had the most diminutive (economic status: 9.3% points, educational status: 7.0% points and place of residence: 5.6% points). For the dimensions, economic status had the widest PAR (ranging from 9.3% points to 31.2% points) while the place of residence had the least (ranging from 5.6% points to 17.6% points).

    View this table:
    Table 5

    Inequality gaps in the coverage of RMNCH services by economic status, educational level and place of residence in 2013 and 2018

    Discussion

    This study provides an insight into Nigeria’s progress towards achieving universal coverage of RMNCH services. The RMNCH index increased by 6.4% points from 2015 to 2019 with a difference of 33.7% points to attain the minimum coverage target recommended by WHO and the World Bank.6

    Regarding the RMNCH indicators, this study shows an increase in the coverage of family planning. Notwithstanding, the result suggests that the progress is negligible. It is worth noting that the coverage increased by only 2.1% points from 2010 to 2015 (before adoption and the year policy was adopted). Likewise, after UHC adoption, the coverage increased by only 4.5% points from 2015 to 2020, and Nigeria still has a difference of 43.6% points to attain the minimum 80.0% target.6 Consequently, many fertile women unwilling to get pregnant are unreached by effective family planning strategies.58 59 According to the Guttmacher Institute, only 4.1 million of the 12.0 million married women aged 15–49 in Nigeria who wanted to avoid pregnancy in 2019 had their demand satisfied with modern methods leaving 7.5 million unmet needs.58 Currently, Nigeria is the second slowest growing country in West Africa regarding the uptake of modern contraception.59 The country’s rapidly rising population shows the poor state of family planning. The population in Nigeria increased from 158.0 million in 2010 to 206.0 million in 2020, with a growth rate of 2.6% per annum. Likewise, the total fertility rate (live births per woman) was 5.4 in 2018.31

    The pattern of family planning coverage observed in this study could be due to a lack of political and financial commitments.17 60 The Nigerian Government had made commitments to address sociocultural norms against family planning, improve the availability of services and commodities, ensure sustainable financing for the national family planning programme, and build partnerships to improve access to contraceptives.61 However, implementing the government’s policies to advance the utilisation of family planning methods in Nigeria remains suboptimal, with poor financing posing a significant challenge.17 60 According to Mandara17, the Federal Government of Nigeria committed to contributing US$3.0 million in the 2011 fiscal budget to address the deficit in commodity supply donated by the United Nations Population Fund (UNFPA). However, the funds were not released to UNFPA, and family planning commodities were disturbingly out-of-stock. Likewise, the Federal Government approved a counterpart funding of US$4.0 million annually for the procurement of contraceptives for a period spanning from 2017 to 2020, of which only US$2.7 million and US$3.3 million were released for the 2017 and 2018 fiscal years, respectively. Consequently, there was a shortfall of US$2.0 million for the 2 years, and Nigeria still depends on donors for their contraceptives.60 This scenario clearly shows a lack of commitment; therefore, it is imperative to reposition the efforts towards improving family planning uptake with the government taking a leadership role in promoting family planning.

    Regarding ANC 4+ visits, our analysis also suggests an insignificant increase in coverage. It is important to note that though ANC 4+ visits increased by a 3.0% points after UHC adoption, there was a 2.6% points decline from 2010 to 2015 (before adoption and the year policy was adopted). Additionally, Nigeria still has a coverage difference of 23.0% points to attain the minimal coverage target.6 This result agrees with previous reports that insufficient ANC attendance is a significant issue in Nigeria.25 26 Studies have documented that women’s sociodemographic background significantly determines the utilisation of ANC services.19 25 26 However, after controlling for sociodemographic factors, the availability of ANC services from the supply-side poses a significant hurdle to ANC utilisation in Nigeria.26 62 Despite the numerous health interventions to improve healthcare in Nigeria, the healthcare system remains sub-optimal regarding human resources and commodities (such as equipment and drugs) at the service delivery points.62 63 In Gage et al’s study, it was reported that basic amenities for ANC provision in health facilities were inadequate.62 Likewise, Okoli et al reported that 44.0% of the primary healthcare facilities enrolled in the Midwives Service Scheme (a government programme designed to address the national shortage of skilled birth attendants) did not provide all the ANC components recommended by WHO.63 64 Therefore, the poor uptake of ANC services in Nigeria could also be associated with a lack of political will, inadequate resource allocation and management. This finding suggests that maternal healthcare policies and programmes be scaled up and accompanied by regular supportive supervision to reduce the underutilisation of ANC services.

    Further, the low level of family planning and ANC 4+ visits coverage observed in this study could be associated with the persistently high maternal and child deaths reported in Nigeria. Studies have reported that a higher proportion of demand satisfied by modern methods and ANC services correlates with lower maternal and perinatal morbidity and mortality.18 27 65–67 In 2017, Nigeria accounted for 23.0% (67 000 out of 295 000) of the global maternal deaths with an MMR of 917/100 000.8 Likewise, Nigeria ranked first among the top five countries (including India, Pakistan, the Democratic Republic of Congo and Ethiopia) with the highest under-5 deaths in 2019, with 855 964 under-5 deaths.11 15 This finding highlights the urgency of expanding access to reproductive and maternal healthcare services in Nigeria, as the low level of coverage poses a severe threat to the attainment of UHC.

    DTP3 immunisation also increased after the adoption of UHC. The level of coverage increased by a 15.0% points from 2015 to 2020. The improvement might be due to the high investments in immunisation programmes, mainly through the efforts of Gavi, the Vaccine Alliance, which fosters equal access to vaccines for populations living in the world’s low-resource and high-burden countries like Nigeria.68–70 According to the WHO and United Nations Children's Fund (UNICEF) report, the group of ‘Gavi countries’ has substantially reduced its gap in immunisation coverage with the rest of the world since the start of 2015 to 2020 strategic period.69 However, it is essential to note that while DTP3 immunisation coverage increased after UHC adoption, the trend analysis shows a decline of 12.0% points from 54.0% in 2010 to 42.0% in 2015, which implies that the increase after the policy adoption year is trivial. The analysis also shows a slow annual increase of 1.0% point from 2017 to 2019 and stable coverage of 57.0% from 2019 to 2020. Likewise, Nigeria still has a difference of 23.0% point to attain the minimum 80.0% target.6 This result indicates that Nigeria’s coverage of child immunisation services is poor. Child vaccination is a proven tool to protect a population from deadly vaccinable diseases, and the DTP-containing vaccine is used to monitor the ability of immunisation programmes to deliver at least three doses of essential vaccines to infants.69 However, despite the proven benefit of vaccines, this study shows that DTP3 coverage is low, and Nigeria lags behind other countries of Africa and the world.71 Within the West African region, DTP3 coverage in Nigeria is among the lowest compared with 91.0%, 93.0% and 94.0% coverage reported in Burkina Faso, Cabo Verde and Ghana, respectively, in 2020.39 Likewise, 3.9 million (78.3%) of the 5.0 million DTP3 unvaccinated children in West Africa lived in Nigeria.71

    Furthermore, Nigeria ranked first among the ten countries that accounted for 62.0% (12.2 million) of the 20.0 million unvaccinated and undervaccinated under-5 age children in 2019.69 Accordingly, there has been an upsurge in vaccine-preventable diseases from 9364 cases in 2010 to 19 540 in 2015 and 32 474 in 2019.72 The surge in vaccine-preventable diseases might hinder achieving the SDG of reducing child mortality in Nigeria. The poor immunisation coverage in Nigeria has been linked to the long distances to health facilities, non-availability of vaccines, weak and poorly financed health systems, and the rapidly growing population.69 71 73 74 Wariri et al71 reported that Gambia, Burkina Faso and Cabo Verde, which have higher DTP3 coverage than Nigeria, are relatively small countries with most of the population living within a convenient distance from a health facility and the government provides routine immunisation services via outreach clinics. Likewise, the WHO and UNICEF recommend that more infants be vaccinated to improve and sustain high immunisation coverage as the population grows.73 75 Therefore, the national immunisation programme needs to be scaled up to improve and sustain a high vaccination coverage in Nigeria.

    There was also an increase in the coverage of care-seeking for pneumonia in this study. The level of coverage increased by a 5.0% points from 35.0% in 2015 to 40.0% in 2019. The reasons for this improvement are unclear; however, it could be due to the commitments of the Global Action Plan for Prevention and Control of Pneumonia (GAPP). GAPP initiative focuses on increasing the awareness of pneumonia as a major cause of child death, scaling up the use of proven beneficial interventions and providing guidance on how this can be done in high burdened countries.76 Notwithstanding the increase in coverage, the number of pneumonia under-5 deaths increased from 140 520 in 201677 to 162 000 in 2018.21 Nigeria ranked first among the five countries (others include India: 127 000, Pakistan: 58 000, the Democratic Republic of Congo: 40 000 and Ethiopia: 32 000) that accounted for more than half of child pneumonia deaths in 2018.78 According to the reports by Save the Children, Nigeria will not achieve the GAPP target of reducing pneumonia deaths to less than 3/1000 live births until after 2050.79

    The upsurge in pneumonia deaths observed in Nigeria has been linked to untimely and inappropriate healthcare-seeking behaviour and inaccurate diagnosis.79 80 Studies have reported that poor knowledge of pneumonia-specific symptoms and risk factors among caregivers and community members in Nigeria is associated with delays in seeking healthcare.79 80 In a study by Bedford and Sharkey, pneumonia‐specific symptoms were the least recognised by caregivers compared with malaria and diarrhoea.81 Additionally, poor recognition of symptoms by healthcare workers and a lack of laboratory services results in misdiagnosis, specifically when pneumonia presents with other conditions, such as malaria, diarrhoea and sepsis.79 82 In Graham et al82 study, 41.4% of the sick children who met WHO severe pneumonia criteria83 were diagnosed with only malaria (64.3%), sepsis (37.8%) and diarrhoea (11.4%). This finding may explain why progress with pneumonia control has lagged compared with other childhood killer diseases.79 Other factors such as financial constraints, gender roles and household decision-making process, and non-availability of medication have also been associated with delay in seeking care and the rise in pneumonia death.79 80 84 85 Therefore, policies and interventions should improve knowledge of pneumonia, train healthcare workers on diagnosis and treatment guidelines, and increase access to low-cost, high-impact child health services at the community level.

    The trend analysis shows a fluctuating pattern in service coverage across the years for all the indicators except family planning. For instance, ANC 4+ visits, DTP3 immunisation and care-seeking for pneumonia coverage declined in 2016, shortly after UHC adoption. The decline in coverage can be explained by the termination of the National Health Insurance Scheme-Millennium Development Goals Free Maternal and Child Health Program and the Subsidy Reinvestment and Empowerment Programme on Maternal and Child Health in 2015.86 87 The programmes aimed to improve access to facility-based maternal and child health services by providing free healthcare and conditional cash transfers to pregnant women and children under 5 years. However, they ended due to insufficient funds, ineffective monitoring and evaluation systems, and poor intersectoral coordination.86 87 Likewise, the coverage of care-seeking for pneumonia declined by a 34.5% points from 2018 to 2019. This result signals poor sustainability of health services coverage in Nigeria. Thus, it emphasises the need to formulate and implement strategic policies to improve and sustain RMNCH services in Nigeria.

    The coverage gaps among the subgroups for each indicator showed a shift towards the equity line. Thus, indicating a decline in inequality. The improvements could be due to the increase observed in the national coverage of all the indicators from 2013 to 2018. Only the care-seeking for pneumonia indicator had an increase in inequality for the educational status dimension. Likewise, the inequality measured by ACI and SII was greater by educational status for DTP3 immunisation. This result suggests that low maternal education could be associated with delayed healthcare for children with suspected pneumonia,79 80 poor vaccine coverage and drop-outs.73 Significant inequality reductions were noted for care-seeking for pneumonia and family planning, while DTP3 immunisation and ANC 4+ visits had the highest equity gaps. This trend was also observed in 2013. The variations in the magnitude of inequality across the indicators are unclear and necessitate further studies. Additionally, it was noted that the broadest absolute inequality across the indicators in 2013 and 2018 was by economic status, while the least was by place of residence. This finding suggests that a lack of financial resources could hinder progress towards attaining universal coverage of RMNCH services in Nigeria. Nigeria has implemented several initiatives to advance equitable access to quality RMNCH services through primary healthcare, specifically in rural areas. These initiatives include the Midwives Service Scheme88 and the Basic Healthcare Provision Fund.89 However, healthcare resources in Nigeria are allocated in favour of secondary and tertiary care facilities against primary care, thus promoting inefficiency and inequities.90–92 According to the UN (2015), equity is fundamental to achieving the UHC target and SDGs. This result emphasises the need to examine equity gaps within subgroups and across health programmes while monitoring the progress towards achieving universal coverage of RMNCH services. In addition, our findings highlight critical areas requiring urgent intervention and signal the need for effective policies focusing on marginalised groups.

    Despite the country’s oil wealth and abundant natural resources, the state of RMNCH services remains poor. Nigeria consistently accounts for the broadest equity gaps between the extreme subgroups of the equity dimension.7 22 93 94 Several studies have established that individual socio-demographic factors and some country-level determinants such as inadequate government health financing and funding of UHC, poor level of political commitment, weak health system, lack of policy implementation and enforcement, poor quality regulation, unsatisfactory data management and research, a deficit in health workforce and gender inequality influence the coverage of health services.55 95–98 However, this study highlights the need to further examine the impact of other factors. Recent reports have emphasised that the number of people covered by health services will be offset by population growth, poor commitments and investments in healthcare.27 55 69 Conversely, little is known about the impact of population growth on RMNCH services coverage in Nigeria. It can be observed in this study that family planning services had the least coverage. Correspondingly, Nigeria’s population has multiplied with a growth rate of 2.6% per annum.31 Furthermore, while the population increases, the CHE as a percentage of GDP remains within 3.0% while the government spending as a percentage of GDP is below 5.0%, with OOP payments continuously accounting for over 70.0% of the CHE. The government spending on health in Nigeria is meagre and below the minimum target of 5.0% of GDP recommended by WHO for countries progressing towards UHC.97 UHC is a continuous process that changes in response to shifting demographic, epidemiological and technological trends.55 The findings of this study are based on the analysis of recently available data; updated data may show substantial improvements. However, to achieve UHC, the study shows that Nigeria needs to increase the government expenditure on health, build a robust health system relative to its growing population and reduce the heavy reliance on OOP payments.

    Furthermore, the upsurge of conflicts and terrorism in the country might be associated with the poor coverage of RMNCH services, specifically in Northern Nigeria.99 This study could not assess the level of coverage by geographical regions in the equity gap analysis due to limited data. The analysis could offer an insight into the coverage of RMNCH services in Northern Nigeria. Based on the report of the 2017 fragile state index, Nigeria was one of the seven high and very high alert countries (including South Sudan, Chad, Central African Republic, Somalia, Afghanistan and Guinea) with a very high MMR (ranging between 500 and 999).8 100 Likewise, Nigeria ranked third among the countries with the highest impact of terrorism in the 2017 and 2020 global terrorism reports.101 102 Previous studies have reported that conflicts and terrorism can affect the delivery of RMNCH services.27 28 94 103–105 Finally, the emergence of the COVID-19 highlights the need for further research on the coverage of RMNCH services. Reports show that the COVID-19 pandemic could undo the successes in improving health services coverage.27 106 107 Previous studies have reported that the Ebola outbreak caused a significant disruption in providing and using health services, including vaccinations, obstetric care and reproductive health services.108–111 Given the poor and fluctuating coverage of maternal and child healthcare, it is imperative to assess the impact of the COVID-19 outbreak on RMNCH services in Nigeria. This assessment will facilitate the prescription of evidence-based strategies and policies for strengthening health system resilience as Nigeria strives toward achieving UHC by 2030.

    This study shows that Nigeria did not achieve significant progress towards the universal coverage of RMNCH services after UHC adoption. Also, it provides an overview of the possible determinants of health service coverage based on the literature reviewed. However, there are some limitations. First, aggregated data from publicly accessible websites and literature, which compiles datasets from different sources, were used. Thus, this study is unaware of any nuance or glitch in the data collection process that may be important for interpreting specific data variables. Second, due to limited data availability, the latest RMNCH service index reported was 2019. The latest year reported for the indicators was 2019 (for ANC 4+and care-seeking for pneumonia) and 2020 (for family planning and DTP3 immunisation). The time points for comparing inequality before and after UHC adoption was limited to 2013 and 2018. It is possible that updated data may show substantial improvements or otherwise. Additionally, the equity gap analysis excluded the subnational dimension. Likewise, the interpretation of results was limited by the depth of information available on crucial topics, such as the impact of conflicts and the coronavirus pandemic on health services, the quality of care for essential interventions and others. Therefore, we recommend further primary research on the coverage of RMNCH services in Nigeria. Notwithstanding the limitations, our analysis gives an insight into the pattern of service coverage in Nigeria within the included years.

    Conclusion

    The goal of UHC is to ensure that all people have access to the health services they need, but this study revealed that Nigeria has failed to achieve significant progress towards its realisation. The coverage of RMNCH services in Nigeria is progressing slowly in a fluctuating pattern, and inequalities persistently exist among the different sociodemographic groups. These results highlight the urgent need to formulate effective policies focusing on marginalised groups and improve the allocation of resources towards achieving the 2030 target for RMNCH services. In addition, progress towards UHC is a continuous process that changes in response to shifting demographic, epidemiological, technological trends and people’s expectations. Thus, more research needs to be conducted periodically to monitor the progress and investigate the country’s-level determinants of service coverage.

    Data availability statement

    Data are available in a public, open access repository. The data underlying the results are freely available from the WHO Global Health Observatory data repository, United Nations Population Division, World Bank database, and UHC 2017 and 2021 global monitoring reports as cited in the study.

    Ethics statements

    Patient consent for publication

    Ethics approval

    The study was approved by the ethics committee of the Department of Social Medicine and Health Management, School of Public Health, Lanzhou University. Informed consent was not applicable in the study because it used secondary data that were publicly accessible.

    Acknowledgments

    The authors are thankful to the data holders for providing the data used in the study.

    References

    1. ↵
      1. United Nations
      . Transforming our world: the 2030 agenda for sustainable development. resolution adopted by the general assembly on 25 September 2015; A/RES/70/1:1–35, 2015. Available: https://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E [Accessed 9 Dec 2020].
    2. ↵
      1. United Nations Statistical Commission
      . Sdg indicator 3.8.1 metadata; 2020: 1765. https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-01.pdf [Accessed 9 Feb 2021].
    3. ↵
      1. Black RE,
      2. Walker N,
      3. Laxminarayan R
      . Reproductive, maternal, newborn, and child health. Reprod Matern Newborn, Child Heal Dis Control Priorities 2016;2.doi:10.1596/978-1-4648-0348-2_ch1
    4. ↵
      1. World Health Organization
      . State of inequality: reproductive, maternal, newborn and child health, 2015. Available: https://www.who.int/docs/default-source/gho-documents/health-equity/state-of-inequality/state-of-inequality-reproductive-maternal-new-born-and-child-health.pdf?sfvrsn=f4034289_2 [Accessed 12 Mar 2021].
    5. ↵
      1. United Nations
      . UN Documents-gathering a body of global agreements. United Nations millennium development goals, 2022. Available: http://www.un-documents.net/mdg.htm [Accessed 10 Apr 2022].
    6. ↵
      1. World Health Organization and World bank
      . Monitoring progress towards universal health coverage at country and global levels framework, measures and targets; 2014: 1–14. https://apps.who.int/iris/bitstream/handle/10665/112824/WHO_HIS_HIA_14.1_eng.pdf?sequence=1 [Accessed 9 Dec 2020].
    7. ↵
      1. Hasan MM,
      2. Magalhaes RJS,
      3. Ahmed S, et al
      . Meeting the global target in reproductive, maternal, newborn, and child health care services in low- and middle-income countries. Glob Health Sci Pract 2020;8:654–65.doi:10.9745/GHSP-D-20-00097
      OpenUrlAbstract/FREE Full Text
    8. ↵
      1. World Health Organization
      . Trends in maternal mortality: 2000 to 2017 estimates by who, UNICEF, UNFPA, world bank group and the un population division, 2019. Available: https://www.unfpa.org/sites/default/files/pub-pdf/Maternal_mortality_report.pdf [Accessed 13 Mar 2021].
    9. ↵
      1. United Nations Inter-Agency Group for Child Mortality Estimation
      . Levels & trends in child mortality report 2020: estimates developed by the UN Inter-agency Group for Child Mortality Estimation, 2020. Available: https://www.unicef.org/media/79371/file/UN-IGME-child-mortality-report-2020.pdf.pdf [Accessed 3 May 2021].
    10. ↵
      1. Costello A,
      2. Naimy Z
      . Maternal, newborn, child and adolescent health: challenges for the next decade. Int Health 2019;11:349–52.doi:10.1093/inthealth/ihz051pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/31529111
      OpenUrlPubMed
    11. ↵
      1. World Health Organization
      . Children: improving survival and well-being; 2020. https://www.who.int/news-room/fact-sheets/detail/children-reducing-mortality [Accessed 13 Mar 2021].
    12. ↵
      1. Kana MA,
      2. Doctor HV,
      3. Peleteiro B, et al
      . Maternal and child health interventions in Nigeria: a systematic review of published studies from 1990 to 2014. BMC Public Health 2015;15:334.doi:10.1186/s12889-015-1688-3pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/25881020
      OpenUrlCrossRefPubMed
    13. ↵
      1. Kamer L
      . African countries with the highest maternal mortality rate in 2017 (deaths per 100,000 live births), 2022. Available: https://www-statista-com.ezproxy.u-pec.fr/statistics/1122869/maternal-mortality-rate-in-africa-by-country/ [Accessed 4 Feb 2022].
    14. ↵
      1. Ekholuenetale M,
      2. Wegbom AI,
      3. Tudeme G, et al
      . Household factors associated with infant and under-five mortality in sub-Saharan Africa countries. Int J Child Care Educ Policy 2020;14.doi:10.1186/s40723-020-00075-1
    15. ↵
      1. World Health Organization
      . Number of deaths among children under-five, 2020. Available: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/number-of-under-five-deaths [Accessed 4 Nov 2020].
    16. ↵
      1. Sedgh G,
      2. Bankole A,
      3. Okonofua F
      . Meeting young women’s sexual and reproductive health needs in Nigeria Guttmacher Institute; 2009: 24. https://www.guttmacher.org/sites/default/files/report_pdf/asrh_nigeria.pdf [Accessed 13 Apr 2021].
    17. ↵
      1. Mandara M
      . Family planning in Nigeria and prospects for the future. Int J Gynaecol Obstet 2012;117:1–4.doi:10.1016/j.ijgo.2012.01.002pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/22342053
      OpenUrlPubMed
    18. ↵
      1. Ahmed S,
      2. Li Q,
      3. Liu L, et al
      . Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet 2012;380:111–25.doi:10.1016/S0140-6736(12)60478-4pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/22784531
      OpenUrlCrossRefPubMedWeb of Science
    19. ↵
      1. El-Khatib Z,
      2. Kolawole Odusina E,
      3. Ghose B, et al
      . Patterns and predictors of insufficient antenatal care utilization in Nigeria over a decade: a pooled data analysis using demographic and health surveys. Int J Environ Res Public Health 2020;17:8261–14.doi:10.3390/ijerph17218261
      OpenUrl
    20. ↵
      1. VanderEnde K,
      2. Gacic-Dobo M,
      3. Diallo MS, et al
      . Global routine vaccination coverage — 2017. MMWR Morb Mortal Wkly Rep 2020;67:1261–4.doi:10.15585/mmwr.mm6745a2
      OpenUrl
    21. ↵
      1. United Nations Children’s Fund
      . One child dies of pneumonia every 39 seconds, agencies warn, 2019. Available: https://www.unicef.org/press-releases/one-child-dies-pneumonia-every-39-seconds-agencies-warn [Accessed 23 Mar 2021].
    22. ↵
      1. Alhassan JAK,
      2. Wariri O,
      3. Onuwabuchi E
      . Access to skilled attendant at birth and the coverage of the third dose of diphtheria-tetanus-pertussis vaccine across 14 West African countries – an equity analysis. Int J Equity Health 2020;19:1–11.
      OpenUrlCrossRefPubMed
    23. ↵
      1. Fatiregun AA,
      2. Etukiren EE
      . Determinants of uptake of third doses of oral polio and DTP vaccines in the Ibadan North local government area of Nigeria. Int Health 2014;6:213–24.doi:10.1093/inthealth/ihu027pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/24844557
      OpenUrlCrossRefPubMed
    24. ↵
      1. Austin A
      . Unmet contraceptive need among married Nigerian women: an examination of trends and drivers. Contraception 2015;91:31–8.doi:10.1016/j.contraception.2014.10.002pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/25453583
      OpenUrlPubMed
    25. ↵
      1. Dahiru T,
      2. Oche OM
      . Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria. Pan Afr Med J 2015;21:321.doi:10.11604/pamj.2015.21.321.6527pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/26587168
      OpenUrlPubMed
    26. ↵
      1. Fagbamigbe AF,
      2. Idemudia ES
      . Barriers to antenatal care use in Nigeria: evidences from non-users and implications for maternal health programming. BMC Pregnancy Childbirth 2015;15:1–10.
      OpenUrlCrossRefPubMed
    27. ↵
      1. United Nations Department of Economic and Social Affairs Population Division
      . World family planning 2020 highlights: accelerating action to ensure universal access to family planning (ST/ESA/SERA/450). Available: https://www.un.org/development/desa/pd/sites/www.un.org.development.desa.pd/files/files/documents/2020/Sep/unpd_2020_worldfamilyplanning_highlights.pdf [Accessed 16 Mar 2021].
    28. ↵
      1. Oleribe OO,
      2. Taylor-Robinson SD
      . Before sustainable development goals (SDG): why Nigeria failed to achieve the millennium development goals (MDGs). Pan Afr Med J 2016;24:1–4.doi:10.11604/pamj.2016.24.156.8447
      OpenUrl
    29. ↵
      1. World Bank
      . World bank open data, 2021. Available: https://data.worldbank.org/country/nigeria [Accessed 3 Mar 2021].
    30. ↵
      1. Federal Ministry of Health Nigeria
      . National policy and strategic plan of action on prevention and control of non-communicable diseases (NCDs), 2013. Available: https://extranet.who.int/ncdccs/Data/NGA_B3_NCD POLICY AND STRATEGIC PLAN OF ACTION.pdf [Accessed 16 Aug 2021].
    31. ↵
      1. United Nations Population Division
      . World population prospect: estimate 1950-2020. population division of the Department of economic and social Affairs of the United nations Secretariat database, 2019 revision. Available: https://population.un.org/wpp/ [Accessed 9 Mar 2021].
    32. ↵
      1. World Bank
      . GDP (current US$) - Nigeria, 2022. Available: https://data.worldbank.org/indicator/NY.GDP.MKTP.CD?locations=NG [Accessed 1 Apr 2022].
    33. ↵
      1. Zandt F
      . Africa’s biggest Economies, 2021. Available: https://www-statista-com.ezproxy.u-pec.fr/chart/26371/african-countries-with-the-highest-gdp-over-time/ [Accessed 13 Dec 2021].
    34. ↵
      1. Federal Ministry of Health Nigeria
      . Second national strategic health development plan 2018-2022: ensuring healthy lives and promoting the wellbeing of Nigerian populace at all ages, 2018. Available: https://www.health.gov.ng/doc/NSHDP II Final.pdf [Accessed 9 Nov 2020].
    35. ↵
      1. Federal Ministry of Health Nigeria
      . National health financing policy, 2006. Available: https://silo.tips/download/federal-republic-of-nigeria-zero-draft [Accessed 13 Sep 2020].
    36. ↵
      1. Onwujekwe O,
      2. Hanson K,
      3. Ichoku H, et al
      . Financing incidence analysis of household out-of-pocket spending for healthcare: getting more health for money in Nigeria? Int J Health Plann Manage 2014;29:174–85.doi:10.1002/hpm.2166pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/23390079
      OpenUrlPubMed
    37. ↵
      1. Uzochukwu BSC,
      2. Ughasoro MD,
      3. Etiaba E, et al
      . Health care financing in Nigeria: implications for achieving universal health coverage. Niger J Clin Pract 2015;18:437–44.doi:10.4103/1119-3077.154196pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/25966712
      OpenUrlCrossRefPubMed
    38. ↵
      1. World Health Organization
      2. Global Health Observatory
      . Children aged <5 years with pneumonia symptoms taken to a healthcare provider (%), 2020. Available: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/children-aged-5-years-with-pneumonia-symptoms-taken-to-a-healthcare-provider- [Accessed 14 Aug 2021].
    39. ↵
      1. World Health Organization
      2. Global Health Observatory
      . Full child immunization: immunization coverage estimates by country, 2021. Available: https://apps.who.int/gho/data/node.main.UHCIMMUNIZATION?lang=en [Accessed 25 Sep 2021].
    40. ↵
      1. World Health Organization Global Health Observatory
      . Antenatal care coverage, data by country, 2020. Available: https://apps.who.int/gho/data/view.main.ANTENATALCARECOVERAGE4v [Accessed 25 Sep 2021].
    41. ↵
      1. World Health Organization
      2. Global Health Observatory
      . Under-five mortality rate (probability of dying by age 5 per 1000 live births), 2021. Available: https://www.who.int/data/gho/data/themes/topics/indicator-groups/indicator-group-details/GHO/child-mortality-levels-probability-of-dying-per-1000-live-births- [Accessed 9 Sep 2021].
    42. ↵
      1. World Health Organization
      2. Global Health Observatory
      . Maternal mortality: estimates by country, 2019. Available: https://apps.who.int/gho/data/view.main.1390 [Accessed 2 Feb 2021].
    43. ↵
      1. United Nations Population Division
      . Demand for family planning satisfied by any modern method (percent), 2021. Available: https://population.un.org/dataportal/data/indicators/8/locations/566/start/2010/end/2020/table/pivotbylocation [Accessed 30 Nov 2021].
    44. ↵
      1. World Bank
      . Current health expenditure per capita (current US$) - Nigeria, 2022. Available: https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=NG [Accessed 1 Apr 2022].
    45. ↵
      1. World Bank database
      . Current health expenditure (% of GDP) - Nigeria, 2022. Available: https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?locations=NG [Accessed 1 Apr 2022].
    46. ↵
      1. World Bank
      . Domestic general government health expenditure per capita, (current US $) - Nigeria, 2022. Available: https://data.worldbank.org/indicator/SH.XPD.GHED.PC.CD?locations=NG [Accessed 1 Apr 2022].
    47. ↵
      1. World Bank
      . Domestic General Government Health Expenditure (% of GDP) - Nigeria, 2022. Available: https://data.worldbank.org/indicator/SH.XPD.GHED.GD.ZS?locations=NG [Accessed 1 Apr 2022].
    48. ↵
      1. World Bank
      . Domestic general government health expenditure (% of current health expenditure) - Nigeria, 2022. Available: https://data.worldbank.org/indicator/SH.XPD.GHED.CH.ZS?locations=NG [Accessed 1 Apr 2022].
    49. ↵
      1. World Bank
      . Out-of-pocket expenditure per capita (current US$) - Nigeria. Available: https://data.worldbank.org/indicator/SH.XPD.OOPC.PC.CD?locations=NG [Accessed 1 Apr 2022].
    50. ↵
      1. World Bank
      . Out-of-pocket expenditure (% of current health expenditure) - Nigeria, 2022. Available: https://data.worldbank.org/indicator/SH.XPD.OOPC.CH.ZS?locations=NG [Accessed 1 Apr 2022].
    51. ↵
      1. World Health Organization and World Bank
      . Tracking universal health coverage: 2017 global monitoring report, 2017. Available: https://www.who.int/publications/i/item/9789241513555?msclkid=62590130c5fb11ecb639a7a59505bd51 [Accessed 10 Dec 2020].
    52. ↵
      1. World Health Organization and World Bank
      . Tracking universal health coverage 2021. Global monitoring report, 2021. Available: https://cdn.who.int/media/docs/default-source/world-health-data-platform/events/tracking-universal-health-coverage-2021-global-monitoring-report_uhc-day.pdf?sfvrsn=fd5c65c6_5&download=true [Accessed 4 Feb 2022].
    53. ↵
      1. World Bank
      . World bank: about us, 2021. Available: https://data.worldbank.org/about [Accessed 12 Nov 2021].
    54. ↵
      1. World Health Organization
      . About the Observatory, 2021. Available: https://www.who.int/data/gho/info/about-the-observatory [Accessed 17 Oct 2021].
    55. ↵
      1. World Health Organization
      . Primary healthcare on the road to universal health coverage: 2019 global monitoring report, 2019. Available: https://www.who.int/publications/i/item/9789240029040?msclkid=39249bcec5fc11ecaa72aa55f28acd59 [Accessed 8 Dec 2020].
    56. ↵
      1. Hogan DR,
      2. Stevens GA,
      3. Hosseinpoor AR, et al
      . Monitoring universal health coverage within the sustainable development goals: development and baseline data for an index of essential health services. Lancet Glob Health 2018;6:e152–68.doi:10.1016/S2214-109X(17)30472-2pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/29248365
      OpenUrlPubMed
    57. ↵
      1. World Health Organization
      . Health equity assessment toolkit (HEAT): software for exploring and comparing health inequalities in countries. Built-in database edition. version 4.0, 2021. Available: https://whoequity.shinyapps.io/heat/ [Accessed 12 Feb 2021].
    58. ↵
      1. Guttmacher Institute
      . Nigeria country profile, 2021. Available: https://www.guttmacher.org/geography/africa/nigeria [Accessed 28 Jul 2021].
    59. ↵
      1. Family Planning2020
      . Over 6.5 million women now use a modern method of contraception in Nigeria, 2019. Available: https://www.familyplanning2020.org/news/over-65-million-women-now-use-modern-method-contraception-nigeria [Accessed 28 Jul 2021].
    60. ↵
      1. Family Planning2020
      . Why Nigeria’s attainment of family planning 2020 goal will be a miracle, 2019. Available: https://www.familyplanning2020.org/news/why-nigeria’s-attainment-family-planning-2020-goal-will-be-miracle-—expert [Accessed 28 Jul 2021].
    61. ↵
      1. Federal Ministry of Health Nigeria
      . Nigeria family planning blueprint (scale-up plan): October 2014, 2014. Available: https://www.healthpolicyproject.com/ns/docs/CIP_Nigeria.pdf [Accessed 28 Jul 2021].
    62. ↵
      1. Gage AJ,
      2. Ilombu O,
      3. Akinyemi AI
      . Service readiness, health facility management practices, and delivery care utilization in five states of Nigeria: a cross-sectional analysis. BMC Pregnancy Childbirth 2016;16:1–13.doi:10.1186/s12884-016-1097-3
      OpenUrlCrossRefPubMed
    63. ↵
      1. Okoli U,
      2. Abdullahi MJ,
      3. Pate MA, et al
      . Prenatal care and basic emergency obstetric care services provided at primary healthcare facilities in rural Nigeria. Int J Gynaecol Obstet 2012;117:61–5.doi:10.1016/j.ijgo.2011.11.014pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/22265191
      OpenUrlPubMed
    64. ↵
      1. World Health Organization
      . WHO recommendation on antenatal care for a positive pregnancy experience, 2016. Available: http://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-eng.pdf?sequence=1 [Accessed 4 May 2021].
    65. ↵
      1. Wang W,
      2. Alva S,
      3. Wang S
      . Levels and trends in the use of maternal health services in developing countries. DHS comparative reports No. 26 United States Agency Int Dev; 2011. https://dhsprogram.com/pubs/pdf/CR26/CR26.pdf [Accessed 18 Mar 2021].
    66. ↵
      1. Kuhnt J,
      2. Vollmer S
      . Antenatal care services and its implications for vital and health outcomes of children: evidence from 193 surveys in 69 low-income and middle-income countries. BMJ Open 2017;7:1–8.doi:10.1136/bmjopen-2017-017122pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/29146636
      OpenUrlCrossRefPubMed
    67. ↵
      1. Tuladhar H,
      2. Dhakal N
      . Impact of antenatal care on maternal and perinatal utcome: a study at Nepal medical college teaching hospital. Nepal j. obstet. gynaecol. 2012;6:37–43.doi:10.3126/njog.v6i2.6755
      OpenUrl
    68. ↵
      1. Gavi the Vaccine Alliance
      . 2011-2015 indicators, 2020. Available: https://www.gavi.org/programmes-impact/our-impact/measuring-our-performance/2011-2015-indicators [Accessed 20 Mar 2021].
    69. ↵
      1. World Health Organization and United Nations Children’s Fund
      . Progress and challenges with achieving universal immunization coverage. 2019 WHO/UNICEF estimates of national immunization coverage, 2020. Available: https://www.who.int/publications/m/item/progress-and-challenges-with-achievinguniversal-immunization-coverage?msclkid=6176b2a6c5fe11ec89ef07d37e6215be [Accessed 21 Mar 2021].
    70. ↵
      1. Jaupart P,
      2. Dipple L,
      3. Dercon S
      . Has Gavi lived up to its promise? Quasi-experimental evidence on country immunisation rates and child mortality. BMJ Glob Health 2019;4:e001789.doi:10.1136/bmjgh-2019-001789pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/31908857
      OpenUrlAbstract/FREE Full Text
    71. ↵
      1. Wariri O,
      2. Edem B,
      3. Nkereuwem E, et al
      . Tracking coverage, dropout and multidimensional equity gaps in immunisation systems in West Africa, 2000–2017. BMJ Glob Health 2019;4:e001713.doi:10.1136/bmjgh-2019-001713
    72. ↵
      1. World Health Organization
      . Annual number of cases of selected VPDs, 2020. Available: https://www.who.int/teams/immunization-vaccines-and-biologicals/immunization-analysis-and-insights/surveillance/surveillance-for-vpds [Accessed 22 Aug 2021].
    73. ↵
      1. World Health Organization and United Nations Children’s Fund
      . Progress and challenges with achieving universal immunization coverage: 2018 WHO/UNICEF estimates of national immunization coverage; 2019: 1–22. https://www.who.int/news/item/12-08-2019-progress-and-challenges-with-achieving-universal-immunization-coverage?msclkid=25cc4e62c5ff11ec9a3b017252f2298f [Accessed 29 Jun 2021].
    74. ↵
      1. Sato R
      . Association between access to a health facility and continuum of vaccination behaviors among Nigerian children. Hum Vaccin Immunother 2020;16:1215–20.doi:10.1080/21645515.2019.1678360pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/31634047
      OpenUrlPubMed
    75. ↵
      1. World Health Organization and United Nations Children’s Fund
      . Progress and challenges with achieving universal immunization coverage: 2017 WHO/UNICEF estimates of national immunization coverage, 2018. Available: https://data.unicef.org/wp-content/uploads/2016/07/Progress-and-Challenges-with-achieving-Universal-Immunization-Coverage.pptx [Accessed 30 Jun 2021].
    76. ↵
      1. World Health Organization and United Nations Children’s Fund
      . Ending preventable child deaths from pneumonia and diarrhoea by 2025. The integrated global action plan for pneumonia and diarrhoea (GAPPD), 2013. Available: https://www.who.int/publications/i/item/the-integrated-global-action-plan-for-prevention-and-control-of-pneumonia-and-diarrhoea-(gappd) [Accessed 5 Jun 2021].
    77. ↵
      1. International Vaccine Access Center
      . Pneumonia & diarrhea progress report 2018 Johns Hopkins Bloomberg School of Public Health; 2018. https://www.jhsph.edu/ivac/wp-content/uploads/2018/11/Pneumonia-and-Diarrhea-Progress-Report-2018-1.pdf [Accessed 11 May 2021].
    78. ↵
      1. United Nations Inter-Agency Group for Child Mortality Estimation
      . Child mortality: estimates developed by the un Inter-agency group for child mortality estimation, 2019. Available: https://childmortality.org/wp-content/uploads/2019/10/UN-IGME-Child-Mortality-Report-2019.pdf [Accessed 29 Mar 2021].
    79. ↵
      1. Lora-Wainwright A
      . Fighting for breath: a call to action on childhood pneumonia Save the Children; 2017. https://www.savethechildren.org/content/dam/usa/reports/health/fighting-for-breath-report.PDF [Accessed 23 Mar 2021].
    80. ↵
      1. Bakare AA,
      2. Graham H,
      3. Agwai IC, et al
      . Community and caregivers’ perceptions of pneumonia and care‐seeking experiences in Nigeria: A qualitative study. Pediatr Pulmonol 2020;55:104–12.doi:10.1002/ppul.24620
      OpenUrl
    81. ↵
      1. Bedford KJA,
      2. Sharkey AB
      . Local barriers and solutions to improve care-seeking for childhood pneumonia, diarrhoea and malaria in Kenya, Nigeria and Niger: a qualitative study. PLoS One 2014;9:e100038.doi:10.1371/journal.pone.0100038pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/24971642
      OpenUrlCrossRefPubMed
    82. ↵
      1. Graham H,
      2. Bakare AA,
      3. Ayede AI, et al
      . Diagnosis of pneumonia and malaria in Nigerian hospitals: a prospective cohort study. Pediatr Pulmonol 2020;55 Suppl 1:S37–50.doi:10.1002/ppul.24691pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/32074408
      OpenUrlPubMed
    83. ↵
      1. World Health Organization
      . Pocket book of hospital care for children: guidelines for the management of common childhood illnesses. 3. 2nd edition, 2013: 77–81.
      OpenUrl
    84. ↵
      1. Stop Pneumonia
      . Fighting for breathe: the global forum on childhood pneumonia, 2020. Available: https://stoppneumonia.org/wp-content/uploads/2019/10/Fighting-for-Breath-Global-Forum-Overview.pdf [Accessed 23 Mar 2021].
    85. ↵
      1. Stop Pneumonia
      . Universal health coverage (UHC): through the lens of pneumonia, 2018. Available: https://stoppneumonia.org/uhc-through-the-lens-of-pneumonia/ [Accessed 23 Mar 2021].
    86. ↵
      1. Onwujekwe O,
      2. Obi F,
      3. Ichoku H, et al
      . Assessment of a free maternal and child health program and the prospects for program re-activation and scale-up using a new health fund in Nigeria. Niger J Clin Pract 2019;22:1516–29.doi:10.4103/njcp.njcp_503_18pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/31719273
      OpenUrlPubMed
    87. ↵
      1. Oduenyi C,
      2. Ordu V,
      3. Okoli U
      . Assessing the operational effectiveness of a maternal and child health (MCH) conditional cash transfer pilot programme in Nigeria. BMC Pregnancy Childbirth 2019;19:1–12.doi:10.1186/s12884-019-2418-0
      OpenUrlCrossRefPubMed
    88. ↵
      1. Abimbola S,
      2. Okoli U,
      3. Olubajo O, et al
      . The midwives service scheme in Nigeria. PLoS Med 2012;9:e1001211.doi:10.1371/journal.pmed.1001211pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/22563303
      OpenUrlCrossRefPubMed
    89. ↵
      1. National Primary Health Care Development Agency
      . Basic health care provision fund (BHCPF), 2021. Available: https://nphcda.gov.ng/bhcpf/ [Accessed 10 Sep 2021].
    90. ↵
      1. Onwujekwe O,
      2. Ezumah N,
      3. Mbachu C, et al
      . Exploring effectiveness of different health financing mechanisms in Nigeria; what needs to change and how can it happen? BMC Health Serv Res 2019;19:661.doi:10.1186/s12913-019-4512-4pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/31519181
      OpenUrlPubMed
    91. ↵
      1. Oyedeji R,
      2. Abimbola S
      . How tertiary hospitals can strengthen primary health care in Nigeria. Niger Med J 2014;55:519-20.doi:10.4103/0300-1652.144715pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/25538375
      OpenUrlPubMed
    92. ↵
      1. Abimbola S,
      2. Olanipekun T,
      3. Igbokwe U, et al
      . How decentralisation influences the retention of primary health care workers in rural Nigeria. Glob Health Action 2015;8:26616.doi:10.3402/gha.v8.26616pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/25739967
      OpenUrlPubMed
    93. ↵
      1. Faye CM,
      2. Wehrmeister FC,
      3. Melesse DY, et al
      . Large and persistent subnational inequalities in reproductive, maternal, newborn and child health intervention coverage in sub-Saharan Africa. BMJ Glob Health 2020;5:e002232:1–9.doi:10.1136/bmjgh-2019-002232pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/32133183
      OpenUrlAbstract/FREE Full Text
    94. ↵
      1. Boerma T,
      2. Requejo J,
      3. Victora CG, et al
      . Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health. Lancet 2018;391:1538–48.doi:10.1016/S0140-6736(18)30104-1pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/29395268
      OpenUrlCrossRefPubMed
    95. ↵
      1. Adeloye D,
      2. David RA,
      3. Olaogun AA, et al
      . Health workforce and governance: the crisis in Nigeria. Hum Resour Health 2017;15:1–8.doi:10.1186/s12960-017-0205-4
      OpenUrlCrossRefPubMed
    96. ↵
      1. Arsenault C,
      2. Johri M,
      3. Nandi A, et al
      . Country-Level predictors of vaccination coverage and inequalities in Gavi-supported countries. Vaccine 2017;35:2479–88.doi:10.1016/j.vaccine.2017.03.029pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/28365251
      OpenUrlCrossRefPubMed
    97. ↵
      1. World Health Organization
      . The world health report: health systems financing; the path to universal coverage, 2010. Available: https://apps.who.int/iris/handle/10665/44371 [Accessed 30 Sep 2020].
    98. ↵
      1. Enabulele O
      . Achieving universal health coverage in Nigeria: moving beyond annual celebrations to concrete address of the challenges. World Med Health Policy 2020;12:47–59.doi:10.1002/wmh3.328
      OpenUrlCrossRef
    99. ↵
      1. Olarewaju OA
      . Insecurity in northern Nigeria: implications for maternal and child health. Clin Epidemiol Glob Health 2021;12:100869.doi:10.1016/j.cegh.2021.100869
      OpenUrl
    100. ↵
      1. Fund For Peace
      . Fragile states index 2017, 2017. Available: https://fragilestatesindex.org/wp-content/uploads/2017/05/951171705-Fragile-States-Index-Annual-Report-2017.pdf [Accessed 13 Apr 2021].
    101. ↵
      1. Institute for Economics & Peace
      . Global terrorism index 2017: measuring and understanding the impact of terrorism, 2017. Available: https://reliefweb.int/sites/reliefweb.int/files/resources/Global Terrorism Index 2017 %284%29.pdf [Accessed 3 May 2021].
    102. ↵
      1. Institute for Economics & Peace
      . Global terrorism index 2020: measuring the impact of terrorism, 2020. Available: https://www.visionofhumanity.org/wp-content/uploads/2020/11/GTI-2020-web-2.pdf [Accessed 3 May 2021].
    103. ↵
      1. Boerma T,
      2. Tappis H,
      3. Saad-Haddad G, et al
      . Armed conflicts and national trends in reproductive, maternal, newborn and child health in sub-Saharan Africa: what can National health surveys tell us? BMJ Glob Health 2019;4:e001300.doi:10.1136/bmjgh-2018-001300pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/31297253
      OpenUrlAbstract/FREE Full Text
    104. ↵
      1. DeJong J,
      2. Ghattas H,
      3. Bashour H, et al
      . Reproductive, maternal, neonatal and child health in conflict: a case study on Syria using countdown indicators. BMJ Glob Health 2017;2:e000302.doi:10.1136/bmjgh-2017-000302pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/29225945
      OpenUrlAbstract/FREE Full Text
    105. ↵
      1. Druetz T,
      2. Browne L,
      3. Bicaba F, et al
      . Effects of terrorist attacks on access to maternal healthcare services: a national longitudinal study in Burkina Faso. BMJ Glob Health 2020;5:e002879.doi:10.1136/bmjgh-2020-002879pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/32978211
      OpenUrlAbstract/FREE Full Text
    106. ↵
      1. World Health Organization
      . Vaccines and immunization, 2021. Available: https://www.who.int/health-topics/vaccines-and-immunization#tab=tab_2 [Accessed 20 Mar 2021].
    107. ↵
      1. World Health Organization
      . World health statistics 2020: monitoring health for the SDGs, sustainable devevelopment goals, 2020. Available: https://apps.who.int/iris/handle/10665/332070?msclkid=ebece166c60011ec93f7911bd11b8122 [Accessed 23 Nov 2020].
    108. ↵
      1. Barden-O'Fallon J,
      2. Barry MA,
      3. Brodish P, et al
      . Rapid assessment of Ebola-related implications for reproductive, maternal, newborn and child health service delivery and utilization in Guinea. PLoS Curr 2015;7. doi:doi:10.1371/currents.outbreaks.0b0ba06009dd091bc39ddb3c6d7b0826. [Epub ahead of print: 04 Aug 2015].pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/26331094
    109. ↵
      1. United Nations Women
      . As front-line caretakers in Ebola crisis, women and girls need gender-based humanitarian response, gender alert says, 2014. Available: https://www.unwomen.org/en/news/stories/2014/9/gender-alert-ebola-west-africa [Accessed 23 Jun 2021].
    110. ↵
      1. Camara BS,
      2. Delamou A,
      3. Diro E, et al
      . Effect of the 2014/2015 Ebola outbreak on reproductive health services in a rural district of Guinea: an ecological study. Trans R Soc Trop Med Hyg 2017;111:22–9.doi:10.1093/trstmh/trx009pmid:http://www-ncbi-nlm-nih-gov.ezproxy.u-pec.fr/pubmed/28340207
      OpenUrlCrossRefPubMed
    111. ↵
      1. Otu A,
      2. Ameh S,
      3. Osifo-Dawodu E, et al
      . An account of the Ebola virus disease outbreak in Nigeria: implications and lessons learnt. BMC Public Health 2018;18:1–8.doi:10.1186/s12889-017-4535-x
      OpenUrlCrossRefPubMed
      1. World Bank
      . Life expectancy at birth, total (years) - Nigeria, 2022. Available: https://data.worldbank.org/indicator/SP.DYN.LE00.IN?locations=NG [Accessed 1 Apr 2022].

    Footnotes

    • Contributors JJM and XW conceptualised the study. JJM, XW and XS were involved in the methodology. JJM, XW, XS and WH contributed to the data curation, formal analysis, writing and manuscript review. All authors read and approved the final manuscript. XW is responsible for the overall content as guarantor.

    • Funding This study was supported by the Swiss Agency for Development and Cooperation (grant number: #81067392). This study was also supported by a supplementary grant from the the Fundamental Research Funds for the Central Universities (grant agreement number: lzujbky-2021-ey13).

    • Competing interests The authors have no conflicts of interest to report.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.