The midwives service scheme: a qualitative comparison of contextual determinants of the performance of two states in central Nigeria

BACKGROUND: The federal government of Nigeria started the Midwives Service Scheme in 2009 to address the scarcity of skilled health workers in rural communities by temporarily redistributing midwives from urban to rural communities. The scheme was designed as a collaboration among federal, state and local governments. Six years on, this study examines the contextual factors that account for the differences in performance of the scheme in Benue and Kogi, two contiguous states in central Nigeria. METHODS: We obtained qualitative data through 14 in-depth interviews and 2 focus group discussions: 14 government officials at the federal, state and local government levels were interviewed to explore their perceptions on the design, implementation and sustainability of the Midwives Service Scheme. In addition, mothers in rural communities participated in 2 focus group discussions (one in each state) to elicit their views on Midwives Service Scheme services. The qualitative data were analysed for themes. RESULTS: The inability of the federal government to substantially influence the health care agenda of sub-national governments was a significant impediment to the achievement of the objectives of the Midwives Service Scheme. Participants identified differences in government prioritisation of primary health care between Benue and Kogi as relevant to maternal and child health outcomes in those states: Kogi was far more supportive of the Midwives Service Scheme and primary health care more broadly. High user fees in Benue was a significant barrier to the uptake of available maternal and child health services. CONCLUSION: Differential levels of political support and prioritisation, alongside financial barriers, contribute substantially to the uptake of maternal and child health services. For collaborative health sector strategies to gain sufficient traction, where federating units determine their health care priorities, they must be accompanied by strong and enforceable commitment by sub-national governments.