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#SAFER trains, equips, and pays trusted community members to provide care for mothers and newborns displaced by conflict in Northern Nigeria

Photo of Ada

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What specific problem(s) are you trying to address?

Armed conflict in North Eastern Nigeria has displaced over 1.8 million people into temporary camps across the country. In these camps, women face multiple barriers to health care use. Overcrowded and understaffed camp clinics discourage women from using maternal and newborn care. Also, where health workers are from other ethnic groups, interethnic tensions and language barriers reduce the acceptability of care. When asked why she had stopped attending antenatal care, a pregnant woman remarked: “They call me Mallam’s wife instead of my name when I visit the clinic”. Thus, without an adequate supply of skilled care that is culturally-competent, displaced mothers and their newborns face an increased risk of disease and preventable death.

What are some of your unanswered questions about the problem(s) you are working to address?

Key unanswered questions are: who does the pregnant or lactating mother consider qualified to provide care for herself and her newborn? If unskilled, how can these trusted individuals be trained to provide evidence-based health care? What other modifiable factors affect health care use among pregnant or lactating mothers and their newborns following displacement?

Explain Your Idea

#SAFER will define key competencies and essential supplies that internally displaced individuals in informal settlements should possess to provide culturally-competent and evidence-based health care to pregnant and lactating mothers and newborns in their settlements. The profile of qualified candidates and healthcare standards will be developed in partnership with potential users and skilled health workers through group interviews. These healthcare standards will include clear protocols for referrals for cases that need specialist care. #SAFER will then develop a curriculum for rapid, simulated, and community-based learning based on these standards and train recruits from the same settlements that fit the pre-specified profile. #SAFER recruits will be paid to find the target users (pregnant and lactating mothers and newborns) and to provide them with a pre-defined set of essential services free of charge. Through partnerships with State Central Medical Stores, grant funds, and corporate sponsorship, #SAFER will provide each mother with a “safe pregnancy pack” containing essential supplies for pregnancy, delivery, and the immediate postnatal period. We will also connect #SAFER recruits to doctors and nurses by phone so that our recruits can receive support for difficult cases in the absence of referral facilities.

Name the three most important ways that your idea will address your identified problem(s).

1. By task-shifting to trained community members in informal settlements, #SAFER aims to increase the supply of health workers among internally displaced populations. 2. #SAFER will address cultural barriers to care by recruiting individuals who speak the user’s language and understand the prevalent culture in the target population. 3. Individuals local to a settlement and trained through #SAFER may be easier to retain in healthcare delivery than doctors or nurses deployed from other parts of the country.

How is your idea unique?

#SAFER draws on resources within the internally displaced community to address gaps in service delivery in contrast to other initiatives that focus on the internally displaced community primarily as service recipients. For instance, the Presidential Initiative for the North East is refurbishing health centers and providing incentives to retain nurses, while non-profits such as FHI360 also support clinics and provide health education and nutrition to displaced persons. Our focus groups indicate that due to overcrowded clinic spaces, interethnic tensions, and language barriers, displaced mothers may choose not to use clinic-based care. Therefore, #SAFER leverages social capital within the internally displaced population to promote community-based access to health care that is culturally competent. In this way, #SAFER improves maternal and newborn wellbeing as a direct health benefit while creating livelihood opportunities for our recruits as an indirect economic benefit.

What are some outstanding concerns or questions that you have regarding your idea?

1) How can #SAFER address the unique physical, emotional, and security challenges of providing maternal and child health services as an internally displaced person? 2) How will #SAFER cover the cost of training, essential medical supplies, and incentives for #SAFER recruits beyond the pilot phase? 3) What are the prospects of career pathways for #SAFER recruits in the formal health care system after normalcy returns?

Who are your end users?

#SAFER primarily targets pregnant or lactating females of reproductive age (15-49 years) and their newborns (below 1 month), who have been displaced from North Eastern Nigeria and live in organized or informal communities, where there is low use of facility-based and skilled care. #SAFER aims to provide these users with antenatal, delivery, and postnatal care. The potential benefits of #SAFER include a reduction in the risk of disease and death from preventable causes and an increase in satisfaction due to culturally-competent health care experiences provided by #SAFER recruits. In our pilot, we aim to reach about 1000 end users, as we refine #SAFER, over the first 6 months.

Where will your idea be implemented?

  • Nigeria

What is the primary type of emergency setting where your innovation would operate?

  • Armed conflict
  • Prolonged displacement

Tell us more about the emergency setting that you intend to implement in

#SAFER will target settlements for internally displaced groups. Key considerations include: 1) Political: Linkages between #SAFER and the Presidential Initiative for the North East will increase the chances of scaling after the pilot.; 2) Financial: The pilot costs of #SAFER will be covered by multiple grants and in-kind support from the State Central Medical Stores. In scaling up this intervention, we will also explore grant funds from the Global Innovation Fund and Grand Challenges.

What is your organization's name?

Health Policy Research Group.

Tell us more about you.

The core #SAFER team has three collaborators. Ada is responsible for intervention strategy, project planning, monitoring, and evaluation; Chinyere will coordinate partnerships with communities, government, non-profit agencies, and health workers; and Ebuwa will be the de-facto project manager, responsible for leading implementation of the intervention, including training and supervision of #SAFER recruits. Altogether, the team has over 25 years of healthcare delivery experience as medical doctors and public health practitioners, including 4 years of service delivery in Northern Nigeria. We have also worked on task-shifting programs within health services and on care delivery among internally displaced populations in Nigeria.

Organizational Characteristics

  • Indigenous-led organization

What is the current scale of your proposed innovation?

  • Still in planning phase and does not exist yet

Experience in Implementation Country(ies)

  • Yes, for more than one year.

Expertise in Sector

  • Yes, for more than a year.

Organization Location

The Health Policy Research Group (HPRG) is based in the College of Medicine, University of Nigeria, Enugu-campus, Nigeria. Dr. Chinyere Mbachu is Assistant Coordinator, Research Projects.

What is your organizational status?

  • Registered non-profit, charity, NGO, or community-based organization.

What is the maturity of your innovation?

  • Early Stage Innovation: exploring my innovation, refining, researching, and gathering inspiration.

How has your idea changed based on feedback?

Feedback from users and the OpenIDEO community has changed our idea in the following ways: 1) Intervention Scope: We had not included delivery care in our scope of services under #SAFER. However, pregnant women in informal settlements remarked that they are choosing to deliver alone, with relatives or friends, and traditional birth attendants, rather than use health facilities. This was also highlighted by Ndume Eliya Nduelib in the comment section. We also discovered that the Presidential Initiative for the North East is exploring training village health workers to increase access to essential care. Thus, we are exploring training in basic childbirth services for our recruits. Users highlighted the importance of cultural competence which we now emphasize in choosing #SAFER recruits. 2) Clarity: Our idea has been in flux for a while, so the advice asking for clarity on what we planned on doing and how was a useful nudge to review the entire concept again for clarity and coherence.

Who will implement this idea?

Chinyere and Ebuwa will be committed full-time towards the implementation of this idea and will be based in Nigeria for the length of the pilot. Ebuwa will be the project manager and will supervise all support staff recruited into the Project while Chinyere will focus on coordinating partnerships necessary for implementation in each settlement, including engaging community leaders, state Government officials, non-profit organizations, and corporate donors. Ada will lead the initial strategy and planning sessions and the mid-term review in Nigeria but is based in the United States. In addition to 50 #SAFER recruits in the pilot, we anticipate that the Project will hire about 5 full-time support staff to facilitate recruit training, administrative duties, and other logistics.

Using a human-centered design approach, you may uncover insights that lead to small or foundational changes to your organization’s existing strategy or processes in order to unlock the potential of your idea. How would your organization go about making such changes?

The Health Policy Research Group is relatively decentralized, allowing for both top-down and bottom-up decision-making on the design, implementation, and evaluation of a range of health projects. Within the organization, regular team retreats ensure that lessons are shared across teams on more effective and efficient ways of carrying out various aspects of the project cycle. The key individuals that shape these retreats are the senior members of the team, of whom Dr. Chinyere is one. Thus, as we learn insights that can dramatically improve the process of designing, of implementing, and of evaluating health projects, Dr. Chinyere could advocate for sharing these lessons with the team and for adoption across the portfolio.

What challenges do your end-users face? (1) What is the biggest challenge that your end-users face on a day-to-day, individual level? (2) What is the biggest systems-level challenge that affects your end-users?

The most pressing issue faced by our end-users is food insecurity - rapid assessments indicate that between 75-93 percent have inadequate food consumption. Women also face an increased risk of sexual and gender-based violence following displacement. On a systems level, logistical challenges, including coordination gaps and a poor road network, are the major constraints to delivering essential supplies to internally displaced persons. Thus, we aim to collaborate with local non-profits focused on nutrition supplementation such as the Social Welfare Network Initiative. On a systems level, we intend to liaise with the State Emergency Management Agency on supply chain logistics to mitigate coordination gaps.

Tell us about your vision for this project: (1) share one sentence about the impact you would like to see from this project in five years and (2) what is the biggest question you need to answer to get there?

IMPACT: By 2022, we aim to have trained 500 #SAFER recruits who will reach 10000 internally displaced mothers and newborns in North Eastern Nigeria with culturally-competent and evidence-based health care. QUESTION: How can #SAFER be adjusted to ensure that the provision of culturally-competent, cost-effective, and evidence-based care for internally displaced mothers and newborns by members of their communities is replicable across Nigeria, enabling us to reach 10000 users by 2020?

What is it that most attracted you to Amplify instead of a more traditional funding model?

At the start, we had several questions about how mothers and newborns in the North East experienced health services, what solutions might be most appropriate, and the scope of our intervention relative to other actors in the North East. OpenIDEO allowed us to be honest about unanswered questions in our project design while providing support for us to iterate and improve it, particularly through user feedback. The room to review the design in this way was the primary attraction to Amplify.

Do you intend to implement your Amplify idea in refugee camps / temporary settlements?

  • We aim to implement our Amplify idea in a refugee camp / temporary settlement.

How long have you and your colleagues been working on this idea together?

  • Between 6 months and 1 year

How many of your organizations’s paid, full-time staff are currently based in the location where the beneficiaries of your proposed idea live?

  • Under 5 paid, full-time staff

Is your organization registered in the country you intend to implement your idea in?

  • We are registered in all countries where we plan to implement.

My organization's operational budget for 2016 was:

  • Between $100,000 and $500,000 USD

What do you need the most support with for your innovation?

  • Program/Service Design


Join the conversation:

Photo of Tien Pham

Hi Ada, I'm currently working at Amnesty International Australia and I'm very interested in your topic. This not only covers the problem of pregnant or lactating mother and her newborn but also offers jobs to refugees. I just wonder if complications would arise and Martha had to go through a cesarean section. Does SAFER also provide service during postpartum?

Photo of Ada

Dear Tien Pham, thank you for the excellent comment. We are actually in the field now, talking with pregnant and lactating women who have been displaced about their service needs and if/how this intervention can help meet these needs - we are exploring the experience of these groups along the continuum from the antenatal to the postnatal period, to identify the key interventions that need to be provided by task-shifting versus linking to skilled providers, including doctors or nurses. As we refine the draft in the next phase, we hope you can look at it, and tell us what your thoughts are on the updated model we arrive at.

Photo of Ashley Tillman

Tien Pham and Ada excited to see the two of you connecting, looking forward to hearing if you are able to share helpful information with each other or collaborate!

Photo of Ada

Thanks, Ashley. Tien Pham's excellent comment about expanding the service scope to the postnatal period informed some of the refinements to the #SAFER proposal. It would be great to partner on implementation as well - it seems to us that while we are piloting #SAFER in Nigeria, this model might be useful in other countries hosting internally-displaced people or refugees - to improve service delivery and provide employment opportunities.

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