THE EFFECT OF PUBLIC HEALTH SPENDING ON MATERNAL MORTALITY IN NIGERIA

CHAPTER ONE

INTRODUCTION

1.1 Background to the Study

The World Health Organization (2010) defines maternal death as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes. This definition makes it possible to identify maternal deaths by their causes as either direct or indirect. The statistics on Nigeria's maternal mortality ratio are both staggering and pitiful, all the more so because evidence abounds that successive administrations, military and civilian, have put rhetoric before action in mitigating this alarming public health problem. The most recent inter-agency estimates show how far the problem has persisted. The United Nations Maternal Mortality Estimation Inter-Agency Group (WHO et al., 2025) puts Nigeria's maternal deaths in 2023 at about 75,000, which is 28.7 per cent of all maternal deaths in the world and the highest number of any country, with a maternal mortality ratio close to 1,000 per 100,000 live births. Nigeria's ratio had fallen by only about 13 per cent since 2000.

The battle against maternal mortality was one of the critical issues at the forefront of the Beijing Conference of 1995, which was held at the instance of women activists from across the globe. The other issues at the conference included the need to address rising household poverty, ensure economic empowerment, improve women's health care, promote girl-child education and uphold women's human rights. Five years later, at the Millennium Summit of 2000, maternal mortality was again a subject of discussion, which showed its magnitude and the need for nations to reduce it by 2015.

Most countries, developed and developing, pursue the basic macroeconomic goals of sustainable economic growth, full employment, price stability and balance-of-payments equilibrium, and they rely heavily on government to provide capital- and labour-intensive projects. The policies and programmes designed to advance human development emanate from the public sector and are implemented by it. In market-based economies growth is generated by the private sector, which is often called the engine of growth, but it is facilitated by government through productive and strategic public investment and the creation of an enabling environment. It is in this function of the public sector that the role of the Nigerian government in the health sector is analysed. The weak performance of some sectors of the Nigerian economy, such as health, needs to be addressed because of their role in economic growth, since the performance of the health sector has a long-run effect on any economy. Governments are often more attached to sectors with short-run effects, and they neglect sectors such as health and education, whose effects are long-run. This can be seen in well-constructed health policies that are not adequately implemented. Governments often forget that a healthy nation is a wealthy nation. A healthy mother begets a healthy child, and if mothers are not properly cared for before and after pregnancy, they may bear unhealthy children, who in the long run affect both the quality and the quantity of the labour force.

The effectiveness and efficiency of a country's health system determine its health outcomes. Neglect of the health sector has caused many developing countries, Nigeria included, to fall far short of the standard set by the WHO for safe motherhood. The dismal state of the health sector, particularly primary health care, contributes to adverse health outcomes such as poor maternal health. A Federal Ministry of Health document of 2004 acknowledges that the health system in Nigeria and the health status of Nigerians were in a deplorable state, and it notes numerous problems, including low motivation among health workers, an annual budget preparation process that the report calls a ritual, a culture of corruption, and little consultation between federal and state health authorities and between the Federal Ministry of Health and other ministries. The poor administration of health care has also been lamented by a former Minister of Health, Professor Babatunde Osotimehin, who said that the competence of health professionals is not in question, but rather the ability to administer the country better. He asked how the country came to spend about 70 to 80 per cent of the resources available for health care on less than 5 to 10 per cent of the population.

External evaluation of the Nigerian health system supports this assessment. About 500,000 women were estimated to die each year worldwide from complications of pregnancy and childbirth, and about 55,000 of these deaths occurred in Nigeria. With only 2 per cent of the world's population, Nigeria accounted for over 10 per cent of the world's maternal deaths. In 2003, the WHO and the Federal Ministry of Health reported that about 145 women died every day in Nigeria from causes related to childbirth, and that the risk of a woman dying from childbirth was 1 in 18 in Nigeria, compared with 1 in 61 for all developing countries and 1 in 29,800 in Sweden. It is not surprising that the WHO (2000) ranked the performance of Nigeria's health care system 187th out of 191 member states of the United Nations in the year 2000. At the time of the study Nigeria was also ranked second only to India in the number of maternal deaths, which confirms the poor condition of its health system. The latest estimates show that Nigeria has since moved to first place (WHO et al., 2025).

Empirical evidence also suggests that maternal mortality in Nigeria is not uniform across the country but varies markedly across geographical zones. The 2003 National Demographic and Health Survey (NDHS) recorded a higher maternal mortality ratio in the northern region than in the southern. In 2003 the ratio was 1,025 in the North-West, 1,549 in the North-East, 165 in the South-West and 285 in the South-East. The latest NDHS, for 2023–24, puts the national ratio at over 500 deaths per 100,000 live births (Nasiru et al., 2025), which is lower than earlier estimates but still very high.

The poor performance of the Nigerian health sector, as shown by the high maternal mortality ratio, brought Nigeria under particular focus with respect to the Millennium Development Goals (MDGs). In September 2000, the United Nations Millennium Declaration was signed by 189 countries, with the aim of eradicating poverty and achieving sustainable development in the world by 2015. The declaration listed eight goals, of which Goal 5 addresses maternal mortality directly. The maternal mortality ratio of 545 per 100,000 at the time of the study (FMoH, 2011) put Nigeria well off track to achieve Millennium Development Goal 5. This was consistent with the finding of the 2003 NDHS that, although maternal mortality in Nigeria was high, little progress had been made in reducing it since the first safe motherhood programmes were launched in the late 1980s. At the then-current rate of reduction, Nigeria was projected to reach a ratio of 540 per 100,000 by 2015, which is more than twice the MDG target of 250 per 100,000 for Nigeria. The ratios and ranks of maternal mortality and other closely related health outcomes were drawn from the NDHS, the United Nations and the Institute for Health Metrics and Evaluation. They show that the neonatal, under-five and maternal mortality ratios moved only slowly between 1990 and 2008 and that Nigeria ranked first among African countries in both newborn and maternal deaths. At the end of the MDG period, the target was clearly missed, and the global community has moved to Sustainable Development Goal 3.1, which sets a target of fewer than 70 maternal deaths per 100,000 live births by 2030. The global ratio stood at 197 in 2023, almost three times the target (WHO et al., 2025).

About 33,000 Nigerian women die each year in childbirth according to the Federal Ministry of Health (FMoH, 2011), and for every maternal death at least seven newborns die and a further four babies are stillborn. Meeting MDG 5 for maternal survival would have required a 75 per cent reduction in maternal mortality from an estimated 1,100 maternal deaths per 100,000 live births by 2015. The most baffling aspect of this statistical evidence is that health sector allocations in Nigeria have been rising from the outset. Despite the rising allocations at the federal, state and local government levels, maternal deaths have continued to escalate. Maternal mortality has been falling in recent estimates from the United Nations, the Institute for Health Metrics and Evaluation and the NDHS, yet the Federal Ministry of Health (FMoH, 2011) maintains that Nigeria is not on track to meet MDG 5. Recent Nigerian studies make the same observation. Adegoke, Mbonigaba and George (2022) note that public health expenditure in Nigeria has increased without a corresponding improvement in health outcomes, and that the 2001 Abuja Declaration, which committed governments to raise funding for health, has not yet produced the improvement expected.

The expenditure figures illustrate the point. In 2003 and 2007, national health spending was N39,685.5 million and N122,400 million respectively (CBN, 2007), while the national maternal mortality ratio stood at 980 and 900 per 100,000 live births. Total health expenditure (THE) was estimated at N661.662 billion in 2003, and it grew nominally by about 19 per cent to N788.72 billion in 2004 and to N976.69 billion in 2005. The total is the sum of general government expenditure (federal, state and local governments) and private health expenditure. Total health expenditure as a proportion of GDP was estimated at 12.25 per cent in 2003 and 8.56 per cent in 2005. Federal government health expenditure was estimated at N47.02 billion in 2003 and grew nominally by 145 per cent to N115.06 billion in 2004 and by 14 per cent to N130.76 billion in 2005. State expenditure was N48.02 billion in 2003, which grew by 19 per cent to N56.96 billion in 2004 and by 38 per cent to N78.78 billion in 2005. Expenditure by local governments was N28.63 billion, which rose by 26 per cent to N36.18 billion in 2004 and by 23 per cent to N44.64 billion in 2005 (National Health Accounts, 2003–2005). In individual states, health spending in 2003 was N21.02 billion in Edo, N26.55 billion in Kaduna and N26.78 billion in Kano, while their maternal mortality ratios were 675, 1,300 and 1,000 per 100,000 live births respectively.

The overall rise in government expenditure and in public health expenditure has unfortunately not translated into the meaningful growth and development in the health sector that was expected. This raises questions about the criteria and rationale for monetary allocations in the health sector. What are the efficiency criteria for health budget allocations if the intended objectives of MDG 5 seem so far out of reach? Funds allocated to the Nigerian health system should be properly managed by all three tiers of government in order to enhance economic growth and achieve the MDGs, even if the goals are achieved after the 2015 deadline. Some scholars support an important role for government in socio-economic development, holding that the provision of socio-economic goods such as defence, roads, education, health and physical infrastructure encourages economic growth, and that government spending on health and education raises the productivity of the labour force and the growth of national output. A serious examination of the relationship between maternal mortality and public health expenditure in Nigeria is therefore necessary. Akintunde (2023), for example, finds that health care expenditure reduces maternal mortality in Nigeria in both the short run and the long run, even after controlling for female literacy, female per capita income and poverty. The findings of this research will enable us to propose economic policies and recommendations on how to use public health spending to reduce maternal mortality in Nigeria by 75 per cent, as stipulated in MDG 5, or beyond that date if the target proves infeasible by the 2015 deadline.

1.2 Statement of the Problem

The UN Millennium Declaration was agreed in 2000 by 189 countries, which showed an unprecedented commitment by rich and poor countries alike to improve human development by 2015. The commitment is summarized in the eight Millennium Development Goals (MDGs), which set targets in poverty reduction, health, education, gender equality, environmental sustainability and global partnership (UNDP, 2003). The eight goals are to eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, reduce child mortality, improve maternal health, combat HIV/AIDS, malaria and other diseases, ensure environmental sustainability, and develop a global partnership for development. The focus on the MDGs has stimulated critical debate on several issues, including the choice of policy options for attaining them and concern about the availability and reliability of data for monitoring MDG outcomes.

Despite these policy debates, studies have shown that some countries, developed and developing, achieved significant progress on the MDG targets, especially MDG 5 (improve maternal health), through health spending. Nigeria has seen a rising trend in health sector allocation but is still ranked second to India among countries with the highest maternal mortality, which is surprising. Along with ever-increasing health expenditure comes the need to evaluate its effectiveness. Did past health expenditure affect health outcomes such as maternal mortality? Are increases in health expenditure needed to improve health outcomes for Nigerian women? These questions can be answered only by studying the relationship between health outcomes such as maternal mortality and health expenditure in Nigeria.

The causal relationship between health expenditure and health outcomes continues to attract attention, but after decades of intensive study there is still no general consensus on the effectiveness of health inputs for health outcomes. Recent Nigerian evidence is also mixed. Adegoke et al. (2022) argue that increases in public health expenditure alone may not have the desired effect on maternal and infant mortality, because macroeconomic conditions also matter. Koginam and Atamenwan (2026) find a long-run relationship between public health expenditure, inflation and maternal mortality in Nigeria, and they call for price stability alongside better public health spending. At the same time, evidence exists for countries that have significantly reduced maternal mortality through public health spending. It therefore becomes imperative to examine critically the government's health expenditure in Nigeria. This study will specifically investigate the effectiveness, and the significance, of public health spending on maternal mortality in Nigeria. If the effect is found to be insignificant, either health spending is an ineffective policy tool or other policies are needed to supplement it, but if it is found to be significant, health spending is a vital government policy for achieving the MDG 5 target.

1.3 Objectives of the Study

The objective of the study is to determine the effectiveness of past health expenditure on maternal mortality in Nigeria. Effectiveness is one yardstick for evaluating performance in fiscal policy, because the budget is indisputably a key government tool for implementing social, political and economic policies and priorities. The disaggregated objectives are to:

1. Determine how effective public health expenditure is on maternal mortality in Nigeria.

2. Analyse the effect of skilled birth attendants (SBA) on maternal mortality reduction in Nigeria.

3. Investigate whether the female literacy rate has any effect on maternal mortality in Nigeria.

4. Determine the effect of the fertility rate on maternal mortality in Nigeria.

5. Investigate whether both female and state per capita health expenditures have any impact on maternal mortality in Nigeria.

1.4 Research Questions

1. Will public expenditure on health have any effect on maternal mortality in Nigeria?

2. Does the number of skilled birth attendants (SBA) have any effect on maternal mortality in Nigeria?

3. Will the literacy rate of women of child-bearing age (15–49) have any effect on maternal mortality in Nigeria?

4. Will the fertility rate have any effect on maternal mortality in Nigeria?

5. Will both female and state per capita health expenditures have any impact on maternal mortality reduction in Nigeria?

1.5 Statement of Hypotheses

The hypotheses guiding this research are:

i. There is no significant effect of public health expenditure on maternal mortality in Nigeria.

ii. Skilled birth attendants (SBA) do not have any effect on maternal mortality reduction in Nigeria.

iii. Female literacy level has no impact on maternal mortality reduction in Nigeria.

iv. There is no significant effect of the fertility rate on maternal mortality in Nigeria.

v. Female and state per capita health expenditures do not have any effect on maternal mortality reduction in Nigeria.

1.6 Justification of the Study

In Nigeria it has been a challenge to assess the extent of progress made towards the MDG 5 target, which is to reduce the maternal mortality ratio (MMR) by three-quarters, or 75 per cent, and to achieve universal access to reproductive health between 1990 and 2015. The study will keep us abreast of the progress made so far towards this target, and it will show whether the target is still achievable by the 2015 deadline. It will also show what the Nigerian government has contributed so far to reducing maternal mortality, and it will help policy makers in the health sector with their policy choices. The work will also help government to allocate the health sector's share of the budget appropriately. Besides benefiting the researcher academically, it will serve subsequent researchers as a guide for their literature reviews. Skilled attendance at birth is one reason the question matters. Fagbamigbe and Oyedele (2022) show that the use of skilled birth attendants in Nigeria rose by less than 1 per cent a year between 1990 and 2018, with rural states doing worst and women's health decision-making power contributing most to improvement.

1.7 Policy Relevance

The findings will be a very useful guide to policy makers in making public spending choices on health at the national and state levels. Many health policy decisions will now be able to rest on quantitative assessments of the effect of public spending on health outcomes such as maternal mortality, which this study analyses in depth. The work will add to the existing literature and knowledge on the performance of the Nigerian health sector. It could be used to sensitize health and other relevant sectors, for example planning, finance and transport, so as to generate political and economic support for the national safe motherhood programmes. International non-governmental organizations that support the safe motherhood initiative in Nigeria could use the results for advocacy among bilateral and multilateral donors.

1.8 Scope of the Study

The research uses a panel data set obtained from 25 states in Nigeria in 2003 and 2008 for its analysis, estimation and comparison, which is the basis of panel regressions. The study examines government input towards maternal mortality reduction from 1990 to 2011, but it compares the effect of public health spending on maternal mortality mainly between 2003 and 2008, since comparison is the logic behind panel estimation. The 25 states are those for which data are available for the analysis.

References

Adegoke, Y. O., Mbonigaba, J., & George, G. (2022). Macro-economic determinants, maternal and infant SDG targets in Nigeria: Correlation and predictive modeling. Frontiers in Public Health, 10, Article 999514. https://doi.org/10.3389/fpubh.2022.999514

Akintunde, T. S. (2023). Health care expenditure and maternal mortality in Nigeria (1991–2021). Department of Economics, Osun State University. https://ajaefm.adsu.edu.ng/index.php/journals/article/view/1

Fagbamigbe, A. F., & Oyedele, O. K. (2022). Multivariate decomposition of trends, inequalities and predictors of skilled birth attendants utilisation in Nigeria (1990–2018): A cross-sectional analysis of change drivers. BMJ Open, 12, Article e051791. https://doi.org/10.1136/bmjopen-2021-051791

Koginam, A. O., & Atamenwan, J. (2026). Influence of inflation and public health expenditure on health outcomes in Nigeria. East African Journal of Business and Economics, 9(2), 100–114. https://doi.org/10.37284/eajbe.9.2.4857

Nasiru et al. (2025). Impact of health expenditure on maternal and child health outcomes in Nigeria: Evidence from NDHS data. UMYUK Journal of Economics and Development, 2(2), 191–202. https://doi.org/10.70861/ujed20250202014

World Health Organization, UNICEF, UNFPA, World Bank Group, & United Nations Department of Economic and Social Affairs, Population Division. (2025). Trends in maternal mortality 2000 to 2023: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. World Health Organization.