-->

Erosion behind the Volume: A Retrospective Longitudinal Analysis of the Resilience of Maternal Newborn and Child Health Services Following USAID exit in Nigeria

Download Article

DOI: 10.21522/TIJPH.2013.14.03.Art026

Authors : Justus Azunku Uzim

Abstract:

Nigeria’s maternal, newborn, and child health (MNCH) services depend heavily on external donor funding, particularly from the United States Agency for International Development (USAID). Following December 2023 closure of USAID’s flagship MNCH project in Bauchi State, and the global suspension in 2025, this study evaluates the impact on sustainability of MNCH services in a high-burden setting. Using a retrospective longitudinal design, the study analysed routine administrative data from 454 health facilities over a 48-month period (January 2022 - December 2025). Nine indicators were assessed using Wilcoxon signed-rank test and Interrupted Time Series analysis to examine performance during and after USAID implementation. The results showed that while absolute volumes on antenatal visits and facility deliveries continued to rise, critical coverage indicators, specifically Penta3 and fully immunized child (FIC) rates, recorded declines (p < 0.05). Multi-variable mixed-effects regression identified participation in the Basic Health Care Provision Fund (BHCPF) as the most consistent independent protective factor for resilience (p < 0.001), followed by location within Maternal Neonatal Mortality Reduction Innovation Initiative (MAMII) priority locations. Private and secondary health facilities demonstrated greater vulnerability to funding shocks. These findings suggest that tracking volume alone can mask the active erosion of quality of care after donor exit. The study concludes that MNCH sustainability is a direct consequence of domestic planning. Policy makers must prioritize stabilizers like the BHCPF and incorporate trend-based monitoring to safeguard gains post donor funding.

References:

[1].   Pitt C, Bath D, Binyaruka P, Borghi J, Martinez-Alvarez M. Falling aid for reproductive, maternal, newborn and child health in the lead-up to the COVID-19 pandemic. BMJ Glob Health. 2021 Jun;6(6): e006089. doi: 10.1136/bmjgh-2021-006089. PMID: 34108147; PMCID: PMC8190982.

[2].   Barasa E, Chuma J, Nonvignon J, Adeyi OO. Avoidable pitfalls on the path to health financing self-reliance in low-income and middle-income countries. BMJ Glob Health. 2025 Nov 29;10(11): e021270. doi: 10.1136/bmjgh-2025-021270. PMID: 41320201; PMCID: PMC12666224.

[3].   African Union Commission, United Nations Economic Commission for Africa, African Development Bank, & United Nations Development Programme. Africa sustainable development report 2025: Accelerating the recovery from multiple crises and the full implementation of the 2030 agenda for sustainable development at all levels. 2025, October 5. Retrieved April 8, 2026.

[4].   Auwal AR, Ishak AS, Saidu Musa S, Musa A, Saadu A, Riaz A. The global implications of U.S. withdrawal from WHO and the USAID shutdown: challenges and strategic policy considerations. Front Public Health. 2025 Jun 2;13:1589010.
doi: 10.3389/fpubh.2025.1589010.
PMID: 40529700; PMCID: PMC12171363.

[5].   Oladele EA, Musheke M, Mulenga F, Samona A, Iyamu I, Phiri A, Phiri N, Chabikuli ON. Preventing disruptions in HIV service delivery to key populations during project transition from an International to a local Implementing Partner: A case study from Zambia. Glob Health Sci Pract. 2026 Jan 6;13(2):e2400186. doi: 10.9745/GHSP-D-24-00186. PMID: 41371945;
PMCID: PMC12838758.

[6].   Modibbo HU, Jibir A, & Abubakar UU. Donor transition and healthcare financing in Nigeria: An analysis of fiscal sustainability and household economic effect. NDA Journal of Economics and Finance. 2006 April;9(1): 224-37.

[7].   Brunner F, Gatti F, & Hall T. A blessing or a curse? The role of money in shaping international health governance. European Journal of International Relations. 2025 Nov 27; https://doi.org/10.1177/13540661251391116

[8].   Sulgodu Ramachandra S, Webster P. USA's exit from the WHO and freeze on USAID funds globally: its perils and possible opportunities. J Public Health (Oxf). 2025 Dec 18;47(Supplement_1):i16-i20.
doi: 10.1093/pubmed/fdaf122. PMID: 41410401; PMCID: PMC12847063.

[9].   Obi US, Ogbuoji O, Mao W, Shahid M, Onwujekwe O, Yamey G. Progress in the face of cuts: a qualitative Nigerian case study of maintaining progress towards universal health coverage after losing donor assistance. Health Policy Plan. 2021 Aug 12;36(7):1045-57.
doi: 10.1093/heapol/czab051. PMID: 33942865; PMCID: PMC8359748.

[10].  Cavalcanti DM, de Oliveira Ferreira de Sales L, da Silva AF, Basterra EL, Pena D, Monti C, Barreix G, Silva NJ, Vaz P, Saute F, Fanjul G, Bassat Q, Naniche D, Macinko J, Rasella D. Evaluating the impact of two decades of USAID interventions and projecting the effects of defunding on mortality up to 2030: a retrospective impact evaluation and forecasting analysis. Lancet. 2025 Jul 19;406(10500):283-94. doi: 10.1016/S0140-6736(25)01186-9. Epub 2025 Jun 30.
PMID: 40609560; PMCID: PMC12274115.

[11].  National Population Commission (NPC), Federal Ministry of Health and Social Welfare (FMOHSW), ICF. Nigeria Demographic and Health Survey 2024. Abuja, Nigeria, and Rockville, Maryland, USA: NPC, FMOHSW, and ICF; 2025.

[12].  Belaid L, Ansari U, Omer K, Gidado Y, Baba MC, Daniel LE, Andersson N, Cockcroft A. "I had to change my attitude": narratives of most significant change explore the experience of universal home visits to pregnant women and their spouses in Bauchi State, Nigeria. Arch Public Health. 2021 Nov 18;79(1):202.
doi: 10.1186/s13690-021-00735-9.
PMID: 34794488; PMCID: PMC8600880.

[13].  Ibrahim U, Wan-Puteh SE. An overview of civil society organizations' roles in health project sustainability in Bauchi State, Nigeria. Pan Afr Med J. 2018 Jun 20;30:150.
doi: 10.11604/pamj.2018.30.150.15851.
PMID: 30374396; PMCID: PMC6201623.

[14].  Matsuoka S, Kawakatsu Y, Koga S, Ayeola N, Iwayemi V, Saito C, Murakami H, Hachiya M. Underlying causes of underutilization of maternal, neonatal and child health (MNCH) services in Africa: A survey from Lagos State, Nigeria. Glob Health Med. 2020 Jun 30;2(3):184-9.
doi: 10.35772/ghm.2020.01012. PMID: 33330805; PMCID: PMC7731355.

[15].  Alawode G, Adewoyin AB, Abdulsalam AO, Ilika F, Chukwu C, Mohammed Z, Kurfi A. The Political Economy of the Design of the Basic Health Care Provision Fund (BHCPF) in Nigeria: A Retrospective Analysis for Prospective Action. Health Syst Reform. 2022 Jan 1;8(1):2124601.
doi: 10.1080/23288604.2022.2124601.
PMID: 36170653.

[16].  Tella E. Accelerating Progress Toward SDG 3: Lessons from Nigeria's maternal and neonatal mortality reduction innovation Initiative (MAMII). The Guardian (Nigeria). 2026 March 26;Opinion. Accessed online on 18th of July, 2026 from https://guardian.ng/opinion/accelerating-progress-toward-sdg-3-lessons-from-nigerias-maternal-and-neonatal-mortality-reduction-innovation-initiative-mamii/

[17].  Dougherty L, Adediran M, Akinola A, Alabi M, Etim EO, Ohioghame J, Adedimeji A. An evaluation of a multi-partner approach to increase routine immunization coverage in six northern Nigerian States. BMC Health Serv Res. 2024 Aug 20;24(1):951. doi: 10.1186/s12913-024-11403-3. PMID: 39164689; PMCID: PMC11337754.

[18].  Chagoma N, Sweeney R, Mazumdar S, Suhrcke M. The impact of official development assistance for health on health outcomes: a rapid systematic review. Health Policy Plan. 2026 Mar 10;41(3):442-459. doi: 10.1093/heapol/czaf102. PMID: 41332186; PMCID: PMC12972673.

[19].  Taylor EM, Hayman R, Crawford F, Jeffery P, Smith J. The impact of official development aid on maternal and reproductive health outcomes: a systematic review. PLoS One. 2013;8(2):e56271. doi: 10.1371/journal.pone.0056271. Epub 2013 Feb 22. PMID: 23468860; PMCID: PMC3579872.

[20].  Qiu M, Paina L, Rodríguez DC, Wilhelm JA, Eze-Ajoku E, Searle A, Zakumumpa H, Ssengooba F, MacKenzie C, Bennett S. Exploring perceived effects from loss of PEPFAR support for outreach in Kenya and Uganda. Global Health. 2021 Jul 17;17(1):80. doi: 10.1186/s12992-021-00729-w. PMID: 34273988; PMCID: PMC8285775.

[21].  Ssegujja E, Namakula J, Kabagenyi A, Kyozira C, Musila T, Zakumumpa H, Ssengooba F. The impact of donor transition on continuity of maternal and newborn health service delivery in Rwenzori sub-region of Uganda: a qualitative country case study analysis. Global Health. 2023 Jul 10;19(1):48. doi: 10.1186/s12992-023-00945-6. PMID: 37430280; PMCID: PMC10334577.

[22].  Dogbanya G. Maternal Mortality in Nigeria: Holding the Line in Uncertain Times. Ann Glob Health. 2025 Mar 25;91(1):16. doi: 10.5334/aogh.4710. PMID: 40161361;
PMCID: PMC11951968.

[23].  United States. Executive Order Number 14169: Reevaluating and Realigning United States Foreign Aid. Federal Register. 2025 Feb;90(8619). https://www.federalregister.gov/documents/2025/01/30/2025-02091/reevaluating-and-realigning-united-states-foreign-aid

[24].  National Population Commission (NPC). Nigeria population projections and demographic indicators: National and states (2007–2022). Abuja: NPC; 2020. Accessed 2026 Jul 18. Available from: https://nationalpopulation.gov.ng.

[25].  Higazi A, Lar J. Articulations of belonging: the politics of ethnic and religious pluralism in Bauchi and Gombe States, North-East Nigeria. Africa. 2015;85(1):103–30. doi:10.1017/S0001972014000795.

[26].  Python Software Foundation. Python Programming Language, Version 3.12.13. Delaware: Python Software Foundation; 2026. Available from: https://www.python.org

[27].  Google LLC. Google Colaboratory. Mountain View: Google LLC; 2026. Available from: https://colab.google.

[28].  Daniel WW, and Cross CL. Biostatistics: A Foundation for Analysis in the Health Sciences. 10th Edition, John Wiley & Sons, Hoboken. 2013.

[29].  Hudson J, Fielding S, Ramsay CR. Methodology and reporting characteristics of studies using interrupted time series design in healthcare. BMC Med Res Methodol. 2019 Jul 4;19(1):137.
doi: 10.1186/s12874-019-0777-x.
PMID: 31272382; PMCID: PMC6609377.

[30].  Bernal JL, Cummins S, Gasparrini A. Interrupted time series regression for the evaluation of public health interventions: a tutorial. Int J Epidemiol. 2017 Feb 1;46(1):348-355.
doi: 10.1093/ije/dyw098. Erratum in: Int J Epidemiol. 2020 Aug 1;49(4):1414.
doi: 10.1093/ije/dyaa118. PMID: 27283160;
PMCID: PMC5407170.

[31].  Lopez Bernal J, Soumerai S, Gasparrini A. A methodological framework for model selection in interrupted time series studies. J Clin Epidemiol. 2018 Nov;103:82-91.
doi: 10.1016/j.jclinepi.2018.05.026. Epub 2018 Jun 6. PMID: 29885427.

[32].  Laird NM, Ware JH. Random-effects models for longitudinal data. Biometrics. 1982 Dec;38(4):963-74. PMID: 7168798.

[33].  Nilsen K, Tejedor-Garavito N, Leasure DR, Utazi CE, Ruktanonchai CW, Wigley AS, Dooley CA, Matthews Z, Tatem AJ. A review of geospatial methods for population estimation and their use in constructing reproductive, maternal, newborn, child and adolescent health service indicators. BMC Health Serv Res. 2021 Sep 13;21(Suppl 1):370.
doi: 10.1186/s12913-021-06370-y.
PMID: 34511089; PMCID: PMC8436450.

[34].  Igbokwe U, Ibrahim R, Aina M, Umar M, Salihu M, Omoregie E, Sadiq FU, Obonyo B, Muhammad R, Isah SI, Joseph N, Wakil B, Tijjani F, Ibrahim A, Yahaya MN, Aigbogun E Jr. Evaluating the implementation of the National Primary Health Care Development Agency (NPHCDA) gateway for the Basic Healthcare Provision Fund (BHCPF) across six Northern states in Nigeria. BMC Health Serv Res. 2024 Nov 14;24(1):1404. doi: 10.1186/s12913-024-11867-3. PMID: 39543589; PMCID: PMC11566299.

[35].  Jibrin MD, Waziri KB, Jibrin EI. Impact of Basic Healthcare Provision Fund on Primary Healthcare Service Utilization in Nasarawa State, Nigeria: A Comparative Study. International Journal of Research and Innovation in Social Science. 2026:(10)4. doi:10.47772/IJRISS.2026.100400480.

[36].  Oluwatola T, Ayodeji O, Ebinim H, Omeje O, Isiaka SD, Oni F, et al. Technical efficiency analysis of the Basic Health Care Provision Fund for the funded primary health care facilities in Nigeria. BMC Prim. Care. 2026; 27(197). https://doi.org/10.1186/s12875-026-03284-8

[37].  Ali M, Iddrisu ZA, Chimsi H. Donor Withdrawal versus Maternal, Child Health and Nutrition Programs in Northern Ghana: A Three‑Parts Study of Implications. 2026; 13(2) doi:10.51244/IJRSI.2026.13020011.