A Task Shifting/Task Sharing investment in Kano State in Nigeria is empowering community health workers and improving maternal and newborn outcomes

KANO, Nigeria – It is antenatal day at Gwale Primary Health Care Centre (PHC) in the suburbs of Kano, the capital of the state by the same name and the second biggest city in Nigeria.

Hadiza Barwa, a Community Health Extension Worker (CHEW), is in a small consulting room with Saádatu Ado, who is pregnant with her fourth child. The blood pressure check has been done in another room.

Now it is Barwa’s turn. She palpates the abdomen carefully, measures with tape, and looks up. “The foetal heartbeat is normal,” she says. “The pregnancy is measuring around 28 weeks.”

Ado smiles. Barwa smiles back. Then comes a quiet one-on-one covering nutrition, hygiene, what to watch for, and when to come back.

“I did my previous three antenatal visits at a hospital far away from this community,” Ado says as she walks out of the room. “The attitude of health workers here has improved tremendously. That is why most of us, the pregnant women in this community, are now accessing antenatal care and delivering in this facility.” 

She is looking forward to delivering her fourth child here – at a PHC not too far away from her front door.

Addressing health worker shortages

Ado is one of hundreds of pregnant and breastfeeding women who have shifted to Gwale PHC in recent months. The shift is not accidental.

Nigeria’s doctor-to-population ratio stands at 2.9 per 10,000 people. Its nurse-and-midwife ratio is 1.6 per 1,000. Most of those higher cadre health workers are concentrated in secondary and tertiary facilities in cities. 

For a pregnant woman in a rural or semi-urban community, the nearest qualified clinician can be hours away, which is precisely where the risk accumulates. 

Kano State, the second most populous state in Nigeria, has some of the highest maternal mortality rates in the country. In certain Local Government Areas (LGAs) within the state, the figure exceeds 1,000 deaths per 100,000 live births.

Against this backdrop, Nigeria enacted a national Task-Shifting, Task-Sharing (TSTS) policy in 2014, formally expanding what CHEWs are permitted to do. 

The policy has existed for more than a decade. However, making it work at the facility level is a different matter. That is the problem the TSTS investment set out to solve. 

Implemented by Impact Catalysts and Pathfinder International Nigeria, in collaboration with the Kano State Primary Health Care Management Board (KNSPHCMB) and with support from the Gates Foundation, the investment has been running since November 2024 across 145 primary health care facilities in 26 LGAs in Kano State. 

Its aim is straightforward: train and mentor CHEWs to safely provide selected maternal and newborn health services that previously depended on the availability of nurses or midwives.

Complete package of pregnancy care

Hafsat Yahaya has worked at Jaen PHC for 18 years. For most of that time, she was an environmental health assistant, important work, but a long way from the consulting room and further still from the labour ward. 

She believed she could do more,  so she enrolled in a School of Health Technology, qualified as a CHEW five years ago, and has been providing care to her community ever since.

When the TSTS investment arrived at Jaen PHC, Yahaya was nominated by her colleagues to receive the clinical training. 

The training, which ran for more than a week, covered Basic Emergency, Maternal, Obstetric and Newborn Care (BEmONC). This included the prevention, detection and management of postpartum haemorrhage using the E-MOTIVE bundle, management of pre-eclampsia, infant resuscitation, the use of a partograph to monitor the progress of labour, comprehensive antenatal assessment and counselling, postpartum contraception and neonatal vaccination.

It was, in the words of one implementation staff member, a complete package, from the first antenatal visit to postnatal care.

Yahaya’s first real test came quickly. A woman was brought to the facility convulsing after delivering at home. Yahaya recognised the signs of eclampsia. On a normal day, Yusif Adamu, the facility in-charge, says, they would have referred the woman immediately to a higher facility. There was every chance she would not have made it. 

“Hafsat stabilised the woman by administering magnesium sulfate before we referred her,” Adamu says. “Since then, she has been a star in this community. People believe she has special skills, and that has attracted many more pregnant women within the community to deliver at this facility”

Yahaya now has a permanent post in the labour room at Jaen PHC. She has delivered many babies. She has prevented and managed postpartum haemorrhage and stabilised women with pre-eclampsia. She has also been running step-down training sessions for her fellow CHEWs at the facility, passing on what she has learned, multiplying the effect of the investment.

It is immunisation day at Jaen PHC, and Yahaya is holding a six-week-old baby. The infant’s mother, Hassana Umar, brought her daughter for vaccination and came to see Yahaya specifically so she could see the child she helped deliver.

 “Hafsat held me throughout the labour until I delivered,” Umar says. “She encouraged me and supported me to walk around the labour room. When I brought my baby for vaccination today, I had to bring her here. I wanted Hafsat to see her.”

Skills and supplies 

The investment does not stop at training. A CHEW who knows how to manage postpartum haemorrhage but has no uterotonics on the shelf is in an impossible position. 

Impact Catalysts and Pathfinder International Nigeria have been working with the KNSPHCMB to ensure that the medications and equipment that CHEWs are now trained to use are available in the facilities where they work.

That list includes magnesium sulfate for eclampsia, the E-MOTIVE bundle for postpartum haemorrhage prevention and management, chlorhexidine gel for cord care in newborns, and manual vacuum aspiration (MVA) kits. For a CHEW at a rural PHC, each item on that list represents a situation that used to end in a referral, and all the uncertainty that came with it.

Safiya Ibrahim is a CHEW at Dawakiji PHC. She has been through the TSTS training and is now under ongoing mentorship. 

“There is nothing as painful as not being able to help a pregnant woman or newborn in distress,” she says. “I have been in situations here where we had to refer women, and we would not know what became of them on the way to a higher facility. I would go home thinking about whether they made it or not.”

That is no longer her reality. Ibrahim has delivered babies, managed PPH, handled retained placenta, and resuscitated newborns. 

She recalls a non-responsive newborn brought to the facility after being delivered at home. Working with her colleagues, she resuscitated the infant. 

She recalls a woman with a retained placenta; she applied the uterine massage and controlled cord traction techniques she had practised in training, the placenta came away, and the bleeding was controlled. 

“We now know how to monitor the progress of labour using a partograph,” she says. “We know how to prevent and manage complications. We know when to refer.” 

There have been no maternal or neonatal deaths at Dawakiji PHC since August 2025, when Ibrahim underwent the training and returned to provide services at the facility.

Mentorship is what makes it stick

The training is the foundation. The mentorship is what makes it stick. The TSTS investment engaged 26 senior nurses and midwives, each with decades of clinical experience, to serve as mentors across the 26 LGAs where it operates. 

Each mentor is assigned to one LGA and rotates through the facilities in their area, observing CHEWs at work, assessing their skills, and providing continuous hands-on coaching.

This is a different model from a one-off training followed by a certificate and a return to the status quo. It is designed to build competency over time, to catch mistakes before they become harmful, and to give CHEWs the kind of structured support they need to use new skills safely. The mentors are not supervisors in the traditional sense. They are clinical teachers, showing up at the facility and working alongside the health workers they are developing.

What comes next?

As the investment approaches the end of its implementation period, the question of what comes next is unavoidable. The 145 facilities, the 26 mentors, the medications and equipment, the step-down training sessions have been running on the investment support. What happens when that support ends?

Prof Salisu Ahmad Ibrahim, the executive secretary of KNSPHCMB, is direct about what the Kano State government is taking on: “The improvement we have seen is across board, from documentation to the management of haemorrhage and eclampsia, to referral. It is a testament that the investment has succeeded,” he says. “Even after it rounds up, the state government will take it over and sustain it.”

He offers specifics. From 2027, the state will make budgetary provisions for TSTS implementation and sustainability. As Impact Catalysts and Pathfinder International Nigeria prepare to exit, the Board is planning to wholly take up the initiative. Already, the Board proposes recruiting 18 additional mentors, bringing the total to 44, one for each LGA in the state. These are meaningful commitments. They are also exactly what an investment like this depends on if the gains it has made are not to evaporate the moment the funding cycle ends.

Back at Gwale PHC, Saádatu Ado is preparing to leave. Her blood pressure is good. The baby is in the right position. She will be back in four weeks. 

Three previous pregnancies, three long trips to a hospital that felt far from everything. This one is different. She has been coming here from the beginning, seen by Barwa, whose hands she now trusts. 

She will deliver here, in the community where she lives, attended by a health worker who was trained and mentored and equipped to do exactly this.

That is not a small thing. In Kano State, where the road between a PHC and a hospital can be the difference between a woman surviving childbirth and not, it is the whole thing.

Image Credits: Bashar Abubakar/ Impact Catalysts.