The Health Policy Research Group (HPRG) at the University of Nigeria spotlights 13 studies for the second quarter of 2025. In this edition, we address key health systems and policy issues impacting Nigeria, including healthcare in urban slums, health communication, accountability in health systems, sexual and reproductive health, and health financing for the poor.
Study 1: Inequities in household out-of-pocket spending among urban slum dwellers in southeast Nigeria
Authors: Ozor, O., Nwokolo, C., de Siqueira Filha, N, Odii, A., Hicks, J., Li, S., Ezenwaka, U., Dawkins, B., and Onwujekwe, O
Journal and year: International Journal of Public Health (2025)
Central Message: Urban slum residents, who are primarily poor, rely on informal health providers such as drug vendors and traditional healers. Despite being poor, they often spend a lot of money on these providers, and much more on formal health services like primary health centres (PHCs). Data from 1025 residents show that those with higher incomes within the urban poor group pay the most for healthcare, which strains their ability to afford other household necessities like food and utilities. On the other hand, those with little or no money face the most severe difficulties. The combination of poor-quality healthcare that still costs a great deal and dependence on unqualified healthcare providers worsens health problems for urban slum dwellers.
Policy and practice consideration: Through the Basic Health Care Provision Fund (BHCPF), PHCs in urban slums can be prioritised. They can be targeted for interventions through the Vulnerable Group Fund (VGF) and other social health insurance schemes.
Download paper: SSPH+ | Inequities in Household Out-Of-Pocket Spending Among Urban Slum Dwellers in Southeast Nigeria
Study 2: Solving delayed referrals of childbirth cases from unskilled to skilled birth attendants in Nigerian urban communities: a case study exploration of new frontiers
Authors: Agwu, P., Poitier, F., Mbachu, C., and Onwujekwe, O
Journal and year: Midwifery (2025)
Central Message: Referrals from traditional birth attendants (TBAs) to primary health centres (PHCs) and other formal clinics are on the rise due to various maternal health interventions. Nevertheless, many of these referrals are delayed, resulting in pregnancy complications and maternal and infant fatalities. A case study examining maternal care within the spheres of TBAs and PHCs revealed subtle and nuanced factors contributing to these delays. These include younger health workers being overlooked by pregnant mothers who favour TBAs; mothers and TBAs viewing pregnancy as spiritually symbolic; mothers fearing some TBAs perceived as diabolic; and TBAs prioritising income over safety.
Policy and practice consideration: Primary healthcare authorities, through the Sector Wide Approach (SWAp), are launching the Maternal and Neonatal Mortality Reduction Innovation and Initiatives (MAMII). Addressing the subtle factors behind TBAs’ patronage and delayed referrals should be included in the health promotion strategies of MAMII. Additionally, as efforts to integrate TBAs into the formal health system increase, stricter sanctions for practising beyond their defined scope should be implemented.
Study 3: Communicating health information at the community level in Nigeria: examining common practices and challenges
Authors: Abah, A., Etiaba, E., and Onwujekwe, O
Journal and year: Journal of Communication in Healthcare (2025)
Central Message: Despite Nigeria’s rapid growth in digital communication, many communities continue to depend on traditional, human-centred sources for health information. Failing to recognise this as a form of health communication results in a significant loss of health information at the community level. The study found that Nigerian communities place strong trust in direct, one-on-one interactions, especially with informal health providers, teachers, community health workers, and community leaders. Community members demonstrate strong confidence in these relatable communication networks, and they encourage their recognition by health authorities.
Policy and practice consideration: Nigeria’s health sector is aligning with the ‘state of health of the nation report’ and the ‘joint annual review’ under SWAp. While these initiatives are positive, they must be implemented in ways that incorporate effective human communication within communities. The same principle also applies to various health interventions and policies aimed at communities.
Study 4: Multigenerational attitudes to gender norms on intimate partner violence and the sexual and reproductive health of young people in Nigeria
Authors: Mbachu, C., Ozughalu, J., Agu, I., Agu, C., and Onwujekwe, O
Journal and year: Scientific Report (2025)
Central Message: From a sample of 1630 adults and young people, it was found that gender norm attitudes toward intimate partner violence are consistent across generations. However, perspectives on sexual and reproductive behaviour have shifted. The younger generation now generally adopts views emphasising equality and autonomy, reflecting a more progressive outlook.
Policy and practice consideration: The National Reproductive Health Policy, which promotes rights-based sexual and reproductive behaviours, has achieved notable progress among younger generations. However, maintaining this progress requires accessible youth-friendly centres within communities and school curricula that foster equity and respect in intimate relationships.
Study 5: Examining how well an intervention improved adolescents’ attitudes towards contraception, unsafe abortion, and intimate partner violence in southeast Nigeria
Authors: Agu, I., Agu, C., Eze, I., Nwankpa, O., Okeke, C., Eigbiremolen, G., Mbachu, C., & Onwujekwe, O
Journal and year: Discover Public Health (2025)
Central Message: In this study, an intervention focused on adolescents’ attitudes towards contraception, unsafe abortion, and intimate partner violence was implemented in 12 communities. By the end of the two-year intervention, most adolescents had become assertive against sexual harassment and coercion, while showing a significant improvement in positive attitudes towards condom use and safe abortions. The communities where the intervention happened also reported a notable decrease in unwanted pregnancies.
Policy and practice consideration: Sexual and reproductive health initiatives are most effective when integrated into community frameworks such as primary health centres, schools, faith-based organisations, and local groups. These initiatives should be tailored to support adolescents, fostering an environment where they feel comfortable sharing their concerns. The functions and practices of adolescent-friendly health centres need to align with school health services, with intentional efforts to address adolescents’ communication needs regarding access to sexual and reproductive health information.
Study 6: Does academic excellence predict non-cognitive competencies? Insights from a situational judgement test among medical students in Nigeria
Authors: Agu, I., Obi, U., Mbachu, C., and Chukwuma, A.
Journal and year: BMC Medical Education (2025)
Central Message: The medical profession relies on clinical and behavioural competencies, where clinical skills relate to treatment services and behavioural skills emphasise relational, emotional, and people-centred abilities. This study, using situational judgement tests, found that students with stronger clinical performance often lacked behavioural competencies.
Policy and practice consideration: Reforms in medical education should focus on behavioural competencies, integrating experts from related fields. Additionally, healthcare practice in Nigeria must promote interprofessional collaboration, effectively balancing medical and behavioural disciplines.
Study 7: Community leaders’ perspectives on linking formal and informal health providers in Nigerian urban slums: a qualitative study
Authors: Okechi, B., Orjiakor, T., Nwokolo, C., Ajaero, C., Mahua, D, and Onwujekwe, O
Journal and year: Discover Social Science and Health (2025)
Central Message: Healthcare in urban slums is primarily provided by informal health providers such as drug vendors and traditional healers, who are highly regarded in their communities. Community leaders recognise the positives and negatives regarding community support for informal health providers. They also considered that primary health facilities, intended as the formal healthcare solution, are often viewed as inadequate, leading people to prefer informal health providers instead.
Policy and practice consideration: The Traditional, Complementary, and Alternative Medicines Department (TCAM) should acknowledge urban slums as distinct healthcare units at all levels. Priority should be on primary health interventions in these areas, working closely with local leaders to understand health-seeking behaviours and create strong connections between informal and formal health providers.
Study 8: Referral experiences of healthcare consumers: results from a cross-sectional study in urban slums in southeast Nigeria
Authors: Obi, C., Arize, I., Nwokolo, C., OKechi, B., Ebenso, B., and Onwujekwe, O
Journal and year: Frontiers in Public Health (2025)
Central Message: Referrals from informal health providers to formal health facilities continue to be the most practical route for an integrated health system, particularly in underserved regions such as urban slums. The study revealed that residents in these slums largely avoided PHCs and instead sought care from drug vendors, who often referred them to private clinics and laboratories. Only residents with higher incomes tended to self-refer to secondary and tertiary health facilities, still generally avoiding PHCs.
Policy and practice consideration: The underlying reasons why slum residents avoid PHCs must be addressed to improve referrals from informal health providers. Authorities should ensure that informal health providers operate within a defined scope of practice and work to standardise referral procedures through protocols. This will, in turn, generate helpful data for health planning.
Download paper: Frontiers | Referral experiences of healthcare consumers: results from a cross-sectional study in urban slums in southeast Nigeria
Study 9: Strengthening intersectoral collaboration for adolescent sexual and reproductive health: a community-embedded intervention in Ebonyi State, Nigeria
Authors: Mbachu, C., Eze I., and Onwujekwe, O
Journal and year: Reproductive Health(2025)
Central Message: Improving sexual and reproductive health among adolescents requires coordinated efforts across three key areas: the health and education sectors, government and non-government organisations, and community stakeholders and service providers in facilities. These partnerships should be based on trust, mutual respect, and adequate funding to ensure their sustainability. When successfully implemented, these collaborations can ensure effective management and active delivery of sexual and reproductive health services to adolescents at the frontline.
Policy and practice consideration: The National Policy on the Health and Development of Adolescents and Young People recognises these collaborations, as highlighted by this study. However, Nigeria’s ineffective school health policy has diminished the education sector’s role in supporting adolescent sexual and reproductive health (ASRH). Therefore, while ASRH desk offices in the states should ensure that these collaborations are active and well-implemented, a revised and effectively enforced school health policy in Nigeria must be encouraged by health and education authorities.
Study 10: Catalyzing community ownership and engagement for functional primary healthcare facilities in Nigeria
Authors: Mbaegbu, C., Agwu, P., Etiaba, E., and Onwujekwe, O
Journal and year: Discover Public Health (2025)
Central Message: Local resourcing for primary healthcare is a vital strategy for maintaining PHCs amidst global and national health funding limitations. This study identified specific community-based methods to ensure PHC functionality, including how these methods are implemented. The findings revealed that different communities employ varied approaches. However, community actors involved in these activities to sustain their PHCs often remain unnoticed by the system, which could be discouraging.
Policy and practice consideration: To achieve consistently optimal performance across PHCs in Nigeria related to community input, successful community engagement practices should be standardised, documented, and shared. Also, primary healthcare authorities should create mechanisms to recognise local community members actively involved in their PHCs’ operations.
Download paper: Catalyzing community ownership and engagement for functional primary healthcare facilities in Nigeria | Discover Public Health
Study 11: What does it take to operationalise gender transformative approaches across different African contexts
Authors: Amde, W., Ananya, G., […] Ezumah, N., […] Mbachu, C., and Wallace, L
Journal and year: African Journal of Reproductive Health (2025)
Central Message: Gender inequalities and inadequate sexual and reproductive health rights have partly hindered Africa’s progress toward its full potential. Overcoming these challenges demands dedicated, evidence-based efforts that acknowledge the capabilities of different genders and promote mutual respect.
Policy and practice consideration: This collection offers a valuable resource for policymakers and practitioners working in gender-sensitive environments. It guides understanding of gender dynamics at various societal levels and promotes the need for policies and practices that recognise and respect the uniqueness and rights of different genders.
Study 12: Applying community-based action learning in the provision of gender-transformative sexual and reproductive health services in Ebonyi State, Nigeria
Authors: Agu, I., Agu, C., Mbachu, C., Ekwueme, C., Nwankpa, O., Ezumah, N., and Onwujekwe, O
Journal and year: African Journal of Reproductive Health (2025)
Central Message: Unequal gender norms, such as criticising young single women and boys who seek contraceptive and sexual health support, are common among health workers. These norms heavily influence young people’s use of sexual and reproductive health services. Nonetheless, gender transformative approaches can address these norms by recognising them as restrictive, which can lead young people to engage in risky sexual behaviours, ultimately causing harm to themselves and others.
Policy and practice consideration: As primary healthcare authorities in Nigeria focus on retraining PHC staff nationwide, it is important to promote gender-transformative approaches that acknowledge gender sensitivities and encourage respect. These retraining initiatives should include peer-to-peer learning and simulations among health workers, as evidence indicates this method best facilitates the internalisation of gender-sensitive practices.
Study 13: Corruption and the emergence of healthcare ‘marketplace’ in Nigeria’s primary health centres
Authors: Odii, A., Hutchinson, E., Onwujekwe, O., Agwu, P., Orjiakor, T., Ogbozor, P., McKee, M., and Balabanova, D
Journal and year: Social Science & Medicine (2025)
Central Message: Following three months of participant observations and interviews, this study found that soliciting and providing healthcare in PHCs have become mostly transactional, driven by the economic aims of providers and those in authority positions. This transactional environment can best be described as a ‘marketplace’, where health services such as maternal and childcare are bought and sold, contrary to the ideal humanistic expectations of a typical PHC. Transactions were described mainly as survival strategies to keep PHCs operational in the absence of committed, timely, and regular funding and supervision by health authorities.
Policy and practice consideration: PHC revitalisation interventions like the BHCPF must be supported by robust reforms in organisational practices and individual behaviours. Otherwise, such financial measures might only serve to reinforce or be overtaken by the prevailing capitalistic interests in the primary healthcare environment.
Download paper: Corruption and the emergence of a healthcare ‘marketplace’ in Nigeria’s primary health centres: reframing drivers and solutions – ScienceDirect
Conclusion
The spotlighted studies in this edition are relevant to Nigeria’s health sector vision, with lessons for similar countries. We are happy to share the full papers with you if you find any inaccessible.
Best wishes from us!
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