Author: HPRG

HPRG’s health sector 2024 roundup: Evidence, knowledge, politics

December 2024

The Health Policy Research Group, University of Nigeria (HPRG) has stayed optimistic about the ‘renewed hope’ agenda for Nigeria’s health sector. The 2023 health sector roundup hailed the Health Sector Renewal Investment Initiative (HSRII) as timely and well-positioned to radically improve the country’s health sector if well-funded and aggressively implemented. In a year now, our optimism has been energized by the subsequent operationalization of the HSRII in Nigeria’s Health Sector Strategic Blueprint (HSSB) and the rallying of diverse health sector strategies around the HSRII. There is no doubt that this clear vision for the health sector in Nigeria is commendable.

As one of Africa’s frontline health systems research evidence hubs, and in operation for over two decades, HPRG remains committed to evidence generation and application to health policies, strategies, and programmes. In the 2023 roundup, we used evidence to define some important pathways for the health sector in 2024, encompassing five areas listed in the image below.

This year’s roundup looks at the sector’s progress for 2024 based on the pathways listed above. Our thoughts and analyses are driven entirely by data from our cutting-edge studies.

(a) The use of evidence for health policy and systems strengthening

Although the evidence-to-policy space remains wide, we reckon deliberate efforts by the current health administration to fill the gaps. We have observed progress in the use of evidence to build the accountability framework for the Basic Health Care Provision Fund (BHCPF); the viability of the Research Knowledge and Management Division (RKMD) at the Federal Ministry of Health and Social Welfare (FMoHSW); the Joint Annual Review (JAR) of the health sector; evidence-use as part of the criteria for the national primary healthcare leadership award; rapid digitalization of health services and data, and health policymakers engaging evidence-led policy dialogues and symposia

However, the full potential of the RKMD to serve as a national health research hub is yet to be realised. There are expectations for the RKMD to focus on timely retrieval, synthesis, consolidation, and communication of a range of health research in the country, including leading evidence-based conversations at the National Council on Health (NCH). Also, the HSRII pillars would benefit from clearly including health policy and systems research (HPSR).

In the same context of evidence-use, Nigeria faces a pivotal moment in its history as the Global Alliance prepares to transition funding responsibilities to countries. Nigeria already recognises this shift, owing to the topicality of vaccine financing in most national health discourses. It has become crucial that Nigeria must prioritize the most impactful vaccines at the best cost. To help with this, HPRG has championed initiatives like Health Technology Assessment (HTA), cost-effectiveness analyses, and localized quality-of-life value sets. These efforts are aiming to ensure sustainable and evidence-based decision-making tailored to local needs for vaccines.

(b) Aggressively pruning informal health spaces

Informal health providers (IHPs) like Traditional Birth Attendants (TBAs), Patent Medicine Vendors (PMVs), Traditional Bone Setters (TBS), etc., have proven useful to Nigeria’s under-resourced healthcare space. However, they constitute enormous threats to care quality.

At the 65^th NCH, concerns were raised about the continuous patronage of TBAs over skilled birth attendants, likewise normative patronage of PMVs. HPRG is working on a linkage system between IHPs and the formal health system. Findings from our interventive study document the aspirations of community stakeholders to provide more formal oversight to the activities of IHPs, and IHPs showing willingness to get linked to the formal health system. In one of our published studies, just about 7% of 238 IHPs could identify risk factors and symptoms of hypertension and diabetes mellitus. And we can authoritatively report many ungoverned spaces among IHPs.

Efforts outlined at the 65^th NCH and JAR in engaging TBAs as referral sources, deploying primary healthcare service protocol to Community Pharmacists and PMVs, strengthening the Community Health Influencers and Promoters (CHIPs) and revamping primary healthcare facilities make a lot of sense. But these efforts should extend to the bone setters and herbal practitioners, and overall, should rely on ‘proof-of-concept’ manuals, protocols, and practices – HPRG is always willing to share its intervention experiences with health authorities.

(c) Focusing on sexual and reproductive health and rights (SRHR) needs of school-aged children, adolescents, young people, and other vulnerable groups

The expansion of the Reproductive, Maternal, Newborn, and Child Health (RMNCH) to cover Adolescent and Elderly Health (RMNCAEH) is commendable. The design and adoption of a national strategy for it, including the clinical protocol for adolescent health services is laudable. However, we are deeply concerned about the readiness of our primary health centres (PHCs), schools, and communities to key into delivering the visions and objectives of these several policy documents and guidance.

Our concerns stem from the incomprehensive staffing of PHCs that are often without laboratory diagnostic and social care professionals; PHC workers usually adhering to rigid gender norms that result in judgemental attitudes and discriminatory practices that negatively impact adolescents and young people’s access to SRHR services; the poor orientation of mental health services and adolescents’ care needs among communities, and the absence of school-based health services.

In response to these concerns, we have undertaken several past and ongoing initiatives including the development of manuals, job aids and training programmes for PHC workers. These efforts aim to enhance the provision of youth-friendly SRHR services through gender-transformative and intersectional approaches in PHCs, and communities.

Close to adolescents are school-aged children who are 5 years and above. There is evidence that this population group, although vulnerable, do not get the attention they deserve. The poor implementation of the Child’s Rights Act and the conflict between the Ministries of Education and Health have hampered the implementation of the National School Health Policy. Sadly, many children in Nigeria are not covered by structured health programmes, and they continue to be victims of poor health-seeking practices obtainable within their homes and communities, with no one in their defence.

While it is important to address the policy framing and leadership of school health alongside the aggressive implementation of the health components of the Child’s Rights Act, HPRG is strategically clustering schools around functional PHCs using Geographic Information System (GIS). This is expected to re-envision the school-based health services and enhance health protection for Nigerian children who are 5 years and above, including adolescents.

Contingent on the foregoing, the definition of vulnerable people as contained in the listing of those who qualify for the Vulnerable Group Fund (VGF) under the BHCPF, may benefit from contextual subnational flexibilities. For instance, our work in Edo State found grave health challenges facing survivors of human trafficking, yet the health system is completely disconnected from their realities. And some health challenges faced by the elderly may rather need social care. The ideals for which the VGF was designed to achieve can be derailed if the definitions of ‘who is vulnerable’ and ‘what services they should receive’ solely rest on the Federal health authorities.

(d) Addressing systemic inefficiencies marring value for health programmes and investments

Our sincere commendation for the Sector Wide Approach (SWAp) cannot be overstated. Its goal of enhancing service delivery across the sector is welcoming. However, the challenge of aligning funding and local health priorities remains, as reported in a Cross-Programmatic Efficiency Analysis (CPEA).

There are concerns about subnational health authorities lacking evidence of their health priorities and casually producing Annual Operational Plans (AOPs), perhaps due to the lack of real-time evidence transmission from health facilities to health authorities. Also concerning are the weak planning and research departments, poor supervisory practices, and suboptimal attention to Charts of Accounts. Going forward, health partners may consider investing in addressing these fundamental concerns at the subnational. The reason is to ensure that the country’s health system builds a strong culture for quality control and can make sustainable progress even when donors are no more.

In addition, SWAp and other health authorities must look into the insecurity crises affecting the functionality of primary health facilities across the country. Undoubtedly, places affected by terrorism and banditry are high risk, but we see insecurity tensions also in slum areas and non-slum urban settlements. The evidence available to us shows that insecurities faced by PHCs have increasingly taken a national outlook and will benefit from a national PHC-security agenda. Local and national strategies to address this threat have become imperative and unavoidable.

(e) Build and enhance systems to drive health anticorruption and accountability

On July 18, 2024, the Minister for Health and Social Welfare was emphatic about the health sector significantly affected by corruption. For more than 7 years, HPRG has studied health corruption in Nigeria, culminating in setting up a coalition. We acknowledge efforts in setting up SWAp, including the anticorruption unit at the FMoHSW to challenge health corruption and improve accountability. However, for these efforts to yield the desired result, they must be facility-centred and driven by the subnational.

Also, we cannot sufficiently address corruption if the systemic drivers continue to thrive, enabled by the actions and inactions of health authorities. Decentralised Facility Financing (DFF) model for PHCs will only work when PHCs and health units in the Local Government Areas (LGAs) are given statutory monthly allocations. There is an ongoing “privatization” of PHCs by facility managers who invest their private resources to keep facilities running, including employing volunteers. Expectedly, they are compelled to pursue their profits, even to the detriment of the service users. So, when the BHCPF is disbursed, there are justifications for kickbacks and mismanagement.

Our lessons from studying health corruption are clear about the intersecting areas in the image below.

The non-justiciability of health rights in Nigeria is a critical issue. Without legal frameworks, it would be difficult for citizens to hold the health systems accountable. It is about time Nigeria should consider empowering citizens with the right to enforce their health rights through the law courts.

Conclusion

As critical friends within Nigeria’s healthcare space, we desire a health system that prioritizes the wellbeing of the Nigerian people and offers commensurate value for every investment. Our 2024 roundup has aligned evidence with policy interests of health authorities, particularly focusing on improving population health. We remain committed to driving meaningful change and, in 2025, we look forward to more progress in the following areas:

Clear strategy/commitment of RKMD towards aggregating, synthesizing, communicating, and demonstrating the use of evidence from health research in Nigeria.

Health authorities using evidence-based manuals, protocols, and practices in linking IHPs to the formal health system and aggressively enforcing scope of practices within the informal sector.

Expansion of health attention and protection to children who are 5 years and above, enforcing the health components of the Child’s Rights Act, and addressing the leadership issues and constraints that have hampered efficient delivery of the National School Health Policy.

Scale up services in PHCs to holistically address health needs of adolescents/young people, while decentralizing identification of vulnerable groups and the services due to them for effective utilization of the VGF.

Build partnerships with communities and stakeholders aimed at challenging harmful gender norms and fostering supportive environments where adolescents and young people can access SRHR services.

Use CPEA’s evidence to reorganise operations of health partners and subnational health authorities to achieve the coordination/accountability objective of SWAp.

Collaboration between SWAp, the subnational health authorities, and security agencies to establish a physical security agenda/policy for PHCs with clear and realistic operational procedures and targets.
Facility-centred and Subnational commitments to addressing systemic actions/inactions that sustain corruption and accountability issues in the health sector, especially at service delivery points.

Our team wishes everyone Merry Christmas and Happy New Year.

Professors Obinna Onwujekwe and Benjamin Uzochukwu
On behalf of the Health Policy Research Group, University of Nigeria

Contributors: Prof Chinyere Mbachu, Prof Enyi Etiaba, Dr Prince Agwu, Ifunanya Agu, Chinelo Obi

Click to download PDF version

Acknowledgement: We thank all our funders, partners, and collaborators for an eventful 2024 and looking ahead to 2025.

How to cite: Health Policy Research Group (2024). HPRG’s health sector 2024 roundup: evidence, knowledge, politics. https://hprgunn.com/hprgs-health-sector-2024-roundup-evidence-knowledge-politics/

Stakeholders reflect on the national survey that reports significant health sector corruption in Nigeria: a communique from the Health Anticorruption Advisory Committee (HAPAC)

In a 2016 published survey, of the 14 most significant problems faced by Nigerians, corruption was ranked in third place, while healthcare was in fifth position. In the second version of the survey published in 2019, healthcare and corruption switched positions. And in 2023, corruption ranked in fourth position, and healthcare fifth.

Both corruption and healthcare have consistently remained problematic to Nigerians for decades. And one can only imagine what happens when the two problems intersect. Health corruption has been studied by the Health Policy Research Group, University of Nigeria (HPRG) and the Bayero University, Kano (BUK) for about seven years, leading to the establishment of the Health Anticorruption Project Advisory Committee (HAPAC), which is in partnership with the International Centre for Investigative Reporting (ICIR).

July 2024, health sector actors in Nigeria were, again, implicated in the third edition of the National Corruption Survey (NCS) published by the United Nations Office on Drugs and Crime (UNODC) and the National Bureau of Statistics (NBS) with support from the MacArthur Foundation and the Ministry of Foreign Affairs of Denmark. Key findings from the report suggest that the health sector ranks among the top-4 homes for bribery in Nigeria, manifesting in private health providers collecting bribes, and bribes paid for free services, to speed up procedures, or as an appreciation for care. Despite significant accounts of bribery within the health sector, reports or whistleblowing by service users who have been asked or forced to pay bribes were scarce.

Commendations to the UNODC and co-publishers

First, as stakeholders, we commend the efforts of the UNODC, NBS, and the supporting organisations for consistency in the conduct of the NCS, robustness of the sample, and data analytical rigour. We recognise that the organisations have been genuinely intentional about the issue, eliciting compelling and comparable data over the years, while open to improvements. The robustness of the sample manages errors and secures a good representation of Nigeria’s large population. Thus, we encourage continuity and sustainability of the survey as a means of tracking the progression or retrogression of sector-by-sector anticorruption efforts in Nigeria.

Special focus on the health sector

The NCS covers key sectors in Nigeria like security, education, judiciary, health, and public service. Over the years, it has significantly focused on bribes, the diverse forms they take, and the actors involved. In corroboration, academic and journalistic investigations affirm the prevalence of bribes in the health sector, also documented in some pieces of work as “informal payments”. Beyond bribes, scientific investigations have equally documented much more damaging corruption in the health sector like absenteeism of health workers, procurement fraud, health financing malfeasance, and employment irregularities.

Explaining the focus on bribes by the NCS, a representative of the UNODC reflected on Goal 16 of the sustainable development goals (SDGs), which targets substantial reduction of the prevalence of bribery if strong institutions must be built. The significance of achieving this target for the health sector cannot be overstated due to the sector accounting for the highest patronage (30 percent) by Nigerian citizens, even when compared to the Police – according to the survey.

For most health corruption enquiries, the private sector has been silent. So, the NCS has unlocked an area for future enquiries and anticorruption intervention by reporting the collection of bribes among medical doctors in private practice. Reacting to this, a representative of Nigerian private practitioners alluded to some corrupt practices happening within the system but had reservations about the significant indictment of medical doctors despite other health and non-health personnel delivering health services in the private sector.

On the way out of health corruption in Nigeria, available, efficient, and responsive reporting mechanisms must be present. Unfortunately, the NCS recorded no reports of bribery in the health sector. Comments from a participant who is familiar with the Medical & Dental Council of Nigeria (MDCN) affirmed poor reporting of corrupt practices to authorities, suggesting an urgent need to build an efficient reporting mechanism for the health sector.

The representative also mentioned that some practitioners may be unaware of the content of the MDCN code abhorring some of such normalised practices like demanding informal payments and receiving gifts from service users. As stakeholders, we hope that the MDCN will scale up awareness of the contents of its code among practitioners using effective sensitization measures, including curriculum approaches.

Important takeaways to strengthen future National Corruption Survey as per the health sector and to improve anticorruption

While we commend the thoughts and efforts that have consistently gone into the production of the NCS, concerning the health sector, we recommend the following for consideration:

The inclusion of more health sector corruption concerns like absenteeism, procurement irregularities, etc., based on available ranking in published academic outputs.
The organisations should build partnerships with more stakeholders in corruption research.
A good description of ‘other health workers’ (non-medical doctors) or apply the use of “health workers” as a common name for all health practitioners in the health system.

Overall, an important takeaway from the NCS for the health sector is that anticorruption agencies must now intensify their work with the health sector and grassroots leadership to mainstream efficient, user-friendly, and responsive reporting mechanisms at the points of health service provision. This can be co-produced with academics and investigative journalists who have historically worked on health corruption in Nigeria, as well as health workers, policymakers, and community representatives.

In all, HAPAC looks forward to the next national corruption survey, with the hope that lessons from the 2023 version will be used to improve the anticorruption prospects of the health sector. It also expects that data gathering and analysis for the health sector will benefit from engagements with health anticorruption scholars in Nigeria. HAPAC commends the NCS for finding its place within Goal 16 of the SDGs – Peace, Justice, and Strong Institutions, which has strong implications for Goal 3 – Good health and wellbeing.

Click to download PDF version of the communique

Acknowledgement

Dr Idris Muhammad – Chairperson, HAPAC
Dr Tarry Asoka – Deputy Chairperson, HAPAC
Victoria Bamas – Secretary, HAPAC
Professor Obinna Onwujekwe – Convener, HAPAC
Dayo Aiyetan – ICIR
Prof Muktar Gadanya – Bayero University, Kano
Dr Moses, C – Association of Nigerian Private Medical Practitioners
Princess Chifiero – United Nations Office on Drugs and Crime (UNODC)
Health Policy Research Group, University of Nigeria (HPRG)
Accountability in Action Research (AiA)
SOAS-Anticorruption Evidence Consortium (SOAS-ACE)
London School of Hygiene and Tropical Medicine (LSHTM)

We thank Dr Prince Agwu for the review of the communique.

For correspondence, send an email to vbamas@icirnigeria.org, Cc prince.agwu@unn.edu.ng

Child healthcare isn’t for infants and under-5 alone: communique from a policy dialogue on the health and health rights of urban school-aged children in Nigeria

More than half of Nigeria’s over 200 million population are under the age of 18, and just about 29 percent of the over 100 million Nigerian children are under 5 years. Children between the ages of 5 and 17 comprise the larger share of Nigeria’s children population but are least catered to by the Nigeria’s health system that is more interested in the under-5s. As such, health rights of children between 5 and 17 years have remained threatened, calling for urgent attention.

Supporting our assertion above is the evidence of demarcation between under-5 and school-aged children (5 – 17 years) in Nigeria’s National Health Policy but the listing of child-health-related Key Performance Indicators (KPIs) for under-5s alone. Similarly, the guideline for the implementation of the Basic Health Care Provision Fund (BHCPF) recognises just under-5s as among the five vulnerable groups, again, leaving out children between 5 and 17 years.

Understandably, policies like the 2003 Child’s Rights Act (CRA), 2006 National School Health Policy (NSHP), 2019 National Policy on the Health and Development of Adolescents and Young People (NPHDAYP), and 2022 National Child Health Policy (NCHP), have made attempts to recognise the uniqueness of children aged 5 – 17 years and the need to dedicate special care to their health and health rights. However, academic assessments and other significant evaluations of these policies have shown that they have not been strategic enough or well-implemented to provide sufficient protection for school-aged children’s health and health rights. Unsurprisingly, the Nigeria’s National Development Plan (2021 – 2025) decried poor enforcement of children’s rights laws and the absence of children’s viewpoints in health policymaking/enforcement.

Indeed, Nigeria may not have come to terms with the significant harm this lack of intentionality towards the health and health rights of school-aged children has caused. This was revealed in a recent research conducted by the Health Policy Research Group – University of Nigeria and the School of Humanities & Social Sciences/Law, University of Dundee, under the CHORUS Urban Health Consortium, with support from the Rivers State Ministry of Health. As national and subnational level stakeholders in health, education, social welfare, and human rights fields, drawn from 24 ministries, agencies, and organisations in Nigeria, we have gone through the study, validated the data, and have come up with our position. But first, we present a summary of the research evidence.

Evidence from the research

Four levels of research inquiries involving document reviews, in-class observations of children, and interviews and policy dialogue with a broad collection of national/subnational stakeholders inclusive of children, caregivers, teachers, school owners, attorneys, and policymakers were applied to gather evidence on (1) the policy environment for the protection and promotion of the health and health rights of school-aged children (2) patterns of seeking healthcare for school-aged children, and (3) threats to the rights of school-aged children to quality, safe, and timely healthcare. The research was focused on urban settlements in Rivers State, inclusive of urban slums. Across the three areas of inquiries, the study found that:

Policies and laws expected to protect and promote the health and health rights of school-aged children failed several set expectations when judged against evidence from academic investigations and other significant inquiries. Notably, the 2006 National School Health Policy designed to play a pivotal role in supporting other related policies, has largely failed in its implementation. Conflicts in the leadership of the School Health Policy undermined its implementation progress and significantly contributed to the isolation of schools away from the health system, especially primary healthcare.
Health seeking for school-aged children largely defied the provisions of safety and quality in the Child’s Rights Act [CRA]. The dominant health-seeking routes were home management of illnesses using self-prescribed medications; drugs bought from drug vendors or self-mixed herbal remedies; herbal practitioners’ recommendations, and solicitation of spiritual interventions from religious clerics even at critical times. The significance of primary healthcare was hardly recognised, as many rather jumped to private clinics or secondary/tertiary facilities when prior self-help and informal arrangements failed them.
The school-aged children decried the absence of health personnel and health facilities in their schools. More so, they complained about the absence of a responsive care and reporting system to either discuss their physical and mental health needs or to report risky health options and behaviours stimulated and encouraged by their caregivers. The children equally recognised inefficiencies and unsupportiveness of health facilities, particularly the unruly attitudes of health workers toward children and their caregivers, high fees for health services, poor emergency response to children in health crises, and constrained physical access to health facilities.

Policymakers and other stakeholders validate evidence and prioritize actions

On August 5 and 6, 2024, stakeholders met in Port-Harcourt, Rivers State, Nigeria, and without reservations we commended the now nationally accepted and domesticated CRA across the country’s federating units. We also appreciated the working groups for adolescents’ health based on the emergence of health programmes for adolescents and the progressive scaling of adolescent-friendly health centres. And importantly, we hailed the ongoing health systems strengthening blueprint that recognises the centrality of school health services to the health needs of school-aged children.

Notwithstanding these commendable efforts, we pointed out fifty-one concerns which we later condensed to five specific areas using a Modified Delphi Technique to deliberate and consensually rank priorities. Our agreed five areas and suggested actions for governments at all levels are:

Leads of the health, education, and social welfare (women affairs in some cases) ministries must leverage current evidence for the review of school health-related policies with the aims of: (a) harmonization of contents (b) setting very feasible targets with realistic benchmarks to gauge progress, and (c) reaching a definitive consensus on the leadership of school health with clear definition of roles and responsibilities.
Leads of the health, education, and social welfare ministries should work with the legislative committee on health, the criminal justice system, children’s parliament, and the child’s rights implementation committees to design and enforce clear and widely communicated standard operating procedures for reporting and responding to actions that violate the rights of school-aged children to safe, quality, and timely healthcare.
The above actors should work with the national orientation agency, academia, civil society organisations, community-based organisations, children’s parliament, and media to design a simplified and effective communication framework for the harmonized policy contents and standard operating procedures which must include: (a) mainstream into school curriculums (b) pasted prints in health facilities and schools (c) repeated announcements in religious gatherings, and (d) unrestricted digitized accessibility.
The lead of the state health ministry should work with the primary healthcare development agency, health insurance agency, and the education ministry to: (a) design schools’ clusters around designated functional primary health facilities with school health desks headed by appointed school health desk officers (b) encourage appointments of school health focal persons to link schools with the designated health facilities (c) design terms of reference and workflow modalities (d) explore inclusion of school-aged children in the basic healthcare provision fund, and (e) nudge schools toward employing at least one qualified health personnel and setting up equipped sickbays in the long-run.
The consensually agreed leadership of school health will explore external funding while compulsorily including school health services in the annual operation plans and budgets to cover funding the desk offices, enforcement of the standard operating procedures, and all other health systems and wider responses to the health and health rights of school-aged children.

Our conclusive position

As stakeholders, we acknowledge the fragility of the under-5 population, hence the enormous attention accorded to their health needs, and we encourage even more. However, it is worrisome that the bulk of the country’s population between the ages of 5 and 17 years who are also children have not received as much attention as they deserve health-wise. The consequences are regrettable, evidenced by gross violation of their health rights, poor institutional responses to their health needs and rights, and avoidable cases of morbidities and mortalities.

As stakeholders from different fields, we underscore the need for a more coordinated, strategic, and inclusive approach to health policymaking that prioritizes the unique needs of school-aged children. This should begin with reviewing and implementing an effective school-health or holistic child-health policy that prioritises the health rights of school-aged children, school-health services, and easily accessible primary healthcare services for school-aged children. It should be supported by widely communicated and accessible deterrence mechanisms to put an end to the violation of the health rights of school-aged children in Nigeria. By adopting a more holistic and intentional focus on the health rights of school-aged children, Nigeria can make progress towards ensuring that all children, regardless of age, have access to safe, quality, and timely healthcare.

Acknowledgement

Rivers State Ministry of Health
Rivers State Ministry of Education
Rivers State Ministry of Social Welfare and Rehabilitation
Federal Ministry of Health (Family Health Department/Child Health Division)
Federal Ministry of Education
Federal Ministry of Women Affairs
National Primary Health Care Development Agency
Rivers State Primary Healthcare Management Board
National Health Insurance Authority, Rivers State
Rivers State Adolescent Technical Working Group
National Child Rights Implementation Committee
Rivers State Family Court
Aret and Bret LLP Law Firm
Results for Development, Nigeria
Marine Base Community
Assemblies of God Church, Amadi-Ama, Rivers State
Police Station Mini-Okoro Mosque
The Boy Child Support Network
Rhema Care
Channels TV
Wish FM
Model Senior Secondary School, Rivers State
Pneuma Citadel Academy, Rivers State
Dr Tarry Asoka (Independent Health Consultant)
UNICEF, Rivers State Field Office
CHORUS Urban Health Research Consortium
University of Dundee, United Kingdom
Health Policy Research Group, University of Nigeria

Research Team (L-R): Ifunanya Agu (Project Manager), Dr Aloysius Odii (Research Associate), Prof Uzoma Okoye (Research Co-Lead), Dr Adaeze Oreh (Hon. Commissioner for Health, Rivers State, Nigeria), Dr Prince Agwu (Research Lead), Chinelo Obi (Research Associate)

Correspondence: prince.agwu@unn.edu.ng

Click to download the communique in pdf

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Using scientific evidence to ensure value for investments in making vaccines available and impactful in Africa

Vaccines are among the most powerful inventions in human history, and it is not just a medical duty but a moral responsibility to ensure that everyone has unrestricted access to vaccines.

Vaccines are central to healthy societies because they prevent illnesses and effectively curb the spread of communicable diseases. They help create antibodies to resist illnesses like measles, meningitis, polio, yellow fever, etc. Since 1796 when Dr Edward Jenner created the world’s first successful vaccine against cowpox, vaccines have continued to save lives, estimated annually by the World Health Organisation at 2.5 million lives, the majority of whom are children.

Indeed, vaccines are among the most powerful inventions in human history, and it is not just a medical duty but a moral responsibility to ensure that everyone has unrestricted access to vaccines.

Keeping up with the call to ensure unrestricted access to vaccines may seem difficult in current contexts where it can be financially demanding to develop and/or procure vaccines, hence inaccessible by low-resource regions of the world and deprived populations. To address this challenge, efforts must be channelled toward procuring vaccines with the most impact on addressing disease burden and for the most effective cost.

To achieve the foregoing, a multi-country project on “vaccine economics” has been flagged in Nigeria, Kenya, and Zambia to promote economic evidence in vaccines administration. The project applies Health Technology Assessment (HTA) to systematically assess and evaluate the overall conditions of vaccines as a product of health technology and the economic, social, and ethical concerns they raise.

Click here to learn more about HTA.

Two main outcomes when vaccines are effectively deployed are: (a) improves the quality of the lives of people (Quality-Adjusted Life Years – QALYs), and (b) reduces incidents of disability and premature deaths that cut short the lives of people or reduces the quality of their being alive (Disability-Adjusted Life Years – DALYs).

Achieving these outcomes is contingent on how well the development, procurement, and administration of vaccines are budgeted for and financed. This is why Budget Impact Analysis (BIA) is a significant exercise that must be conducted to ensure optimal representation of vaccines in annual budgets in ways that would not compromise spending on other significant areas of development and wellbeing.

Click here to learn more about cost-effectiveness of vaccines and BIA.

Of priority to our work are vaccines for measles and malaria, and the 5-in-1 meningococcal vaccine that protects against different types of bacteria that cause meningitis. As these vaccines become available, delivering them is of prime importance, which also has cost implications.

Click here to learn more about vaccine delivery mechanisms and costing.

In summary, in one of our meetings, Prof Abdul Aguye, Chairman, Nigeria Immunisation Technical Advisory Group (NGI-TAG) of the National Primary Health Care Agency (NPHCDA) reminded everyone that Nigeria has a high disease burden, and that prioritizing some of the vaccines based on their cost effectiveness would go a long way to mitigate the effects of the diseases on the population.

Click here to read full press release.

African Health Observatory calls for blogs on Climate change and health in Africa

The African Health Observatory – Platform on Health Systems and Policies (AHOP) is seeking to commission a blog series on climate change and health in Africa to supplement an upcoming policy brief on the subject.

Policy Brief Summary

AHOP is set to publish a policy brief on existing policies, frameworks, and strategies in Africa that mitigate the negative impacts of climate change on health systems. The policy brief summarises evidence on how climate change is affecting African health systems and assesses the strategies currently in place to mitigate these negative impacts. The brief synthesises evidence from peer-reviewed journal articles, grey literature (including Ministry of Health reports and strategic documentation from international organisations) and regional climate change and health experts. It aims to support decision-makers and institutions in developing and implementing policies that promote public health and protect health systems from the adverse effects of climate change.

Blog Concept and Requirements

The blog should respond to three questions:
• How is climate change affecting population health and health systems in the target country?
• What are the existing policies and strategies in place for reducing the negative impacts of climate change on health systems at a national and/or sub-national level in Africa?
• What lessons can be learned from existing policies about how to design and implement climate and health policies in the African region?

We welcome submissions on national or sub-national (e.g. state, provincial) policies, frameworks and strategies from countries within the WHO African region. The link between climate change and health systems should be clearly identified in the submission.

By providing accessible, concise analyses on climate change and health policies in several African countries, the blog series will help AHOP to further discussion on the topic amongst a wide range of readers including non-specialists, students, researchers, and policymakers.

Click to download the full call here

Primary Health Centres in Nigeria are becoming responsive to boys’ sexual health: early success story of an ongoing intervention

By Joy Ozughalu, Irene Eze, & Chinyere Mbachu

“In the quiet corners of Primary Healthcare Centres in these communities, where whispers sometimes replace bold requests, condoms find their way into the hands of rightful young seekers. The request was “Bulletproof” or if you like “Vitamin C” and the response – Condoms? Condoms serve as more than mere contraceptives—they symbolise a bridge between vulnerability and empowerment, health and illness. As health care workers continue in their roles with dedicated efforts, they remind us that sometimes, a playful nickname can change [saves] lives.”- Authors’ musings

In one of the communities in Ebonyi State where the Health Policy Research Group (HPRG), University of Nigeria is implementing a project on Sexual and Reproductive Health Rights (SRHR) and services for adolescents, a new trend is emerging, involving young boys who now engage health workers to talk about their sexual health.

Prior to the intervention led by HPRG’s SRHR project, boys felt they did not need to visit the health centres, despite being largely at risk of harmful sexual consequences such as sexually transmitted diseases (STDs) and even responsible for several unwanted pregnancies. As commonly observed, girls have always been the focus of SRH interventions, with little or no attention to the boys. The consequence of this one-sidedness is that we have had compliant girls who end up sexually battered by non-compliant boys. We report in this blog the SRHR successes we are recording by working with boys.

Boys say, ‘rather than being irresponsible in secret, I can be responsible by speaking up.’

The discreet sexual activities of young boys in communities are well-known and problematic. An avenue for boys to speak about issues relating to their sexual health is very important. Our intervention has stimulated consciousness among boys in the communities where we work. Some of the boys now visit health facilities to share concerns about their sexual health needs, and some bolder ones try to seek access to condoms, demonstrating their consciousness around protective sex.

However, instead of the boys making straightforward requests, they employ an array of nicknames for condoms. These nicknames serve as both a verbal disguise for condoms and a way to break the ice, bridging the gap between embarrassment and necessity. Some of these nicknames include “Raincoats”, Bulletproof”, “Rubber”, “CD”, “Tarpaulin”, “Vitamin C”, and “Chewing gum” (which they have localized as ‘chingum’).

Each nickname carries a hint of humour, making the conversation less clinical and more relatable. It is a linguistic dance—a delicate balance between discretion and openness. Despite improved knowledge and actions towards SRHR among boys, many have remained nervous with such requests, and they always want health workers close to them while making their nick-named requests for condoms or talking about their sexual concerns.

Early Insights from our Community Inclusive Gender-Transformative Approaches (GTA)

Our interventions are gender-transformative in principle and practice. By gender-transformative approach, we mean seeing both boys and girls as equals and deserving of help. We underscore the SRH needs of different gender, including the barriers they face, and we develop evidence-informed responses.

The training of health workers and community leaders in the communities where we work relies on a gender-transformative approach, which has now made these stakeholders less judgmental and open to conversations with boys about their sexual health. Here are some early insights we are coming to understand from this important work:

Society considers it taboo for boys to come out openly with their sexual needs. However, with organised SRHR intervention targeting boys, boys attempt to navigate this minefield using playful postures. It is a way for them to say, “I need protection, but let’s keep it light.”
Boys who come to health facilities to discuss their sexual concerns with health workers or to request condoms do so based on trust in the health workers. They will be disappointed if any of the health workers exposes them to their families or the public and they may become discreet with their sexual concerns going forward.
Boys residing in communities where houses are closely packed are very mindful of reputational damage. Health workers in such communities will have to be very mindful not to undermine the trust such boys have in them by being open about their sexual health and needs.
For primary health workers to be approachable by boys, they must present themselves in a somewhat youthful and relatable manner.
Sex education must be comprehensive by equally focusing on boys and girls, so as to create a more equitable society where everyone is equipped to make healthy and informed decisions about his/her sexual and reproductive health.

Final message – In sexual and reproductive health for young people, silence could be dangerous

While it is endearing that boys could use nicknames to express their need for condoms in Nigeria, this experience also highlights gaps in sexual education. And so, we are reminded of the responsibility to advance community awareness campaigns to normalise conversations surrounding sexual and reproductive health rights and services.

In addition, healthcare workers need routine training to address sexual and reproductive health of young people without judgment. They should make themselves available, listen attentively, be intuitive to decode the nicknames, and provide the necessary information and services. With this, they will build trust, dismantle barriers, and avert the consequences of sexual silence and discrete sexual behaviors.

Authors’ Bio

Joy Ozughalu is a Public health researcher with the Health Policy Research Group (HPRG) affiliated with the University of Nigeria.

Irene Eze is a Consultant Public Health Physician at the College of Health Science, Ebonyi State University and a researcher at the Health Policy Research Group.

Chinyere Mbachu is a Professor of Community Medicine, Public Health advocate and Health Systems researcher with the Health Policy Research Group, University of Nigeria.

Acknowledgement

We thank Dr Prince Agwu for expert review of the blog.

The research project received funding from IDRC Gender Transformation for Africa implementation research project on sexual, reproductive, and maternal health (IDRC grant number: 109809)

Communique: Coalition speaks tough on health corruption and accountability problems in fulfilment of Nigeria’s health renewal plan

Nigeria’s health sector is on the path of restoring confidence of citizens in its health system. Under the present health leadership, the Health Sector Renewal Compact (HSRC) recognises the importance of accountability as the glue that should firmly hold and drive its social compact with Nigerian citizens. To achieve this, the current leadership must pay attention to cutting-edge evidence that identifies accountability gaps in the health system, their effects on health service delivery and uptake, and how they can be addressed.

Stakeholders have been requested to support the current Nigerian health leadership’s vision of entrenching an accountable and transparent health system. In response to this call, a coalition of health anti-corruption scholars, policymakers, civil society, and health and media practitioners has been established. This coalition known as the Health Anticorruption Project Advisory Committee (HAPAC) is driven by over seven years of research on accountability and corruption in the health sector across sub-Saharan Africa. HAPAC will deploy evidence-based information to support Nigeria’s health leadership towards achieving an accountable health system.

On February 28 and 29, 2024 in Abuja, the coalition met to reflect on the findings from an ongoing study over the past 7 years on health corruption and accountability in Nigeria. The study was presented by the Health Policy Research Group, University of Nigeria (HPRG), and the broader Accountability in Action (AiA) Research Team drawn from prominent scholars within and outside Nigeria. As validated by HAPAC the seven crucial highlights from this study can be seen in the below infographic.

Therefore, HAPAC calls on the leadership of the health system to take concerns about the seriousness of the issues raised and mainstream them into the sector’s accountability agenda. HAPAC has shown commitment by using evidence to point to what the fundamental problems are, firmly encouraging that these fundamental issues must be addressed squarely. Otherwise, any accountability structure leaving them out will be nothing but cosmetic.

Accountability priorities for HAPAC as regards the health sector emphasise three areas which are:

1. Basic Health Care Provision Fund

2. Human Resource for Health

3. Coordination of donors and donors’ resources.

These three areas are critical for strengthening the Nigerian health system and ensuring value for every investment in it.

HAPAC will engage more with the government, leveraging evidence and experience to help achieve an accountable health sector that is transparent, people-centred, and corruption-free.

The three HAPAC accountability priorities will be pivotal to these engagements. To intensify HAPAC’s chase of these priorities, the coalition will expand its network to include membership from the WHO, Finance Ministry, Public Complaints Commission, Consumer Protection Commission, Gates Foundation, Foreign Commonwealth and Development Office, and frontline anticorruption civil societies.

In all, HAPAC uses this opportunity to commend the current health sector leadership for rolling out the much-needed Health Sector Renewal Compact (HSRC), seeking consensus with Nigerian citizens in improving health indices on the road to Universal Health Coverage. Nevertheless, taking out the cogs embodied by corruption and weak accountability remains the most viable path to the fulfilment of HSRC for the Nigerian people.

For correspondence: obinna.onwujekwe@unn.edu.ng and prince.agwu@unn.edu.ng

Download full pdf version of communique

As published by the Guardian

Acknowledgment

Health Policy Research Group, University of Nigeria (HPRG)
Bayero University, Kano, Nigeria (BUK)
Nigerian Academy of Science (NAS)
Health Reform Foundation of Nigeria (HERFON)
International Centre for Investigative Reporting (ICIR)
Results for Development Institute (R4D), Nigeria
BUDGIT
Voice Against Corruption in Nigeria
Voice of Nigeria (VoN)
London School of Hygiene and Tropical Medicine (LSHTM)
Health Systems Research Initiative (HSRI)
Foreign, Commonwealth, and Development Office (FCDO)
Anticorruption Evidence Consortium – School of Oriental and African Studies (SOAS-ACE)
United Nations Office on Drugs and Crime (UNODC)

L-R front row: Dr John Onyeokoro (Health Watch Resources Ltd); Prof Muktar Gadanya (BUK); Prof Chinyere Mbachu (HPRG); Prof Isa Abubakar (BUK); Prof Ekanem Braide (NAS); Dr Idris Muhammad (Health Reform Foundation and Chair, HAPAC); Victoria Bamas (ICIR); Iyanuoluwa Bolarinwa (BUDGIT)

L-R back row: Dr Tarry Asoka (Independent Consultant); Prof Obinna Onwujekwe (HPRG and Convener, HAPAC); Isiyaku Ahmed (Voice and Accountability Platform); Dr Divine Obodoechi (HPRG); Dr Femi Ajayi (UNODC); Dr Aloysius Odii (HPRG)

HAPAC Members not in picture: Dr Felix Obi (R4D); Runcie Chidebe (Project Pink-Blue); Dr Charles Orjiakor (HPRG); Dr Prince Agwu (HPRG); Dr Eleanor Hutchinson (LSHTM); Prof Dina Balabanova (LSHTM)

This work was supported by a research grant from the Health Systems Research Initiative with funding from the UK the Foreign, Commonwealth & Development Office (FCDO), the Medical Research Council (MRC) and Wellcome, with support from the UK Economic and Social Research Council, (grant no. MR/T023589/1)

Under 50% of Nigerian Medical Doctors Renewed Licence in 2023: Brain drain hits hard (Video)

The Medical and Dental Council of Nigeria has reported that 58,000 of 130,000 licensed medical doctors in Nigeria renewed their licenses in 2023. This may be unsurprising, as studies reported that before the COVID-19 pandemic, more than 80 percent of Nigerian medical doctors and above 50 percent of Nigerian nurses sought work abroad. At the end of 2023, 26,715 Nigerians were in the United Kingdom on health worker-related Visas – a 215 percent increase from 2022. It is also reported that over 110,000 Nigerian nurses are currently practising in the United States of America. This flight of health personnel from Nigeria to several parts of the world is troubling, given the importance of the health workforce to the health of every nation, and to the achievement of Universal Health Coverage, which Nigeria currently lags at under 40 percent.

Recognizing this, The African Health Observatory Platform (AHOP) hosted in Nigeria by the Health Policy Research Group (HPRG), University of Nigeria, with support from the World Health Organisation (WHO) organised a policy dialogue on brain drain of Nigeria’s health workforce, and Africa at large.

This is coming just after the Federal Ministry of Health and Social Welfare has revealed that a National Policy on Health Workers’ Migration has been developed to address the issue of health workers migration in the country. The Deputy Director, Health System Department of Health Planning Research and Statistics, Dr Nwakaego Chukwuodinaka stated this at the policy dialogue on Thursday, 25th April 2024.

Chukwuodinaka said the Ministry has submitted a memo to the Federal Executive Council recently. “What we are requesting is to have a managed migration, and to be able to implement that policy, we need a nod from the FEC. One of the key component of the Health Workforce Policy is to incentivise those that are on ground working, especially those in the rural and underserved areas. Also to sign a pact with the destination countries. The pact is for us to equally gain from them poaching our health workers in the area of bringing technology for us, infrastructure and exchange programmes to help those we are training in-country.”

Read the full news here. You can also find it here.

Survey results on sexual behaviours among secondary school students in Nigeria reveal surprising scales of sexual engagement

By ***Angela Iwuagwu* and *Benjamin Uzochukwu***

“Researchers can be surprised at their data …” This was said by one of the authors of this blog, who due to Nigeria’s conservative cultural outlook, was surprised at how almost 50% of surveyed secondary school students affirmed sexual activeness. It was even more surprising that some of the sexually active secondary school students were involved in sexual intercourse with the same gender.

In Nigeria, the typical age for secondary school students should be between 10 and 18 years. Those within this age bracket are considered to be adolescents. It is an age of experienced puberty, marked by changes in bodily organs and hormones, early sexual urges, and exuberance.

In typical Nigerian families, parental vigilance increases as soon as children begin to mature into adolescents because they will for the first time be exposed to new feelings, inclusive of sexual feelings and manifestations of exuberance, which could go against laws and moral principles. In fact, vigilance over adolescents in a typical Nigerian setting extends beyond the home to include vigilance by adult figures in schools, neighbourhoods, markets, and worship places. Such scale of vigilance reflects the popular parlance, ‘it takes a community to train a child’.

Adolescents are expected to be steadfast in their training in school, acquire skills, and grow into becoming contributing members of society. Even in societies that support the sexualization of adolescent women, there is an increasing number of intense campaigns against such. Unfortunately, despite the many emphases of small- and large-scale vigilance over adolescents, many do not keep to the expectations of morality society has placed on them or even to the ideals of the diverse campaigns protecting adolescents from sexual engagements.

Sexual behaviours among adolescents in Nigeria pose a significant public health problem

For adolescents, there is just a thin line between risky and non-risky sexual behaviours. This is due to the inability of adolescents to regulate and bear the overall consequences of sexual engagements. It is for this reason, that sexual-related campaigns targeting adolescents mainly advocate abstinence. The most popular one in Nigeria for the past decade is the ‘Zip-UP!’ campaign. However, available statistics indicate that Nigerian adolescents tend not to heed such campaigns, and it is important to understand why and seek alternative approaches.

The fertility rate of 104 births per 1,000 Nigerian adolescent women is among the highest in the world. A study reported that among 428 adolescents in northern Nigeria, condomless sexual intercourse was found to be prevalent in one-third. Besides the spread of sexually transmitted infections (STIs), other concerns being witnessed as a result of this high prevalence of sexual intercourse among adolescents include unplanned pregnancies, truncated schooling, unsafe abortion, psychological worries for both adolescents and their carers, and death. The health challenges posed by sexual behaviours among adolescents extend to their carers, which is why this subject has remained of significant interest to a broad range of stakeholders.

Figures for adolescents’ sexual behaviours in southern-Nigeria are becoming scary

We surveyed 880 adolescents in secondary schools in the south-eastern part of Nigeria. They were between 10 and 19 years of age, drawn from rural and urban divides. We went ahead to conduct group discussions with another 80 adolescents in the region to seek more insights into the results from the survey.

Almost half (47.7%) of the surveyed adolescents confirmed participation in sexual intercourse, and some of them mentioned sexing the same gender, while others claimed to have more than one sexual partner. Substance misuse during sexual intercourse was found to be common at 93%. The misused substances in particular order are alcohol, marijuana, cigarettes, codeine, tramadol, methamphetamine, cocaine, and heroin. Of those who are sexually active, 86% never used condoms, and 75% said they had oral sex after misusing a substance. This group of adolescents also used sex as a means of exchange for drugs.

After sexual activity, less than 25% of the adolescents had confirmed pregnancies. However, adolescents in rural areas were less likely to have an abortion than those in urban areas. The study found poor parenting, exposure to uncensored videos, peer pressure, and limited knowledge of sexual and reproductive health as key factors driving up the numbers. A significant finding was that adolescents from poor homes could engage in sex for basic survival.

We discovered that primary health centres within the adolescents’ neighbourhoods were designed to provide sexual and reproductive health tips and services. Schools were also prepared to offer similar services. Disappointingly, while a good number of adolescents were unaware of such services around them, those that have ever utilised the services complained about stigmatisation and breaches of confidentiality.

A call to action

For several people, the scale of sexual engagement and risky sexual behaviours among adolescents in a typical conservative society like Nigeria may be surprising. The consequences are too significantly destructive, hence the need to take critical actions. First, the availability of sexual and reproductive health services in primary health centres and schools should be widely communicated, and those who are responsible for these services should be trained on the vital skills needed to work in such spaces.

Five important skills would be empathy, non-judgemental attitude, acceptance, respect for confidentiality, and case management. We reckon that these skills are home to the social service disciplines like social work and psychology, and it would be appropriate to begin to take dramatic and urgent measures to strengthen the operations of the social service professionals in health centres and schools.

The relationship between substance misuse and risky sexual behaviours among adolescents has been established. A firm approach should be in place to regulate and criminalize adolescents’ exposure to such substances. This should also include community-led awareness campaigns against substance misuse in relation to risky sexual behaviors.

Finally, we recommend community-led recreational and extracurricular activities that will keep adolescents engaged, and will serve as platforms for targeted health education content. Overall, for sustainable interventions to address these scary figures, government, non-government, and community actors will have significant and concerted roles to play. Efforts should also be made to improve sexual and reproductive health rights among adolescents in Nigeria.

Authors Bio

Dr. Angela Chiebodi Iwuagwu is a Nigerian medical doctor with the Community Medicine department of the University of Nigeria Teaching Hospital, and Fellow of the West African College of Physicians with expertise in public health, particularly endemic and epidemic diseases. With years of experience in sub-Saharan Africa, she has worked in various roles, including senior registrar, implementing public health programmes, and providing healthcare services to mothers and children. She has also worked as a health policy researcher and participated in various health projects.

Prof. Benjamin Uzochukwu is a public health physician and professor at the University of Nigeria, Nsukka. He is a renowned figure in Nigeria and Africa in health policy, systems research, and analysis. He has advised various organisations on implementation research, healthcare financing, and realistic evaluation of health programs. Professor Uzochukwu is a member of several committees, including the Ministerial Expert Advisory Committee on COVID-19 Health Sector Response in Nigeria. He is a Fellow of the National Academy of Science (FAS) and the Academy of Medicine Specialists of Nigeria (FAMedS).

Correspondence: Dr. Angela Iwuagwu

+234 803 528 6369

angelaiwuagwu@gmail.com

Acknowledgment: We thank Dr Prince Agwu for expert review.

Over 7 years of Health Sector Corruption Research Births Coalition for Accountability and Anticorruption in Nigeria’s Health Sector (Video)

HPRG Media

The health sector leadership in Nigeria is keen on ensuring an accountable and transparent health system that is patient-centered and resonates with the well-being of health providers. Stakeholders have been invited to support this ambition. In response to this invitation, a coalition of health anticorruption scholars, policymakers, civil society, and health and media practitioners has been established – The Health Anticorruption Project Advisory Committee (HAPAC). This coalition is birthed by over seven years of research on accountability and corruption in health.