Using scientific evidence to improve healthcare in Nigerian slums: an evolving story of hope and possibilities

Nigerian “ghettos” deserve quality health services
Popularly referred to as “ghettos”, slums have remained in Nigeria, inhabited by those who may not afford to live in well-off urban locations. About 50% of Nigeria’s population live in slums, and there are predictions that more people will relocate to slums if life continues to be difficult.
There have been many positive and negative stories about Nigerian slums. On the positive side, we have heard of several entertainment stars that emerged from slums, including football stars, and very talented technocrats. In fact, the image that is painted for most of Nigerians is that success stories may be incomplete without mentioning living in the slum at a time.
And on the negative stories of slums, we hear about several cases of violence, poor access to sanitation and hygiene, quick spread of diseases, and overall poor living conditions. As regards health, it is of deep concern to the Health Policy Research Group, University of Nigeria (HPRG), that amidst the sufferings in slums, basic quality and safe healthcare is difficult to come by.
HPRG believes that since the government has been slow in improving the overall living conditions in slums or improving lives generally, such that slums will no longer be needed, there should at least be some attention paid to the healthcare of those living in slums.
What is HPRG doing to change the face of healthcare in slums?
Slums are not actually in lack of healthcare services, but the problem is that many of those health services are informal, coming from untrained people. In these slums, people rely on those they call ‘chemists’ (technically referred to as Patent Medicine Vendors [PMVs]), traditional birth attendants who are women that help other women to deliver children in their homes, bone setters, and other traditional healers. These informal health providers are well respected in slums, even though they are not trained and they make medical errors that could take lives.
But then, is it possible that the Nigerian government which spends just about 5% of its annual budget on the health sector can build enough health facilities and employ enough health workers that can serve all the slums in the country that house above 100 million persons?
You will agree that the above question is rhetorical, especially when experts are saying that even the appropriated 5% is yet to yield an actual health value of 5%. Therefore, health systems actors like HPRG, Ministries of Health, Primary Healthcare Agencies, healthcare unions, etc., must begin to think differently about improving healthcare in slums using available resources.
The strategy of linking informal health providers to a formal health system
Recall the untrained people providing healthcare services in slums – the PMVs, traditional birth attendants, etc.? Do you think they are useful?
Interestingly, HPRG on the CHORUS urban health project has been conducting a study on health service delivery in urban slums. The team has mapped out many informal and formal providers in slums in Enugu and Onitsha and can affirm that a lot of informal health service deliveries go on in slums. Informal providers in slums help their neighbours to deliver children, treat them for malaria/fever and several illnesses, help them to correct dislocated and fractured bones, etc. So, indeed, we can give them flowers because they are doing what they can to meet the health needs of their neighbours who are poor, not so educated, and may not be able to access good health facilities because they are not available. Nevertheless, not so many of these cases turn out successful. Thus, what should we do?
In the urban health study conducted by HPRG, the research thinktank has seen that it is possible to pull these informal providers into a formal system that can monitor their activities, provide them with responsive health facilities where they can make quick referrals, train them to know the scope of health issues they can handle and how to offer basic attention to them, and importantly, identify and sanction those informal providers that continue to be a threat to safe healthcare for those living in slums.
Stakeholders continue to converge to shape and implement the findings from HPRG
In what is technically referred to as “co-creation of interventions”, HPRG has pulled together stakeholders from diverse sectors to chart ways forward for safe and quality healthcare in slums. The sectors include, The State Ministry of Health in Enugu, State Primary Healthcare Development Agency, Community Leadership, Unions of informal and formal providers, informal and formal frontline healthcare providers, and the academia. The first co-creation meeting was held between February 6 and 9, 2023, and the second, held on 25th May 2023.
Resolutions from the co-creation meetings so far
The stakeholders have agreed that to guarantee quality and safe healthcare in slums, three areas of focus should include governance, service delivery, and information management. Across the three areas, the proposal which will be implemented includes among others:
  • Establishing a desk office at the Ministry of Health to coordinate the linkage of the informal health providers into an efficient formal health system.
  • Through the desk office, identifying, registering, and training informal health providers to understand the scope of health services they can offer.
  • Ensure that the desk office works with focal persons in the slums to monitor activities of informal providers to be consistent with safety.
  • Providing a standard guide for referrals from the informal to the formal, including a simple referral form.
  • Training informal providers on some good practices in health service delivery that can enable them to perform quality basic care and to know when to refer cases exceeding their scope to functional formal health facilities around them.
  • Provide data collection tools for all activities within the informal health space in the slums and the connections with the formal health system.
In all, the policymakers, providers, community leaders, and representatives of the unions of the providers are appreciative of the findings coming from the urban health study being conducted by HPRG. They have looked through the interventions and have agreed that the interventions are feasible to implement. Steps have been designed on how to go about implementing the interventions, and in the coming months, it is believed that reasonable progress will be made to make the healthcare space in slums to be safe.
Acknowledgment of contributors
Prince Agwu (PhD)
Chinyere Mbachu (MBBS, FWACP)
Obinna Onwujekwe (MBBS, PhD)
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Unfavorable working conditions in primary health centers are hindering access to sexual and reproductive health services for young people in Nigeria

Some facts about the sexual and reproductive health of young people
Adolescents in low- and middle-income countries (LMICs) contribute an estimated 21 million pregnancies yearly. Half of these pregnancies are unplanned, and half of them end in unsafe abortions.
One in every five girls in Nigeria between ages 15 and 19 has commenced childbearing. Early childbearing has negative consequences on the physical and mental health of girls. Up to 50% of dropout among adolescent girls is caused by teenage pregnancy.
The risk of acquiring a sexually transmitted infection (STI) is highest among young people aged 15–24. The most recent National HIV & AIDS and Reproductive Health Survey (NARHS) reported that about 9.8% of young people in Nigeria experienced symptoms of STI in the year preceding the survey.
Primary health centres are not meeting the SRH needs of young people
One way to ensure that young people have access to lifesaving SRH information and services is through viable social services like counselling and youth-friendly centres. Unfortunately, such centres are scarce in Nigeria, creating the need for replacements through primary health centres (PHCs). PHCs are well-positioned to address the SRH needs of young people due to the availability of trained health workers, and the possibility of finding social service professionals like social workers and psychologists to work in primary healthcare facilities.
“Think about the 17-year-old pregnant Sophia who resides in a remote village in Nigeria where the only skilled health worker is in the PHC, or the 21-year-old Jimoh who has an STI and his only access to proper treatment is the PHC.”
The reality here is that the PHC should be the rallying point for young people who need SRH services such as counselling, contraceptives, treatment of STIs, maternity care and post-abortion care. However, PHCs in their current state do not appeal to young people. They (young people) prefer to go elsewhere when they need SRH services, and their reasons are linked to the attitudes of health workers.
The big question here, is – “How do health workers repel young people from PHCs, and why?”
Findings from a stakeholder consultation workshop
Researchers from the Health Policy Research Group, University, University of Nigeria, held a two-day stakeholder consultation workshop at Abakaliki, Ebonyi State on the 3rd and 4th of May, 2023 with stakeholders in adolescent sexual and reproductive health. In attendance, were: relevant officials from the State Ministries of Health, Women Affairs, Youth, Sports, and Social Development, as well as officials from the Ebonyi State Primary Healthcare Development Agency, implementing partners, facility health managers and representatives of adolescents.
Stakeholders lamented that inefficiencies in the Primary Health Care system make it difficult for primary healthcare workers to provide sexual and reproductive health services to young people
In the table below, we highlight how these inefficiencies are making PHCs less appealing to young people, that is the ‘whys’ and the ‘hows’ respectively.
The ‘hows’ The ‘whys’
PHCs are not open in the late afternoons or evenings (that is after school or work hours) when young people are able to access services PHCs do not have the number of health workers that are required to provide 24-hour services
The skilled health workers are not available in the PHCs in the evenings. There is no provision for accommodation for skilled health workers. Or the available accommodation is poorly maintained and not livable. Absence of security in the facilities to provide cover at night for health workers and epileptic power supply with little or no provision of an alternative means of power supply  
PHC workers do not have the skills or training to provide the services that young people need Many PHCs are manned by unskilled health workers such as community health extension workers. The State government has not employed skilled health workers to replace the retired workforce and there are no qualified social service professionals like social workers and psychologists. 
The design of the PHC may not be appealing to young people and may discourage them from seeking care Many PHCs do not have separate entrances and exits for young people. There is no provision for secluded spaces for young people to receive care
Poorly motivated PHC health workers may affect their attitude toward providing friendly care Many of the health workers at the PHCs are either unpaid volunteers or underpaid workers
Non-provision of certain SRH services to young people who come to seek care Religious beliefs and personal values of health workers conflict with their provision of contraceptive services to young people. Health workers are constrained by the restrictive abortion laws in the country
What is the way forward?
  • The stakeholders agreed that there is a need for continuous advocacy to the State government to employ more health workers and social service professionals in the facilities.
  • There is a need to integrate the volunteer health workers formally into the health workforce so that they receive payment for their services. This will improve the motivation of these health workers who are a major contributor to the staff strength of the PHCs.
  • The State government should channel funding to improve the working conditions and environment in the PHCs. The Basic Health Provision Fund (BHCF) can be leveraged in funding things that are allowed by the tenet of the funding.
  • PHC-model which is young people-friendly and welcoming to young people was proposed to enable the PHCs to be the first port of call for young people.
  • The research team will go further to implement co-designed intervention strategies at the PHC level to make SRH services more appealing to young people.
Acknowledgement of contributors
Chinazom Ekwueme (MBBS, MWACP) Prince Agwu (PhD)
Ifunanya Agu (MSc) Chinyere Mbachu (MBBS, FWACP)
Irene Eze (MBBS, FWACP) Obinna Onwujekwe (MBBS, PhD)
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Evidence from Cross Programmatic Efficiency Analysis of Health Programmes (CPEA) reveals that inefficiencies marr investments in Nigeria’s health sector

By Health Policy Research Group (HPRG), University of Nigeria
What to know about Cross Programmatic Efficiency Analysis of health programmes
Nigeria’s health sector enjoys investments from bilateral and multilateral agencies like the WHO, USAID, Global Fund, etc., that come as partners to strengthen the country’s health system and improve health service delivery. Investments from partners are add-ons to budgetary allocations to the health sector by federal and state governments, as well as locally sourced resources for health. Yet Nigeria’s health space is said to suffer suboptimal funding, which is a vital concern documented by the Lancet on Nigeria’s investment in health and population health outcome performance.
However, conversations are currently about how to get value for the current ‘suboptimal’ health investments. Indeed, more money may not guarantee more health, if steps are not taken to ensure efficient allocation and utilization of scarce resources in ways that offer maximal value for every penny invested in the health sector.
To address these concerns about efficiency in resource allocation and use of resources in health sectors, the WHO developed a diagnostic approach, the  Cross Programmatic Efficiency Analysis (CPEA). CPEA focuses on mapping programmes within the health systems of countries, for the purpose of identifying inefficiencies. These inefficiencies manifest in the form of duplications, overlaps and misalignment of roles and functions across or within governance, procurement system, service delivery, financing, and information management systems. And they have implications on success or failure of priority health programmes, such as HIV, Tuberculosis, Malaria, Immunization, and Reproductive Maternal, Newborn, Child and Adolescent Health (RMNCAH).
CPEA study was conducted in three states in Nigeria (Anambra, Imo and Sokoto). Although there is an implementation focus in Anambra, with plans for spreading into other states in future. The study also considers the need to reflect with federal agencies like the Federal Ministry of Health (FMoH) over the work being done at state level, since most of the partners will always come into the country through the ‘Federal gate’.
Stakeholders meet to look at previous CPEA findings
The CPEA study was conducted between 2018 and 2019, using key-informant interviews and review of documents. As the study nears implementation of its key recommendations, concerned stakeholders such as directors at the FMoH, State Ministry of Health (SMoH) including commissioners of health, Executive Secretaries/Chief Executive Officers of health agencies, representatives of development/implementing partners, and health systems and health economics expert, were invited to a 2-day implementation meeting (18th and 19th April 2023) at Valencia Hotel, Abuja.
The stakeholders yet again looked through the key findings from the CPEA study, identifying areas of improvement within their health systems since 2019 when the CPEA study was concluded. Indeed, there were some remarkable improvements, especially around centrally governing diverse partners through the SMoH.
A representative of one of the states said, “Unlike at the time the CPEA study was conducted, we now have ownership of health programmes in our state, particularly in terms of approval and oversight. It is no longer the usual case of partners coming in with programmes and we have no idea of what is happening. That has changed since after 2019”.
Nevertheless, there was consensus that a number of inefficiencies still exist in the coordination of the programmes, particularly in areas of financing, information management, service delivery, and some components of governance that have to do with planning, human resource management, and sustainability of programmes at the exit of donors.


Cross-section of participants with the Director of Planning, Research, and Statistics, Federal Ministry of Health and Commissioner of Health, Sokoto State
In retrospect, what were the findings from CPEA?
During the 2-day meeting, health systems and policy experts from the Health Policy Research Group, (HPRG) University of Nigeria, led by Professor Obinna Onwujekwe, together with Dr Francis Ukwuije of the Health Financing Technical Office of the World Health Organisation, Nigeria, recapped key findings from the CPEA study done in Anambra, Imo, and Sokoto States. Interestingly, identified inefficiencies were common across the three states. Inefficiencies were found in the following areas:
  • Partners pursuing financing of health programmes that do not align with the health priorities of the states.
  • Decisions of health programmes to execute by partners at the federal level with almost no input from the states.
  • Due to the lack of contributions by stakeholders at the state and local government levels to health programmes, partners could bring health programmes that are not actually needed in certain communities, which leads to wastage of resources.
  • Partners fund health programmes and assign budget lines that have already been captured in the national or state health budgets, leading to more wastage of scarce resources.
  • While there is a need for diverse health programmes, supervisory and accountability lines should be mainstreamed for efficiency. As against having too many supervisory/accountability lines, like “too many cooks, spoil the broth”.
  • “Too many cooks spoiling the broth” was again manifest in information management. When different programmes have unique data reporting tools and dissemination platforms, it could cause confusion and even data inaccuracy, which could affect decision-making.
  • Health programmes may not be informed by evidence, as gaps between generated data and decision-making persist.
  • Health programmes could be counterproductive to the management of human resources for health, in the sense that health workers in a bid to attend to the demands of programmes may neglect the core responsibilities of attending to patients in facilities. And some of the health workers could want to lobby themselves into health programmes with more funding.
As inefficiencies across the health programmes persist, what way forward?
Interestingly, stakeholders acknowledge that these inefficiencies must be tackled if the health system will make progress. Uche Ezenwaka on behalf of the HPRG, led the activity on priority and agenda setting in addressing the identified inefficiencies.
First, the stakeholders were made to understand the concepts of feasibility and fidelity in designing priorities and agenda. Followed by being talked through the core focus of CPEA in areas of governance, financing, service delivery, information management, and procurement.
Although still a work in progress, a summary of agenda setting achieved by the states with support from the federal level, are:
  • Establish a special desk office under the Commissioner of Health that will compulsorily be the entry and exit of health partners supporting programmes. This will help states to assume ownership of the programmes and stay well informed of the programmes’ contents and management.
  • Activate the health partners coordination committee (HPCC) in the FMoH, and source funding for the committee through budgetary allocation to the Ministry. This will help achieve harmonization of programmes, as well as supervise coordinated input from states on health programmes.
  • Aggregate insights from facilities and local government health authorities before drawing up budgets for the health sector in states.
  • Advocate for early passage of annual budgets to guide annual operational plans for the health sector.
  • Organise state-owned partners’ forum for harmonization of health programmes in the state and achievement of health spending based on unique health priorities in states.
  • Establish desk offices in Ministries of Health for scouting and distilling research evidence for use by policymakers in engaging partners and members of the state executive council.
  • Engage and sensitize the Civil Society Groups to participate in monitoring the activities of partners and demanding accountability.
  • Guided by the Primary Healthcare Under One Roof (PHCUOR) to improve the relationship between the State Primary Healthcare Development Agencies and Local Government Health Authorities to strengthen supervision of programmes at the primary healthcare level.
  • Activate state level data operation center (DOC) that collates, harmonize and coordinate data for decision-making commissioned by UN and WHO to help streamline reporting line and data.
  • Establish a Logistic Management and Coordination Unit (LMCU) to address fragmented procurement system across supply chain
  • Establish a Health Workforce registry to serve as a database to enable acute and timely evidence-based health workforce information and management.
The involvement of top players in the health sector of the selected States is an important step towards the achievement of the desired efficiency across the health programmes and health sector at large. Also, the acknowledgement of inefficiencies by these top players, and the commitment of their time to begin drawing up feasible and workable remedial strategies, offers a strong sense of conviction. The implementation of CPEA is large on prioritization, implying that the implementers understand how ambitious it can be trying to address all inefficiencies. So, the focus will be on specific state priority areas for efficiency. Lessons learnt will be used to pursue CPEA in other states of the country.
(1) World Health Organisation
(2) Federal Ministry of Health, Nigeria
(3) Resource for Development (R4D)
(4) Strategic Purchasing Africa Resource Centre (SPARC)
(5) State Ministries of Health, Anambra, Imo, and Sokoto.
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Media gurus and health systems researchers meet to amplify health research evidence for governance and improving communities

By The Health Policy Research Group, University of Nigeria
Researchers serially complain of the lack of spread of the wonderful and interesting scientific evidence they generate. Why this is so, is because researchers use a lot of technical languages in their works. In contrast, the media remains public friendly, writes using simple words and utilize creative means to reach the public. The media is known for inspiring political debates, causing political actors to pay close attention to them, far more than the attention given to scientific publications. A blog, titled, “Everyone!! wants to read a blog but your scholar-colleagues want to read your journal article” discusses why it is essential for academics to go beyond just writing academic papers.
With the understanding that the media takes care of the limitations of researchers in research communication, the Health Policy Research Group (HPRG), University of Nigeria, through the Community-led Responsive and Effective Urban Health Systems (CHORUS) organised a research-media bootcamp between April 12-14, 2023 in Enugu, for researchers and media/public relations (PR) gurus to have a handshake and build collaborations. The bootcamp provided an opportunity for knowledge and skills exchange between the media experts and researchers, with the focus of improving seamless and widespread communication of health research evidence to the public and policymakers.
What researchers are saying
To pull together and make sense of quality research evidence is no small feat. The processes and funding are tasking. Yet researchers at HPRG have remained committed to the cause of regularly producing research evidence in health systems and policy. In more advanced countries, investments in research are indeed huge, and governments commission researchers to go in search of evidence used to make policies and programmes to improve governance and the lives of citizens. According to the World Bank, Nigeria’s expenditure on research is less than 0.5% of its Gross Domestic Product (GDP), compared to countries like South Africa and more advanced countries like the United Kingdom and Canada that spend close to (and) over 2% of GDP on research. These countries ensure that their policies and programmes, including those of the health sector are informed by research evidence – a practice that is yet to gain strong footing in Nigeria.
Quality time during the bootcamp was dedicated to coaching the media/PR experts on how research is conducted, identification of quality research evidence and their types, and how media/PR experts can find the central message in published studies. This section was facilitated by Dr Aloysius Odii, who emphasized that with the media, research evidence will be at the doorsteps of the public and those that make policies and programmes in Nigeria.
It is important to note that HPRG, since its establishment in 2002, understands the importance of not abandoning research evidence to academic publications alone. The Health Policy and Systems Research (HPSR) Hub has developed a framework on Getting Research into Policy and Practice (GRIPP), published in the Journal of Globalization and Health. Dr Enyi Etiaba, one of the developers of the framework acknowledged the vital roles of the media in GRIPP which were not well captured as of the time the framework was designed. However, in the last couple of years, HPRG has taken seriously, the advantages of the media in research communication by leveraging the radio, social media, blogs, setting up an institutional website, and developing a yet to be published strategic research communication plan with the media as a vital component.
What media/PR experts are saying
The Nigeria Health Watch (NHW) continues to play significant roles in health communication. Chibuike Alagboso representing the NHW addressed the trends in health communication and the usefulness of the approach of solution journalism (SoJo). Supporting NHW were two Mass Communication experts from the University of Nigeria, Drs. Celestine Gever and Ijeoma Ajaero, who spoke about the politics of the media and importance of conducting media assessment during research communication.
Ifesinachi Cyril, Sandra Nwankwo, and Okechukwu Agubama of Radio Nigeria, Dream FM, and NTA Enugu, respectively, buttressed the importance of media assessment to be included in research planning, while adding that researchers must be intentional with building collaborations and partnerships with the media. Steps in building these collaborations, such as courtesy visits and frequent communications of research evidence with the media were enlisted by the PR experts from the University of Nigeria, Inya Agha and Obianuju Akamigbo.

Media-focused writing was extensively discussed during the bootcamp, led by Alex Enebeli of the News of Agency of Nigeria, Patience Ihejirika of Leadership News, and Vanessa Offiong. Researchers writing for the media must ensure that research findings are presented in formats that are clear, brief, and relatable, with results at the top and clear calls to actions. The use of infographics was mentioned to be important in writing for the media, and interestingly, James Ozoagu, an infographic expert was present to drill all attendees at the bootcamp infographics skills.
Finally, as the issue of corruption continues to feature in most of the studies conducted by HPRG, it was important to use this bootcamp as an opportunity to learn and discuss about how the media reports corruption. Victoria Bamas of International Centre for Investigative Reporting (ICIR) touched on vital dos and don’ts in gathering information about corruption issues and reporting them. This cuts across strategic tracking of sharp practices, leveraging the Freedom of Information (FOI) Law, and reporting what is lost to corruption as against just the corruption itself.
Call to action
An established network of researchers and media/PR experts is formed, and a strategic plan for research communication through the media for the next five years is currently being designed. As agreed, the plan will be reviewed intermittently. Objectives of the strategic plan are focused on relationships and communications, responsibilities, funding, and content and style of research products for the media. The network looks forward to expansion in the coming years, strongly believing that all gaps between researchers and media will be bridged, and health research evidence will be regularly disseminated and communicated for policy impact and improvement of the health of Nigerians.
List of presentations
We have compiled all presentations during the bootcamp. Kindly click on the links below to download.
    1. Using Public Relations for Research Impact
    2. Understanding research methods
    3. Mass Communication for Health
    4. Research in journalism for policymaking
    5. Reporting for corruption in the health sector
    6. The act and practice of journalistic writing
    7. Getting research into policy and practice
    8. Introducing infographics
    9. Infographic with CANVA

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Improving Access to Quality Healthcare in Urban Slums: Researchers Collaborate with Government, Healthcare Providers and Communities to Design Feasible Interventions

By Prince Agwu, Chinyere Mbachu, & Obinna Onwujekwe
The realities of living in informal settlements in Nigeria are telling of the healthcare conditions in such areas and are described as urban health risk. Over 54% of urban residents in Nigeria reside in informal settlements, and in the absence of  actions towards urban renewal, the situation will only get worse. It is as well expected that the continuous increase in multi-dimensionally poor Nigerians may push more citizens into relocating to urban slums or creating more informal settlements as a survival strategy. Thus, while we envision the upgrading of urban slums and proper integration into city plans, we must begin to work towards improving the health conditions of the slum dwellers.
The Health Policy Research Group (HPRG), University of Nigeria, is involved in a multi-country research project, CHORUS Consortium, which is aimed at improving access to quality and essential health services for the urban poor. Having completed a baseline assessment of access to health services in selected urban slums in Enugu and Onitsha, the HPRG has begun to engage key stakeholders in Enugu State to identify, select and design feasible interventions that would guarantee access to safe and decent healthcare for slum dwellers.
Okpoko Slum, Onitsha, Anambra State
The HPRG-CHORUS Strategy for better health for slums
The most radical approach to improve health conditions in slums is to improve the economic livelihood of the residents, demolish shanty structures and replace with better livable buildings, build good hospitals staffed with well-qualified medical practitioners, and provide critical amenities for the people. But we must ask, ‘how realistic can these be achieved in present Nigeria?’
Also, it is important to point out that based on emerging evidence, there are slum residents who choose to patronize traditional practitioners and patent medicine vendors (PMVs), even when a functional health facility is easily accessible. So, a comprehensive approach to ensure safe and quality health for people living in slums is to make sure that the informal healthcare providers are formally engaged in health promotion activities, and conscientiously supervised by the public (government) health system to the benefit of the urban poor. This is what we in HPRG-CHORUS refer to as “linkage of informal providers to the formal public health system”. By informal providers, we refer to the traditional medicine practitioners, traditional birth attendants, and PMVs.
Cross-section of stakeholders co-designing health interventions for slums
HPRG-CHORUS Team reviews research findings and conducts a field validation visit
The team at the University of Nigeria hosted one of the leads of the CHORUS Consortium from the University of York, Professor Helen Elsey between February 6-9, 2023. The four-day visit comprised interactive sessions with HPRG researchers, advocacy visits to key policymakers, and site visits to two urban slums within Enugu city.
Together with Helen, HPRG researchers reviewed findings from the baseline assessment which consisted of (a) reconnaissance of informal and formal health provisions in the urban slums, (b) in-depth interviews and focus group discussions with informal and formal providers, community leaders and residents, and policy makers, and (c) quantitative survey of formal and informal healthcare providers and households in the urban slums. A key output from this conversation is that there are ongoing relationships between the formal and informal providers that need strengthening through education of providers and service users, institutionalization through policies and government-approved/supervised practices and addressing frictions between the informal providers and the formal providers.
HPRG-CHORUS Core Team discussing research findings
The site visits to the urban slums confirmed that the conditions of the slums in terms of access to health services and other basic amenities had worsened or remained the same, at best. Remarkably, the primary health centres in the slums were yet to have the optimal and right mix of staff, lacked pro-poor financing, and lagging behind in overall management. In fact, one of the health facilities had become a den for criminal elements, completely shut, despite being supported by the Basic Heath Care Provision Fund (BHCPF). However, informal providers continue to provide health services in the slums although their connections to the formal health system were still very weak. Due to this lack of formal oversight on informal providers, some had taken to inappropriate practices, including administering harmful substances to persons that reside in and off the slums.
HPRG-CHORUS Team at Abakpa Slum, Enugu
HPRG-CHORUS Team meets with policymakers to chart actions
Armed with evidence from the baseline assessment and the recent site visit, advocacy visits were made to the Executive Secretary of the State Primary Health Care Development Agency and the Commissioner for Health in Enugu State. They expressed convictions over the State government’s commitment to strengthen primary healthcare and outlined some strategies being implemented including the establishment of model PHCs across the State. However, both policymakers acknowledged that a lot still needs to be done to optimize the formal healthcare system, particularly in the urban slums, and that formalizing linkages with informal providers could contribute to improving access to quality and essential healthcare for the urban poor.
Nevertheless, they cautioned that pursuing linkages with informal providers must be done with carefulness, guided by a thorough understanding of the processes and treatment procedures adopted by the informal providers. Interestingly, the WHO has committed to ensuring that informal providers function within defined scope for safety reasons. A Joint Health Sector Inspectorate was recommended by the Commissioner as an important regulatory body to ensure quality service delivery across the formal and informal health blocs. Also, dysfunctional health facilities in the slums have been noted and urgent actions will be taken to ensure that they are considerably efficient to serve the health needs of the slum residents.
HPRG-CHORUS Team with the Enugu Commissioner of Health – Prof Ikechukwu Obi (centre)
HPRG-CHORUS Team with Enugu Executive Secretary of Primary Health Care Agency – Dr George Ugwu (centre)
An organized forum where interventions for proposed linkages are designed
From February 15-17, 2023, the HPRG-CHORUS Team facilitated a workshop in which researchers collaborated with policymakers, programme managers, informal and formal health providers, and community (slum) leaders to identify, select and begin to operationalize feasible interventions for formalizing linkages between the informal providers and the formal (public) health system. A total of 22 interventions were listed, of which in a merging and ranking exercise, they were further condensed to ten.
Group work during the co-design engagement
Currently, stakeholders are working in technical groups to design operational plans and tools for the following interventions, (1) Community engagement for awareness about available formal health services and educate residents on the need for linking informal to the formal (2) Training and reorientation of informal providers to accept linkage to the formal health sector (3) Regulate and improve referral systems between both providers (4) Incentives for informal providers to optimally accept and pursue proposed linkage to the formal (5) Create policies and structures to ensure sustainability of linkages.
Looking forward to the future
In the coming months, the researchers and stakeholders will finalize the operational plans and tools for piloting the interventions in four slums in Enugu State. Also, a co-creation workshop will be implemented with key stakeholders in Anambra State (focusing on Onitsha city).
The HPRG-CHORUS Team appreciates the support and cooperation it has received from policymakers who will be the chief implementers of the interventions and ensure their sustainability. We also appreciate the participation of other stakeholders who are keen on achieving improved access to quality healthcare in urban slums. Indeed, there is hope that healthcare for slums can be made safe and decent, and the outputs from the current study can provide a blueprint to manage the healthcare space across other slums in Nigeria.
We are happy that the HPRG-CHORUS Team will be expanding its research focus on urban health. For the next two years, Prince AgwuTochukwu Orjiakor, and Uche Ezenwaka will be leading studies on health seeking of school children in urban slums in Port Harcourt, addressing crime issues and health impacts in slums in Aba and Onitsha, and water/sanitation/hygiene in Onitsha slums, respectively. These novel studies will certainly strengthen urban health understanding and actions in Nigeria, with great lessons to emerge for similar countries.
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HPRG’s Thought Leadership on Advocacy for Policy Change

By HPRG News
Kurt Lewin said, “no research without action, and no action without research”. The reality of this quote lies in the essence of conducting research, which is to change society. Such change could be to inform, influence, or introduce great policies and programmes; or to improve conditions for the poor and vulnerable; or to even inform effective governance. Any which way, a goal for academia is to ensure that research brings real-time and tangible positive changes to the lives of people, and that generated evidence makes sense to policymakers and used for the good of the public.
These precedents motivate the Health Policy Research Group (HPRG), University of Nigeria to engage in building capacities in advocacies and influencing policies and programmes using research evidence. A well-researched study on bridging gaps between policymakers and researchers was published by the HPRG, and they have gone forward to mainstream these insights and approaches into mentorship programmes for organisations. Very recently, HPRG was engaged to build the capacity of the staff of the German Leprosy and Tuberculosis Relief Association/RedAid Nigeria (GLA/RAN) in Enugu on advocacy for policy change using research evidence.
GLA/RAN, Enugu, is currently implementing an innovation grant from the STOP TB Partnership, titled – ‘Catalysing improvements in drug-resistance tuberculosis (DR-TB) care in Nigeria: A sustainable patient-centred approach’. The core aims of the project include reducing pre-treatment loss to follow-up and commencing treatment for newly diagnosed DR-TB cases as fast as possible, by addressing factors that affect the patient-care pathway from efficacy of investigations through initiation of treatment for DR-TB. In addition, a core part of their research aims will be to get generated evidence into policies and practice. To achieve this, the following important resources from HPRG will be needful:
  1. Concept and importance of advocacy for policy change – By Dr Chinyere Okeke (Click here to download presentation)
  2. Understanding the use and role of media and communication for effective advocacy – By Prince Agwu and Chinelo Obi (Click here to download presentation)
  3. Foundational principles and key components of developing advocacy strategies – By Chioma Onyedinma (Click here to download presentation)
  4. Methodologies and tools for effective advocacy – By Prof Chinyere Mbachu (Click here to download presentation)
  5. How to write a policy brief – By Prof BSC Uzochukwu (Click here to download presentation) 
  6. Planning, implementing and evaluating advocacy and communication for policy change – By Dr Chinyere Okeke (Click here to download presentation)
  7. Getting research into policy and practice – By Prof BSC Uzochukwu (Click here to download presentation)


“Corruption in the health sector is stealing from the sick”: Policy Forum for insights and action on accountability and corruption in health

By Prince Agwu, Obinna Onwujekwe, Dina Balabanova and the Accountability in Action Research Team
Despite anticorruption thrusts that have always been a part of the manifestos of successive governments in Nigeria, corruption has remained considerably high in the country. With corruption being common in many sectors of Nigeria, the country in the 2021 Corruption Perception Index (CPI), scored 24 of 100, making it the 154th most corrupt country out of 180 countries in the world, and among the 15 most corrupt countries in Africa. Disappointingly, the health sector continues to feature as among the top-5 corrupt sectors in the country.
Image 1: Nigeria’s CPI since 2012 (Source: Trading Economics)
Is corruption in health a lack of morals or a failure of systems?
Thomas Hobbes described life as nasty and brutish, constantly in a state of war, which explains how the nature of man is disapproving of principles and good behaviour. Hobbes further used this philosophy to buttress the importance of social control (rules and institutions that keep to the demands of the rule of law) against the deviant nature of people and make them more compliant with rules. Just as Hobbes, Sigmund Freud argued that societies get better when the superego (comprising ideals, principles, laws, etc.) is enforced to quell the irrational and socially unacceptable personalities of people (ego). In these, and in other traditional scholarship, the innate tendency to be corrupt appears to be part of human nature, but people can be less or not corrupt in systems that are built to be intolerant of corruption. This is why the Anti-corruption Evidence Consortium argues for the need to strengthen vertical (government offices) and horizontal forces (grassroots people), such that systems can become self-enforcing against corruption.
Therefore, corruption may not entirely be the moral failure of individuals, but even more, a failure of institutions that creates incentives for corrupt practices. At times, institutions may fail to the extent that corruption becomes the only way for people to survive and support their families. Thus, instead of just identifying and punishing individuals who break the rules, an anticorruption agenda must seek to make corruption unattractive and difficult to perpetuate, and at the same time, build a system that can be self-enforcing against corruption.

A reminder about Nigeria’s health sector corruption
A recent review on health sector corruption and a nominal group technique with frontline health workers and policymakers in Nigeria revealed the most common forms of health sector corruption, which were absenteeism, informal payments, health financing corruption, employment irregularities, diversion of patients from public to private facilities, theft of consumables, and illicit procurement practices. More focused research approaches using ethnography, interviews, and group discussions have also shown that the Nigerian health sector is truly challenged by corruption, devastatingly affecting Nigeria’s progress toward achieving global health goals and leading to inefficient use of the current low budgetary appropriations and donor funding to the health sector. The poorest and most disadvantaged groups are most at risk as they have few alternatives to obtain adequate quality care. Indeed, corrupt practices change the ethos of the health system and distort priorities and procedures.
Image 2: Corruption ranking in Nigeria (Source: Channels TV)
While the situation often seems helpless, there is hope in the fact that anticorruption can be successful when governance structures are set up and incentivized in ways to gradually curb it, and when grassroots actors finally say, “enough is enough”. Therefore, the question is – how do we stimulate and galvanize the interests and actions of macro governance structures and community actors toward anticorruption in the health sector? Also, how do we ensure that anticorruption approaches do not only work for a period of time but become an integral part of the system and sustainable?
Stakeholders in health sector anticorruption gathered to find solutions
The Health Policy Research Group (HPRG), University of Nigeria and the Bayero University, Kano (BUK), with partnership from the London School of Hygiene and Tropical Medicine (LSHTM) are vigorously pursuing an anticorruption agenda in the health sector of Nigeria through research and the use of evidence from research to inform policies and strategies that will eliminate corruption in the health system. To achieve this goal, the team convened a Policy Forum on Anticorruption in Nigeria tagged “Stop Health Sector Corruption”, attracting various key stakeholders in the Nigerian health system and anticorruption vanguards from several bodies in Nigeria.
Those that were represented included the Independent Corrupt Practices Commission (ICPC), Nigeria Academy of Science (NAS), Health Reform Foundation of Nigeria (HERFON), International Centre for Investigative Reporting (ICIR), Results for Development (R4D), National Health Insurance Scheme (NHIS), Budgit, UNODC, Nigeria Health Watch, Project Pink Blue, Anticorruption Academy of Nigeria, National Primary Health Care Development Agency (NPHCDA), SERVICOM, Nigeria Governors Forum, etc. The stakeholders narrated several personal experiences of health sector corruption and reinforced the urgent importance of addressing this failure.
With several presentations of documented evidence from the research team from UNN and BUK on the realities and dynamics of corruption in Nigeria’s health sector, particularly primary healthcare, the stakeholders confirmed that thoroughness of the research already done by the team, even though they pointed more areas to cover. Strong emphases were made on the managerial components of the health sector, as corruption, unaccountability, and sheer incompetence at that level have allowed for the thriving of corruption and accountability issues at the level of service delivery. The weakness of the Human Resource (HR) component of the public sector, as well as the lack of properly communicated context-specific rules and regulations for the health sector, were considered enablers of corruption.

Image 3: Cross-section of policy forum attendees
Where do we go from here?
The stakeholders who attended the Policy Forum were clear on where to begin to address health sector corruption. Unanimously, they emphasized the need to drive solutions using evidence from research. Implying that more conversations between researchers in corruption studies and policymakers should be encouraged. Also, based on the reported evidence, stakeholders opined that anticorruption will be unsustainable if strategies do not emanate and include actors at the frontline and those that are affected. It is more like tying the ends of macro politics (the big ‘P’) that comprise the managers at the authority level and their political networks in local government and beyond, with those of micro politics (the small ‘p’) comprising community actors and frontline health workers.
It was for instance suggested that a ‘Rule book’ on anti-corruption in health should be developed and deployed across the country, and civil society groups and community leaders should be encouraged and incentivized to play supportive supervision roles across health facilities. An important incentivization as mentioned by the policymakers is to ensure that the top-level managers act on reports tendered to them by community actors and civil groups. Such is needed for confidence building and developing trust across the “big” (P) and “small” (p) pees. Also mentioned included rapid digitalization of systems, educating service users on patients’ rights as enshrined in law using townhall meetings and media, establishing and optimizing human resource management across health facilities, and putting together reward mechanisms for committed health workers, to mention but a few.
Image 4: Cross-section of policy forum attendees
There is hope!
With the coming together of these powerful actors sourced from organisations and circles that are influential within Nigeria’s health system and policy space, a critical mass of people and systems that can drive a sustainable anticorruption agenda in the health sector is feasible. The policy forum attendees have made their commitments to this cause and are optimistic about improved situations within the health sector going forward. Therefore, more strategic and meaningful engagements will continuously hold until anticorruption in the health sector becomes an indispensable part of Nigeria’s health system, and the rule of law rises to becoming self-enforcing by the system.
With the amount of information asymmetry in the health system, where service users are barely aware of expectations, ensuring prominence of the rule of law remains a viable anticorruption strategy. We understand that this may be difficult to achieve in developing climes like Nigeria, where individuals and organisations can be even more powerful than the system. It is for this reason scaling-up and optimizing the awareness and voices of citizens at the grassroots is much needed and an achievable anticorruption agenda. And civil groups and researchers will continue to pursue avenues to hold government actors to account and draw their attention to the pathetic consequences of undermining the rule of law as applied to healthcare. More voices are needed in health sector anticorruption, and the Accountability in Action Research Team is excited at the rapidly growing institutionalization of health sector anticorruption, evidenced by:
  1. The Thematic Working Group on Action on Accountability and Anti-corruption for SDGs (TWG AAA) at Health Systems Global, where Prof Obinna Onwujekwe and Prof Dina Balabanova (are Co-Chairs)
  2. The proposed African Resource Center for Accountability and Anti-corruption in Health, to be based in Nigeria
  3. Forthcoming Global Network for Anti-Corruption, Transparency & Accountability in Health Systems (GNACTA) to be launched by WHO, UNDP and other major development agencies in December 2022. 
  4. The Nigerian Policy Forum on Accountability and Anti-corruption in the health system     
Associate Prof Eleanor Hutchinson
Dr Tochukwu Orjiakor
Dr Aloysius Odii
Dr Muktar Gadanya
Dr Maikano Madaki
Pamela Ogbozor
Divine Obodoechi
Accountability and Anti-corruption in Health Project Anti-corruption Evidence Consortium (ACE)

Understanding the Cost-Effectiveness of COVID-19 Vaccination in Nigeria

Benjamin Uzochukwu, Chinyere Okeke, Sergio Torres-Rueda, Carl Pearson, Eleanor Bergren, Anthony McDonnell, Anna Vassall, Mark Jit, Francis Ruiz
Researchers from the Health Policy Research Group (Prof Benjamin Uzochukwu and Dr Chinyere Okeke) were part of a project that sought to understand the cost-effectiveness of COVID-19 vaccination in terms of procurement and administration. This was documented by the Centre for Global Development (CDG), presenting useful information in scaling up campaigns against COVID-19 and improving responses to future pandemics in Nigeria.
Indeed, COVID-19 has disrupted health systems across the globe. Nigeria reported its first COVID-19 case in February 2020, and, since then, the government has rolled out four vaccines to help control the pandemic—Moderna, Oxford-Astra Zeneca (AZ), Johnson & Johnson (J&J) and Pfizer-BioNTech.
Nigeria set an ambitious goal of vaccinating 40 percent of its over 200 million people before the end of 2021, and 70 percent by the end of 2022. The vaccine rollout was organised into four phases, as shown in table 1. Access to vaccines in Nigeria has been limited, however, and vaccine hesitancy has further slowed down deployment. There is also limited evidence on the comparative clinical and cost-effectiveness of COVID-19 interventions—including vaccination—in the Nigerian context specifically.
Health Technology Assessment (HTA) is a framework for assessing whether healthcare interventions—including vaccines—offer good value for money and take into account a wide range of considerations. The University of Nigeria Nsukka, the London School of Hygiene and Tropical Medicine, the Center for Global Development, and the Africa Centres for Disease Control collaborated to support key national and regional stakeholders in evaluating the cost-effectiveness of Nigeria’s COVID-19 vaccine strategies using an HTA framework.
  1. Which COVID-19 vaccines should Nigeria purchase and how much would it cost?
  2. How should these vaccines be distributed?
  3. What age groups should be targeted?
To read more click here

Using Modeled Evidence in Nigeria’s Health System: understanding the gaps and promoting the value of evidence-based decision making

By Chinyere Mbachu, Prince Agwu, God’stime Eigbiromolen, Ifunanya Agu, Benjamin Uzochukwu and Obinna Onwujekwe
Statistics makes it possible to simulate real life behaviors using models, and this is termed ‘modeled evidence. Mathematical models that simulate different potential health scenarios around disease transmission, and/or the impact of policy interventions on health outcomes, can be valuable to decision makers. They can be used to prioritize and choose between complex trade-offs and ensure the best possible results in efficiency, effectiveness and impact of health policies and interventions.
Literature has shown that, although policymakers are aware of the need to make decisions that are based on scientific evidence, they do not regularly put this concept into practice. This is particularly the case with modeled evidence. Recent disease outbreaks and disasters have highlighted the need for a more proactive health system that anticipates and prepares ahead of health emergencies. At the onset of the COVID-19 pandemic, the Nigeria Center for Disease Control (NCDC) relied extensively on evidence from mathematical models to understand the trajectory of the epidemic and to develop an appropriate response strategy.
As the usefulness of modeled evidence gains more traction in the Nigerian health system, it is necessary to learn how policymakers can be supported to use modeled evidence in decision making. This could be achieved by examining the extent to which modeled-evidence is understood, valued and used by decision makers, as well as the factors/mechanisms that enable or constrain the translation of modeled-evidence to decision-making.


Figure 1: Translation of Modeled Evidence to Policy: Nigeria’s Ecosystem Canvas
The target audience for this policy brief comprises all the stakeholders in the modeling to decision making ecosystem, including modelers, decision makers, and knowledge brokers who facilitate exchange between them.
Click here to download and read the full policy brief.
Acknowledgement: This project was done in partnership with Results4Development and funded by the Bill & Melinda Gates Foundation.
Suggested citation: Chinyere Mbachu, Prince Agwu, God’stime Eigbiromolen, Ifunanya Agu, Benjamin Uzochukwu and Obinna Onwujekwe (2022). Values, gaps and getting evidence generated from modeling into decision making in the Nigerian health system. A Policy Brief from the Translation of Modeled Evidence for Decision Making project in Nigeria.

“The pandemic is not over, as its impact persists in Nigeria’s health system”: Professor Onwujekwe at the Congress of Postgrads’ Medical Fellows

By HPRG News
The effects of COVID-19 pandemic continue to bite health systems, particularly those of low-resource regions. Quoting the Organisation for Economic Co-operation and Development, “The COVID-19 pandemic has shown how vulnerabilities in health systems can have profound implications for health, economic progress, trust in governments, and social cohesion”. The question of strengthening health systems has been recurring since the pandemic and has gotten more answers than actions. However, the conversations must not cease, as it is needful to keep discovering and reminding ourselves of those areas in our health system that have been affected by the pandemic, while underscoring practicable solutions. It is in this regard that Professor Obinna Onwujekwe of the Departments of Health Administration & Management/Pharmacology & Therapeutics and the Health Policy Research Group, University of Nigeria delivered a lecture, titled “Impact of COVID-19 pandemic on healthcare delivery in Nigeria” at the 16th Annual Scientific Conference and All Fellows’ Congress of the Postgraduate Medical College Fellows’ Association that held at Eko Hotels & Suites, Victoria Island, Lagos in August 2022.


Figure 1: Cross-section of participants
Prof Obinna questioned the resilience of Nigeria’s health system for its failure to achieve the health-related MDGs and its slow pace toward the 2030 health-related SDGs targets. He showcased the indicators that reveal low-level access to quality healthcare services in Nigeria and minimal financial risk protection for health service users. He discussed further how the pandemic disrupted the delivery of essential health services like antenatal, post-partum, intrapartum care, family planning, vaccination services as well as treatment of non-communicable diseases, as health facilities were forced to shut down, some even shutting down unofficially. The impacts of this lack of resilience on morbidity and mortality cannot be overstated. For instance, UNICEF projected that an additional 950 Nigerian children might die every day from preventable causes over the next six months as the COVID-19 pandemic disrupted routine services. The figure below shows the steep downward dive in antenatal visits as the pandemic persisted:


Figure 2: Antenatal attendance fell drastically in 2020 compared to 2019 (MSDAT, 2020)
Click here to gain access to the full content of the lecture.
How to cite: Onwujekwe, O. (2022). Impact of COVID-19 pandemic on healthcare delivery in Nigeria.