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 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 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 become 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.

 

 
Acknowledgment

Health Policy Research Group, University of Nigeria (HPRG)


Bayero University, Kano, Nigeria (BUK)


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)


Nigeria Academy of Science (NAS)


Health Reform Foundation of Nigeria (HERFON)


Results 4 Development (R4D)


BUDGIT


International Centre for Investigative Reporting (ICIR)


Voice Against Corruption in Nigeria


Voice of Nigeria (VoN)

Is weak governance and lack of accountability fuelling the cholera epidemic in Southern Africa?

By Dorothy Chisare
 
Southern Africa is facing a severe and preventable cholera epidemic affecting 13 countries. Originating in Malawi’s Machinga District in March 2022, it rapidly spread to South Africa, Zimbabwe, Zambia, and Mozambique by February 2023. While cholera is a waterborne disease that can strike any community, the severity and persistence of the epidemic raises concerns about deeper systemic issues. This blog presents insights on often overlooked factors – weak governance and inadequate accountability structures, as critical contributors to the recurring cholera crisis in Southern Africa.
 
What should be known about the cholera crisis in the southern region of Africa
Cholera is an infectious disease that causes severe diarrhoea, which can lead to dehydration and even death if untreated. Claiming  four million lives globally each year, the disease is spread through eating food or drinking water contaminated by faeces from an infected person. While treatable with oral rehydration solutions and preventable with a two-dose vaccine, cholera persists, highlighting issues of inequity and social development gaps. Communities facing poor living conditions, such as insufficient access to clean water, sanitation, hygiene services, and lacking healthcare infrastructure for treatment or prevention, are particularly vulnerable to infection.
Zimbabwe, previously scarred by one of the world’s deadliest cholera outbreaks in 2008 and another in 2018, reported its first case on February 12, 2023, and now has over 18,000 suspected cases and 71 confirmed deaths as of January 2024.
South Africa, facing its first cholera outbreak since 2003, battled cholera cases linked to travel from Malawi, facilitated by porous borders. The Malawi outbreak, intensified by the impact of Tropical Cyclone Freddy in 2023 which brought heavy rains, floods, mudslides and strong winds, led to displacement and limited access to clean water, and has resulted to 59,000 cases of cholera as of 2024.
In Zambia, the current cholera epidemic is the largest in recent years, with 11,947 infections. The country’s first case is linked to the Mozambique outbreak confirmed in January 2023. To highlight the urgency of the situation, the World Health Organization (WHO) classified the epidemic as a multi-country emergency, indicating the highest level of concern for a health crisis.
 
Corruption, unaccountability, and weak governance damage public health infrastructures in Southern Africa
A just public health system functions free from corruption, ensuring accountability for all actions and prioritizing the fair distribution of health resources and services among users. However, corruption and unaccountability have significantly worsened in many African health sectors, impeding efforts to contain diseases like cholera. While the cholera epidemic is multifaceted, its roots lie in core issues of poor governance, leading to inadequate sanitation services and limited access to clean water. Legacy issues such as infrastructure neglect, mismanagement, underinvestment, and misallocation of funds culminate a perfect storm of challenges.
The outbreak in Zimbabwe stems from the decay of water and sanitation systems that have surpassed their intended lifespans. Irregular and inadequate water supply, especially in cities like Harare, exacerbates the problem. The local government, responsible for water services, provides only a quarter of the required 1200 megalitres of potable water daily. During water purification shortages, the supply is entirely cut off, and the council blames the national government for a lack of investment. This is due to opposition councils being obliged to navigate through the Zimbabwe National Water Authority (ZINWA), an autonomous government-owned entity managing the country’s water resources.  The political obstruction, unclear roles and responsibilities, and ultimately the blame game between local and national authorities, turn clean water into a political pawn and leave citizens to the mercy of inadequate services.
South Africa faces dysfunctional municipalities and inadequate wastewater treatment, resulting in untreated sewage release into water resources. These challenges stem from a lack of accountability, mounting debt, and inadequate infrastructure spending spanning over two decades. The sewage dumping frequently surpasses government quotas. This is often linked to the failure of national and provincial authorities to adequately monitor municipalities. Left to self-report pollution events, municipalities have grossly under-reported them. This raises the question of who is overseeing the overseers.
The crisis is intensified by the increase in underserved households in illegal peri-urban settlements without water connections, leading to poor hygiene practices, as seen in Malawi. Urban informal settlers pay at least double the going rate for water from ‘water kiosks,’ managed by private individuals and ad hoc committees. In these settings, there is a risk of administrative or petty corruption, wherein service providers may be influenced through bribes for preferential treatment.
Similarly, for over two decades, Zimbabwean councils bypass urban planning regulations in allocating residential land, leaving residents with inadequate infrastructure, and relying on contaminated water sources. This negligence echoes the 2003 cholera outbreak in South Africa, triggered by the withdrawal of public services in expanding impoverished informal townships and resulting in 140,000 infections. These failures in urban planning and water policies are deeply rooted in mismanagement, corruption, and a lack of accountability within council systems.
 
Cholera thrives where corruption and unaccountability persist
Corrupt practices and accountability gaps in the region severely impact public health systems, contributing to infrastructure fragmentation and triggering the cholera crisis. Recognizing accountability as a cornerstone of good governance is particularly crucial. Whether at the state, healthcare provider, or individual levels, accountability serves as a critical tool and ensures that necessary actions are taken for effective responses.
The urgent nature of health emergencies creates opportunities for corruption and unaccountable behaviour, as seen in South Africa’s unmonitored sewage dumping beyond safety limits and insufficient infrastructure spending. This not only contaminates water resources or jeopardizes quality but also establishes conditions favourable for cholera to spread through communities already burdened with systemic failures.
In Malawi, vulnerable communities are exploited to pay exorbitant rates for water from unregulated sources. The lack of oversight and accountability enables individuals or entities to profit from this basic need, exposing marginalized communities to compromised hygiene practices and fostering cholera’s spread.
Urban planning negligence influenced by corrupt practices such as bribery or favouritism within Zimbabwean councils leads to misallocation of residential land and inadequate infrastructure that is not planned for, exposing residents to contaminated water and insufficient sanitation provisions – well known factors for cholera. There is a concerning increase in corrupt allocation of residential stands and lack of transparency from councils, with some houses developed on land above sewer tanks, causing sewage pipes to burst inside several houses. The lack of accountability allows these hazardous conditions to persist without corrective measures.
Addressing these governance gaps is not merely a matter of cholera containment; it is a necessary step toward building resilient health systems capable of withstanding future pandemics. Only through comprehensive reforms and strengthened governance mechanisms can the region hope to break free from the trail of cholera and safeguard the well-being of its communities.
 
A pathway forward
Cholera is a complex interplay of political and economic factors demanding a blend of vertical and horizontal solutions. Governments need to shift to proactive measures by establishing strong governance and accountability mechanisms before, during, and after any potential outbreaks. A collaborative regional cholera preparedness plan within and between countries, ensures a unified and efficient response. Preparedness plans must embrace the whole of society, from communities, local actors, health systems and government ministries. For instance, responses to the epidemic must extend beyond the health sector, integrating efforts across education, economy, trade, and water sectors.
Assigning clear responsibilities and holding national health authorities accountable for infrastructure maintenance, particularly water treatment and sewage systems creates a proactive environment. This requires monitoring mechanisms like public consultation and appeals for improvements from horizontal actors such as civil society organisations and citizens. To strengthen outbreak response efforts, governments can establish inclusive multi-stakeholder task forces and committees. These groups would provide diverse expertise and resources, contributing to the improvement of public engagement and shared accountability.
During an outbreak, streamlined governance enables rapid response activation and optimal resource allocation. A way to approach this could be an undertaking of a series of visits and consultations with actors at the grassroots to understand the challenges and to revise the approaches accordingly. This consultative policymaking, coupled with media advocacy, can instil confidence in the authorities, attract provisions from the private sector or donors, and lead to significant improvements. Concurrently, strict accountability measures ensure transparent communication and timely actions, pivotal in halting the outbreak’s progression.
In the aftermath of the outbreaks, it is crucial for governance to evaluate the effectiveness of the response, guiding updates to preparedness plans. Holding individuals and institutions accountable for outcomes encourages necessary reforms, breaking the cycle of repeated outbreaks, preventing future epidemics, and mitigating potential pandemics.
 
About the author
Dorothy Chisare is a Research Officer specializing in African Health Systems within the Department of Health Policy at the London School of Economics and Political Sciences. She is a part of the LSE team working on the African Health Observatory – Platform on Health Systems and Policies (AHOP) hosted by the WHO Regional Office for Africa. She can be contacted at d.chisare@lse.ac.uk X/Twitter: @dorothyct9

Implications of fuel subsidy removal on achieving Universal Health Coverage in Nigeria

By Professor BSC Uzochukwu
 
Over the years, the government has provided financial support to maintain artificially low prices for petroleum products, particularly petrol and diesel. This practice is implemented to protect customers from the full impact of international oil price variations, which can increase fuel prices. So, since the 1970s, fuel subsidies are payments from the federal government in Nigeria that are used to cover gaps between market price and regulated price. Paying for fuel subsidies generally implies a trade-off between protecting consumers from rising fuel prices and the economic and fiscal implications of continuing to subsidize fuel.
Removing fuel subsidies in Nigeria refers to the government’s decision to end the policy of paying subsidies to oil marketers and importers of petrol. The decision to remove fuel subsidies has been motivated by the need to reduce government spending, promote economic growth, and curb corruption in the oil and gas sector. However, removing fuel subsidies has never been easy. At different times in 1978, 1993, 2003, 2012, 2016, and 2020, fuel subsidy removal attempts were met with stiff resistance from the public.
Surprisingly, on May 29, 2023, President Bola Tinubu at his inauguration as President of the Federal Republic of Nigeria announced the removal of fuel subsidy, leading to about 200% surge in the price of Premium Motor Spirit (PMS). It is expected that money saved from the removal of fuel subsidies will be used to invest in the health sector, which is why there is an emphasis on political will to achieve Universal Health Coverage (UHC).
However, a closer look at the removal of fuel subsidies and implications on the achievement of UHC shows impacts that are multifaceted and complex, with both positive and negative effects. While the positive effects like health insurance expansion, increased funding for health, etc., can only be guaranteed by transparency, accountability, and people-focused governance, the negative effects like increased household expenditure, increased vulnerability, etc., will likely wash away the existing gains towards achieving UHC.
 
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How to cite: Uzochukwu, B. (2023). Implications of fuel subsidy removal on achieving Universal Health Coverage in Nigeria. https://hprgunn.com/implications-of-fuel-subsidy-removal-on-achieving-universal-health-coverage-in-nigeria/

HPRG’s health sector 2023 roundup: Evidence, knowledge, politics

December 2023
 
The transition to a new government led by President Bola Tinubu with an agenda of ‘renewed hope’ was a significant moment in 2023. It is expected that the agenda drives growth and development in Nigeria, inclusive of the health sector. Health Policy Research Group (HPRG), University of Nigeria, has since the past two decades contributed to Nigeria’s health sector through the generation and implementation of research evidence to significantly inform health policies and practices.
In February 2023, HPRG published a synopsis of the health contents of the manifestos of the top contenders for the presidency. A common argument was that Nigeria’s health sector needed dramatic reforms and investments to attain Universal Health Coverage (UHC). The manifestos also agreed that health-related research would be pivotal to the UHC journey – a commitment that has been restated in the Nigeria’s Health Sector Renewal Plan (NHSRP).
Therefore, ‘this health sector 2023 roundup’ lays before the public, research evidence from some studies conducted by HPRG in Nigeria. It provides in brevity, distilled evidence for policy and practice interest in five areas that include (a) Evidence use by policymakers (b) urban health (c) sexual and reproductive health (d) inefficiencies in health programmes, and (e) corruption and accountability.
 
The use of evidence by health policymakers
Our work with the Results4Development (R4D) and the Gates Foundation explored the evidence-to-policymaking culture among health policymakers in Nigeria. Although we were more interested in health policymakers’ usage of evidence from mathematical and economic models, we also permitted conversations on other kinds of evidence from qualitative and non-modelling quantitative enquiries.
Generally, we found poor relationships and weak communication between researchers and policymakers, weak translation of evidence for easy understanding by policymakers, as well as poor attitude of policymakers toward seeking for, funding, and making use of research evidence. It leaves us worried that most of policymaking in the health sector may not be tied to evidence, which contrasts best practice. Nevertheless, we found that the Nigeria Centre for Disease Control and Prevention (NCDC) was an exception, especially as evidence was at the core of its engagements in containing COVID-19.
 
Urban health: Health and healthcare in urban slums
HPRG under the CHORUS Urban Health Consortium has an ongoing large piece of work in Nigerian urban slums, which currently accommodates about 50 percent of the urban population. We have seen first hand the amount of deprivation in slums and the dominance of healthcare by informal providers like Patent Medicine Vendors (PMVs), bone setters, Traditional Birth Attendants (TBAs), herbalists, etc. In some cases, we have found abandonment of health facilities by slum residents for reasons pertaining to the inefficiencies and cost of receiving care in the health facilities and/or the trust and confidence slum residents have over the years built in informal providers.
At the heart of our research is the consensus among formal and informal health stakeholders on the need to pull the informal health providers into the formal health system, while ensuring the effectiveness of catchment PHCs around the slums. We are already working with health authorities in Enugu State to implement this co-created intervention which evidence has shown will strengthen healthcare in slums. Interestingly, we recognise that the Federal Ministry of Health and Social Welfare (FMoHSW) is also thinking in this direction. Thus, we recommend that our intervention can be monitored for feasibility/adoptability, and where practicable, should be scaled.
 
Transformative approaches to sexual and reproductive health of adolescents
Over 50 million Nigerians are between 10 and 24 years, which is more than a quarter of Nigeria’s population. Yet this population does not receive the amount of healthcare attention it deserves. HPRG in recognising this gap, is working with the International Development Research Centre to pursue a transformative approach that will support adolescents to receive youth friendly sexual and reproductive health (SRH) services in their communities. We are doing this by working with adolescents and community stakeholders in Ebonyi State to further understand the prevalence of the consequences of risky sexual behaviours and identifying how health facilities can function to become attractive to adolescents in need of SRH services.
With our evidence, health workers are currently trained to provide youth friendly SRH services to adolescents. Yet this speaks to the human resource shortage in our PHCs, as none has been seen to have qualified social workers and psychologists. Laboratory professionals are also scarce, leaving us to worry about if PHCs are comprehensively positioned to deliver quality and comprehensive care under one roof.
 
Health programmatic inefficiencies
Nigeria’s health space considerably enjoys donor-funded programmes. While this is a useful resource to scale up the country’s underfunded health system, it presents the possibility of crisis and anti-development if not managed. Our work on Cross-Programmatic Efficiency Analysis (CPEA) done in partnership with the WHO office in Nigeria and the Strategic Purchasing Africa Resource Centre (SPARC), has exposed defects in the governance arrangement of health programmes, with knock-on effects on health financing, service delivery, procurement, and health information system.
Among several inefficiencies found in the study, fragmentation and duplications in health programmes, misalignment between health programmes and health priorities at subnational levels, lack of sustainable plans for health programmes when donors exit, poor budgeting and procurement practices, weak practices in communication and enforcement of policies, weak accountability mechanisms, and lack of coherence between evidence and policy actions/decision making mar health programmes and the overall health system. This study has developed solutions following root-cause analysis of the identified inefficiencies.
 
Corruption and unaccountability in the health sector
In the health sector, corruption has been rightly identified as the difference between life and death and a clear case of robbing the sick. An incredible amount of time in HPRG has been spent on studying system-wide and facility-centred corruption using a range of research approaches. We have identified absenteeism, informal payments, employment malfeasance, procurement and health financing irregularities as the most common forms of corruption in the health sector. The prevalence of these corruption concerns especially in primary health, frustrates healthcare for the poor and everyone at grassroots.
We used absenteeism as a case study in a recent publication to show how defective systems encourage and sustain corruption. In the NHSRP, social accountability involving civil societies, citizens, and other non-state actors was emphasized, which aligns with our evidence on grassroots-led anticorruption. In addition, the need to rejig and efficiently communicate health sector-specific regulations; improve workplace satisfaction and welfare; deal with information asymmetry in health facilities through public communication and responsive reporting channels; responsive health authorities to reports from service users and local monitors, and use of evidence to produce a sustainable anticorruption agenda for the health sector, lead our pack of proof-of-concept anticorruption evidence.
 
Where from here? Looking ahead to 2024
We extend commendation to the health sector leadership for the blueprint embodied by the NHSRP. We recognise the need for finance to drive the plan, which is why we commend states like Borno and Abia, among others, that have kept to the recommended 15 percent  benchmark of annual budget for the health sector in 2024. However, we urge that beyond budgeting should be timely release of funds and tracking of funds to guarantee value for money. At the same time, we express concerns about the under 5% to the health sector by the Federal Government, which we fear may mar the lofty ideals of the NHSRP. Notwithstanding, we are of the view that some progress can be made by ensuring that Nigerians get commensurate value for what has been budgeted and evidence from several studies of ours points to what the leadership can do, which include:

 

    • Deliberate and improved inclusion of evidence in policymaking and strengthening relationships between the academia and policymakers, while urging academia to distil evidence in non-technical bits for policymakers.

    • Aggressively prune ungoverned spaces in the informal health space by mapping and integrating informal health providers into the formal health system, while maximally improving on the efficiency of catchment PHCs within slums and other deprived locations.

    • Look toward maximising the potentials of PHCs for sexual and reproductive health of young people, and making sure that PHCs are rightly staffed and deliver comprehensive health services inclusive of psychosocial care under one roof.

    • Pay attention to current research on programmatic inefficiencies in the health system and use the results to squarely address identified lapses in vital areas of governance, service delivery, health financing, procurement, and health information system.

    • Pursue health-focused anticorruption agenda by addressing management- and facility-centred drivers through health sector specific regulations, curb excessive management discretions of facility managers and health workers, mainstream accountability monitors in facilities, funding, enhanced workplace satisfaction, and enhanced responsiveness of health authorities to accountability concerns from the grassroots.

We look forward to an improved health sector in 2024. On behalf of our team, we wish everyone happy holidays.
 
Professors Obinna Onwujekwe and BSC Uzochukwu
On behalf of the Health Policy Research Group, University of Nigeria
 
Contributors: Dr Prince Agwu, Ass Prof. Enyi Etiaba, Prof. Chinyere Mbachu
 
Contact: obinna.onwujekwe@unn.edu.ng Cc: bscuzochukwu@gmail.com
 
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How to cite: Health Policy Research Group (2023). HPRG’s health sector 2023 roundup: Evidence, knowledge, politics. https://hprgunn.com/hprgs-health-sector-2023-roundup-evidence-knowledge-politics/

HPRG researchers @3rd Nigeria Conference on Adolescent and Youth Health and Development

The 3rd Nigeria Conference on Adolescent and Youth Health and Development organized by the Society for Adolescent and Young People’s Health in Nigeria (SAYPHIN) took place at the Zone Conference Center Gbagada, Lagos, Nigeria. The conference started on the 16th of August and concluded on the 19th of August, 2023. The theme was EKO2023 – Achieving 2023 Targets: Driving Innovation for Adolescent and Youth Health.
The Health Policy Research Group, University of Nigeria contributed to the conversation by presenting six different outputs from its over 3 years of research on adolescents and sexual and reproductive health services in Ebonyi State, Nigeria.
 
Presentation 1
Unequal power relations between healthcare providers and young clients: barriers to accessing Sexual and Reproductive Health services in Ebony State, southeast Nigeria
Presented by Chibuike Agu
This was a cross-sectional study using qualitative data collection methods. Power dynamics between providers and young clients occurs on the basis of different social stratifiers. The provision of youth-friendly health services in the state is adversely influenced by the power imbalance between providers and young clients. Findings showed the various forms of expression of power by service providers towards young people seeking sexual and reproductive health care. Healthcare providers do not respect the SRH rights of young people. Thus, they often dictate the type of services young people should have. Sometimes, healthcare providers deny certain forms of SRH services. They also verbally abuse young people and report them to their parents or school authorities as punishment for accessing SRH care. The effect of the power imbalance is that young people feel humiliated, ashamed, or scared to visit health facilities for SRH services.
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How to cite: Agu C, Agu I, Mbachu C, Onwujekwe O (2023).  Unequal power relations between healthcare providers and young clients: barriers to accessing Sexual and Reproductive Health services in Ebony State, southeast Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 2
Effects of a School Health Intervention on Adolescents’ Knowledge of Sexual and Reproductive Health Issues in Ebonyi State, Southeast Nigeria
Presented by Chibuike Agu
This study evaluated the impact of a school-based health intervention on the knowledge of SRH among adolescents in six local government areas of Ebonyi State, Nigeria. The study applied the matching method of impact evaluation using ‘synthetic’ controls. Data were collected from 503 adolescent boys and girls aged 13–18, using a pretested structured, interviewer-administered questionnaire. Participants were selected through simple random sampling technique. A significantly higher proportion of respondents who participated in the intervention (94.16%) had good knowledge of SRH compared to those who did not participate in the intervention (85.77%), p = 0.002. Female adolescents were 3.2 times less likely to have good knowledge compared to male adolescents. Other predictors of good knowledge about SRH include living in rural areas and participating in the intervention. The school-based intervention improved the knowledge of SRH issues among adolescents. The adoption and scale-up of such interventions should ensure that there is equal participation of girls, junior students, working adolescents, and those who reside in urban areas.
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How to cite: Agu C, Mbachu C, Agu I, Ebigbiremolen G, Iloabachie U, Agu O, Onwujekwe O (2023). Effects of a School Health Intervention on Adolescents’ Knowledge of Sexual and Reproductive Health Issues in Ebonyi State, Southeast Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 3
Determinants of health service providers’ attitude towards equitability in sexual relationships in south-east Nigeria.
Presented by Ozioma Agu
Understanding the beliefs and attitudes of health service providers toward gender equitability in sexual relationships is significant in designing interventions for the effective delivery of gender-equitable youth-friendly sexual and reproductive health (SRH) services. This study examines health service providers’ attitudes toward young girls’ and young boys’ expectations in sexual relationships. This was a cross-sectional study carried out in six local government areas in Ebonyi State, Southeast Nigeria. The findings show that a good number of respondents 104(40.78%) agreed that young men and women should have sex before they become engaged to see whether they are suited for each other. Further analysis showed that health service providers whose health facilities are located in urban areas were more likely to have negative attitudes towards male expectations (t-value= -2.04) in sexual relationships by 18%. Health service providers’ attitudes toward equitability in sexual relationships underline the need to prioritize interventions that take into account the predictors of gender and societal norms regarding sexual relationships for the effective delivery of gender-equitable youth-friendly SRH services among young people.
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How to cite: Agu O, Mbachu C, Onwujekwe O (2023). Determinants of health service providers’ attitude towards equitability in sexual relationships in south-east Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 4
Attitude of healthcare providers towards providing youth-friendly health services to young people in Nigeria
Presented by Aloysius Odii
Healthcare providers of Youth Friendly Health Services (YFHS) are expected to have respect for young people and ensure privacy and confidentiality during contact with them. However, there are reports of poor treatment of young people who access sexual and reproductive health services. We have asked policymakers, young people, and health workers to describe the contexts and attitudes of providers toward adolescents seeking YFHS. The study was conducted in Ebonyi State because it has a high rate of teenage pregnancies and an unmet need for contraceptives among young people. A total of 20 In-depth Interviews (IDIs) and 10 focus Group Discussions (FGDs) were held with healthcare providers, policymakers and young people aged 15-24 years. Findings indicate that healthcare providers express both negative and positive attitudes when providing YFHS to young people. The attitude expressed is context-specific – depends on the disposition of the healthcare provider, the type of services sought, the age, marital status and gender. Healthcare providers’ attitude when dealing with young people is inconsistent and subject to change, depending on the context, which has implications for policy.
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How to cite: Odii A, Mbachu C, Onwujekwe O (2023). Attitude of healthcare providers towards providing youth-friendly health services to young people in Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 5
Multi-level predictors of young people’s attitude towards gender biases concerning rape, sexual and domestic violence in an intimate relationship among young people, Ebonyi State, Nigeria
Presented by Ifunanya Agu
Many victims of sexual violence, rape, stalking, and intimate partner violence were first victimized at an early age. To cultivate healthy relationships among young people, there is a need to address adverse gender norms and inequalities that facilitate rape and violence in intimate relationships. This study assessed multi-level factors that shape young people’s attitudes towards gender biases about rape, sexual violence, and violence in intimate relationships. Data were collected from 1,020 young people using an interviewer-administered questionnaire. Findings revealed that most (64%) young people agree that when a girl doesn’t physically fight back, you cannot really say it was rape. Many agreed that a girl who is raped is promiscuous or has a bad reputation (50%) and usually did something careless to put herself in that situation (45%). A good number 360(35%) of young people also agree that violence against a wife or girlfriend is a private matter and the girl/young woman 323(32%) should tolerate violence to keep her relationship or family together. Young girls showed a more positive attitude about sexual violence (b=0.10, CI=0.04-0.16), rape (b=0.13, CI=0.07-0.18) and domestic violence (b=0.09, CI= -0.03-0.15), in intimate relationships than young boys.
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How to cite: Agu I, Eze I, Agu C, Mbachu C, Onwujekwe O (2023). Multi-level predictors of young people’s attitude towards gender biases concerning rape, sexual and domestic violence in an intimate relationship among young people, Ebonyi State, Nigeria. Presented at EKO 2023 Conference from 16th to 19th August.
 
Presentation 6
How well did an intervention to improve adolescents’ attitudes towards contraception, abortion, and sexual violence work in southeast Nigeria?
Presented by Ifunanya Agu
This study identified the factors that explain the attitudes of adolescents to the use of condoms, contraception, abortion, and sexual violence in urban and rural communities, following the implementation of an intervention in Nigeria. The intervention led to an increased number of adolescents who discuss sex-related matters with someone (b=0.076; cl=-0.02-0.1). Age was a significant predictor of improved attitude to issue on SRH and with every year’s increase in age among adolescents, there was a 5% and 3% increase in a positive attitude towards condom use(b=0.047) and contraception(b=0.025). The FGDs showed that with participation in school- and community-based interventions, adolescents became bolder in their decision to use condoms when engaging in casual sexual intercourse and were more confident and assertive to say no to sexual harassment and forced sex. Adolescents reported that the attitudinal change in condom use decreased the occurrence of parents arresting male sexual partners for getting adolescent females pregnant in the communities. There is a need to sustain and scale up the intervention to cover the entire state and all parts of Nigeria with similar contexts for the universal promotion of positive attitudes towards contraceptive use, abortion, and sexual violence among diverse adolescents.
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How to cite: Agu I, Agu C, Eze I, Agu O, Okeke C, Eigbiremolen G, Mbachu C, Onwujekwe O (2023). How well did an intervention to improve adolescents’ attitudes towards contraception, abortion, and sexual violence work in southeast Nigeria? Presented at EKO 2023 Conference from 16th to 19th August.
 
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“Nobody should be treated as an animal”: The dark realities of patients in Nigerian psychiatric hospitals

In a small room with faded paint and worn-out chairs, a diverse group of people with mental health conditions gathered, their stories etched upon their faces. They seemed visibly relieved to have a respite from the chaotic and overcrowded environment of the psychiatric wards. This gathering marked the beginning of narratives coming from a place of pain and the thoughts of improving the quality of care for people with mental health conditions in psychiatric hospitals.
In four focus group discussions, 30 patients in two psychiatric hospitals in Nigeria discussed their perceptions and experiences of coercive practices within the hospitals. Strikingly, the expressions of abuse and hopelessness were the same across the hospitals. It seemed to be a parallel universe where people seeking healthcare got harmed by the very hospitals they had turned to for help.
Talking about mental health issues is no longer taboo these days because almost everyone has either experienced or knows someone who has experienced a common mental health problem like anxiety or depression. Society is, however, still uncomfortable talking about serious problems like schizophrenia or other psychotic disorders. Apart from the widespread stigma and discrimination against people with these conditions, they are subject to a wide range of human rights violations.  They could be subject to coercive practices like the use of chains, holding them hostage in cages, sheds, prayer camps, and severe beatings in traditional healing centers and other community settings.
When people read about the cruel treatment faced by individuals with mental health conditions in the media or reports from human rights organizations, they are often filled with shock and horror. It is easy to assume that the mistreatment and human rights violations happen mainly in traditional healing centers and prayer homes. We think to ourselves, if only these patients could afford proper psychiatric care in hospitals, they would be treated with the respect and dignity they deserve. Our study findings have shed light on the harsh reality that even when these people pay exorbitant fees for psychiatric care, they are still not spared from the horrors of human rights violations.
 
Experiences and ordeals narrated by those that are affected
The participants of the focus group discussions perceived coercion in mental health care to be a necessary evil in severe cases but recognized that it was anti-therapeutic to their recovery. They knew that coercive measures were an extension of the stigma they experienced due to their mental health condition and interestingly, also highlighted that it was a vicious cycle of abuse. Using coercive measures made them frustrated and agitated (as would any other person), and this reaction is met with even stiffer coercive measures evoking more frustration and agitation, thereby perpetuating a cycle of aggression and coercion.
The study participants narrated their experience of involuntary admission which revolved mainly around deception, maltreatment, and disdain. They were either deceived to go to the psychiatric hospital or tied in chains which often caused injuries for them. They were flogged for refusing to accept medications, some of which caused intolerable side effects. Mechanical restraint with chains was a common experience for reasons including refusing medications, preventing absconding, and in other cases, punitively. The use of chains was viewed by participants as dehumanizing and excruciatingly painful. They could not understand why mental health workers who were supposedly knowledgeable about mental health would cause them additional trauma by using inhumane devices such as chains.
Although the common assumption is that ‘their head is not correct’, meaning that they lack the ability to think reasonably, and these coercive measures were done for their good. The study participants unanimously reported that they had clear memories of these negative experiences and that it was traumatic for them and aggravated their conditions. In the words of one of the study participants, “Nobody is supposed to be treated as an animal. For you to be forced to have a chemical, to be injected, or to be chained is not normal.”
 
What must Nigeria do going forward to protect patients in psychiatric hospitals?
At the time the study was conducted, the existing mental health law was the obsolete colonial Lunacy Act of 1958 which was not only derogatory but did not recognize the rights of people with mental health conditions. This meant that being diagnosed with a mental health condition automatically stripped one of many fundamental human rights. Thankfully, Nigeria’s National Mental Health Act 2021 has been passed this year but this is just a first step among several steps the government and society need to take in protecting the rights of this vulnerable population.
Although frequently criticized, mechanical restraints are a typical feature in many psychiatric facilities around the world, yet they are usually soft flexible belts rather than chains. The hospitals had a limited supply of belts and occasionally made do with chains. With less than 300 psychiatrists for its enormous population of over 200 million, Nigeria has very low levels of human resources and infrastructure for mental health care which severely worsens this issue. The World Health Organization (WHO) recommends that setting up community mental health services can be an effective way to encourage people to seek help early and safeguard their human rights. This is daunting for a resource-limited country like Nigeria, however, integrating mental health care into primary care is an effective and feasible alternative. While this is being done, the existing primary care must be revitalized to be accessible and affordable to all.
Another crucial aspect that cannot be overlooked is the stigma surrounding mental health conditions which is a major barrier to early help-seeking for mental health conditions. Addressing this stigma is not solely the responsibility of governments; each one of us has a vital role to play in ending discrimination toward people with mental health conditions.
 
Author: Deborah Oyine Aluh
Deborah is a PhD student researching the contextual factors influencing the use of coercion in mental health services at the Lisbon Institute of Global Mental Health. She is also a staff of the Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria Nsukka. Nigeria
Affiliations: Lisbon Institute of Global Mental Health, Comprehensive Health Research Centre (CHRC), Nova Medical School, Nova University of Lisbon, Lisbon, Portugal
Department of Clinical Pharmacy and Pharmacy Management, University of Nigeria Nsukka. Nigeria
Twitter: @debbilici0uss
Reference Article The original article was published in International Journal of Mental Health Systems, and you can read it here.

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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