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:
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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.
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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.
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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.
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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.
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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.
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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/
Video: How Nigerian Researchers Push for Better Healthcare for Urban Slums
https://www.youtube.com/watch?v=SyleT05LIjs
Fifty-three percent of Nigerians who live in urban areas reside in slums. This means that over half of Nigeria’s urban population are slum dwellers, and there are projections that this will increase further, as it has, since 2014. The big question is, what plans does Nigeria have for the health of its growing urban slum population?
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:
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Establishing a desk office at the Ministry of Health to coordinate the linkage of the informal health providers into an efficient formal health system.
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Through the desk office, identifying, registering, and training informal health providers to understand the scope of health services they can offer.
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Ensure that the desk office works with focal persons in the slums to monitor activities of informal providers to be consistent with safety.
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Providing a standard guide for referrals from the informal to the formal, including a simple referral form.
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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.
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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?
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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.
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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.
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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.
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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.
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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.
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:
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Partners pursuing financing of health programmes that do not align with the health priorities of the states.
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Decisions of health programmes to execute by partners at the federal level with almost no input from the states.
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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.
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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.
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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”.
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“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.
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Health programmes may not be informed by evidence, as gaps between generated data and decision-making persist.
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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:
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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.
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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.
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Aggregate insights from facilities and local government health authorities before drawing up budgets for the health sector in states.
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Advocate for early passage of annual budgets to guide annual operational plans for the health sector.
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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.
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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.
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Engage and sensitize the Civil Society Groups to participate in monitoring the activities of partners and demanding accountability.
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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.
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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.
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Establish a Logistic Management and Coordination Unit (LMCU) to address fragmented procurement system across supply chain
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Establish a Health Workforce registry to serve as a database to enable acute and timely evidence-based health workforce information and management.
Conclusion
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.
Acknowledgement
(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.
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Using Public Relations for Research Impact
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Understanding research methods
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Mass Communication for Health
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Research in journalism for policymaking
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Reporting for corruption in the health sector
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The act and practice of journalistic writing
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Getting research into policy and practice
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Introducing infographics
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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.
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.
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.
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 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.
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.
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 Agwu, Tochukwu 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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