A review of Nigeria’s health systems response to COVID-19: lessons for strengthening the health systems for improved service delivery

By: Chinyere Okeke, Chioma Onyedinma, Benjamin Uzochukwu, Obinna Onwujekwe

The COVID-19 pandemic has challenged the health systems of almost all the countries in the world. A strong health system is characterized by its ability to respond to emergencies while remaining resilient in delivering high-quality routine essential services promptly. This is not the case in most low- and middle-income countries, of which Nigeria is one of them, making them very vulnerable to COVID-19 pandemic. Prior to the pandemic, health systems had not received adequate attention. However, with this pandemic, the country’s leadership has made efforts to respond to reduce its spread. These efforts are worth documenting, as they will inform policymakers and other stakeholders in Nigeria to reflect on the ways to adapt and scale up the positive measures identified.

A scoping review of published and grey literature including journals, news/ media documents and official documents that were published from 1st December 2019 to 31st December 2020 was conducted. The reviewers read and extracted relevant data using FACTIVA in a uniform data extraction template. The template was structured in themes using the health system building blocks and service delivery subtheme that captured technical support and interventions targeted at health workers was used for the manual content analysis.

The identified interventions and strategies that have affected health service delivery were mostly technical support and interventions targeted at health workers. These included training of about 17,000 health workers, supervising and engaging more workers, upgrading laboratories and building new ones to improve screening and diagnosis, motivation of health workforce with incentives (financial and non-financial). There was influx of philanthropic gestures and improved data and information systems, supply of medicines, medical products and non-pharmaceutical preventive materials through local production. Overall, the presence of political will and government’s efforts in health systems response to COVID-19 facilitated these interventions.

The interventions of state and non-state actors have to some extent, strengthened the health systems for improved service delivery. However, more needs to be done towards sustaining these gains and towards making the health system strong and resilient to absorb the unprecedented shocks.

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A review of corruption and accountability issues in Nigeria’s COVID-19 response: Implications for health systems governance

By: Prince Agwu, Nma Ekenna, Uche Obi, Tochukwu Orjiakor, Aloysius Odii, Enyi Etiaba, Benjamin Uzochukwu, Obinna Onwujekwe

Flexible and urgent health spending during public health emergencies distorts procurement processes and potentially encourages corrupt practices in health systems. This can erode public confidence, resulting to poor compliance to health safety measures during public health crisis. Thus, anticorruption in health, and in pandemic responses is key. COVID-19 related articles (reports from various government bodies and CSOs) on resource mobilization, appropriation, public perceptions towards accountability and anticorruption, were reviewed. Findings were organised under three themes: i) mobilized resources for COVID-19, ii) evidence of corruption or anticorruption in spending them and iii) implications for health systems governance.

About N36.3b ($US93.5m) was raised through 295 donations to federal and state governments, to combat the virus. Additionally, Nigeria appropriated N10b ($27m) to epi-centres and the disease control agency in the country. Whilst information on available resources are freely available, that on expenditure has been opaque, which has generated heated concerns. Lack of evidence of optimal utilization of resources under the frames of accountability and anticorruption has aroused public concerns and trust in the actual existence of a pandemic. Diminished health worker motivation connects with industrial actions.

CSOs need to be actively engaged in driving government to show accountability, through partnering with multilateral organisations and donors to increase pressure on government to be accountable with resources mapped out for pandemic responses. Health workforce groups and Associations also need to actively engage government and demand accountability. Finally, conversations on corruption and accountability issues that affect health systems should be encouraged.

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Progress in the face of cuts: a qualitative Nigerian case study of maintaining progress towards universal health coverage after losing donor assistance

By: Uche Shalom Obi,  Osondu Ogbuoji,  Wenhui Mao,  Minahil Shahid,  Obinna Onwujekwe, Gavin Yamey

In the coming years, about a dozen middle-income countries are excepted to transition out of development assistance for health (DAH) based on their economic growth. This anticipated loss of external funds at a time when there is a need for accelerated progress towards universal health coverage (UHC) is a source of concern. Evaluating country readiness for transition towards country ownership of health programmes is a crucial step in making progress towards UHC. We used in-depth interviews to explore: (1) the preparedness of the Nigerian health system to transition out of DAH, (2) transition policies and strategies that are in place in Nigeria, (3) the road map for the implementation of these policies and (4) challenges and recommendations for making progress on such policies.

We applied Vogus and Graff’s expanded transition readiness framework within the Nigerian context to synthesize preparedness plans, gaps, challenges and stakeholders’ recommendations for sustaining the gains of donor-funded programmes and reaching UHC. Some steps have been taken to integrate and institutionalize service delivery processes toward sustainable immunization and responsive primary healthcare in line with UHC. There are ongoing discussions on integrating human immunodeficiency virus (HIV) services with other services and the possibility of covering HIV services under the National Health Insurance Scheme (NHIS). We identified more transition preparedness plans within immunization programme compared with HIV programme. However, we identified gaps in all the nine components of the framework that must be filled to be able to sustain gains and make significant progress towards country ownership and UHC. Nigeria needs to focus on building the overall health system by identifying systematic gaps instead of continuing to invest in parallel programmes. Programmes need to be consolidated within the overall health system, health financing priorities and policies. A comprehensive and functional structure will provide continuity even in the event of decreasing external funds or donor exits.

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Policy Dialogue between African Health Observatory and stakeholders in Nigeria’s Health Financing

Central to the achievement of Universal Health Coverage (UHC) is to improve service coverage, financial access, and financial protection for health service users. Concerned about Nigeria’s slow pace toward UHC, the Nigerian National Centre (NC) of the African Health Observatory Platform (AHOP) organized a policy dialogue (PD) that brought together key members of the National Healthcare Financing (HCF) and equity Technical Working Group (TWG) (HCF-TWG) and FMOH to discuss the current policy issues on health financing (interest on health financing governance and domestic resource mobilization (DRM)), with a focus on UHC. The dialogue was to brainstorm about the future directions in terms of strategic activities or actions that will be taken to make a change in the context of strengthening the Nigerian health system and achieving UHC. The dialogue explored how to specifically enhance efforts towards achieving UHC in Nigeria through domestic funding lenses and improved health financing governance.

The participant for the dialogue comprised 17 people drawn from the NC (HPRG) and the National HCF-TWG: FMoH (5), International/Development partners (4), National Health Insurance Scheme (NHIS) (2), NC (5), and Academia (1).

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Photo representation of participants


Health Policy Research Group, University of Nigeria stretches research into urban health

With an estimated urban population growth rate of 4.3%, Nigeria’s urban population is expected to double by 2050.[1] The notable consequence of the rapid urbanisation that is taking place in the country is the expansion and increase in numbers of informal settlements within and around large cities. These informal settlements, referred to as urban slums, are characterised by poor housing, lack of basic amenities and poor access to urban resources, including health, nutrition and education.

Rapid urbanisation and the growth of unplanned urban slums have necessitated global attention towards ensuring social inclusion and equitable access to urban resources, particularly for vulnerable groups. A critical area of intense concern in Nigeria, and other low resource settings, is access to comprehensive and quality health services in urban slums. Urban slums have a relatively higher burden of communicable disease, and this can be attributed to overcrowding, poor ventilation, low economic status, and low literacy level. Moreover, financial access to quality healthcare for urban slum dwellers is further limited due to lack of social health insurance and heavy reliance on out-of-pocket payments. Hence, ensuring access to quality and affordable healthcare for this group of people should be prioritised.

Informal healthcare providers (IHPs) are a crucial source of healthcare in urban slums, essentially filling the gap caused by the absence of formal healthcare providers (FHPs). Informal healthcare providers include patent medicine vendors (PMVs), village health workers, traditional birth attendants (TBA), traditional healers and itinerant (travelling) drugs vendors, among others. These categories of IHPs are ubiquitous, they provide affordable healthcare to the urban poor, and they enjoy the patronage and confidence of slum dwellers. However, the health services they can provide to clients are limited to their skills and capacities, and there are legitimate concerns about the quality of health care that is provided by IHPs [250 words left]

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COVID-19 containment and coordination strategies in Nigeria and lessons from four other African countries

COVID-19 pandemic will forever remain a major disruption of global activities and lifestyles. However, conversations have rapidly shifted from the dreadedness of the pandemic to the actions and inactions of systems in combating its spread and ameliorating its devastating effects. The pandemic appears to have affected different locations differently, of which there are clinical, public health, economic and social explanations to such dynamics. While it looks as though Africa has one of the least occurrences of fatalities arising from COVID-19, it is never in doubt that the continent has had its fair share of the effects of the pandemic, and some have indeed been extreme. Therefore, to encourage better health emergency responses, it is needful to reflect. The continent needs to look inward to understand its strengths, weaknesses, limitations, and prospects, for the purpose of improving its public health space and better positioned to challenge health emergencies, going forward.

Inspired by the African Health Observatory – Platform on Health Systems and Policies (AHOP), COVID-19 containment and coordination strategies across five African countries, including Nigeria, were evaluated. As quoted from an AHOP document: “[…] Threats of new variants loom and low vaccination coverage raises questions on the future of the response to COVID-19. Prevention remains the key strategy in most sub-Saharan countries. Below, five National Centres (NCs) from the African Health Observatory Platform on Health Systems and Policies (AHOP), based in Ethiopia, Kenya, Nigeria, Rwanda and Senegal, reflect on lessons to be learnt from their coordination and containment responses in the initial phases. They construct timelines to highlight the policies and challenges associated with introducing a range of public health containment measures and discuss the extent to which these measures continue to be valuable given the ever-changing nature of the pandemic.”

To read the report on COVID-19 coordination strategies across the five African countries, kindly click here to download

And to read the report on COVID-19 containment strategies across the five African countries as well, kindly click here to download

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Understanding the complementary relationships and roles of Integrated African Health Observatory (iAHO) and African Health Observatory Platform (AHOP)

The Ministerial Conference on Research for Health in the African Region, held in Algiers from 23 to 26 June 2008, adopted the Algiers Declaration renewing the commitment of Member States to strengthen national health research, information systems and knowledge management systems to improve health in the African Region. The Algiers Declaration offers a framework to narrow the knowledge gap and thereby improve knowledge generation and the use of knowledge to inform policies, strategies, and actions.

The World Health Organization (WHO) started work on health observatories in the African region in 2010 when it established the African Health Observatory (AHO).1 This followed the 2009 recommendation of the Regional Committee for Africa (AFR/RC59/5).2 In November 2012, during the sixty-second session of the Regional Committee for Africa (RC62) held in Luanda, health ministers of the African Region agreed to establish national health observatories in their respective countries and adopted the resolution entitled “The African Health Observatory: an opportunity to strengthen health information systems through national health observatories.” With the support of the AHO, several countries are developing their national health observatories (NHOs) to strengthen their national health information systems and promote the use of data for better action.

AHO is the regional observatory based and managed by WHO/AFRO. It brings together all the key information (Data – Analytics – Knowledge) on the WHO African region and on the 47 member states. It is a one-stop shop for standardized and validated information at both national and international levels with clear information on data sources. The NHOs are national declinations of the AHO and strengthen the national health information system. They thus contribute to reducing fragmentation and making key information available in a one-stop shop at national and sub-national levels. The institutional anchorage varies from country to country, but in the region, there are three groups: (i) integrated as a structure in the Information System/Planning Directorate of the Ministry of Health, (ii) integrated as a unit attached to the General Secretariat or the Minister’s Office, or (iii) integrated as a fully-fledged structure attached to the Prime Ministry.

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AHOP Writing Style

Researchers working across National Centres of AHOP are to write in a particular style that is consistent with the African Health Observatory Platform (AHOP) and World Health Organisation (WHO). The AHOP’s abridged version of the full WHO editorial style manual, which draws on the abridged style guides used by WHO Africa Regional Office (AFRO) and the European Observatory on Health Systems & Policies can be downloaded below. The style guide aims to ensure correctness, consistency, impartiality, and credibility across AHOP outputs, both electronic and print, and offers guidance on avoiding the most common stylistic errors. Please, note that this guide is a living document and will be adapted as further decisions are made on AHOP style across the various outputs. It is intended to be used alongside the full WHO Style Guide. Both Guides are expected to guide persons who write across the AHOP project.

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Click here to download the broader WHO Writing Style Guide



Scientists from the Health Policy Research Group, University of Nigeria rank highly on the globe – AD Scientific Index 2021

In a recent ranking of scientists on the globe, scholars from the Health Policy Research Group took top spots. Professors Obinna Onwujekwe and Benjamin Uzochukwu who are both academics at the University of Nigeria and founders of the renowned Health Policy Research Group clinched 1st and 3rd positions respectively, as top scientists in the University of Nigeria with over 3000 academic staff. The ranking is done by AD Scientific Index.
Prof Obinna Onwujekwe
At country-level, Obinna Onwujekwe ranks 3rd, 171 in the African region, and 39940 on the globe. Whereas, Benjamin Uzochukwu popularly known as BSC ranks 8th in Nigeria, 271 in the African region, and 54284 on the globe. Obinna and Benjamin are each with over 300 research items on ResearchGate, and combined citations of almost 34,000 as calculated by Google Scholar.
Prof Benjamin Uzochukwu
Interestingly, AD Scientific Index has moved beyond citations’ counts to focusing on the actual impact of scientific outputs which can be sourced by designing algorithms around i10 index, h-index and citation scores. You can read more on AD Scientific Index here. It is, therefore, right to say that the duo are impactful scientists, putting the University of Nigeria and the African Scientific Community on the map of global excellence.
Overall, 10 scientists from the University of Nigeria are within the top-100 in the country, and 6 made it to Africa’s top-1000. Their names include Chinua Achebe, Peter Akah, Nnabuk Okon, Joe Mbagwu, James Ogbonna, Martin Eze, Fabian Ezema, and Anthony Attama. You can find more here.
Interacting with Professors Obinna and Benjamin, it is evident that they do not intend to retire from their craft anytime soon. They have extended their wealth of knowledge to younger academics and researchers across the globe, and are indeed worthy models and mentors in the academic community. The Health Policy Research Group which is their brainchild is a no-brainer when it comes to research excellence. It is today, powered by the proteges of the Professors, some of whom are now Professors. Indeed, hearty congratulations to Professors Obinna and Benjamin on this deserving feat.

COVID-19 and crowding out of essential healthcare services: HPRG presents @ 37th Scientific Conference of the Association of Public Health Physicians of Nigeria

The Association of Public Health Physicians of Nigeria (APHPN) held its annual scientific conference at Abuja, Nigeria. The conference featured over 55 selected abstracts from a large pool of submissions. HPRG, under the African Health Observatory Platform (AHOP) presented a synthesis of findings from secondary sources on “crowding out of essential healthcare services amidst COVID-19”. The presentation was made by some members from the AHOP Nigeria Centre. They include Chinyere Okeke, Uche Ezenwaka, Chinelo Obi, Benjamin Uzochukwu, and Obinna Onwujekwe.
The well-researched presentation highlighted the huge burden of COVID-19 on the Nigerian health system, which overwhelmed health resources, with severe impacts on essential healthcare services (EHS). There were mentions of preventable health complications and mortalities that resulted from a somewhat overstretch of health resources. The scholars argued the need for a study of this kind to document the “why” of crowding out of healthcare services during disease outbreaks, and the responses that are expected. The implication of this study to the strengthening of health systems building blocks such as service delivery and governance cannot be overstated.


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Acknowledgement: African Health Observatory Platform (AHOP)