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

The African Health Observatory – Platform on Health Systems and Policies (AHOP) is seeking to commission a blog series on climate change and health in Africa to supplement an upcoming policy brief on the subject.
Policy Brief Summary
AHOP is set to publish a policy brief on existing policies, frameworks, and strategies in Africa that mitigate the negative impacts of climate change on health systems. The policy brief summarises evidence on how climate change is affecting African health systems and assesses the strategies currently in place to mitigate these negative impacts. The brief synthesises evidence from peer-reviewed journal articles, grey literature (including Ministry of Health reports and strategic documentation from international organisations) and regional climate change and health experts. It aims to support decision-makers and institutions in developing and implementing policies that promote public health and protect health systems from the adverse effects of climate change.
Blog Concept and Requirements
The blog should respond to three questions:
• How is climate change affecting population health and health systems in the target country?
• What are the existing policies and strategies in place for reducing the negative impacts of climate change on health systems at a national and/or sub-national level in Africa?
• What lessons can be learned from existing policies about how to design and implement climate and health policies in the African region?
We welcome submissions on national or sub-national (e.g. state, provincial) policies, frameworks and strategies from countries within the WHO African region. The link between climate change and health systems should be clearly identified in the submission.
By providing accessible, concise analyses on climate change and health policies in several African countries, the blog series will help AHOP to further discussion on the topic amongst a wide range of readers including non-specialists, students, researchers, and policymakers.


Click to download the full call here

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

The Medical and Dental Council of Nigeria has reported that 58,000 of 130,000 licensed medical doctors in Nigeria renewed their licenses in 2023. This may be unsurprising, as studies reported that before the COVID-19 pandemic, more than 80 percent of Nigerian medical doctors and above 50 percent of Nigerian nurses sought work abroad. At the end of 2023, 26,715 Nigerians were in the United Kingdom on health worker-related Visas – a 215 percent increase from 2022. It is also reported that over 110,000 Nigerian nurses are currently practising in the United States of America. This flight of health personnel from Nigeria to several parts of the world is troubling, given the importance of the health workforce to the health of every nation, and to the achievement of Universal Health Coverage, which Nigeria currently lags at under 40 percent.
Recognizing this, The African Health Observatory Platform (AHOP) hosted in Nigeria by the Health Policy Research Group (HPRG), University of Nigeria, with support from the World Health Organisation (WHO) organised a policy dialogue on brain drain of Nigeria’s health workforce, and Africa at large.
This is coming just after the Federal Ministry of Health and Social Welfare has revealed that a National Policy on Health Workers’ Migration has been developed to address the issue of health workers migration in the country. The Deputy Director, Health System Department of Health Planning Research and Statistics, Dr Nwakaego Chukwuodinaka stated this at the policy dialogue on Thursday, 25th April 2024.
Chukwuodinaka said the Ministry has submitted a memo to the Federal Executive Council recently. “What we are requesting is to have a managed migration, and to be able to implement that policy, we need a nod from the FEC. One of the key component of the Health Workforce Policy is to incentivise those that are on ground working, especially those in the rural and underserved areas. Also to sign a pact with the destination countries. The pact is for us to equally gain from them poaching our health workers in the area of bringing technology for us, infrastructure and exchange programmes to help those we are training in-country.”
Read the full news here. You can also find it here.

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.
Click to download full presentation
How to cite: Uzochukwu, B. (2023). 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: Cc:
Click to download article
How to cite: Health Policy Research Group (2023). HPRG’s health sector 2023 roundup: Evidence, knowledge, politics.

“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)
Photo Gallery

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)
Photo Gallery


Evidence from Cross Programmatic Efficiency Analysis of Health Programmes (CPEA) reveals that inefficiencies marr investments in Nigeria’s health sector

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


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


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

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

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

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


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