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

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

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

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

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

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