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 AgwuTochukwu 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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