CPED Policy Brief Series 2015, No. 5












                                        Policy Brief by


   Centre for Population and Environmental Development, CPED                                              













This Policy Brief is supported by Governance for Equity in Health Systems Program of the International Development and Research (IDRC) and the West African Health Organisation (WAHO) as well as the Think Tank Initiative also of IDRC.


(C) Centre for Population and Environmental Development (CPED)

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     P.O. Box 10085, Ugbowo Post Office,

     Benin City, Nigeria.

     Tel: +234-8080472801

     E-mail: enquiries@cpedng.org

     Website: www.cpedng.org




All rights reserved. This Policy Brief is copyright and so no part of it may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, electrostatic, magnetic tape, photocopying, recording or otherwise without the express written permission of the publisher, and author who is the copyright owner.





First produced in 2015




Series Editor:


Professor Andrew G. Onokerhoraye

Executive Director, CPED, Benin City















This policy brief is the sixth in the series of communication to policy and decision makers on the on-going research project of the Centre for Population and Environmental Development (CPED) titled “Strengthening the health system in Nigeria through improved equitable access to Primary Health Care (PHC): The Case of Delta State, Niger Delta region” funded by IDRC and WAHO.


The policy brief series is designed to draw attention to key findings and their policy implications as the project is being executed. This edition presents a summary of the stakeholders’ recommendations on the improvement of primary health care during interaction with them in focus group discussions and key informant interviews.


We are particularly grateful to IDRC and WAHO as well as the Think Tank Initiative for the support to CPED which has enabled the Centre to carry out the study and the publication of this policy paper. We also appreciate the corporation of the Delta State Government and other stakeholders within and outside Delta State in collaborating with CPED in the execution of the on-going research project so far.



Andrew G. Onokerhoraye























Summary of Stakeholders’ Recommendations on Strategies to Improve Primary Health Care in Delta State, Nigeria



This policy brief is based on the findings of an on-going research on “Strengthening the health system in Nigeria through improved equitable access to Primary Health Care (PHC): The Case of Delta State, Niger Delta region. The project is funded by Canada’s International Development Research Centre (IDRC), Ottawa and the West African Health Organization (WAHO). The general objective of the research programme is to contribute to a body of evidence on the strengthening of the health system in Nigeria that can influence the development and modification and implementation of policies on equitable access to health care with specific focus on the primary health care component. As a participatory research programme, this study collated the recommendations of the respondents and participants in focus group discussions so as to provide the framework for the articulation of policies and strategies on the improvement of PHC services in Delta State in particular and Nigeria in general.  Most of the suggestions for improving services can be classified into five categories as follows:

Equitable geographical location of PHCs

Respondents and participants in the study hold the view that PHCs should be equitably located so that their activities can cover remote rural areas, especially in the wetland areas where transportation constraints prevent people in such areas from using PHCs located far away from them. It was strongly recommended that in situations where establishing new PHCs are not immediately possible, existing PHCs nearer to such localities should be empowered with more staff and facilities to extend their activities to such remote and largely inaccessible localities.

Provision of adequate drugs

The lack of appropriate drugs available at PHC facilities was a problem in two ways: one, it may mean that the appropriate treatment is not possible, and, two, it obliges the patient to seek the medication in a local chemist shop, where the drugs may be expensive. Respondents wanted to be able to obtain the medicines directly from the medical staff even if it meant some payment. They would like PHC facilities to stock the drugs needed for treatment rather than to write a prescription to be filled in a pharmacy. The availability of medicines was one reason cited for patronizing a particular facility, just as the lack of drugs was mentioned as a reason for avoiding a facility. Consequently it was recommended that more drugs should be provided in the PHCs. Drugs should be made available and affordable in the PHCs, so that they could receive all their prescriptions at one place. Lastly, the national drugs policies and essential drugs list need to be reviewed, making them more responsive to PHC patients' needs and improving availability.

Improvements in PHC workforce

The lack of adequate staff for PHCs was viewed as unacceptable if PHC services are to reach the poor in rural communities. It is in this context that the following recommendations were made for implementation:

·         Efforts must be undertaken in Delta State in particular and other parts of Nigeria in general to reduce the impact of the health worker shortage on its health system by giving considerable attention to the recruitment of staff for PHCs, especially those located in rural areas;

·         Presently low health staff production, particularly of nurses, has to be substantially accelerated to catch up with growing demands and attrition;

·         Improve the retention and distribution of the health workforce in rural PHCs by improving working conditions and financial (and non-financial) incentives, such as free days, study or maternity leave and better social dialogue;

·         Improve the performance and productivity of existing staff by increasing opportunities for life-long training and improving career development prospects;

·         Develop and strengthen rural health service coverage by equipping the semi-skilled health workforce to maintain rural health centres;

·         The government needs to invest not only in its health workers but also in its facilities, by ensuring regular medical supplies, upgrading facilities and improving working conditions in rural and poorer areas;

·         Provision of housing for health workers in under-served areas;

·         In-service training and career development opportunities for health workers;

·         Formulation of hardship pay policy for health workers in rural/underserved areas;

·         Articulation of a programme on the utilization of unemployed and retired health workers through expanded hiring and contracting;

·         Increased use of new cadre of health workers;

·         Development of an overtime policy for their health-care workers. This would supplement the professional nurses’ salaries and assist with filling the gap in available human resources.

·         Some health workers were perceived as rude, unfriendly, unapproachable or impatient, or did not respect patients. They should be trained on how to handle patients because the attitude of health staff towards patients complicates their health challenges.


Improvements in the availability of doctors in PHCs

One of the major constraints to visiting PHCs, especially public ones in the study areas is the fact that the services of doctors are not readily available. Respondents and participants in the study areas recommend strongly that efforts should be made to ensure that the services of medical doctors are available in PHCs as regularly as possible.

Improvements in Maternal and child health care

Despite the emphasis on maternal and child health in the activities of the PHCs, the rate of utilisation of those services remains low, especially in remote rural communities. Improving community awareness and perception on skilled providers and their care by targeting women who prefer non-skilled providers and those who do not have any awareness is very important. The vast proportion of the respondents and participants in the surveys appreciated the importance of using maternal and child health services provided by skilled personnel in PHCs. However, they made recommendations that could enhance the use of skilled health facilities as outlined below:

·         There is need for increased attention to safe motherhood education using the available communication networks in the rural communities;

·         There is urgent need for informational campaigns in the remote rural communities so as to improve the awareness and perceptions of women with regard to the importance of skilled maternal and child health services provided in PHCs;

·         Ensuring the improved performance of basic essential obstetric care facilities in PHCs  is also very critical, especially for improving the rate of skilled attendance at birth;

·         Increasing availability and accessibility of maternal health centres to rural women in underserved communities, especially in the wetland areas of the state;

·         There should be vigorous campaigns against social norms that are harmful to women's health;

·         Efforts should be made to increase women’s socio-economic status in society, especially in rural communities;

·         Campaigns with respect to the utilisation of maternal and child health services should specifically target men so that they can support their wives in maternal and child health care provided in PHCs;

·         Improve the access of rural communities to PHCs through improved roads and other means of transportation;

·         Conscious efforts must be made to ensure the provision of PHCs in localities that are at present too far from the existing ones.




Community participation must be enhanced if the PHC system must be effective in the delivery of services. Commitments to meet this challenge continually demand policy makers and professionals to hold serious dialogues with those for whom they provide service and care. To date this dialogue has often been delayed in many parts of Nigeria by several factors. Firstly, there is the existence of attitudes of professionals who tend to disregard opinions and views of those outside the profession. Secondly, there is the historic view that health interventions can only be verified by outcome measures. The Delta State PHC research project has provided for the integration of community participation. This is done by involving all stakeholders, particularly rural health care seekers and end-users of PHC services, in the implementation of the project through: gender-balanced membership of the project management committee, on the one hand, and attendance and participation at all briefing and information-sharing meetings at which felt needs are articulated and prioritized, on the other. This will enable them to assume responsibility for their health and welfare, as well as building their capacities to contribute to policy on health through involvement in planning, implementing, monitoring, evaluating and above all, ensuring the sustainability of health interventions. This suggests that policy makers should look seriously into the recommendations and suggestions of stakeholders and users in the planning and provision of primary health care in different parts of the country.