Ensuring that people everywhere have access to affordable, quality healthcare at the point of need, is an imperative that requires urgent action. Access is one of the three important components of Universal Health Coverage (UHC). The global health and development community marked UHC Day on December 12, bringing attention to the important role of quality and affordable healthcare for national development. The day was also used to encourage leaders to keep to the promises, pledges, and commitments they have made to achieve UHC in their respective countries. The most recent pledge is the high-level political declaration on Universal Health Coverage made at the 2019 United Nations General Assembly. World Health Organisation (WHO) Director General, Dr Tedros Adhanom Ghebreyesus referred to the declaration as “a landmark for global health and development”.
Even though these commitments are usually made by governments on behalf of their countries, turning them into action requires a collective effort from everyone. It requires every stakeholder — government, communities, the private sector, donor agencies and partners to roll up their sleeves and work as a team.
Melinda Gates, Co-Chair of the Bill & Melinda Gates Foundation seemed to agree when she said, “Now that the world has committed to health for all, it is time to get down to the hard work of turning those commitments into results”.
Working where it matters
In the last Multiple Indicator Cluster Survey (MICS) 2016–2017 of Lagos State, the infant mortality rate was 45 per 1,000 live births. This means one out of 22 young children in the state die before their first birthday. The survey estimated under-five mortality to be 50 per 1,000 live births meaning that one out of 20 children die before their fifth birthday.
To prevent some of these deaths, it becomes critical to ensure that children and newborns are vaccinated against childhood diseases. In Lagos, 63% of children aged 12–23 months received all recommended vaccinations by their first birthday according to the survey.
While 92% of women in the state received antenatal care from a skilled provider, only 44.7% of women had adequate antenatal visits (four or more antenatal visits) before delivery, and 79.5% of women age 15–49 used a health facility for their last delivery.
Partnership to improve health
To help improve maternal and child health in the state, the Japan International Cooperation Agency (JICA) keyed into plans by the Lagos State government to improve their health indices through improved access to life-saving interventions in urban and hard to reach riverine areas. The agency fully embedded into the state’s program to adequately understand its concerns, co-create solutions and follow up during implementation while ensuring the state was ready to take ownership and sustain their efforts. The Agency set up in the premises of the Lagos State Primary Healthcare Board (LSPHCB) located in Yaba, Ikeja. Director of Community Health Services at the Board, Dr Tunde Okelarin, said JICA keyed into the state’s health reform agenda, and conducted a needs assessment before reaching a decision with the state on areas for health intervention. These efforts started in 2014. JICA supported the state in two broad areas — health education and community outreaches. Dr Okelarin’s highlights three projects under his directorate that have been able to help extend quality care to Lagosians through JICA’s support.
The first joint effort to increase health indices in the state was the development of an appointment reminder & defaulter tracing platform which helped ensure that women in 32 implementing facilities remained consistent with their hospital visits before and after delivery. It also helped facility staff monitor the default rate on immunisation schedules. Service areas monitored by the platform included immunisation, family planning, antenatal and postnatal care.
Staff at the Simpson Primary Healthcare Centre (PHC), a busy health facility located in Ebute Metta, Lagos Mainland LGA said the platform is helping women remember medical appointments for themselves and their babies. It has also helped improve their relationship with their patients as they always thank them for their concern. Patients assume the messages come directly from the facility staff.
The major challenge they mentioned with the platform was inconsistent internet access which made it difficult to sign up patients to the reminder app. They haven’t been able to sign up anyone for over week, a staff member at the health facility said. Also, some of the cases they tag as defaulters were just women who customarily go to stay with their mothers-in-law during childbirth and return home afterwards.
The second project supported the LSPHCB, the state Traditional Medicine Board (TMB) and Association of TBAs to design tools for Traditional Birth Attendants (TBAs) to report their activities and refer cases that they were not able to handle. They also designed a community health information management system (CHIMS) reporting platform for the state. TBAs who were registered with the traditional medicine board received training on how to make use of the tools and now submit data from their practice to the LSPHCB and refer more cases to primary health centers (PHCs).
Training TBAs and providing them with tools to report and refer patients helped improve their practice, while delivering services to their patients. This, Dr Okelarin said has increased teamwork between the TBAs and the PHCs in the area of patient referral.
For the third project, focused on outreaches, Dr Okelarin said JICA provided logistics including boats, vehicles and other supplies for medical outreaches in hard-to-reach areas especially the fishing communities that live on water in the Iwaya waterside, close to Makoko. He said community outreaches are about reaching the unreached and even though JICA officially stopped supporting the project in December 2018, the state continued to sustain it throughout 2019. He brings out his phone, puts a quick call across to find out the schedule for the next outreach and was told it will take place the following Monday.
For Mrs Clara Owojuyigbe who heads the Directorate of Health Education at LSPHCB, JICA’s support especially in terms of funding helped in training and mentoring community resource persons. They use the local languages to sensitise their community members on child and maternal care, immunisation and mobilisation of community members during health outreaches.
Health on the waters
Mr Awhi Bernard Sewanu, whose first name means ‘gentle man’ in his native Egun language, wanted something different for himself when he left his home on the black waters of Iwaya waterside. He attended the University of Lagos and graduated in September 2000 from the Department of Computer Science and Management. But while in school, he had already made up his mind on what to do after graduation. He wanted to alleviate the suffering of his community from health issues especially pregnant women who he said, “died like chickens”.
He went back to his native Badagry, renowned for herbal medicine, took part in some training from Lagos College of Health Technology and the Economic Community of West African States (ECOWAS) that targeted herbal practitioners. By August 2006, he was set and proceeded to register his business with the TMB before starting his practice in a facility built in the same waterside community where he grew up. His one storey facility is located just opposite his late father’s house and he is now one out of the three TBAs providing care to the community.
“There are over 500 housing units on this water and in each household, you will find not less than 12 persons. That’s over 6000 people,” he said. The closest government health facilities are Aiyetoro PHC and Comprehensive Health Centre Iwaya, both accessible by a 15 minute boat ride depending on traffic in the waters or a 20 minute drive on land. This is where he established his practice to contribute his quota to improve health outcomes.
His practice has been smooth, though with its attendant challenges. But it improved significantly through JICA’s supported interventions over a year ago.
“We received orientation on how to improve our practice and stop harmful practices. We used to have this sheet that we submit to the state about our practice, but when JICA came, there was a lot of changes and the reporting was expanded,” Sewanu said, adding “they also encouraged us to maintain a good working relationship with the health facilities”.
From land to sea: Improving maternal and child health access in Iwaya waterside
He once referred a case of pre-eclampsia after examining a pregnant woman having decided that she needed more qualified care. He also referred a woman with rhesus (RhD) negative blood group to the Aiyetoro PHC to forestall complications during her childbirth.
For family planning, he used to prescribe some herbal remedies for his clients, but during the JICA supported training, he learned about modern contraceptives. Now, he counsels patients and refers them to health facilities where they receive further counselling before choosing a suitable contraception method.
In one of his recovery rooms, three women who recently gave birth are resting before they catch a canoe ride back to their respective homes later in the evening.
Some of his challenges include the inability of some of the women to pay their bills. “The men just get them pregnant and leave them to cater for everything. When they deliver or we render care, we ask them to bring what they have, and we write it down. They pay the rest gradually. Sometimes they don’t. There are many children in this community that I delivered and haven’t been paid for,” he said.
Transporting patients to health facilities when the water level is low is also a challenge. They resort to speed boats and use another facility where he has a good relationship with the doctor.
Despite these challenges, it makes him happy to contribute his skills to the largely uneducated community. He loves seeing healthy women and their babies after delivery and the respect from the community. These are the things that keep him going.
Scaling to 2030
One of the targets of the Sustainable Development Goal (SDG) three is achieving Universal Health Coverage by 2030. This means 11 more years are left to achieve this.. Eleven years may not be enough time to get all the work done, but it is enough time to make significant change. A lot of health interventions have piloted across different locations by government and different stakeholders such as JICA, but what is even more important is ensuring that these interventions are not just one-off activities but that they are carefully assessed to determine if and how they impact target communities, and what made them successful. After this, successful projects should be scaled up and replicated in other locations bearing in mind factors that made them work and challenges they faced. Finally, the sustainability of these interventions is critical. This is achieved by ensuring that local community ownership is front and centre of the intervention at inception and a sustained funding mechanisms are put in place.