ESSENTIAL HEALTH SERVICES: NIGERIA

The research and analysis for this study were conducted by research partners at the University of Ibadan and the Makerere University School of Public Health.

Introduction and Key Takeaways

Around the world, public health emergencies such as the COVID-19 pandemic can profoundly disrupt the delivery of routine or essential health services including routine immunization, antenatal care, and chronic care.¹ For instance, public health emergencies can reduce the supply of those services by redirecting health care workers and resources toward the emergency response. Among other reasons, clients’ fear of infection in public places during a pandemic, especially in health care facilities, can also reduce demand for essential health services and prevent people from receiving the care they need.²

Why Did We Study Nigeria?

We selected Nigeria for this study, alongside three other countries in sub-Saharan Africa (Democratic Republic of the Congo, Senegal, and Uganda), because together they demonstrate a wide and variable spectrum of COVID-19 responses and outcomes and because they have experience managing past public health emergencies. These four countries have also established strong partnerships between researchers and health officials, which facilitates access to data for quicker decision making. Further, Nigeria has a large, culturally diverse population and a history of successful responses to outbreaks of contagious disease, such as Ebola virus disease.³

In early 2020 at the onset of COVID-19 in Nigeria, human and financial resources were diverted from routine health services to pandemic response activities. Health services were scaled down and some facilities were closed completely, which limited access to health care. As in many locations around the world,⁴ COVID-19 has caused high rates of morbidity and mortality among health care workers in Nigeria, leading to further staffing shortages.

In Nigeria, these barriers—along with COVID-19 itself—had significant initial effects on key public health indicators. Overall, researchers have reported that the COVID-19 pandemic in Nigeria resulted in a 26 percent reduction in access to health services, a 13 percent drop in the number of fully vaccinated children, a 16 percent drop in the number of women seeking medical care during pregnancy, a 15 percent decrease in family planning service provision, and a 6 percent decrease in in-facility deliveries in April, May, and June 2020 compared with 2019.⁵

Key Takeaways

We know that health system shocks such as COVID-19, as well as the official response to those shocks, can undermine essential health services demand and delivery. In general, Nigeria’s health system had certain weaknesses even before 2020. The COVID-19 pandemic—and the interventions Nigeria implemented to control it, especially lockdowns—further undermined the delivery of critical health services. Countries can be ready to act to mitigate this threat. Nigerian officials quickly implemented a variety of new and adapted interventions to overcome supply- and demand-side obstacles to essential health services and reverse their effects. These interventions include:

What Was the Pre-pandemic Context in Nigeria?

Pre-pandemic Health System Indicators and Essential Health Services in Nigeria

Nigeria’s health system had a decentralized three-tier structure:

1. The national government was responsible for policy and technical support for the overall health system, the health management information system, and the provision of specialized health services through tertiary teaching hospitals and national laboratories. Each state had at least one tertiary facility.
2. State governments were responsible for secondary hospitals and the regulation of, and technical support for, primary health care services.
3. Local governments coordinated primary health care facilities, which were most people’s initial point of contact with the health system. Each local government area had at least one primary health care facility.

Nigeria has a low health worker-to-population ratio of 1.6 health workers (including doctors, nurses, and midwives) for every 1,000 people, which is considerably lower than the World Health Organization (WHO) recommendation of 4.45 health workers for every 1,000 people. Additionally, the health workforce is concentrated in urban tertiary health care facilities in the southern part of the country.⁷ Because health workers tend to cluster in higher-paying jobs in these better-resourced facilities, lower-level and rural facilities are left understaffed. Nigeria has five hospital beds for every 10,000 people⁸ and 350 ICU beds in all (one ICU bed for every 250,000 people).⁹

Universal health care effective coverage measures a variety of indicators related to delivery of essential health services, such as infectious and noncommunicable disease treatment and reproductive, maternal, newborn, and child health, among others. According to estimates of universal health care effective coverage, Nigeria ranked 193 of 204 countries, meaning that about 90 percent of all countries outperformed it.¹⁰ Although total health expenditures in Nigeria—3.9 percent of gross domestic product and US$86 per capita in 2018—met the WHO recommendation of $86 per capita, they were far below the Abuja Declaration of 15 percent of gross domestic product.¹¹ In 2018, out-of-pocket (private) health spending was 71 percent of the total, much more than experts typically recommend. As of 2018, about 3 percent of Nigerians had private health insurance.^12,13

Compared with other countries in Africa, Nigeria had somewhat strong performance on some essential health services indicators, such as antenatal care coverage; by contrast, it had a high rate of maternal mortality and comparatively low rates of routine childhood immunizations.^14,15

COVID-19 in Nigeria

Nigeria found its first confirmed case of COVID-19 on February 27, 2020, when a traveler in Lagos tested positive for the virus. As of early November 2021, Nigeria reported 212,000 COVID-19 cases and 2,900 deaths.¹⁶ Nigeria’s COVID-19 burden was likely much higher than official case counts reflected, however, especially during the early months of the pandemic. A serological survey in Lagos between September and October 2020 found that 23 percent of people tested had neutralizing antibodies against SARS-CoV-2, suggesting that many COVID-19 cases had gone unreported. Beginning in December 2020, Nigeria experienced a spike in reported cases, probably related to increasing levels of mobility, including international travel and travel to religious gatherings and festivities.¹⁷

As of early November 2021, about 1.5 percent of Nigeria’s population (some 3 million people) had received both doses of a COVID-19 vaccine.¹⁸ Health officials hoped to vaccinate 40 percent of the population by the end of 2021 and 70 percent of the population by the end of 2022.¹⁹

In 2020, WHO categorized Nigeria, one of Africa’s most densely populated countries, as one of the highest-risk countries on the continent for COVID-19.²⁰ Further, its health facilities and equipment were—and remain—insufficient for a COVID-19 emergency response. Nigeria had a total of 112 isolation facilities as of May 2020 and ICU capacity has increased, but limited quantities of personal protective equipment and other essential supplies continued to place health workers at high risk of contracting the virus.

Public health and social measures, including nonpharmaceutical interventions to limit the spread of COVID-19, have been key parts of Nigeria’s pandemic response. These included:

• Movement restriction and physical distancing

At the end of March 2020, Nigeria’s Presidential Task Force on COVID-19 implemented movement restrictions. These restrictions covered the Federal Capital Territory, Lagos, and Ogun states—epicenters for the COVID-19 pandemic to date—and included international, interstate, and local travel bans and curfews. For instance, as the number of COVID-19 cases in the country and around the world increased at the end of March 2020, Nigeria closed its airports to international flights to limit the possibility of imported cases. State governments soon implemented movement restrictions of their own. Initial lockdowns were eased at the end of April, and officials lifted movement restrictions altogether at the end of July. International flights resumed in August.

• Strategies to support mask wearing

The Nigeria Centre for Disease Control released guidance recommending the use of face masks in public in mid-April 2020. On April 27, a Presidential Task Force on COVID-19 communiqué mandated the use of face masks in all public settings. Schools, government ministries, and nongovernmental organizations (including institutional organizations such as the Academic Staff Union of Universities, churches such as the Church of Jesus Christ of Latter-day Saints, nongovernmental organizations such as the After My Heart Global Foundation and the Dare to Care Foundation, and state ministries of health) provided incentives and donations to support this mandate, but individuals were still responsible for finding or purchasing their own masks.

• Precautionary measures in public places

Nigeria’s educational institutions were closed on March 23, 2020. They reopened in September.

As a result of these pandemic response measures, mobility decreased sharply in the first months of the pandemic—especially to and around transport hubs and stations, health facilities, and workplaces. People still tended to visit groceries, pharmacies, and food markets and travel freely around their immediate neighborhoods. Mobility was most impacted in the pandemic’s epicenters (Federal Capital Territory, Lagos, and Ogun), where the Presidential Task Force on COVID-19 enforced travel restrictions and social distancing.

What Effect Did Nonpharmaceutical Interventions Have on Maintenance of Essential Health Services in Nigeria?

Along with the COVID-19 pandemic itself and the unprecedented disruption it caused in the global supply of essential health commodities, nonpharmaceutical interventions and other precautionary measures created supply- and demand-side barriers to the maintenance of essential health services in Nigeria. The country has also recorded substantial service disruptions in maternal health, newborn care, vaccination, sick-child care, family planning, and noncommunicable disease treatment, although we cannot claim a causal relationship between these disruptions and the nonpharmaceutical interventions.²¹ Mathematical models suggest that these disruptions could leave 5 million children without 3 doses of the diphtheria, tetanus, and pertussis (DTP3) vaccination and 700,000 women without access to in-facility delivery. Researchers also predict that childhood mortality could increase by almost 20 percent and maternal mortality by almost 10 percent over a one-year period.²²

The following findings are organized according to the Health Systems Building Blocks framework.

Barriers to maintenance and delivery of essential health services in Nigeria during the COVID-19 pandemic include the following:

Supply-Side Barriers

Leadership and Governance

An April 2020 policy document developed by the Federal Ministry of Health and the National Primary Health Care Development Agency contained both Nigeria’s COVID-19 response and strategies to maintain service delivery at the primary health care level. Still, in a study, health care workers reported that they were unaware of any guidelines from Nigerian policy makers for the maintenance of essential and preventive health services during the COVID-19 pandemic.²³ (It does appear that some practitioners adopted the US Centers for Disease Control and Prevention guidelines for provision of essential health services.²⁴ ) Likewise, in collaboration with other partners, the Nigeria Centre for Disease Control developed and periodically updated guidelines for health facilities to help maintain essential health services in Nigeria, but these guidelines were rarely communicated to primary health care workers at the local level.¹⁹ No community programs to promote access to essential health services in Nigeria were documented.

Finances

Nigeria’s economy depends on the importation of goods from other countries. Unprecedented inflation during Nigeria’s lockdowns limited international trade and increased the cost of health care even as household incomes declined due to job losses and wage reductions in the country’s predominantly informal economy. At the same time, widespread drug shortages and breakdowns in the public-sector supply chain pushed those who could afford them to private pharmacies, drugstores, and patent-medicine vendors where goods tend to be more expensive (high prices that were exacerbated by the COVID-19 pandemic) and may not be approved by regulatory bodies.

A deeper dive into COVID-19-related budgetary challenges in Kaduna state illustrates ongoing financial barriers to the provision of essential health services across Nigeria, on the supply side as well as the demand side. A national survey of hospital readiness during the COVID-19 pandemic in Nigeria showed that most hospitals (70 percent) maintained essential hospital services²⁵ and 55 percent had allocated resources for continuity of essential hospital services. In some states, however, essential health services funding was extremely limited. In Kaduna, for instance, the impact of COVID-19 on 2020 state revenue led to budget cuts across all budget line items, including that of the Primary Health Care Board, which experienced an 11.5 percent cut in its budget allocation. This budget cut occurred well into the pandemic. This undermined the effective delivery of essential services, such as deliveries by skilled birth attendants, antibiotic management of new cases of pneumonia among children under five years of age, treatment of diarrhea cases using zinc and oral rehydration salts, and the management of clients clinically diagnosed with malaria using artemisinin-based combination therapies. On the demand side, the capital budget allocation for the Kaduna State Contributory Health Management Authority, which was largely for payment of poor and vulnerable residents’ enrollment into the state health insurance scheme and their essential health services, was reduced by 24 percent.²⁶ These budget cuts will likely expose more poor people to catastrophic out-of-pocket health payments and limit the authority’s ability to fulfill its obligations to those who need care, slowing the pace to achieve universal health care in the state. As stated earlier, in a survey in Nigeria, 26 percent of respondents who needed health services were unable to access these services, and of those respondents, 55 percent said that cost was the major prohibitive barrier to access.⁵

Health Workforce

In Nigeria, the COVID-19 pandemic—and the health system’s response to it—depleted an already diminished health care workforce. For instance, a considerable number of providers were diverted from routine health care services to pandemic response tasks, such as case management and contact tracing. In Kaduna state, the Kaduna State Ministry of Health increased its budget by 1.6 percent to cover the costs of hiring health care workers.²⁶ At the same time, officials asked junior-cadre health workers to stay home to comply with social distancing guidelines. Further health worker shortages were caused by an exodus of Nigerian health workers—particularly doctors in key specialties such as anesthesia, emergency medicine, and surgery—to countries such as Saudi Arabia.²⁷ Making matters worse, Nigeria’s resident doctors (the majority of doctors in tertiary and referral hospitals) went on strike for nine weeks in the late summer and fall of 2021 to protest deplorable working conditions, such as poor and inconsistent payment of salaries, low hazard pay, and nonpayment of death allowances to practitioners who died from COVID-19. The strike ended in early October 2021.²⁸

During the COVID-19 pandemic, some of Nigeria’s primary health care facilities were shut down completely; where they remained open, many workers worried about the risk of contracting COVID-19.² Anecdotal reports suggest that some health care workers left their jobs as a result, especially those who worked in facilities without a reliable supply of personal protective equipment.¹⁹

Infrastructure and Commodities

The COVID-19 pandemic and subsequent interventions to control it amplified preexisting infrastructural deficiencies in Nigeria. For instance, already frequent materials shortages for essential health services grew worse during the pandemic. Surgical masks were quickly used up, increasing their cost. Stocks of thermometers in hospitals, pharmacies, and supermarkets were likewise exhausted, which also led to an increase in their price. Drug stockouts made it difficult for providers and clients to treat common conditions such as hypertension and diabetes. Lockdowns early in the pandemic compounded this problem: A quantitative analysis conducted in July 2020 examined the impacts of the COVID-19 pandemic on ease of access to essential medicines. It showed that 35 percent of respondents who were receiving treatment for chronic illness struggled to access essential medicines during the COVID-19 lockdown periods.²⁹

Hospitals and health facilities were repurposed for the pandemic response. For example, some wards were evacuated so they could be dedicated to COVID-19 treatment. Some hospitals’ infectious-disease units likewise shifted their focus to COVID-19 at the expense of other diseases, such as tuberculosis and HIV.

Health Service Delivery

One of the most significant barriers to accessing essential health care in Nigeria during the early part of the COVID-19 pandemic was the limitation of movement during the April to May 2020 lockdowns.³⁰ Informants reported that, during those two months, the number of clients who visited health facilities declined by as much as 50 percent. Movement restrictions also limited health workers’ ability to commute to work.²¹ Additionally, automobile and motorcycle taxis were difficult to find during the lockdowns.

It is important to note that COVID-19 and interventions to control it were not the only barriers to health service delivery in Nigeria. For example, the country is working to contain outbreaks of Lassa fever across terrains that are difficult for ambulances and health care providers to navigate and access.³¹ Conflict areas in northeast Nigeria are also experiencing high levels of displacement combined with a severe shortage of skilled health care workers.³²

Health Information Systems

The COVID-19 pandemic and the restrictions Nigeria implemented to control it affected health data reporting across the board. Informants reported that officials and digital innovators focused on the implementation of the new Surveillance Outbreak Response Management and Analysis System (SORMAS) tool for COVID-19 surveillance, neglecting surveillance activities for other disease areas.¹⁹

Demand-Side Barriers

Reduction in health care seeking proved to be a major demand-side barrier to essential health services delivery of in Nigeria. The stigma and fear associated with COVID-19 kept many people from using available essential health services, especially in the public sector.^{21, 33} Especially during lockdowns, many Nigerians stayed away from public health care facilities in favor of more conveniently located private ones (which sometimes provide lower-quality, more expensive care). One study found that the fear of being diagnosed with COVID-19, a diagnosis that would subsequently lead to quarantine or isolation, was also a barrier to care seeking for COVID-19-like symptoms.³⁴

Findings from a Partnership for Evidence-Based Response to COVID-19 (PERC) survey in August 2020 showed that about 40 percent of household members who needed medical care in the first six months of the pandemic delayed or skipped that care.³⁵ By the middle of 2021, this number had declined by half—to around 20 percent—which was significantly lower than August 2020 but still substantial. These findings were also consistent across gender and residence, with 20 percent of men and 18 percent of women, and 23 percent of urban residents and 19 percent of rural residents, delaying care during the pandemic. People with lower incomes were more likely to skip care than those with higher incomes (44 percent compared with 22 percent).

In that survey, cost was the most frequently cited reason for skipping health care visits not related to COVID-19. Cost was also more frequently cited as a reason for skipping care during the pandemic than before the pandemic, suggesting that COVID-19 had major economic impacts on households throughout the country.³⁶ High unemployment rates and rising inflation, especially with rapid increases in food costs, have contributed to major economic instability in Nigeria during the COVID-19 pandemic.³⁶ Respondents cited COVID-19-related health facility closures and other disruptions as major reasons for the reduction in their care seeking. The most common types of care people skipped were routine or general visits, followed by care for malaria, infectious diseases, and reproductive, maternal, and child health.³⁵

What Interventions Did Nigeria Put in Place to Ensure the Maintenance of Essential Health Services?

With the support of local and international partners, Nigeria’s Federal Ministry of Health implemented a range of interventions to overcome supply- and demand-side barriers to essential health services delivery during the COVID-19 pandemic.

The following findings are organized according to the Health Systems Building Blocks framework.

Leadership and Governance

• Guidelines for essential health services maintenance

The Presidential Task Force on COVID-19 produced guidelines and communiqués on the COVID-19 response. In addition, the Nigerian Federal Ministry of Health and National Primary Health Care Development Agency developed a set of policy documents that adapted preexisting national guidelines and WHO guidance for essential health services maintenance.¹⁹ In particular, the Preparedness and Response to Coronavirus Disease 2019 (COVID-19) at Primary Healthcare and Community Level, which was released in April 2020, emphasized the need to maintain service delivery at the primary health care level—especially reproductive, maternal, newborn, child, and adolescent health and nutrition services.¹⁹ These guidelines made specific recommendations for antenatal and postnatal care, labor and delivery, breastfeeding, sick-child visits, childhood and adolescent immunization, family planning, and routine immunization. However, these guidelines were not always well disseminated at the local level.

Additionally, in collaboration with partners, the Nigeria Centre for Disease Control developed and periodically updated guidelines for health facilities to help maintain essential health services in Nigeria. These guidelines were rarely communicated to health care workers, however, and they did not make people more likely to visit facilities.

Assessment plans for essential health services maintenance

The Nigerian government adopted the suite of health service capacity assessments for the COVID-19 context that WHO and its global partners developed in the spring of 2020. These modules can be used to assess health facilities’ capacity to maintain essential health services delivery as well as the demand-side factors that affect access to essential health services during health emergencies.

Finances

• Allocation of funds for essential health services maintenance

The Nigerian government allocated funds for the country’s COVID-19 response, most of which came from bilateral and multilateral organizations such as the World Bank and the United Nations COVID-19 Basket Fund. Health officials used some of these donated funds to support essential health services maintenance and delivery, procure personal protective equipment (such as face masks), and equip health facilities with basic hand-hygiene points.

Health Workforce

• Training, supervision, and capacity-strengthening for the COVID-19 response

Following a cascade training model, health managers and doctors in tertiary hospitals received training in COVID-19 prevention and control, and they in turn trained lower-cadre health workers, including newly hired community health workers, so that essential health services could continue uninterrupted. This occurred in facilities across many states in Nigeria. Volunteer health care workers from tertiary institutions were also engaged at the state level to support the COVID-19 response, especially surveillance and case management, which enabled most health care workers to continue working in essential health services maintenance.

• Provision of personal protective equipment, support, and other nonfinancial incentives to health care workers

Early in the COVID-19 pandemic, the federal government of Nigeria received noncash donations, such as personal protective equipment and other materials for infection prevention and control to be used across many states in Nigeria. The Coalition Against COVID-19, comprising local private organizations and individual donors, also provided both financial and material support, including hospital beds and medical equipment, which improved COVID-19 and non-COVID-19 client management in health facilities.^{37, 38}

• Task shifting to community health workers

On an ad hoc basis across all of Nigeria, many low-cadre health workers, such as community health workers, gained responsibilities as their superiors were redeployed to COVID-19 isolation and testing centers. For instance, community health workers were deployed to implement COVID-19 control activities such as contact tracing. Additionally, community health extension workers handled in-facility deliveries and traditional birth attendants were trained to attend some home deliveries in compliance with COVID-19 maternal and child guidelines. Because these guidelines were not well disseminated, however, their efficacy is unclear.

• Health worker exemption from movement restrictions

In April and May 2020, federal and state officials exempted health workers across Nigeria from lockdowns, curfews, and other travel restrictions.

• Staff redeployment and recruitment

The Lagos state government hired about 400 additional health workers between October 2020 and March 2021 to cover part of the health workforce deficit.³⁹ Similarly, the Kaduna state Ministry of Health added 1,225 new staff to the primary health care system in November 2020.⁴⁰

Infrastructure and Commodities

• Emergency orders of essential products

The Nigerian government pooled donations and ordered the importation of health commodities for COVID-19 management, such as personal protective equipment, ventilators, ambulances, and test kits and reagents for health facilities. The private sector played a key role in strengthening capacity and providing financial support for key medical supplies and essential health services maintenance.

Health Service Delivery

• Designation of facilities for COVID-19 treatment

To relieve the pressure on health facilities so they could continue to provide routine essential health services, almost all Nigerian states built or adapted facilities for testing, treating, and isolating suspected and confirmed COVID-19 patients. As of May 2020, there were 112 COVID-19 isolation and treatment centers in Nigeria.

Some health care facilities were closed temporarily to non-COVID-19 care at the beginning of the pandemic, and others were temporarily closed after COVID-19 exposure or contamination. Subsequently, health care facilities delivered non-COVID-19 care through an appointment-based system; attending physicians triaged non-COVID-19 emergencies immediately to determine the necessity for continued care.

• Use of multiple communications platforms

Telemedicine and other digital health solutions, especially in the private health sector, helped fill Nigeria’s service delivery gap and allowed people to seek care despite their fears of contracting COVID-19.⁴¹ With support from nongovernmental organizations, some private health facilities monitored noncommunicable diseases via remote consultations using mobile phones and video. For example, Wellvis, a Lagos-based online health information services company, created the COVID-19 Triage Tool, which uses a series of clinical and epidemiological questions to categorize users’ risk of COVID-19 infection based on the Nigeria Centre for Disease Control case definition; high-risk users were given priority to access care and linked to a nearby health facility.⁴² Additionally, GeroCare, a home medical care provider, provided affordable home visits to elderly people, on-demand doctor visits, and telemedicine during the pandemic.⁴³ Health workers also used their own phones to perform follow-up exams and seek advice from other clinical team members, although this increased workers’ out-of-pocket expenditures. Some nongovernmental organizations also gave smartphones to tuberculosis and hypertension patients so that they could film themselves taking medication and send the video to a nurse to monitor their adherence to treatment.

• Multimonth prescriptions

To reduce the frequency of client visits to health care facilities, care providers prescribed and distributed essential drugs to clients with HIV, tuberculosis, and psychiatric illnesses for longer periods of time than they typically do (one to six months, depending on the person’s health condition). Several professional bodies, such as the Association of Psychiatrists in Nigeria, recommended this change to mitigate the problem of skipped medication as the pandemic restricted in-person care.

• Promotion of routine immunization

Nigeria’s health officials worked to mitigate the impact of COVID-19 on routine immunization in the immediate and short terms through strategies such as scheduling appointments, deploying geolocated mobile health vans in some states, and holding targeted, temporary fixed-post immunization sessions.⁴⁴ Charter-flight shipments of vaccination supplies for measles, meningococcal disease, and yellow fever—some of which were supported by Gavi, the Vaccine Alliance—helped alleviate shortages.

• Adaptation of service delivery models

To boost essential health services maintenance during the COVID-19 pandemic, Nigerian health officials and providers reconfigured intake processes to reduce the number of clients in a facility at one time. They also adopted home visits for follow-up and palliative care, extended service hours, and intensified community outreach.

Health Information Systems

• Data collection to address reporting gaps

In addition to providing essential maternal and child health services, trained community health workers collected case counts, as well as demographic, clinical, contact history, and symptom surveillance data on COVID-19 and other diseases designated for notification.

• Transition to electronic health databases

In 2020, Nigerian health officials transitioned to using a national electronic database to collect and monitor the maternal mortality rate in Nigeria with help from the WHO. The system is known as the Nigeria Maternal and Perinatal Database for Quality, Equity and Dignity (MPD-4-EWD) and tracks data across tertiary facilities nationwide.⁴⁵

How Did Nigeria Perform across Essential Health Service Indicators during the COVID-19 Pandemic?

The COVID-19 pandemic—and the response to it—substantially disrupted essential health services delivery at the national level, especially immediately after lockdowns in March and April 2020. Various indicators can reveal different patterns of disruption to essential health services:

• DTP3 immunization

This indicator refers to the number of doses of DTP3 vaccine given to children under one year of age in a given month.⁴⁶ In Nigeria, levels of DTP3 immunization coverage in 2020 were generally lower compared with 2018 and 2019, and coverage was significantly lower between March and September 2020 than in the previous year.

• In-facility deliveries

This indicator refers to the total number of women who give birth in a health facility in a given year.⁴² In Nigeria, the trend in total in-facility deliveries did not change much between 2019 and 2020—except in March, April, and July 2020, when the number of women who gave birth in health facilities was much higher than in the previous year.

• Maternal deaths

In Nigeria, there was a considerable increase in maternal deaths recorded in 2020: four times as many women died between March and September 2020 as in those same months in previous years. Interviews indicated that this change may have had less to do with COVID-19 than with Nigerian health officials’ transition to an electronic database to track this indicator; in other words, 2020’s records may simply be more accurate than those from previous years.⁴⁵

In general, our interpretation is that the movement restrictions in April 2020 limited access to essential health services—such as DTP3 immunization and visits to outpatient departments for diabetes mellitus and hypertension—especially in urban areas in the central region of Kampala and Wakiso. After restrictions were lifted in May, barriers in access to health care and services were likely due to other issues, such as fear of contracting COVID-19 at health care facilities.

What Are the Key Lessons from Nigeria’s Efforts to Maintain Essential Health Services During the COVID-19 Pandemic?

Nonpharmaceutical interventions—such as movement restrictions, physical distancing in public places, and strategies to support mask wearing—effectively slowed the spread of COVID-19 in Nigeria, but they also interfered with essential health services supply and demand. Most key indicators of essential health services in Nigeria have not yet recovered from the strain of these interventions.

Recommendations for other geographies based on learnings in Nigeria

• Shift various COVID-19 and routine health services to community health workers and train those workers effectively.
• Strengthen public-private partnerships and source funding from local for-profit companies so that the public health budget can continue to be used for essential health services maintenance.
• Implement new service delivery strategies, such as regular or geolocated health vans (for location tracking to ensure delivery), multimonth drug dispensing, digital client follow-up, and targeted, temporary fixed-post immunization sessions.

Lessons learned from research applicable to the Nigerian COVID-19 context

• Develop and effectively disseminate clear guidelines on how to maintain essential health services during health emergencies.
• Improve surge workforce capacity at all levels of the health system.
• Improve and expand communication in communities to reduce fear of pursuing routine services and raise awareness on availability of services among health workers and the public.
• Expand the availability of essential services and medicines at public facilities in lower levels of care to improve access for rural and poor communities.
• Implement stronger digital and electronic infrastructure in health systems, such as electronic medical records, electronic referrals, and online appointment systems.
• Maintain surveillance of all high-priority diseases, not just pandemic surveillance.

AUTHORS Steven N. Kabwama, Suzanne N. Kiwanuka, Olufunmilayo I. Fawole, David M. Dairo, Ayo S. Adebowale, Segun Bello, Eniola A. Bamgboye, Rotimi F. Afolabi, Mobolaji M. Salawu, Rhoda K. Wanyenze