Iheomimichineke Ojiakor (Guest writer)
When Grace’s son developed a high fever one evening in Ikirike, an informal settlement in Enugu, the nearest primary health care (PHC) centre was closed. She unable to fford the transport fare to the next hospital, a journey that previously cost about ₦2000, had risen to nearly ₦5000. Like many families living in informal urban settlement, Grace turned to the familiar nearby chemist, a Patent and Proprietary Medicine Vendor (PPMV) who is often the first point of care for fever, malaria and other common illnesses in the community.
Across Nigeria’s cities, millions of families rely on informal healthcare providers (IHPs) including PPMVs, traditional birth attendants (TBAs), and traditional bonesetters (TBS). These providers are trusted, accessible, and often providing care that is affordable and close to where people live. However, because many operate outside formal regulatory and referral systems, gaps remain in care coordination, quality assurance and continuity of services.
To address this gap, researchers at the Health Policy Research Group (HPRG), University of Nigeria, through the Community-led Responsive and Effective Urban Health Systems (CHORUS) project, launched an initiative to strengthen links between informal and formal providers, enabling low-income residents to access safer and better-quality care.
Building local buy-in
Before designing the intervention, the team convened a stakeholder consultation with the Enugu State Ministry of Health (ESMoH), the Enugu State Primary Healthcare Development Agency (ESPHCDA), community leaders, and informal and formal providers to jointly discuss the challenges and identify feasible, local grounded solutions. Through this process, four communities in Enugu and Onitsha were selected. The communities had overcrowded housing, limited basic services, and limited access to primary healthcare facilities.
The team also conducted inspection visits which found that informal healthcare providers dominate urban informal settlement in southeastern Nigeria, operating alongside formal providers within a context where supervision and coodination is weak. The findings also showed that delays in childbirth referrals are shaped by a combination of beliefs, trust, and financial incentives. In particular, traditional birth attendants may face financial losses or decreased social status when referrals are made early, creating pressures that can delay timely referral during labour.
Baseline data was collected from healthcare providers and households to understand the health needs of urban informal settlements residents and their health-seeking behaviours. The baseline data showed strong support for formal linkages between informal and formal care. Overall 92% of service users and 87% of providers support integrating IHPs into the health system, preferably through training, supervision, and a structured referral system led by the Ministry of Health and backed by legislation.
Only 7.4% of respondents who sought care from IHPs reported receiving a referral, and most referrals were verbal and undocumented. As a result, completion rates were poor and feedback mechanisms weak. Many IHPs had knowledge and equipment gaps. For example, many providers were not using simple diagnostic tests for malaria and diarrhoea diagnosis. Knowledge of NCDs such as hypertension and diabetes was limited. Only about 9% of assessed providers demonstrated adequate understanding of basic identification and referral processes.
It was also revealed that providers who had received training performed much better. Households, especially the poorest, still spent heavily out-of-pocket and often relied on informal providers, putting them at greater risk of poor health outcomes. Despite high out-of-pocket spending, 65% of households said they would consider a small one-time payment of ₦1,353 if it guaranteed safer, better-supervised services and reliable referrals. This finding suggests demand for quality assurance, but any financing approach would need to protect the poorest households.
Designing a linkage model
In February 2023, the team reconvened stakeholders to design solutions around three pillars of service delivery, health information systems and governance. This led to a simple plan to train, equip, supervise and institutionalise. In July 2024, Enugu State set up an Urban Health Unit within the Ministry of Health and the SPHCDA to coordinate all linkage activities. The HPRG team supported with tools, training, and technical guidance.
By September 2024, the project had trained 27 PPMVs, 26 TBAs, 9 bonesetters, 12 PHC workers, and 28 community leaders on safe service delivery, referrals, and record-keeping. Each participant received user-friendly tools such as referral booklets, registers, job aids, posters, birthing and first-aid kits, and hygiene supplies.
To support lasting change, the project introduced monthly supportive supervision, friendly collaborative visits from PHC staff, community leaders, government officers, and the CHORUS project team from HPRG. “When they call first and come to correct me, I don’t feel attacked. I try the new way,” said Mr Emeka, a traditional bonesetter in Abakpa.
Since the research team began implementation, community awareness and acceptance of the linkage solution have grown. Community leaders say people now understand that informal providers should refer when a case needs a higher level of care. Pa Simon, a WDC chairman, put it simply: “The community is now aware… if they are not responding well to treatments by informal providers, they can ask the IHPs to refer them.”
He added that referrals now help patients move faster at facilities, “once patients arrive at facilities with their referral forms, they are quickly attended to.” On the facility side, relationships between PHC staff and IHPs are improving. Nurse Nwamaka, a PHC Officer-in-Charge (OIC), explained, “It is getting better… we started working together,” she said, noting that informal providers are “the ones that send people. They are sending referrals to us.”
There are also early examples of referrals reaching facilities and getting feedback to the referrer, even if the paperwork is not perfect yet. Mrs Nkechi, another PHC staff, described a recent PPMV referral. “Yes, the person came, I treated her, and she later came and told me that she was fine,” adding they phoned the PPMV to give feedback because the form was incomplete.
Record-keeping has improved in places but remains a work-in-progress. PHC staff say they now coach providers during visits. Nurse Nwamaka further narrated that, “we advise, teach them how to record… to make sure they write everything down in the register.” Still, some IHPs hesitate to share registers, sometimes because they “feel that they are always under attack or… being monitored by the government.” Persistence helps. “You have to be patient and go back if you must get what you want,” Nurse Nwamaka noted.
Among informal providers, the training and job aids are building skills and confidence, especially with hygiene, safer practices, and knowing when to refer. Mr Emeka, a bonesetter, said “most of the things I learnt from the training, I did not have any idea of such… it really added a lot to my knowledge.”
He explained that he emphasises hygiene to prevent germs and infection and is more aware of nerve and vessel injury risks. He also keeps the job aid close. “It is very helpful… I use it. When a patient comes and I check the person, I will refer the client if it is something I cannot handle. I have gained more knowledge.”
Despite the positive changes, there are still some constraints that explain slow spots. Some IHPs still hesitate to refer due to fear of losing clients, consistent with what the baseline and co-creation workshops revealed. PPMVs also voiced two persistent concerns, the risk of losing clients if they refer and the cost and availability of basic diagnostics. Mrs Onoh, a PPMV, noted that “I have challenges getting RDT for testing malaria, even now, I have not gotten it.”
Their requests are practical – more registers and referral booklets when supplies run out, affordable test kits such as RDTs, thermometers, glucometers, sphygmomanometers, and short refresher trainings to sustain improvements over time.
What this means for scale-up
The CHORUS project demonstrates that improving access to quality healthcare in urban informal settlements does not always require new infrastructure, but smarter integration of existing systems. This approach aligns with Nigeria’s push for stronger primary healthcare and UHC by improving quality and continuity of care without waiting for large capital investments.
Strengthening linkages between informal and formal healthcare providers can enhance service quality, referral completion, and data flow across tiers of care. Practical interventions, such as training, provision of referral tools, and supportive supervision, has proved effective in building trust, improving record-keeping, and service quality.
Image credit: Nigeria Health Watch
However, sustaining these gains requires deliberate government ownership through institutional mechanisms like the Urban Health Unit, which ensures coordination, supervision, and data integration. Policy frameworks should formalise informal provider engagement under clear regulations and supervision mandates, while addressing real-world barriers such as transport costs for referrals, diagnostic tool shortages, and provider fears of client loss.
Embedding supportive supervision, periodic refresher training, and affordable diagnostic access in state health plans will strengthen urban primary health care delivery. Ultimately, the policy lesson is clear- linking informal providers to the formal health system is a low-cost, high-impact pathway for advancing Universal Health Coverage (UHC) in Nigeria’s urban informal settlements.