Fifteen-year-old Mathias Ofoke is one of four children in his family born with type 1 diabetes. Whenever his symptoms worsened, he was taken to the nearest primary healthcare (PHC) center where he was repeatedly treated for malaria. 

It wasn’t until February, when a non-governmental organization (NGO), Abby Cares Foundation, organized a clinical outreach at Ezza Ofu Health Centre that Ofoke’s condition was properly diagnosed. 

His blood sugar result of 543 mg/dL alarmed everyone when it was displayed on the glucometer screen. But the understaffed PHC facility at Ezza Ofu could not admit him as they were not properly equipped to care for him.

The NGO facilitated his admission to a secondary health facility and began sourcing insulin for his treatment.

“We frequently see cases of hypertension, diabetes, and cancer but we are not able to manage them, so we refer,” says Elizabeth Nwovu, the officer-in-charge at Ezza Ofu Health Centre. She is a community health extension worker (CHEW) who trained to be a matron.

An estimated 27% of deaths in Nigeria are linked to diabetes, cancer, cardiovascular and chronic respiratory diseases. These four major non-communicable diseases (NCDs) are the leading causes of mortality globally, with the majority of deaths occurring in low- and middle-income countries (LMICs). 

Diabetes, characterized by elevated blood glucose levels, affects 537 million adults (20-79 years) worldwide. This number is expected to rise by 46% in 2045. 

As urbanization increases, diets change and populations age, Nigeria has also seen a surge in adults living with diabetes, from 209,400 in 2000 to 3.6 million in 2021—only South Africa had a higher prevalence in 2021. 

Diabetes is responsible for about 4.5% of deaths in people under 60 years old in Nigeria, with common complications including hyperglycemic emergencies, diabetic foot ulcers, chronic kidney disease and stroke.

PHCs prioritized in NCD management 

A national survey on NCDs conducted between 1990 and 1992 revealed that less than a quarter of the estimated 1.05 million Nigerians living with diabetes were aware of their condition. Following this survey, the Nigerian government attempted to integrate NCDs into PHC facilities, but these efforts met with minimal success.

Efforts to tackle NCDs in Nigeria were reignited in 2021 following the Brazzaville Declaration on NCDs and the subsequent political declaration at the 66th United Nations General Assembly on the Prevention and Control of NCDs. These declarations set the precedent for the WHO Global NCD Action Plan 2013-2020, which has now been extended to 2030.

Over the years, Nigeria has built on these regional and global strategies to develop several national policies for NCD prevention and control. Notable among these are the National Multi-Sectoral Action Plan for the Prevention and Control of NCDs and the National Guideline for the Prevention, Control, and Management of Diabetes Mellitus in Nigeria.

The scope of the national guideline for diabetes management was developed using the Population, Intervention, Professions, Outcomes, and Healthcare setting (PIPOH) checklist. 

The interventions outlined in the guideline emphasize the importance of integrating community health workers, such as CHEWs, and scaling-up screening, diagnosis and treatment in PHC facilities.

Task-shifting to community health workers

According to the national diabetes guideline, a key indicator of progress is the successful delegation of certain aspects of diabetes care to lower-level health professionals, such as CHEWs and lay health workers.

Similarly, the national multi-sectoral action plan, which informed sections of the diabetes guideline, recommends expansion of the Task-Shifting and Task-Sharing Policy for Essential Health Care Services to include NCD management among its priority areas. Currently, this policy focuses on maternal and child health, and communicable diseases (HIV/AIDS, malaria, and tuberculosis).

In line with this recommendation, during the technical session of the 64th National Council on Health (NCH) in November 2023, the Ministry of Health and Social Welfare announced plans for a National Task-Shifting and Task-Sharing (NTSTS) policy focused on the prevention and control of NCDs.

“This policy, if adopted, will complement the existing Task-Shifting and Task-Sharing Policy for Essential Health Care Services,” said Dr Anyaike Chukwuma, Director of Public Health, during the event.

The NTSTS policy aims to address the rising burden of NCDs in Nigeria by decentralizing preventive, diagnostic, treatment, and rehabilitative services to PHC facilities.

“By implementing this policy, the country hopes to adopt a patient-centered approach, accelerate progress towards NCD prevention and control, achieve universal health coverage, and work towards the Sustainable Development Goals,” Chukwuma added.

PHCs are ready but support is inadequate

“PHCs are not adequately supplied with medications,” said Nneka Nwankwo, founder of Abby Cares Foundation. She has over 20 years’ experience in public health and social services.

Her NGO sources Ofoke’s daily insulin injection from a tertiary hospital in the city center. Nigeria’s annual diabetes-related health expenditure per person is estimated at $499.7, which falls below the African regional average. If current trends continue, the prevalence of diabetes in the country is predicted to increase by up to 120% by 2045.

In his study on improving primary health care services for NCDs in Nigeria, Whenayon Ajisegiri found that some government stakeholders’ skepticism about the qualifications of community health workers, who constitute the majority of the PHC workforce, has been used to justify the limited supply of NCD drugs at PHCs. Ironically, NCD drugs are contained in the list of essential medicine and should be available at PHC facilities.

“When PHC facilities repeatedly fail to provide patients’ medications, it leads to frustration. And when you lose patients’ trust in the initial stages, it is difficult to regain,” said Nwankwo.

A survey of 30 PHCs in Abuja, Nigeria’s capital city, reported a readiness to integrate diabetes care in terms of available paper-based health management information systems, equipment, and personnel. However, the poor availability of diabetes medications makes it impossible to harness this opportunity.

“If we can get access to testing kits and the drugs, it will improve our ability to manage patients with diabetes,” said Nwaovu.

The survey recommended a subsidized drug-revolving fund mechanism to maintain drug inventory, drawing from programs like the Hypertension Treatment in Nigeria (HTN) Program and the Academic Model Providing Access To Healthcare (AMPATH) program in Kenya.

Community health workers play an integral role

The slow progress in integrating diabetes and other NCDs into PHCs is also linked to the omission of community health workers from NCD policies.

The critical shortage and uneven distribution of skilled health workers, particularly physicians and nurses, have necessitated the deployment of community health workers to support essential health services delivery.

Prior to the introduction of the NTSTS, existing policies like the National Standing Orders, which guides the training and practice of community health workers, restricted their role to only screening and referral. Ajisegiri noted that frequent referrals to higher health facilities—secondary and tertiary—could undermine public trust in the services provided at PHCs.

Formalization of task-sharing 

Given the Nigerian government’s prioritization of PHCs to tackle NCDs, experts have advocated for capacity building, while formalizing task-sharing and task-shifting policies for NCDs among community health workers.

In a survey of 30 PHCs in Abuja, Nigeria’s capital city, only 37% reported having at least one staff member trained in diabetes diagnosis and management within the past two years. With the NTSTS for NCDs set to be adopted, Nigeria appears to be on track to address this issue. 

This task-sharing and task-shifting model has already been successfully implemented in maternal and child care, as well as in the management of infectious diseases.

While this approach is expected to help the government maximize the available health workforce for NCD management, it is crucial to allocate sufficient resources to PHC to enhance infrastructure, ensure consistent medicine supplies, and bridge the significant skill gap among community health workers. Additionally, refining the practice scope in the National Standing Orders is essential to prevent interprofessional role conflict.

Funding and political will are paramount

The national multi-sectoral action plan acknowledged the problem of medication access and called for action towards ensuring a reliable supply of essential medicines for treating diabetes and other major NCDs.

It recommended expanding the Basic Minimum Package of Health Services, funded by the Basic Healthcare Provision Fund (BHCPF), to cover comprehensive care and treatment of NCDs. The BHCPF serves as a catalytic funding source to enhance access to primary health care, particularly for poor and vulnerable groups. 

This expansion aims to reduce out-of-pocket expenses for treatment. However, funding for the BHCPF has been inconsistent. 

Nwankwo recalled that Ofoke’s father was reluctant to bring his other children living with diabetes for treatment due to the costs. Despite her offer to subsidize the insulin injections by 50%, her efforts to persuade him were unsuccessful. 

“Even with your help, I can’t afford it,” she remembered him saying. Eventually, he brought one more child for screening.

Only half of the initial 55.1 billion naira allocated to the BHCPF in 2018 was released and by 2021, the budget had decreased to 35 billion naira. Between 2019 and 2022, it is estimated that 89 billion naira was allocated through the BHCPF, with only 7,250 out of the 35,514 Primary Healthcare Centres in the country receiving these funds.

This scenario is all too familiar for Nwankwo. “At Ezza Ofu Health Centre, the quota for the health insurance scheme is around 300 people, but it’s just a drop in the pond,” she said. During her organization’s first outreach at the PHC, over 1,000 people showed up seeking medical care. “Creating policies is not enough if they are not backed with the right resources,” she added.

Pius Ukpai contributed to this reporting from Ebonyi State, Nigeria.

Image Credits: Chimdiebube Ikechukwu, IDF Diabetes Atlas, Whenayon Ajisegiri.