The study was designed to investigate the experiences of PHCs in selected States of Nigeria on the management of SRHR services and explore the potential effects of the pandemic in limiting the delivery and access to such services. We focused on PHCs given that they are the entry point and the first port of call into the Nigerian health care system, ensuring equitable and affordable access to services for all citizens (20, 21). With respect to SRHR and other essential services, we investigated the five domains of service opening (availability of the service), service utilization, challenges in service utilization, availability of PPEs for prevention of COVID-19 and other infections, and case-reporting of COVID-19 in the health facilities.
The results showed an increased tendency for the PHCs to open for antenatal and delivery services, but less so for postnatal services. This is possibly due to the importance of pregnancy and delivery that had occurred before or during the pandemic which the health facilities identify as essential to be provided.
Most noteworthy was the slight decline in the number of health facilities offering family planning immunization services, and childcare during the period. Although insignificant, these declines have the potential to reduce the tenacity with which such services are offered in the PHCs, which could dampen the future effectiveness of family planning and immunization programs.
It was of interest that adolescent services did not decline during the period, and indeed, the offering increased in some of the health facilities. This may be due to the importance attached to adolescent health services by the health facilities. By contrast, the services offered for other diseases – malaria, HIV, hypertension, diabetes etc. – declined significantly during the lockdown but rebounded immediately after the lockdown.
A further area we investigated was the extent to which services were utilized before and after the lockdown. This was obtained through reviewing weekly statistics on service utilization in the PHCs before, during, and after the lockdown. The results showed a 30–50% reduction in service utilization for family planning, antenatal, delivery, postnatal care, immunization, childcare and adolescent health services during the lockdown as compared to the pre-lockdown period. While service utilization for most components improved after the lockdown, adolescent health services continued to witness reduced counts in all the facilities after the lockdown. This may be due to the special nature of adolescents, their free mobility, and the fact that they have their own notions of health care utilization which may manifest as a result of the pandemic (22). This aspect must be further investigated as adolescents are at high risk of, physical, mental and social effects of the pandemic and gender-based violence which has been postulated to have an increased incidence as a result of the lockdown associated with COVID-19 (23, 24).
In a country that is characterized by a lack of accurate data, methods must be identified to ensure the accurate documentation of data related to essential health services utilization. Without such new methods, planning and policy formulation related to SRHR services will continue to rely on guesstimates, which will reduce the quality and effectiveness of interventions being proposed and implemented. It is within this context that our team is currently working on an App to be used on smartphones for the early reporting and documentation of cases of gender-based violence, family planning failures, unwanted pregnancy, HIV, COVID-19, etc. within primary health care settings is being developed by UNFPA/WHARC. When available and fully tested for its efficacy, it will help to resolve the timely reporting of SRHR challenges, especially in rural settings.
We investigated the challenges reported by the respondents as limiting their delivery of essential reproductive health services during the COVID-19 lockdown. Several anecdotal reports have featured challenges in health facilities as a major difficulty during the pandemic, but no substantive empirical evidence has yet been provided. Close to three-quarter of the health facilities in all States reported major challenges, with the majority reporting multiple challenges. Such challenges were mostly reported in Akwa Ibom, Gombe, Kaduna, Kano, Lagos and Ogun States. They ranged from “out of stock syndrome” (mostly in Gombe, Borno, and Sokoto), contraceptives not available (largely in Gombe, Borno, Kaduna, and Sokoto), and police harassment (in all States, especially in Kaduna, Sokoto and FCT, where more than 90% of the health facilities reported this outcome).
Other reported challenges with the delivery of services included difficulties with transportation and insufficient PPE. With respect to PPE, only 2% of the health facilities overall and 16% reported the availability of protective gowns and hand gloves. By contrast, temperature checker and hand sanitisers were more frequently present.
If the health facilities are to be efficient in managing COVID-19, these challenges must be addressed on an ongoing basis. Our direct questioning on whether the PHCs had reported cases of the virus showed that up to 10% answered affirmatively, which means that the situation is real and requires urgent attention by managers of the facilities. Such measures should include the provision of guidelines for managing and triaging potential cases of the virus in the PHCs, the early referral of suspected cases to confirmatory, isolation and treatment sites, the provision of comprehensive PPE and precautionary measures in the health facilities, staff motivation, and the training and re-training of PHC staff on COVID-19 management.
Study Strengths and Weaknesses
Although the curtailment of essential services due to the COVID-19 pandemic has been a major source of concern in Nigeria and other parts of Africa, to the best of our knowledge, this is one of the first empirical investigations of the nature and extent of this challenge. Our focus on PHCs in rural, semi-urban and urban settings ensures that the most basic unit of health care that is available to all citizens and where COVID-19 prevention measures can be universally delivered is one of the strong points of this study. Furthermore, our selection of 30 LGAs in 10 States, and 307 PHC health facilities for the study provides a good representation of all six geo-political zones of the country. This suggests that the results of the study can be generalized throughout the country.
However, on the downside, the study is limited by the fact that only one single key informant per health facility was interviewed. The interviews largely relied on recall of events such as challenges experienced in the health facilities which could not have been witnessed by only one informant. Recall bias was therefore a potential weakness of the study. The triangulation of these results with those obtained from focus group discussion with groups of health providers would have increased the accuracy of some of the results obtained. Nevertheless, the fact that the key informants supported the information they provided with existing records in the health facilities helped to improve the accuracy of the data obtained.