Improving the Quality of Health Services in a Challenging Environment: Lessons from the Fellowship Program in Nigeria

Improving the Quality of Health Services in a Challenging Environment: Lessons from the Fellowship Program in Nigeria

Blog post also appeared on Global Health Magazine.

PEPFAR Fellow in the field

As the country with the second highest maternal mortality rate in the world, outranked only by India, Nigeria loses one in every 18 women during child-birth. The country also has one of the highest infant mortality rates in the world, one of the lowest life expectancy rates---estimated at 47 years---and the second largest population of people living with HIV & AIDS, with only 30% of people eligible for anti-retroviral treatment able to access these life-saving drugs.

These grave statistics can be associated with poor health worker/client ratios, and the disconnect between health professionals’ knowledge and their ability to improve services. Statistics show that the number of health workers here is simply inadequate for the huge population they serve. Most skilled workers are unable to convert their knowledge into action and mobilize their communities to effect sustainable change. Consequently, additional skills adaptable to local context are crucial to overcome most of these challenges to quality service delivery, especially in underserved and challenging environments.

One capacity-building intervention that has succeeded in integrating these elements is the PEPFAR Health Professionals Fellowship Program, designed and managed by Management Sciences for Health, Nigeria. The program operates on the philosophy that health professionals who receive adequate and effective post-certification training are significantly more likely to implement effective HIV & AIDS treatment, care and support services than those who have not been trained. This is crucial considering that certain problems arising in the Nigerian health sector (for example, lengthy patient waiting time) can be addressed through improved processes as opposed to increased financial or material resources.

The program has four major components: classroom training, community-based activities, practical training and mentoring/peer support mechanism, with teaching tools and techniques adapted to suit local experiences.

Results from the trained health professionals who have completed this program have been very impressive. Eighty of the 81 health professionals who participated in the program between April 2008 and November 2009 reported that they are better able to overcome challenges that seemed insurmountable before their participation. To date, the Fellowship Program in Nigeria has produced about 135 health professionals who have impacted over 350,000 lives with their increased knowledge and skills.


One laboratory scientist, John Tiva, returned from the program to transform his laboratory in General Hospital, Michika, Adamawa State, to an efficient assembly line. Through his ambition, a twice-weekly sample collection circle was scaled up to a daily collection routine for CD4 count, hematology tests, and other critical lab samples. The outcome? Congestion was drastically reduced in the laboratory as access increased, with patients getting their results in two days instead of two weeks! Turnaround time for results was thereby reduced by 70%. According to Tiva, patients who would have not followed up with treatment---because they were too weak or too poor to return for test results---now get treatment, and some are immediately placed on anti-retroviral drugs.

Other trained fellows have helped reduce the mortality rate in a prison, worked with a team to reduce client waiting time in over three facilities, improved quality of laboratory services in other facilities, increased Tuberculosis case detection in two facilities, improved adherence to HIV anti-retroviral drugs, and improved service provider/client relationships in the facilities.

This has not been the case for most of their colleagues who did not participate in the Fellowship Program.

The next step is to integrate the services of the trained fellows within a wider scope that would include state government and civil society organizations.

Based upon our experience here, similar programs could be adapted and mainstreamed into the health system throughout Nigeria. With more health workers receiving continued training, we could lose fewer mothers to childbirth, fewer infants to preventable deaths, and greatly increase the number of people receiving anti-retroviral therapy. Improving health services is an achievable goal. We need to give the people responsible for those services the tools to mobilize change effectively.


Chioma Ogbozor is Associate  Director, Civil Society Organisations for the Program to Build Leadership and Accountability in Nigeria's Health System (PLAN-Health), a USAID-funded project being implemented by Management Sciences for Health  in Nigeria.