Nigeria, a country of over 177 Million inhabitants is the most populous in Africa and although has the highest Gross Domestic Product (GDP), it has the second highest Maternal Mortality Rate  in the World after India. Despite noticeable progress, Nigeria did not meet any of the Millenium Development Goals (MDG) of the United Nations (UN), especially MDG 4 (Reduce Child Mortality), MDG 5 (Improve Maternal Health), and MDG 6 (Combat HIV/AIDS, malaria and other diseases). In 2015 the World Health Organsation (WHO) recorded the Maternal Mortality Rate at more than 814/100’000,) and the neonatal mortality rate at 34/1000 live births, (WHO 2010).  The Adult literacy rate is 49% and life expectancy in 2014 has risen to 52,7 years. Poverty, poor accessibility and inadequate health facilities constitute major causes of high mortality and morbidity from treatable and preventable diseases like malaria and other infectious diseases. Nigeria is one of the three countries in the world still battling with Polio. There is a paucity of trained medical personnel with a Doctor/Patient ratio of 1/2’500-5’000 and Nurse-Midwife/Patient ratio of 1,6 /1’000 (WHO 2009/2008).

Makoko/Iwaya Waterfront community is a marginalized sprawling century-old informal fishing neighborhood on the lagoon of Lagos, Nigeria. The community accommodates upwards of 40,000 inhabitants comprising five ethnic groups coexisting in a peaceful manner. The majority lives below the poverty line of USD2 per day and lives on wooden stilt-houses on the Lagoon. They have no access to basic infrastructure, nor have they access to reliable clean drinking water, electricity, sewage and waste disposal, nor the existence of conventional health care services.

The focus of the project lies on mother, newborn and child health and reproductive healthcare, aiming to reduce pregnancy related maternal and neonatal mortality and the high rate of adolescent pregnancy, thus improving the health of the most vulnerable groups.  There are no written statistics but the community repeatedly decries its high Maternal Mortality Rate and infant death.  According to local reports, Makoko community accounts for the highest prevalence of adolescent pregnancy in the country. Besides the prevalence of malaria, pneumonia, measles & HIV/Aids, there are frequent outbreaks of water borne diseases like diarrhea, cholera and typhus, due to the congestive living and very poor hygienic conditions.

The community led Makoko/Iwaya Waterfront Regeneration Plan identified healthcare in the community as one of the priority development issues and recommended eight healthcare centers to be established to create healthcare access for the residents. During the investors‘ engagement  convened by  Social and Economic Rights Action Center (SERAC) and Heinrich Boll Stiftung, Nigeria in 2014,  SUPPORT, a Non-Profit developmental aid organization founded in 2007 in Switzerland confirmed interest to intervene in the healthcare sector in conjunction with the community. This led to full establishment and implementation of Makoko/Iwaya Primary Healthcare Project (MIPHP) in 2015.

The project comprises three components;

1. Awareness Raising, Health Promotion and Capacity Building: The project is initiated with regular health promotion, awareness raising events and community mobile health outreach events at different locations in the community; continuous seminars and workshops with and for the traditional healers and traditional birth attendants; and explore cooperation in unified system of hygienic standard maintenance, risk and emergency recognition and other preventive healthcare models.

2. Establishment of a System of 8 Health Posts in Every Sector of the Community: Patients will be able to access services for counselling and for minor ailments. Existing traditional healthcare providers could be upgraded to offer these roles in line with criteria, ethics and standard to be stipulated.

3. Establishment of an Advanced Primary Healthcare Centre (APHC) – Pre-General Hospital Clinic with a short stay unit (24/7 with second tier service delivery): There will be a special Mother and Child Department with focus on Mother and Child Health, family planning and reproductive healthcare counselling.

Although, MIPHP is long term in nature, but it has been divided into phases to reflect the priorities on the ease of implementation, resources availability and impact. The early stages of the project identified institutional structure of project delivery, relationship among the stakeholders, community engagement and mapping of project relevant stakeholders as priorities.

The project commenced with component one, Awareness Raising, Health Promotion and Capacity Building and progress will be made on other components based on the timely response of the state institutions on the proposal for PPP, especially for component two. 

The Makoko/Iwaya Primary Healthcare Project initiated by SUPPORT, Switzerland is currently being driven by Arctic Infrastructure (AI) based in Lagos, Nigeria while Social and Economic Rights Action Center (SERAC) has been working on the forefront of community coordination, engagement and participation. AI is a private establishment with broad focus on infrastructure delivery, urban development and environment. AI is working in collaboration with SUPPORT, a Non-Profit developmental aid organization founded in 2007 in Switzerland with the aim to supporting non-governmental, non-profit medical institutions and health projects in West Africa. The partners will, in due course, yield the implementation of the project including this PPP framework to a new Non-Governmental developmental aid Organization, Iroko Healthcare Support (IROHES) currently undergoing registration processes in Nigeria.

Implementing organizations have been collaborating with St. Nicholas Hospital, Lagos, the World Health Organization (WHO), United Nations Children Fund (UNICEF), Health Information Managers Association of Nigeria - Lagos University Teaching Hospital, Idi-Araba, Lagos, Cantonal Teaching Hospital, Aarau, Switzerland and other key stakeholders in the health sector in the implementation of the project. Since the commencement of the project in 2015, consultations have been held with broad stakeholders in the healthcare sector while the project has received strong support and participation from relevant government institutions including the Lagos State Ministry of Health (LSMoH), Lagos State Primary Healthcare Board (LSPHB), Lagos State Traditional Medicine Board (LSTMB) and Yaba Local Council Development Area (LCDA).

SUPPORT, Switzerland is currently funding levels one and two, that is project management and Awareness Raising, Health Promotion and Capacity Building component. The third level financing (establishment of a System of 8 Health Posts in Every Sector of the Community) is being modeled as cost sharing in Public Private Partnership. The Lagos State Government will provide an existing functional primary healthcare center while SUPPORT, Arctic Infrastructure and IROHES will provide furniture, equipment, personnel and operate the healthcare facility. Deliberations of an appropriate approach for the fourth level financing for component three (establishment of an Advanced Primary Healthcare Centre)is on-going.  

The Makoko/Iwaya Primary Healthcare Project has recorded considerable milestones since it became operational in 2015. The table below shows the performances on different components of the project.

1. Health awareness and promotion programs in the community

- Training conducted for 20 pre-selected youth in the community as Health Champions focusing on health literacy, environmental improvement, sanitation and disease prevention

- 20 Health Champions already working on the field with routine house to house health awareness sessions. Each Health Champion receives monthly stipend, subject to performance

- 2 healthcare outreach programmes held in the community (one on water, the other on land)

2. Training programs for Traditional Birth Attendance and Healers

- 3 training workshops conducted for 40 Traditional Birth Attendants and Healers  on different areas of healthcare service delivery

- Gradually moving Traditional Birth Attendants and Healers from informal and clandestine operators to formal service providers with the relevant Lagos State Government institutions

- Increased in number of Traditional Birth Attendants and Healers registered with the Lagos State Traditional Medicine Board from 3 to 9 with the aim to register all participants

- Attraction of private and multilateral stakeholders and resources into the healthcare sector of Makoko/Iwaya Waterfront Community and Lagos State

3. Delivery of Primary Healthcare Center and Health Posts

- Land already provided by Makoko/Iwaya Waterfront Community

- Challenge of development approval through the regeneration plan and community project funding

- Decision to change the location of the originally planned PHC from Makoko/Iwaya Waterfront Community to Aiyetoro Community taken on Saturday, October 7, 2017 (see Barriers and Challenges)

Within the component of Primary Healthcare Centre of the project, the initial concept was to build and operate the Primary Healthcare Centre in Makoko/Iwaya Waterfront Community providing greater  physical accessibility to the residents living on water. However,  the delay in securing approval from the Lagos State Government (LASG) for the redevelopment plan submitted by the community informed the change in concept including location. Through engagement and validation by all stakeholders, Makoko/Iwaya and Ayetoro Communities and Yaba Local Council Development Area (LCDA), the exisiting but dilapidated Aiyetoro Primary Healthcare Centre, located in a relatively short distance from Makoko/Iwaya Waterfront is now being considered for use in fulfilment of component two.

Another challenging aspect is the conflict of supremacy on the ownership of Aiyetoro Primary Healthcare Center between the state and local authority which was resolved in favour of state authorities highlighting the minimal influences of local authorities to operate and manage basic urban infrastructure and services in the city of Lagos. 

The main success factors of the project are outlined below;

a. Enduring, understanding and strong relationship between the partners from global north, SUPPORT, Switzerland and global south, Arctic Infrastructure based in Lagos, Nigeria

b. Clear inclusionary strategy of engaging and including community members in all the value chain of project’s delivery processes.

c. Extensive networking and collaboration opportunities with relevant stakeholders in the implementation of the project

d. Clear project strategic plan and monitoring mechanism

On scalability, there is an effective demand from the Lagos State Traditional Medicine Board on how the healthcare project can be implemented on city wide basis from the current focused area, Makoko/Iwaya Waterfront Community. The request is being reviewed by the project stakeholders, SUPPORT and Arctic Infrastructure

1) WHO Global Health Observatory Date Repository: Density by 1000 Country Data (Nigeria) Last Data: 2009

2) Mojeku, J. N; Ibekwe, U.: (2012) Maternal Mortality in Nigeria: Examination of Intervention Methods; International Journal of Humanities and Social Science, Vol. 2 No. 20, Special Issue.

3) Federal Ministry of Health (Nigeria). Integrated Maternal, Newborn and Child Health Strategy 2 (2007)