By Iheomimichineke Mystery Mimi Ojiakor, Health Policy Research Group, University of Nigeria
In Nigeria’s urban slums, when a child has a fever or a woman goes into labour, the first point of call is rarely a hospital. It is the neighbourhood chemist, the traditional birth attendant (TBA), or even the bonesetter down the street. These informal healthcare providers (IHPs) are close, trusted, and affordable—but they operate outside the formal health system. Without supervision, their practices vary widely, referrals are mostly verbal, and the quality of care is inconsistent.
Recognising this reality, the CHORUS Nigeria Project 1, part of the global Community-led Responsive and Effective Urban Health Systems (CHORUS) Research on Urban Health, set out to bridge this critical gap. Implemented by the Health Policy Research Group at the University of Nigeria, the project’s goal is simple but transformative: link informal providers to the formal health system so that even the poorest residents in slums can access safe, timely, and equitable care.
The journey began with listening. From 2021, the CHORUS team held consultations with state health authorities, primary healthcare agencies, and community leaders in Enugu and Onitsha, two cities with dense slum populations. Through mapping and reconnaissance, eight informal settlements were identified. Baseline research revealed what many had suspected but few had quantified: nearly nine out of ten slum residents support linking informal providers to the health system, and most are even willing to pay small fees for better quality care.
Armed with this evidence, the team convened a co-creation workshop where government officials, providers, and community members co-designed simple, locally workable solutions. These included structured training, easy-to-use referral booklets, registers for record-keeping, and job aids to guide diagnosis and treatment. Beyond the tools, CHORUS supported the creation of an Urban Health Unit within the Enugu State Ministry of Health, ensuring a permanent home in government to coordinate, supervise, and evaluate the linkage.
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The impact is now visible. Patent medicine vendors check blood pressure before dispensing drugs. TBAs use gloves and know when to refer complicated births. Bonesetters disinfect tools and recognize when fractures need X-rays. Community leaders, trained to monitor progress, take the message to churches and markets: “If your provider cannot handle it, ask for a referral.” Referrals, once rare and verbal, are now written and tracked. Feedback between providers and PHCs is improving, one phone call and one referral slip at a time.
Challenges remain – some providers still fear losing clients if they refer, and patients struggle with the costs of transport or diagnostics – but the foundation is strong. The Urban Health Unit now serves as an accountability bridge between informal providers and the formal system. For the first time, data from slums can feed into the District Health Information System (DHIS2), ensuring visibility and inclusion in state planning.
The lesson from the CHORUS project is clear: fixing the health system is not always about building new hospitals, it’s about strengthening the links that already exist. When policymakers invest in these connections, they invest in trust, safety, and sustainability. Nigeria’s journey to universal health coverage will not begin and end in conference rooms; it also includes the chemist shops, maternity homes, and bonesetter homes where care already happens. Because when the system listens to where care truly begins, it learns how to heal where it hurts the most.
About the author: Iheomimichineke Mystery ‘Mimi’ Ojiakor is a PhD candidate in the Department of Health Administration and Management, and an academic researcher with the Health Policy Research Group, both at the University of Nigeria. She is part of the CHORUS Nigeria Project 1, focused on strengthening health system linkages between formal and informal healthcare providers in urban slums. Some of her published works include:
Iheomimichineke Ojiakor, Obinna Onwujekwe, Joseph Paul Hicks, Health Policy and Planning, 2025; czaf068, https://doi.org/10.1093/heapol/czaf068
Iheomimichineke Ojiakor, Enyi Etiaba & Obinna Onwujekwe, Discover Public Health, 2025; https://doi.org/10.1186/s12982-025-00951-6
Chinelo Obi; Iheomimichineke Ojiakor; Enyi Etiaba; Obinna Onwujekwe, International Journal of Public Health, 2024; 10.3389/ijph.2024.1606810
Chibueze Anosike, Iheomimichineke Mystery Ojiakor, Enyi Ifeoma Etiaba, Nkolika Pamela Uguru, Charles C. Ezenduka, Obinna Onwujekwe, Vaccine, 2025; https://doi.org/10.1016/j.vaccine.2025.127853
Chukwudi Nwokolo, Obinna Onwujekwe, Martin McKee, Iheomimichineke Ojiakor, Blake Angell & Dina Balabanova, Health Economics Review, 2025; https://doi.org/10.1186/s13561-025-00654-3
- What is the Future of Nigeria’s Health Sector? A Look at the Presidential Candidates’ Manifestos (https://republic.com.ng/february-march-2023/the-future-of-nigerias-health-sector/ )
- CHORUS Working Paper: The Private Health Sector in Nigeria: An Overview (https://chorusurbanhealth.org/resources/chorus-working-paper-the-private-health-sector-in-nigeria-an-overview/ )