_Elijah Olusegun and Kevin Mwanza (Lead Writers)_
Seidu Olumide's experience at the Igando-Egan Primary Health Centre (PHC) in Lagos was hindered by a significant communication barrier. As someone who requires sign language, he often found unavailable, forcing him to rely on his son as an interpreter during his previous visit in November.
In Kenya, Hamphrey Washika, a patient from Uasin Gishu County, undergoing a daily physiotherapy routine at St. Luke's Orthopaedic & Trauma Hospital, expressed frustration that people with his condition are often overlooked in Kenya's healthcare system. Notably, none of the county's 31 public health facilities, including the Kapsoya Health Centre, offered the specialised services he required.
Nigeria and Kenya have committed to ensuring healthcare accessibility for persons with disabilities (PWDs) by ratifying Article 17e of the Protocol to the African Charter. This article mandates providing healthcare services to PWDs within community settings. Both countries have also enacted national disability laws that share similarities, demonstrating their dedication to promoting inclusive healthcare.
In 2023, Nigeria's disability commission visited Kenya's counterpart to exchange ideas, further solidifying their collaborative efforts. The primary healthcare system management policies in both countries align in recognising the rights to accessible primary healthcare.
However, none of the countries have fully implemented these rights for Olumide and 35 million others in Nigeria -- and the six million Kenyans with disabilities.
**A long time coming**
Nigeria and Kenya's primary health policy initiatives, launched in the 1990s, have a significant flaw: they exclude PWDs. This oversight has persisted to this day, causing concern among organisations like Caritas Nigeria and the Justice Development and Peace Commission (JDPC).
To address this issue, Nigeria's National Primary Health Care Development Agency (NPHCDA) introduced the Ward Health System in 2001, which restructured the Ward Development Committee (WDC). This revamped system proved beneficial when the agency launched the Minimum Standards (MS) toolkits, aimed at providing top-notch primary healthcare services at affordable costs.
Notably, the improved structure allows at least one PWD in each electoral ward to join other community leaders on the WDC, ensuring that every PHC has representation from the disability community.
Kenya's Primary Health Care Strategic Framework similarly introduced the Community Health Committee (CHC) in every county, mirroring Nigeria's WDC structure. Both committees oversee the delivery of essential health services, including rehabilitation, referral, maternal and child healthcare, and other vital services, which are packaged as Kenya Essential Health Packages (KEHPs) and Nigeria's Minimum Service Packages (MSPs), respectively.
Still, many PWDs, especially in Nigeria, lack awareness about inclusive primary healthcare, including Adeleke Razak, a visually impaired community leader in Akinyele LGA in Lagos. As a stakeholder, he may have valuable insights, but the actual responsibility for addressing the issue falls squarely on the WDCs. Their mandate is specifically designed to handle such matters, making them the go-to authority.
Lukman Salami, a lawyer and chairman of the Joint National Association of Persons with Disabilities (JONAPWD) in the state, emphasises that accessibility goes beyond just installing ramps. Despite his efforts to promote inclusivity, Salami notes that the visually impaired, those with learning disabilities, and those with hearing difficulties still face significant barriers in accessing primary healthcare.
_"Look at those with intellectual disabilities,"_ Salami said. _"They can't get drugs and therapy, which are some of the routine treatments they need for their well-being in those PHCs."_
**Lack of representation**
Some non-governmental organisations have successfully implemented aspects of Nigeria's Minimum Standards, particularly the adaptable Ward Health System. Break-Through-Action (BTA), for instance, found that collaborating with WDCs was an effective strategy in Nigeria, following a five-year campaign that engaged 659 WDCs across five states.
However, despite this success, the potential of WDCs in promoting disability inclusion remains unexplored. This oversight raises questions, with some speculating that WDCs might be used to compensate political allies rather than serve the community's needs.
Sunday Ekundayo, chairman of WDC 11 in Akinyele, Ibadan, has been leading his team since the launch of the MS in 2012. Despite their efforts, Ekundayo admits that disability inclusion has never been a consideration for his committee. However, he acknowledges that the JDPC has consistently reminded them to prioritise the needs of people with disabilities.
Kenya's Framework may not have achieved better results. Like Nigeria's MS, the Framework emphasises PHC governance, suggesting that PWDs can have representatives on CHCs that manage over 100 PHCs in Kenya. Kenya's policy goes a step further by providing CHC members with a comprehensive seven-module trainer manual and trainee handbook. In contrast, NPHCDA has not documented its Participatory Learning and Action (PLA) training programme for selected model PHCs. This lack of documentation and guidance may explain why WDCs often overlook disability representation.
**Where the gaps lie**
The WDC members are not unsympathetic, however. "Even if it's not on our minds, we should make provisions for people with disabilities in everything we do," Ekundayo acknowledged, gesturing towards the inaccessible entrance of a PHC where 11 chairmen had met earlier.
Ekundayo's introspection came after he and four other chairmen initially defended their lack of action, citing that their training and manuals made no mention of disability inclusion and that they were unable to find people with disabilities to participate.
On hearing Ekundayo's statement, Salami, the chairman of JONAPWD, expressed scepticism that the committees could not find PWDs to represent their communities. He emphasised that he was not referring to those who are struggling but rather successful individuals who can effectively advocate for their rights. In contrast, Razak and Okiki, two PWDs, believed that the committees underestimated PWDs' capabilities, thinking they could not accomplish tasks, and were simply feigning ignorance.
It was also through this reporting that NPHCDA was informed about the WDCs' neglect of disability inclusion. Ngozi Nwosu, Director of Primary Health Care Systems and Development, acknowledged that the WDCs have not been adhering to the Standards, which include disability inclusion.
Nwosu also stated that the effectiveness of orienting voluntary committees like the WDCs using the PLA approach, especially since the training hasn't been conducted in a while, was subpar except in select model PHCs. She noted that the NPHCDA cannot be everywhere at once, with approximately 10,000 wards to cover, and suggested that state PHC boards should take responsibility.
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In Kenya, despite the availability of the seven-module manual, an analysis of the handbook reveals the omission of a lack of instructions on disability awareness and representation.
Furthermore, it was difficult to confirm whether CHC leaders in Washika's county have PWDs as members, but the committee's apparent lack of awareness on disability issues may lead to neglecting representation for PWDs.
**A path to progress**
Despite initial scepticism, Salami remains committed to ensuring proper disability representation in WDCs. His focus has shifted to understanding the policy, and he, along with his Oyo counterparts, have requested copies of the MS policy. Salami believes that leveraging the Lagos disability law could facilitate uniform implementation across states, including Lagos. He plans to collaborate with the Lagos office of disability to achieve this goal.
Azu-Obi, a disability rights activist in Nigeria, highlighted the importance of launching anti-discrimination campaigns and providing more training focused on the health sector to ensure equality, quality, and access.
Nwosu also noted that they plan to revitalise the WDC structure by providing logistics, and Azu-Obi suggested that this revitalisation should include training on disability awareness to promote inclusivity.
Harun Hassan, a disability rights activist in Kenya, hopes that the country's Economic Agenda 2030 will address this issue. The agenda aims to provide 100% universal health coverage and equitable access to essential healthcare services.
However, the success of this initiative relies heavily on the awareness and knowledge of CHCs in making primary healthcare accessible to people PWDs.