Where are social workers?: Nigeria’s primary healthcare deprived of social care and justice

PRINCE AGWU, PhD 

Prince Agwu holds a doctorate in Social Policy, with affiliations at the Department of Social Work and the Health Policy Research Group, University of Nigeria, Nsukka, as well as the School of Humanities, Social Sciences, and Law, University of Dundee. He is the African Section Editor of Social Work and Social Sciences Review; Associate Editor, Health Research Policy and Systems, and the Communications Lead for the African Health Observatory Platform (AHOP), Nigeria. He can be reached at  prince.agwu@unn.edu.ng

The Minimum Standards for Primary Healthcare (MSHP) in Nigeria made mention of ‘Social Worker’ just thrice. On the first two, social workers were lumped with Community Health Extension Workers (CHEWs), with the caveat that social workers are restricted to counselling, and CHEWs can also perform the same role. The third mention was very ‘reducing’, describing social workers in the category of ‘other community health personnel, as may be available’. This means that Nigeria’s primary healthcare is not obliged to employ social workers, which is shocking. Another shocker is the fact that the MSHP never mentioned ‘psychology’, let alone ‘psychologist’.

A second important policy document for primary healthcare in Nigeria is the 2023 National Mental Health Policy (NMHP). Unlike the MSHP, the NMHP recognises social workers but presents the profession as though it is operational in primary healthcare, and it demonstrates a poor understanding of the roles of social workers in health settings. The document makes a false claim about insufficient quantity of qualified social work workforce in Nigeria and even extends the false claim to other social service professions.

Lapses in social service representation in the two policy documents I have mentioned is indeed concerning. It leaves us worried about the interprofessional competence and awareness of the experts that crafted the policy documents. Thankfully, there is now a blend of social welfare in the naming of Nigeria’s health ministry, but that is not enough. The fundamental intent of this new naming can only be realised when the health sector under Professor Muhammad Pate’s leadership fully and sincerely commits itself to equal recognition for psychosocial and clinical services under one roof.

Social workers are among the best paid in developed nations and many are in healthcare

There are over 107,000 social workers in the United Kingdom, and in the mental health division of the National Health Service (NHS), you are certain to find over 2200 mental health social workers. The USA has over 160,000 healthcare social workers in employment. In both countries, social workers are distributed across all levels of healthcare, and primary healthcare is of top priority. It is so because primary healthcare is the closest level of care to the community, hence in need of social service professionals who are community oriented and trained to pursue social protection, social justice, and community-centred care for all people, inclusive of the vulnerable.

In both the UK and USA, healthcare social workers earn an average of $45,000 annually. The scope of work of social workers, and the amount of money they earn, should do justice to telling anyone the extent of the profession’s workload and importance, including how delicate it is in health settings. Unfortunately, Nigeria is yet to come to this realisation, despite obvious social justice, social protection, and social care gaps in its healthcare system, especially primary healthcare.

Know about social work in a bit

Social work is an umbrella discipline for diverse specialties, and healthcare social work is one. It could be referred to as medical social work, hospital social work, and on the mental health side – psychiatric social work and mental health social work. There are different social work specialties away from the health sector. However, the first level of training for social workers is focused on ‘generalist practice’, where the trainee is theoretically and practically exposed to a broad range of social work fields. The generalist training is designed to ensure that the social worker can get entry employment into any available social work field, before going further to pursue a specialty.

Twelve critical concepts capture the breadth of social work training, and they are: (1) social care (2) social justice (3) empowerment (4) liberation (5) human rights (6) social cohesion (7) social change (8) diversity (9) collective responsibility (10) social protection (11) dignity, and (12) wellbeing. All 12 concepts are at the heart of undergraduate and graduate social work training, tending toward the purpose of making sure that social workers are sufficiently equipped to address life challenges through a combination of material and non-material resources at individual and system levels.

In the health sector, social workers continue to demonstrate the essence of their training, and it is a pity that Nigeria is lost on such essence. First, social workers are part of the multidisciplinary healthcare team. They provide case management roles for patients, where they coordinate effective application of a wide range of services needed to cater to the wellbeing of patients. They ensure communication with families, colleagues, and friends of patients, explaining treatment plans, following up on consents, managing tensions, building hope, following up with those who have been discharged, providing community-based care for outpatients, preventing patients from any form of ill-treatment, explore resource options for service users experiencing hardship, and issuing official communication to those who hope to make decisions based on the recovery status of a patient, e.g., schools and workplaces.

Healthcare social workers are also obliged to the wellbeing of providers, and where necessary, they perform human resource management roles. They stand before authorities, advocating for the wellbeing of the healthcare system, and helping to stimulate political attention for healthcare, with the recognition that healthcare is an inalienable right. There is evidence to show that the avoidance of effectively mainstreaming social work in healthcare and other systems could be deliberate, especially when authorities have refused to be accountable and pro-people.

Is primary healthcare in Nigeria shying away from being socially just and responsible by avoiding social workers?

It is unfortunate to know that there are no qualified social workers in Nigeria’s primary health facilities. By qualified, I mean those who have either a Bachelor’s or Postgraduate social work qualification. This is shocking and puts primary healthcare down. The definition of health by WHO is clear about the physical, social, and psychological components that characterise the full reach of health. And no one health profession is trained to cater to all. It is a disservice to interprofessional commitment that we have a healthcare system in Nigeria, solely focused on clinicians like medical doctors, pharmacists, nurses, laboratory scientists, etc., and other supportive clinically oriented workforce like community health officers and CHEWs.

It is sad that even when health authorities talk about the health workforce in the media, they conspicuously miss out on social service professionals, which is very concerning, and some will say that it questions the quality of interprofessional competence of the health authorities. It does appear that there are no plans for integrating social service professionals into the health system, primary healthcare especially. Even with a crested ‘social welfare’ to the health ministry, nothing has changed as of the time of writing this article.

I have conducted studies that show the abuse and exploitation of service users by clinicians and facility managers. I have also conducted studies where young people refuse to report to health facilities for sexual and reproductive health services because of the unprofessional conduct of clinicians. There are many studies on health sector corruption and weak accountability, with service users at the receiving end. The unfortunate part is that these exploited, abused, and disappointed service users have no one to talk to.

Have we ever asked, who watches the activities of health providers at the frontline? Who ensures that standards are respected, and rights are protected? And even the health providers who feel dissatisfied with the system in terms of economic and social security, availability of health equipment and infrastructure, and unfortunately, lack of physical security, do not have anyone whose duty it is to consistently bring these issues to the fore of conversations and political attention.

Service users walk in and out of a health system that is blinded to their psychosocial concerns and needs. Families and friends of patients have no one to walk them through the system with care and consistent show of empathy. The deprived, vulnerable, and indigents, are left in pitiable conditions, and we can see increased cases of detention in health facilities, especially for a health system that is largely reliant on out-of-pocket spending. It does seem that we have a primary healthcare system that has refused to recognise the social and psychological needs of service users, or that is shying away from social protection and social justice which are central to the professional responsibility of social workers.

There are thousands of qualified social workers in Nigeria

There are over 20 higher education institutions across the six geopolitical zones in Nigeria that train social workers. Over the past five years, more institutions have been gaining accreditation to offer social work. The University of Nigeria which is the foremost social work training institution in Nigeria, annually produces no less than 100 social workers across the bachelor’s and graduate programmes and has been actively producing social workers since the 1970s. If 20 social work institutions have committed to annually produce 100 social workers in the past ten years, it is expected that by 2024 Nigeria should have about 20,000 social workers. And if you add the years before 2014 and those who may have trained in the diaspora, we could have double that figure, notwithstanding those who may have left the country. Functional primary healthcare facilities in Nigeria are about 20,000, and I am confident that the number of qualified social workers in the country would go around the facilities to a reasonable degree. We can also leverage social service support from social work interns through placements.

My sincere and strong appeal

Nigeria’s health sector has grown enough not to be comprehensively serviced. Primary healthcare facilities are the last-mile providers of health services, and we must take them seriously. The health leadership must practicably commit to the overall well being of service users at that level by making sure the facilities are appropriately staffed by clinicians and social service professionals like social workers and psychologists. The leadership should call for an honest interprofessional dialogue for primary healthcare facilities, and standard operational procedures for interprofessional relationships should be documented, communicated, and used to revise existing policy documents on primary health services delivery.

We have studies that have shown a complete mess of clinical interventions because of the absence of corresponding social services. A victim of rape or domestic abuse is most likely to go back to the predator after clinical care because the right professional to assess for such threats and manage such cases is absent. Nigeria will never attain UHC or any other global health goals if primary health facilities remain without qualified social justice and social care professionals.

Social work has been signed into law as a profession in Nigeria. Next is to strengthen their presence in our health facilities, which is the acceptable standard for mainstreaming, preserving, and promoting human rights, social justice, and social protection in healthcare. We must note that psychosocial care is a specialised service, and the right professionals should be employed and deployed to manage all of it at the frontline.

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