(i) review the historical context of health policy development in Nigeria and the roles physiotherapists can play in its implementation,

(ii) propose a conceptual framework on the connection between physiotherapy and health policy development,

(iii) discuss the broadening role of physiotherapists in health policy development and implementation,

(iv) proffer recommendations on how physiotherapists can become more proactive in policy development. 

An exhaustive search of the literature was conducted on the CINAHL and PubMed databases using the combination key words of "Health", "Policy", "Nigeria", and "Physiotherapy" to identify the relevant research that aligns with this article's objectives. Over thirty reports emerged, and they were reviewed and presented below.

The historical context of health policy development in Nigeria

First, a discussion of the historical development of health policies in Nigeria is appropriate here. The period between 1472 and 1880 witnessed the arrival of the country's western-style health care delivery system. Between 1880 and 1945 saw the building and staffing of hospitals by Christian missionary health care workers. From 1945 till today witnessed the development of several national health plans starting with the First Colonial Development Plan in 1945-1955 (Decade of Development). The other ideas that evolved are the following:

(i) 1956-1962: The Second Colonial Development plan 

(ii) 1962-1968: The First National Development Plan 

(iii) 1970-1975: The Second National Development Plan 

(iv) 1975-1980: The Third National Development Plan

(v) 1981-1985: The Fourth National Development Plan 

(vi) 2004-2008: Five Year Strategic Plan (Scott-Emuakpor, 2010).  

The new national health policy adopted in 2006 launched the National health insurance scheme that protects citizens against high costs of treatment, and fair financing of health care. The National Health Act of 2014 and the National Health Policy of 2016 were established to provide the framework for the development, regulation, and management of national health systems and set standards for delivering services. The new policy was a response to several unfinished agenda of the Millennium Development   Goals   (MDGs);   the    new    Sustainable Development Goals (SDGs); emerging health issues (especially epidemics); the provision of the National Health Act 2014; and the new Primary Health Care (PHC) governance reform of bringing Primary Health Care under one Roof and Nigerians’ renewed commitment to Universal Health Coverage (UHC). Other considerations were globalization; climate change; challenges of insurgency, and its impact on the Nigerian health system. Furthermore, the countries' experience in implementing the Revised National Health Policy 2004 and the National Strategic Health Development plan (2010-2015) provided the basis for the development of the new policy. The 2016 National Health Policy acknowledged the transition of disease burden in the country from communicable infectious diseases to non-communicable lifestyle diseases; thus, the strong rationale for the active involvement of physiotherapists in policy development and implementation. 

The underlying philosophy and central focus of the National Health Policy are based on the primary health care (PHC) concept that the services provided can reach the rural communities, where the majority of Nigerians reside. The goal of the PHC is to prevent and treat the disease, which is responsible for much morbidity, disability, and mortality (National Health Policy, 2016). Included in the National Health Policy objective is the involvement of diverse health care workers in PHC. Unfortunately, the participation of physiotherapy in primary healthcare is yet to be appreciated and given prominence. There has been a strong focus on PHC as the cornerstone of the Nigerian health system since 1975(Federal Ministry of Health, 1988). WHO initiated the community-based rehabilitation (CBR) program following the Alma-Ata Declaration in 1978 to enhance the quality of life for people with disabilities and their families, meet their basic needs, and ensure their inclusion and participation (World Health Organization, 2010. The CBR was initially a strategy to increase access to rehabilitation services in resource-constrained settings. However, CBR is now a multi-sectorial approach working to improve the equalization of opportunities and social inclusion of people with disabilities while combating the perpetual cycle of poverty and disability (World Health Organization, 2020). One of the components of CBR is the provision of functional rehabilitation services in rural areas. Though captured in the 2016 National Health Policy, this program is yet to succeed in its implementation.

The conceptual framework defining the connection between physiotherapy and health policy development and implementation

The World Confederation for Physical Therapy (WCPT) encourages physiotherapists to work with national governments and non-governmental organizations (NGOs) to develop policies that support the following stated goals in CBR (WCPT, 2020). 

 (i) Share appropriate CBR skills with health care workers, people with disability and their families, and others who help and support people living with disabilities (PLWD).

(ii) Contribute to the training of CBR workers and provide ongoing support to enhance sustainability.

(iii) Advocate for social change by implementing the disability right law signed into law on January 23, 2019.

(iv) Challenge discrimination and work with organizations that serve PLWD to strengthen positive attitudes about disability.

(v) Strengthen the local referral chain so that PLWD can access general health services as other community members.

(vi) Assist in capacity building to serve PLWD.

(vii) Strengthen the evidence base for CBR by engaging in evidence-based research on its effectiveness.

The Nigerian physiotherapists can potentially play significant roles in implementing the goals mentioned above recommended by WCPT. Sadly, none of the goals have been implemented in Nigeria. The WHO defines non-communicable diseases (NCDs) as "non-infectious and non-transmissible diseases that may be caused by genetic and behavioral factors and generally have slow progression and long duration" (World Health Organisation, 2013) NCDs are the significant causes of morbidity and mortality in most high and middle-income countries (World Health Organisation, 2013) NCD's such as heart diseases and stroke, cancer, diabetes mellitus, and lung diseases are strongly associated with lifestyle behaviors such as physical inactivity, unhealthy diet, and tobacco use. The NCDs are preventable and reversible by lifestyle behavioral change and health promotion (Dean, 2009). Coincidentally, physiotherapists promote the overall health and wellness of individuals with NCDs. Using their expertise in exercise therapy and lifestyle modification, physiotherapists can significantly decrease the burden of disease and disability. Thus, it makes sense to integrate physiotherapists' services in the development and implementation of health policy in the realms of health promotion and wellness (Dean, 2009; Interactive Guide to Physical Therapist Practice, 2003; Nicole, 2020).

A plethora of previous studies revealed that physiotherapists could reduce risk factors, prevent, and reverse NCDs through health and behavior-modifying patients' education. Physiotherapists are trained experts who prescribe physical activities and perform non-invasive hands-on-interventions consistent with the biopsychosocial model (Nicole, 2020). Unequivocal evidence revealed that physical activity positively affects NCDs and remains the most cost-effective intervention in reversing the epidemic. Moreover, physiotherapists play critical roles in mitigating (secondary prevention) the sequelae associated with chronic diseases by modulating pain, decreasing edema, and promoting overall health and   wellness.  Physiotherapists   have   well-established relationships with patients and spend more one-to-one time with them than most other healthcare professionals. Thus, it makes physiotherapists the optimal conduit for disseminating evidence-based preventive and health policy recommendations (Nicole, 2020).

Health promotion is a preventive strategy and a process of enabling people to increase control over and improve their overall health (World Health Organisation, 2019). An essential purpose of health promotion is to prevent disease and disability in individuals and populations (Morris and Jenkins (2018). Traditionally, physiotherapists offer services that focused on individuals or groups with specific disorders or limitations, but emerging evidence is now challenging these models. The global tilt towards health promotion has made it imperative that physiotherapists shift perspective and adapt to the prevailing disease model of prevention to reduce illness and NCDs, accidents, injuries, and disabilities in the population (Morris and Jenkins (2018). The 2016 National Health Policy situation analysis, while admitting the availability of various health promotion units at both Federal and State levels, however, lamented the often lack of effective leadership for health promotion. According to the National Health Promotion Policy 2006, there is little understanding of health promotion concepts, consumer rights, the need for multi-sectorial action, and the promotion of a supportive environment for behavioral changes in health care. 

Besides, there are few frameworks and guidelines in the existing literature for systematic planning and management of health education interventions in which physiotherapists play critical roles (Nigerian National Strategic Health Development Plan (NSHDP), 2010-2015).

Recent epidemiological investigation revealed that several types of cancers in twelve sites - mouth, larynx and pharynx, esophagus, lung, stomach, pancreas, gall bladder, liver, colon, rectum, breast, post-menopause endometrium, prostate, and kidney - are more prevalent among obese individuals due to reduced physical activity and poor nutrition (World Cancer Research Fund, 2019)

In 2009, following a critical analysis of the available evidence, Emeritus Professor Elizabeth Dean from the University of British Columbia, Vancouver, inferred that physiotherapists are the quintessential non-invasive health professional well-positioned play leading roles in health promotion interventions (Dean, 2009). Sadly, a decade later, the Nigerian health care system is yet to recognize physiotherapists as a frontline provider in promoting overall health using physical activities and lifestyle behavioral modification. The interventions are readily accessible in the community, sustainable, and cost-effective (World Health Organisation, 2013, 2020).

On the other hand, the Nigerian health system continues to commit more resources towards treating NCDs rather than preventing and promoting overall health and wellness.   

The first physical therapy summit on global health was held in 2011, and the second summit in 2014. The worldwide conference participants developed action plans for health promotion with the primary goal of reducing the burden of NCDs (Dean et al., 2011, 2014). As a result of these global initiatives, physiotherapists worldwide are now better informed about the management of the sequelae associated with NCDs. The research findings are useful tools for policy development and implementation.

The broadening role of physiotherapists in health policy development and implementation

Besides the well-known role of the physiotherapists in the hospital setting, in the last two decades, the profession has expanded the content of the education curriculum to include knowledge and practice in non-traditional settings. Physiotherapists have an essential contribution in CBR, which provides for besides treatment, initiating CBR programs, and providing policy advice to government, NGOs, and PLWD organizations. In Nigeria, physiotherapy services are extended to rural areas through the community physiotherapy (CP) services provided by itinerant physiotherapists from nearby secondary or tertiary hospitals (Mbada et al., 2019). Studies show that CP has not been impactful because it is not currently integrated into the nation's PHC program. The limitation is due to the unavailability of physiotherapy services in rural communities and poor knowledge of health workers' roles by the community dwellers. It is also due to poor healthcare-seeking behaviors of community dwellers, patronage of traditional health workers, and poor referral practice by health workers (Igwesi-Chidobe and Okafor, 2013; Igwesi-Chidobe, 2012).

A study conducted by Mbada et al. revealed that most physiotherapy services in Nigeria are in urban areas, particularly in teaching hospitals. Physiotherapy services provided within the community were mostly on an ad hoc basis. They concluded that a clear understanding of the determinants of physiotherapy utilization and supply might facilitate efficient resource allocation of service-notably, the services designed to address the needs of rural communities. There should be a dedicated custom-built physiotherapy clinic in every PHC facility in rural settings (Mbada et al., 2019). 

Reproductive and maternal health is among the stated priority areas of the 2016 National Health Policy. The policy goal is to reduce maternal, neonatal, child, and adolescent morbidity and mortality rates and promote full access to reproductive health care services for adolescents and adults throughout their life cycle Women's health is a recognized sub-specialty in physiotherapy by the WCPT since 1999. The role of physiotherapists in women's health has evolved over the years in Nigeria. The subspecialty in Nigeria has made some modest impact in reducing the risk associated  with pregnancy and childbirth and the promotion of obstetrics care. Still, physiotherapy services are underutilized by women of childbearing age because most obstetricians/gynecologists are not familiar with the medical conditions and disorders that are amenable to physiotherapy. The situation had resulted in late or non-referral. The delay accentuates the lingering debilitating symptoms of diseases and impedes the improvement associated with reproductive disorders (Stubblefield, 2017; Auguste and Naimark, 2017). 

Physiotherapists practicing within the women's health subspecialty are members of the obstetrics and gynecology healthcare team. Their intervention includes pelvic floor strengthening exercises (Kegel exercises or pubococcygeus muscle contraction) to help the women regain the bladder functions after childbirth, strengthen, and stretch the weak pelvic floor muscles in individuals with urinary or fecal incontinence pre and post-partum exercise programs (Rogers and Story, 2016). They equally use other adjunct therapies such as diathermy electrical stimulations, EMG biofeedback, vaginal cones, shortwave, TENS, patient education, and appropriate diet. Physiotherapists also evaluate and manage obstetric and gynecological conditions such as chronic pelvic and abdominal pain syndromes, dysmenorrhea, secondary amenorrhea post-operative complications, and neurological disorders (Balogun, 2019). Given this divergent clinical expertise, the physiotherapists can make a valuable contribution both in policy development and implementation as it relates to reproductive health.

As a result of the aging population, increasing incidences of malignancies, and other chronic diseases such as HIV/AIDS, the need for hospice and palliative care (HPC) has grown in Nigeria. HPC is a relatively new concept in Nigeria and is yet to be integrated into the Nigerian Health Policy. In the USA, HPC deals with the care of persons with a terminal illness, and when a patient has six months to live, he/she is categorized as terminally sick and qualifies for HPC. The physiotherapist is a member of the HPC team, which comprises a physician specializing in palliative medicine, a nurse, social worker, clinical psychologist, clergy, occupational, speech, and music therapist (Balogun, 2021) 

The HPC physiotherapist has a significant role within the team. While the goal of physiotherapy intervention in HPC is not to restore premorbid functionality but to give individuals with terminal illness some degree of independence, reduce the care burden, and promote some degree of quality of life. Nigeria is yet to come up with a policy on HPC. As a member of the HPC team, physiotherapists have been engaging in research in this emerging field of healthcare Chugbo et al., 2015) and can contribute to policy development and implementation in this field.

The 21st-century physiotherapist operates on three levels: as a clinician, educator, and researcher. The physiotherapy training curriculum at both undergraduate and  postgraduate degree levels equips the students with the necessary competence and skills to engage in evidence-based research relevant to health policy development and practice. While evidence of research efforts abound, the challenge, the physiotherapist's face is translating research findings into policy. Linking the relevant clinical research with health policies and decision making is necessary to provide decision-makers with empirically-based and scientifically valid information on service delivery. Not much of that has occurred between physiotherapy researchers and policymakers in Nigeria. Could it be that the policymakers are unaware of such research information, or the researchers have insufficient knowledge of the process of translating research findings into policy and practice? There is a need to bridge the gap between researchers and policymakers to influence policy development and implementation to produce greater accessibility to quality, cost-effective, and sustainable physiotherapy services in Nigeria.

Physiotherapists worldwide, including Nigerian trained physiotherapists, have contributed to national and regional policy formulation impacting human services delivery. For instance, a physiotherapist chaired an Institute of Medicine Committee that identified steps to strengthen the evidence for public and private actions to reduce the impact of disabilities on individuals and society in the USA (Crack, 2009)

Physiotherapists serve on the Board of Directors in the Canadian Stroke Strategy Network, which provides a framework to facilitate the adoption of evidence-based best practices to prevent, treat, and rehabilitate Canadian individuals, families, and society (Crack, 2009).

A Nigerian trained physiotherapist, Professor Abiodun Akinwutan, in 2002, chaired a Belgium committee that developed the functional benchmark for issuing driver's license following stroke. In 2003, a Distinguished Professor of Physiotherapy, Joseph Balogun, installed cameras in the public spaces within the resident homes of PLWD. The technology is to enable management to track direct support staff interaction with residents to detect cases of abuse/neglect and theft of medications, food, and properties.

The time has come for Nigerian physiotherapists to decide on the level at which to operate within the healthcare system. The clinical expertise, knowledge, and research evidence generated by physiotherapists should impact health policy development and implementation. Particularly in policies that deal with PHC, CBR, medical rehabilitation, injury prevention, health promotion, reduction of the impact of disabilities, strengthening reproductive and maternal health, and core services of disease prevention and treatment. The physiotherapy community in the country must begin to consider strategic  plans  that  will  enhance  engagement with more significant health care policymakers and other relevant stakeholders at both federal and state levels.  The benefits of incorporating physiotherapy services in PHC should be supported with appropriate empirical evidence.

Efforts should be made towards collaboration with other healthcare professionals to engage in evidence-based research that has implications for physiotherapy services. And pragmatic steps should be taken to ensure the research findings are translated into health care policy. Physiotherapists should collaborate on health policy implementation with other stakeholders - health care providers, NGOs, technocrats, and policymakers. The networking will no doubt increase awareness of the potential contributions of physiotherapy in health care enterprise.

Additionally, the implementation of the approved doctor of physiotherapy (DPT) program in 2018 by the National Universities Commission should be started without further delay. The DPT curriculum should strengthen the health policy and health system contents. The time has come to vigorously pursue the establishment of a Directorate for Physiotherapy at both federal and state Ministries of Health. The creation of the directorate will allow for effective coordination of the broadening scope of physiotherapy services and emerging interventions. Medical Rehabilitation Therapist Board of Nigeria and the Physiotherapy Professional Association should start encouraging and supporting research that generates relevant data that support the urgency of addressing the acute shortage of physiotherapy human resources needs, particularly in the rural areas of the country. A review of the remuneration for physiotherapy services within the National Health Insurance scheme has become imperative to encourage the private practice practitioners' more substantive participation in line with PHC. Health policy and system research should be incorporated in both undergraduate and postgraduate physiotherapy training curriculum.

As a frontline member of the health care team, Nigerian physiotherapists, like their counterparts in high and middle-income nations worldwide, can make meaningful contributions to the national health policy agenda. In conclusion, the issues raised in this article will stimulate the authors’ colleagues to become more proactive in health care policymaking, rather than continue to react to the policies developed by other power player stakeholders. It is time for health policymakers in Nigeria to consider physiotherapists' active involvement in national health policy development.

The authors have not declared any conflict of interests.