TOWARDS FUNCTIONAL PRIMARY HEALTH CARE AND UNIVERSAL HEALTH COVERAGE IN NIGERIA

By Dr Mohammed Jibril Abdullahi,

Independent Blogger

Background

Access to primary health care is the foundation of good health and the major determinant and driver of a nation’s health outcome, and like in many countries, the primary health care system in Nigeria is the cornerstone and the hub of the health system. However, over the years, primary health care system had remained grossly inefficient. The system has been reported to suffer from systemic weaknesses attributed to gaps ranging from infrastructural delay, inadequacy in human resources, essential drugs and other supplies etc (World Bank, Improving Primary Health Care Delivery in Nigeria, 2010). The result has been poor access to quality care and suboptimal health outcomes.  The current status of primary health care in Nigeria cannot guarantee Universality and Equity based on the goal of Health for All.

Incidentally, health frequently becomes a political issue as governments try to meet people’s expectations. In most countries, people rate health as one of their highest priorities, behind only economic concerns, such as unemployment, low wages and a high cost of living.  

For a government that rode to power on the change mantra, it is inevitable that primary health care be accorded top most priority to meet the expectations of the people for better health. Categorically, the path towards better health for the great majority of the population can’t be by any other means than through Revitalization of Primary Health Care.

While there has been some progress in PHC development over the years, evidence from multiple sources indicate that sufficient progress has not been made in our efforts to attain national and international health goals (NDHS 2013, WHO: The African Regional Health Report 2014, Millennium Development Goals End-point Report 2015, MICS 5 2016/2017). The situation calls for greater commitment by the government.

More so, this is the time the goal of the global community is to develop health systems so that all people have access to quality services and do not suffer financial hardship paying for them. This goal is defined as Universal Health Coverage.

The aforementioned developments constitute a strong justification for new commitment towards primary health care revitalization and riding on the current change agenda and international commitment towards Universal Health Coverage (UHC).

UHC is a powerful concept in public health today. It is defined as the ability of all people who need health services to receive them without incurring financial hardship, thereby achieving equity in access. UHC consist of two interrelated components:

1. Coverage with quality health services, including promotion, prevention, treatment, rehabilitation and palliation
2. Coverage with financial protection for everyone.

From the foregoing, it is clear that UHC has both demand and supply perspective. Consequently, the demand side without the supply side cannot guarantee UHC. The existence of a well-functioning health system based on primary health care and a timely access to services is therefore critical for attaining UHC.

Based on available reports, we are aware of the need to address the gaps and inadequacies in PHC delivery.

Learning from the Past

Several attempts have been made in the past to provide effective and efficient health services with wide coverage in Nigeria.

The first attempt was in 1976 when the Federal Government introduced the Basic Health Services Scheme (BHSS) as part of the 1975-1980 Development Plan. Many health facilities of different categories were constructed and equipped all over the country.

In addition, new cadres of community health workers were introduced. These were the Community Health Officer (CHO), Community Health Supervisor (CHS), Community Health Assistant (CHA) and the Community Health Aide (CHAide). The cadres were later on streamlined into 3 cadres, the CHO, Community Health extension Worker (CHEW) and Junior Community Health Extension worker (JCHEW).

The second attempt was in 1986 when 52 pilot LGAs were chosen to be developed as model PHC LGAs. Rigorous activities werecarried out, starting with baseline data survey and situation analysis. Project Formulation and Plan Implementation workshops were conducted to plan activities using collected data. The LGAs were granted a "seed package" comprising a motorcycle, drugs from an "Essential Drugs List" and five hundred thousand Naira each to implement their activities.

In 1988, Bamako Initiative (BI) was introduced as a strategy to strengthen PHC in the same 52 LGAs and the LGAs were supported with resources and provided guidelines. for the managerial infrastructure. Community Development Committees operated a 'Drug Revolving Fund" and this worked well in many LGAs. However, the desired objectives were generally not achieved because the people were passive recipients in most places and had limited power.

The LGA focused PHC initiative which was implemented between1986 and 1992, culminated in the attainment of Universal Child Immunization (UCI) target of 80%, high rating of the country’s PHC programme by the WHO Review Team and the creation of the National Primary Health Care DevelopmentAgency in 1992.

Unfortunately, the period between 1993-1999 witnessed loss of the earlier gains as a result of instability in governance, poor funding, lack of political support, low capacity of the local governments to manage PHC and withdrawal of donor support etc

The third attempt was in 2000. Recognizing the serious deterioration in the nation's health system and the central role of PHC, the new civilian regime in 2000 repositioned the National Primary Health Care Development Agency and mandated it to revitalize the nation's PHC system. The Ward Health System (WHS) was adopted as a strategy for the purpose. Considering the appeal of the WHS initiative and its community orientation and focus, there cannot be a better strategy for PHC revival, and a pathway for Universal Health Coverage.

Strengthening the LGA Health Authority

The LGA Health Authority holds the key to functional and effective primary health care in Nigeria.The LGA level represents the third layer of the health development framework. It is the operational level and the structures and institutions at the LGA level provide overlapping operational support. It is at this level that all resources both human and materials are pooled for implementation of primary health care.

Most Daunting Challenge

Weaknesses in the LGA Health Authority have been the most dauntingand most intractable challenge in developing a sustainable functional PHC system.

For meaningful and sustainable progress in primary health care development, this level must be sufficiently empowered in all ramifications. This must include:

1. Appropriate human resources and capacity, both in quality and quantity in technical and management areas including financial management.
2. Autonomous Operation’s funding.

The budget of the LGA Health Authority must be sufficiently funded and the department or authority be Sub-accounting with the Head designated as Officer Controlling Expenditure with financial responsibility.  This will promote smooth and unimpeded programme implementation.

3. Effective Management Support System

Good management support system that enables supportive supervision, programme monitoring, mentoring, evaluation and sufficient operational logistics must be established.

It is mandatory for the federal government to mobilise sufficient political commitment towards Strengthening the LGA Health Authority.

There can be no progress in PHC implementation without addressing the aforementioned requirements at the LGA Health Authority.

Caveat for Noting

The PHC Reform akin PHC Under One Roof (PHCUOR) was informed by the need to streamline and harmonise the role of stakeholders in PHC development with the aim of strengthening PHC at the operational level. Therefore, the State Primary Health Care Boards or Agencies as the case may be must not operate as the State Ministry of Health. They should exercise more of coordination and facilitatory function aimed at empowering and building stronger LGA health system. Their existence and roles will be meaningless without strong LGA Health Authorities.

Overall Goal

Accelerate progress towards UHC

General Objectives:

Sustainable progress towards UHC requires a strong and resilient primary health care system. In collaboration with other tiers of government and key stakeholders, the Government of Nigeria (GON) should step up efforts targeted at strengthening the primary health care system through multi-year primary health care development plan at the State/LGA/Ward level to create functional Basic Health Unit (BHU) linked to a referral facility and taking into account the existing health facilities to be rehabilitated and equipped, human resources and supply needs in such a way, among others to:

1. Identify, rehabilitate and equip appropriate number of primary health care centres (depending on the ward population) in each ward and designate  as Ward Health Centres.
2. Increase physical access to health services from 40% to 80% by 2030
3. Ensure that at least 80% of wards organise effective ward health service  with particular focus on maternal, neonatal and child care by 2030
4. Ensure that at least 80% of the wards have facility that meet the minimum staffing standards by 2030
5. Ensure that at least 80% of Ward Health Centres have a sustainable drug supply system that delivers adequate, safe and efficacious essential drugs and other medical supplies.

WHS Operational Design

Responding to similar scenario of dysfunctional PHC delivery system in the past, the GON through the National Primary Health Care Development Agency had provided hope and succour for Nigerians to live socially and economically productive lives by the introduction of the Ward Health System.  The development of the ward health system was to contextually align the PHC systems with the current political arrangements with the ward as the smallest political units. The latter provides an operational base for PHC system development and implementation. The political leadership at this level provides a potential rallying point for mobilization and a catalyst for greater community involvement and participation towards a sustainable PHC.

The implementation of WHS has attained nation- wide status, with variable level of success.

Its fundamental principles would be:

1. The WHS is not a vertical response, and therefore, GON’s role will be facilitatory and enabling.
2. WHS will be a collaborative effort between the three tiers of government based on shared roles and responsibilities.
3. WHS approach is a bottom up approach to health development. It will also be community owned and community driven to ensure accountability to our people, and therefore ensure sustainability.
4. The WHS approach will ensure a well-functioning primary health care service delivery that guarantees availability and timely access to services in each political ward.

The WHS Context

The WHS targets provisionof integrated basic services at both the community and facility level through the Ward Health Centres (WHCs) which is or are carefully selected Primary Health Care Centre (s) that has been upgraded in infrastructure, human resources  based on established guidelines, essential drugs, data tools and maternal and child health cards etc, and the satellite PHC Clinics/Posts in the ward.

Each WHC (s)will cover 6 designated (mapped) health areas, with each health area having  Community Health Extension Workersdeployed to lead/anchor community health service delivery, and have a strong linkage with a referral General Hospital in the LGA.

The lessons learnt in the past should be taken into consideration and used to guide the proposed efforts. One key lesson that should be carried forward is the need to ensure that we avoid what did not work.

Implementation Strategies

Strong and committed partnership with the states/LGAs will be required to deliver the programmein a sustainable manner. To achieve this, there is the need to jointly develop and endorse a Cooperative Assistance Framework (CAF)for Primary Health Care Revitalization (CAF-PHCR) with contributions from the states/LGAs and development partners to undertake specific interventions.

The Framework for Primary Health Care Revitalization should be designed into ten (10) strategic project areas:

1. Advocacy, Sensitization and Mobilization: There will be the need for Advocacy, Sensitization and Mobilization of stakeholders for Partnership/Coalitionand Consensus building towards joint planning and programming.
2. Infrastructural Revival: Improving primary health care infrastructure through rehabilitation of facilities and supply of equipment through innovative schemes likeindirect contracting or Conditional Grants Scheme model to beneficiary communities.
3. State Essential Drug Programme: Revival of State Essential Drug Programmeto kick state DRF in the LGAs or direct grant to the Ward Health Centres to be co-managed by the WDCs/Health Facility Management Committees
4. Human Resources: mobilization/deployment & redeployment of health workers. Each State should be encouraged to establish State Volunteer Health Worker Scheme to mobilise and register/collate data on unemployed health workers in each state for deployment to areas of need, first as a volunteer and later as permanent employee of the state/LGA governments after agreed period of time.
5. Improving Primary Health Care leadership and governance: Improving Primary Health Care leadership and governance through management support to SPHCBs/LGHAs and health facility managers including capacity building and effective supervision, monitoring and evaluation.
6. Strengthening Integrated Service Delivery: We would need to create database ofpopulation profile for every community through household registration (house numbering) so that all Nigerians will have health registration number. As a matter of necessity primary health care services must be integrated, community and people-centred, focusing on the  community/household/family with new role of channelling, targeting services and tracking by community nurse/midwife and CHWs, and environmental health assistants/aids becoming more and more significant.
7. Strengthening Community Partnership: Strengthening and institutionalizing community partnership and ownership through revival of WDCs and the training on roles and responsibilities.
8. Capacity building – training and retraining of health workers.
9. Strengthening Health Management Information System
10. Community Health Surveillance

Implementation Strategies &Framework

CAF for Primary Health Care Revitalization should be implemented in a systematic manner in collaboration with other tiers of government and the development partners.

2. Community Mobilization and Household Registration 
   Put in place/reactivate PHC Development Committees at the Ward, Village and Community levels (WDCs, VDCs etc) and train on roles and responsibilities to ensure community ownership and sustainability. A sustainable supervisory and monitoring mechanism for the committees should be put in place, including incentives.Furthermore, aligning with existing opportunities on community and household registration, we would need to collect and collect information on community/household profile to establish database of the households and the population.
3. Mapping of Health Facilities/Assessment of Functional Status
   and There are 111 facilities under this phase. Most of these facilities are relatively stable with sound infrastructure and equipment having been recently constructed under the NASS constituency projects or rehabilitated under the SURE-P MCH project, and all have staff accommodation.
4. Infrastructural Upgrade
   Using a bottom up approach from the ward level after conducting LGA level PHC Resource mapping of all health resources in the ward and building consensus on facility to be selected.  Intervention to be delivered will be determined after the needs assessment. There may be the need for provision of Solar Power, Borehole where necessary.
5. Human Resources
   States should be encouraged to establish and draw health workers from Volunteer Health Worker Scheme to be matched by a FGN Conditional Grant Scheme to ensure sustainability rather than a vertical response similar to the Midwives Service Scheme, and the SURE-P MCH project where health workers were mobilised from distant states.Systematic Training/reorientation of the health workers based on agreed strategies and guidelines/modules, including training of PHC Management Teams at the state/LGA levels on management and leadership
6. Essential Supplies 
   FGN should encourage the states through a kind of Conditional Grant Scheme to revive the Essential Drug Programme to ensure sustainability of drug supply and initiation of re-supply mechanism or award of DFR Grant to WDCs for co-management with Health Facility Management and training on drug and financial management as short term measure. As a long term measure, it is recommended that
7. Management Support System  
   There should be elaborate effort to provide management support: effective logistic management system including operational  vehicle like an Hilux van per LGA to support ISS, M & E, Vaccine/commodity distribution and date retrieval; encourage/support regular meeting of State/LGA Management Team to review progress and provide feedback; health Management Information System -provide HMIS tools or e-tools for data retrieval and collation, train and motivate data managers, production of maternal and child health cards.As a medium term technical assistance, FGN should mobilise and embed NYSC Medical Officers as Medical Officers of Health in select LGAs that do not currently have MOH, with possibility for permanent employment after the NYSC.

Conclusion

Health frequently becomes a political issue as governments try to meet people’s expectations. In most countries, people rate health as one of their highest priorities, behind only economic concerns, such as unemployment, low wages and a high cost of living.  

Access to primary health care is the foundation of good health and the major determinant and driver of a nation’s health outcome, and like in many countries, the primary health care system in Nigeria is the cornerstone and the hub of the health system. However, over the years, primary health care system had remained grossly inefficient. The result has been poor access to quality care and suboptimal health outcomes.  The current status of primary health care in Nigeria cannot guarantee Universality and Equity based on the goal of Health For All.

Fortunately, there is the Universal Health Coverage (UHC) which has today, become a powerful concept in public health.The concept encompasses the ability of all people who need health services to receive them without incurring financial hardship, thereby achieving equity in access.

UHC is consonant to primary health care as it ensures coverage with quality health services, including promotion, prevention, treatment, rehabilitation and palliation.  The goal is to promoteuniversality, equity and better health for the great majority of the population.

Attainment of UHC would require a strong and resilient primary health care system. However, considering lessons from previous interventions towards PHC revitalization, systematic approach through effective collaboration with other tires of government and key stakeholders would be the most vital and most rational approach for strengthening the primary health care system.

PHC revival through the WHS will provide an operational base for effective and sustainable programme implementation, while the political leadership at this level provides a potential rallying point for mobilization and a catalyst for greater community involvement and participation.

Using multi-year primary health care development plan approach at the State/LGA/Ward level, we can create functional Basic Health Units  linked to a referral facility and taking into account the existing health facilities to be rehabilitated and equipped, human resources and supply needs etc.