Health is a human right and everyone, irrespective of location or socioeconomic status has a right to healthcare at their point of need. For a heavily populated country like Nigeria where there are income inequalities, there is a need to examine the healthcare system through the lens of health equity, which is accessible, affordable, and offers healthcare for all that need it. This brings to the fore the importance of primary healthcare which is the bedrock of every health system and should be the first port of call for most Nigerians when seeking healthcare.
It is against this backdrop that on 16 September 2021, Nigeria Health Watch and the Partnership for Advocacy in Child and Family Health at Scale (PacFah@Scale) organised a policy dialogue on Primary Health Care (PHC) in Nigeria themed “40 Years After the Alma-Ata Declaration: Primary Health Care in Nigeria”.
Challenges remain despite policies targeted at PHC delivery
Over the years, Nigeria has developed polices aimed at improving primary healthcare delivery in the country. Some of those policies, as highlighted by the keynote speaker Professor Tanimola Akande, a consultant at the University of Ilorin Teaching Hospital include the ‘Saving One Million Lives for Results (SOMLR)’ and the ‘Basic Healthare Provision Fund (BHCPF)’. Unfortunately, years after these interventions were initiated, the challenges that limit the effective delivery of PHC services still exist. They include, fragmented governance and coordination, poor and dilapidated health facilities, shortage of human resources and poor funding.
In addition to these challenges, Ekenem Isichei, Chief Executive Officer of ACIOE Associates discussed insecurity and rising inflation as other factors mitigating the uptake of healthcare services in the country. Affordability and safety are essential requirements to accessing healthcare. Rising inflation costs are forcing a growing number of families to make the tough decision between using available resources to seek healthcare or purchase other basic needs like food. Also, several states are immersed in some form of insecurity further hindering access to healthcare for both the patient and the health worker.
Private sector investment to improve PHC
Provision of quality, standard healthcare services require resources, epitomising the importance of private sector investment in the health sector. Primary Healthcare in Nigeria has received little investment from the private sector over the years. EHA Clinics, with two health facilities providing quality PHC services in Kano and Abuja, are a clear example of what happens when resources are made available and used shrewdly. According to Dr. Anthonia Hananiya, Chief Medical Officer, EHA Clinics, enormous resources were invested to ensure that the clinics provide patient centred, technology driven, healthcare services. Speaking from the experience garnered in setting up and running the two clinics, she said it is possible to set up PHCs to provide a whole care treatment approach which includes prevention and care for chronic diseases and follow-up.
Dr Hananiya emphasised the importance of leveraging on partnerships with non-governmental organisations and pharmaceutical companies to negotiate treatment prices for people in communities as evidenced by the REACH program implemented by EHA Clinics in communities across Kano State. The REACH program trains community health extension workers to provide affordable primary healthcare services to people in the communities. “We have provided quality healthcare services to over 11,000 people in communities in Kano State using the REACH Program,” she said.
Leveraging the pandemic to improve PHCs
The COVID-19 pandemic came with numerous challenges for healthcare systems around the world. However, embedded in the challenges were opportunities to improve and strengthen these systems. Nowhere is that improvement more necessary than in PHCs. According to Dr. Oyebanji Filani, Commissioner Health & Human Services, Ekiti State, the pandemic was the perfect opportunity for the state to augment the support of its PHC. Infection, Prevention and Control (IPC) mechanisms were improved across all the PHCs, in addition to improving vaccination capabilities of PHCs that resulted in Ekiti State being recognised as one of the best performing states for COVID-19 vaccine uptake in the country.
Dr. Filani added that in 2020, Ekiti State carried out an assessment that examined the reasons for underperformance of the health sector in the state. The results helped them design and implement targeted plans to effectively address the identified challenges. Some of the plans being implemented include the Ekiti State National Youth Service Scheme Medical Fellowship program, which involves deploying corp members who are medical doctors to PHCs across the state, increasing the state health budget by 200% and training of over 600 PHC workers. “The results of these initiatives are beginning to show, with improvements in immunisation and skilled birth attendance across the state,” he said.
Deriving resources to provide quality care
Providing quality healthcare, even at PHC level requires resources, and quality healthcare further attracts people, according to Dr. Charles Ezuma-Ngwu, President and Financial Director, Healthcare Innovation in Delivering Financial Analysis and Actionable Business Insights. Dr. Ezuma-Ngwu suggested that for PHCs to have the required resources to provide quality healthcare, a cost-effective payment system in the form of capitation should be adopted. Capitation is a method of payment for health services in which a physician or hospital are paid a fixed amount per enrollee, to cover a defined scope of services for a defined period, regardless of actual number or nature of services provided.
Power of advocacy
Advocacy plays an important role in both demand and supply of PHC services. This is proven by the work of the Medical Women Association of Nigeria (MWAN) under the PacFah@Scale in Kano State. According to Dr. Rahila Mukhtar, President of MWAN Kano State, their advocacy to both the executive and legislature contributed to the passage of the PHC law in the state, as well as the engagement of over 2000 PHC workers and improved funding for PHC services in the state. She said that the advocacy to religious and traditional leaders also improved uptake of PHC services such as antenatal, post-natal, skilled birth attendance and child immunisation in the state. Kano is presently one of the few states in the country with autonomous primary healthcare boards, thanks to the advocacy of organisations like MWAN PacFah@Scale.
According to the World Health Organisation, about 80–90% of an individual’s healthcare needs throughout their lifetime could be met at the primary healthcare level, further echoing the significant importance of standard, well equipped and well-staffed PHCs, particularly in rural communities.
Lack of functional PHCs endanger the lives of people, especially women and children in hard-to-reach communities. In Niger State, for example, people in Maito village in Wushishi local government area had trouble accessing healthcare due to the dilapidated PHC in the village. However, when it was rehabilitated after a Nigeria Health Watch report, community members enjoyed standard healthcare, and health workers felt encouraged and motivated to provide services.
As echoed by panellists and speakers at the PHC Policy dialogue, governments at Federal, State and LGA level in Nigeria have a lot of work to do to improve the country’s primary healthcare system. Funding, governance, coordination, infrastructure and human resource for health are some of the areas that require urgent improvement for everyone, everywhere to enjoy quality, affordable and accessible healthcare services in Nigeria.
So, 40 years after the Alma-Ata declaration, slow progress has been made improving health outcomes of patients. However, there is still much to do, especially ensuring that there is one fully-functional private or public PHC in every ward in Nigeria, as outlined in the BHCPF guideline document.