The Conceptualization and Implementation of Primary Health Care (PHC) in Nigeria
Primary Health Care (PHC) is a grass-root management approach to providing health care services to communities. Since global leaders published the the PHC concept in 1978, various countries have attained various levels of progress in implementing the strategy. This paper reviews the historical concepts that have driven primary health care in Nigeria. Current efforts at revitalizing primary health care in Nigeria include the Midwives Service Scheme (MSS), PHC Reviews, National Health Management Information System (NHMIS), and the Maternal Newborn and Child Health (MNCH) Week. In all, the role of the people, government, and health workers as critical stakeholders needs to be well defined and pursued to maximize the benefits of primary health care.
After global leaders declared United Nations’ “Health for All” agenda in 1978, Nigeria adopted its primary health care (PHC) system and accepted universally to use the heath care management approach to meet this lofty goal. The world will only become healthy when we achieve Health for All- the developed and developing nations alike, the poor and the rich, the literate and the uneducated, old, and young and women, children, and the elderly. The primary health care system is a grass-root approach meant to address the main health problems in the community, by providing preventive, curative and rehabilitative services (Gofin, 2005, Olise, 2012).
As defined in the Alma Ata declaration, primary health care is the “essential care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination” (WHO, 2012).
The principles of primary health care underscore the excellent value of the approach. These principles which include essential health care, community participation, equity, intersectoral collaboration, and use of appropriate technology are the driving forces behind the efficiency of primary health care as the hope of achieving universal health coverage. This means that primary health care is meant to provide services to people based on needs without geographical, social, or financial barriers through their involvement in the planning, implementation, and evaluation of health programmes. It implies drawing resources from within and outside the health sector and utilizing technologies based on suitability.
The History and Conceptualization of the Primary Health Care (PHC) in Nigeria
Nigeria integrated its primary healthcare as the National Health Policy of 1988 (FMOH, 2004). The PHC became a cornerstone of Nigeria’s health system as part of efforts geared towards improving equity in access and utilization of basic health services. Since then, primary health care in Nigeria has evolved through various stages of development. In 2005, primary health care facilities make up over 85% of health care facilities in Nigeria (FMOH, 2010).
Historically, there were three major attempts at evolving and sustaining a community and people-oriented health system in Nigeria. The first attempt occurred between 1975 and 1980. The fulcrum of this period was the introduction of the Basic Health Services Scheme (BHSS). The Basic Health Services Scheme came into being in 1975 as an integral part of Nigeria’s Third National Development Plan (1975 – 79) (Dungy, 1979, Adeyomo, 2005) and was structured along “basic health units” which consisted of 20 health clinics spread across each LGA, which were backed-up by four (4) primary health care centres and supported by mobile clinics serving an approximate population of 150,000 each. The drawback of this attempt was the non-involvement of local communities who were the beneficiaries of the services. This led to the inability to sustain the Scheme at the close of the third national development plan period. A second attempt led by late Professor Olukoye Ransome-Kuti occurred between 1986 and 1992 (Kuti et al, 1991). This period characterized by the development of model primary health care in fifty-two (52) pilot local government areas all of which were implementing all eight components of primary health care. A key result of this dispensation was the attainment of 80% immunization coverage for fully immunized under-five children. Meticulous application of the principle of active community participation and focus on issues relating to health systems strengthening (HSS) was responsible for the success recorded.
The National Primary Healthcare Development Agency (NPHCDA) was established in 1992 and heralded the third attempt to make basic healthcare accessible to the grassroots. During this period, which spanned through 2001, the Ward Health System (WHS) which utilizes the electoral ward (with a representative councilor) as the basic operational unit for primary health care delivery was instituted. This was in response to the devolution of Primary Healthcare to the Local Governments by the then military government. The Ward Minimum Health Care Package (WMHCP) which outlines a set of cost-effective health interventions with significant impact on morbidity and mortality was also developed. The package took into cognizance the nation’s burden of disease, current trends in disease prevalence and priority diseases of national importance. The Ward Minimum Health Care Package was developed within context of the Ward Health System and aligned with the millennium development goal (MDG) targets of Nigeria. To drive this new policy over five hundred model health centers were established across the nation by the federal government (NPHCDA, 2012). These centers served as a fulcrum for the establishment of the Ward Health System and the community mobilization as Ward Development Committees, which is constituted of selected community representatives, were established around the model primary health care centers.
While it was logical that Primary Healthcare, which is community oriented, be established around the tier of government perceived to be closest to the people, the sudden devolution of primary health care to the local government areas may have had negative implications on sustainability of quality as that level of governance is also known to have the weakest technical capacity. Again, the Federal Government’s intervention by building model health centers for the local government areas, though well-conceived, was paradoxical to the newly initiated principle of devolution of healthcare. While this intervention may have been sustainable under the unitary military dictatorship, its sustainability was challenged by the advent of democracy in 1999.
Implementing Primary Health Care (PHC) in Nigeria
The great idea of grass-root health care delivery as encapsulated in the principles of primary health care requires the strong commitment of all stakeholders to make it work.
Stakeholders are those persons or groups that have personal stake in the delivery of primary healthcare services and in healthcare decisions (AHRQ, 2014). The key primary health care stake holders include the people, the government, and the healthcare workers. The people need to own primary health care through adequate community mobilization. Community mobilization is the process of arousing the interest of the people and encouraging them to participate actively in finding solutions to their problems (Olise, 2012). When the communities engage in the planning, implementation, and evaluation of primary healthcare services, they will not perceive them as forced decisions. Community mobilization is a veritable tool for engendering support for primary health care, especially in the rural areas where over 66% of the Nigerian population live. Rural areas have the worst health indices, findings indicate (NPC and ICF Macro, 2009; FMOH, 2010). Aspects of community mobilization include community entry, community dialogue, and operation of development and health committees. Government at all levels must express, in practical terms, political commitment through funding, capacity building and system support. They must put money where their mouth is and translate the great ideas behind primary health care into great programmers and great services. Primary health care services are not third-class services meant for third-class citizens. Therefore, adequate provision must be made in national, state, and local budgets for quality healthcare delivery using the primary healthcare system. The role of government is critical in promoting access to essential and quality health services (FMOH, 2010). This can be channeled through the building and maintenance of infrastructure, training and retraining of the workforce, and provision of materials and equipment for effective health care.
Health care workers involved in primary healthcare delivery in Nigeria include doctors, nurses/midwives, community health workers, laboratory scientists/technicians, and health assistants among others (Africa Health Workforce Observatory AHWO, 2008). To make primary health care work, workers need to contribute their quota to improving quality service delivery and achieving clients’ satisfaction. This they can do through innovative utilization of available resources, encouraging patient participation in their care, and promoting healthcare worker-patient communication (Babatunde et al, 2013). The disposition of healthcare workers is especially important in enhancing public perception and utilization of primary health care services. Commitment to duty, empathy, and a listening ear are desirable traits in primary health care workers that can enhance service delivery.
The concept of primary health care is still relevant to achieving equitable and quality health care for all Nigerians. However, a persistent effort at implementation at all levels is necessary to maximize the benefits of this people-oriented approach to health care.