Dr. Onyekachi Ifudu
The concept of primary healthcare as currently practiced was formulated at a conference in Alma-Ata, Russia, on September 12th, 1978, organized by the WHO and UNICEF and attended by 134 countries.
The declaration of Alma-Ata defines primary healthcare as “the essential care based on practical, scientifically sound and socially acceptable method and technology made universally accessible to individuals and families in the community through their full participation and at a cost they and the country can afford to maintain in the spirit of self reliance and self determination. It is supposed to be the first level contact of the individual and community in the national health hierarchy, thus bringing healthcare as close as possible to people where they live.”
National Primary Healthcare was launched in Nigeria in 1988. Over time, the envisaged objectives of the primary health care system have evolved, but include:
■ Improve collection and monitoring of health data
■ Improve personnel development in healthcare
■ Ensure the provision of essential drugs
■ Improve on immunization programs
■ Promote treatment of epidemic diseases
■ Improve food supply and nutrition
■ Improve material and child care, and family planning
■ Adequate supply of safe water and basic sanitation
■ Educate people on prevailing health problems and the methods of preventing and controlling them.
Government health institutions in Nigeria include over 20,278 primary health centers, over 33,303 general hospitals, and over 60 teaching hospitals and federal medical centers. The federal government is responsible for tertiary care, state governments are responsible for secondary care, and local governments run primary care.
The Good News
Compared to many African countries, Nigeria has created special cadres of primary healthcare personnel and dedicated schools to train them. Government has made a gallant effort to ensure staffing of primary healthcare centers. Also, Nigeria has a relatively large network of primary health care facilities that are evenly distributed around the country.
Recently, we have recorded improvements in percent of one-year olds who were fully immunized and in percent of children under 5 years who slept under an insecticide-treated net. Furthermore, the spectacular work of the Nigerian healthcare personnel who tackled the Ebola outbreak and COVID-19 pandemic reaffirms our capability and validates that when challenged, we can perform as well if not better than healthcare workers in more developed countries.
The Challenges
i)Too much burden on the “Primary Healthcare” system
Most of the problems in the primary healthcare system derive from the fundamental issue that we have “dumped” the entire burden of our public health problems on the primary healthcare system.
According to a report from the WHO, the top ten diseases responsible for most deaths and hospital visits in Nigerians, are all preventable diseases. Therefore, the thrust of our entire healthcare system should be “aggressive disease prevention”.
Because, irrespective of the core concepts of primary healthcare that were conceived at the Alma Ata conference, how much responsibility each attendee country defers to its primary care system will depend on its unique circumstances, like disease burden, level of development of public health infrastructure, etc.
Curiously, Nigeria entrusts the most important and consequential level of our health care system — primary healthcare — to the weakest tier of government.
ii)Lack of community interest and healthcare not a priority among the healthy
Individuals, communities and nations often demonstrate their priorities by how they allocate their resources. The widespread idea that government must “do everything” has lulled many communities into complacency and thus unable to ensure that their primary healthcare center is top-class.
For example, there are many communities, like mine – Eke – that have spent over one billion Naira in building houses of worship, but failed to invest even 1% of that sum in their primary healthcare center.
In 2001, African heads of state meeting in Abuja recommended 15% budgetary allocation for health. However, in 2012 the federal government allocated 6% to health, while the State government allocation varied from 3% in one State to 9.8% in another.
Furthermore, the issue is not just inadequate funding, but how available funds are deployed. The Local government expenditure on health is low and varies across and within states. In some local governments, only 3% of their total expenditure is allocated to health. Most of the expenditure is on personnel remuneration and very little allocated to maintenance of health facilities and other recurrent costs.
iii)Manpower Issues
Local governments in Nigeria currently lack the technical and managerial capacity to run an effective primary healthcare system. Many health workers are unwilling to render service in rural areas.
iv)Other problems – Include lack of the basic equipment needed to do the job, poor infrastructure maintenance, unenforced mandates, limited scope of services offered as well as poor and uncoordinated referral system.
Rigid delineation into Primary, Secondary and Tertiary healthcare ─ Harmful or Helpful
Since most of the diseases that kill us in Nigeria and lead to most of the hospital visits are preventable, then all tiers of the healthcare system should be preferentially focused on “disease prevention”.
Unfortunately, our “secondary” and “tertiary” healthcare institutions do not view themselves as being in the business of disease prevention or implementing disease prevention programs in the communities they serve.
The next time a Newspaper headline rightfully applauds a successful kidney transplant by a teaching hospital, an appropriate follow-up question should be ─ “What outreach programs do they have in the communities they serve to prevent kidney failure, or detect and control hypertension”
Disease prevention is cost-effective and should be everybody’s focus – Primary, Secondary and Tertiary care levels. The next article will proffer solutions for our primary healthcare challenges.
*Ifudu wrote in via dodokinase@gmail.com
