Primary Health Care (PHC) is the provision of basic essential health services (preventive, promotive, curative, and rehabilitative). It serves as the first point of access to health care by individuals, families, and communities, bringing health services as close as possible to homes and workplaces and has thus been described as the bedrock of Universal Health Coverage (UHC) [1].
In Nigeria, PHC services are delivered by PHC Centers, Basic Health Clinics (BHC) and Comprehensive Health Centers (CHC), with over 30,000 of these facilities spread across 9565 Wards in 774 Local Government Areas [2]. With oversight by the Local Government Authorities (LGAs), majority of these facilities are in the rural, underserved and hard-to-reach areas to ensure improved equity and access to health services.
A review of PHC systems conducted by WHO in 2019 cited political will and good governance; promotion of health reforms; access to essential programmatic initiatives; strong partnerships between governments, civil societies, non-governmental organizations and private sectors; and good organizational management as the key enabling factors in PHC implementation[3].
The National Primary Health Care Development Agency (NPHCDA), responsible for PHC development and implementation in Nigeria has implemented noteworthy policies and programs over the years including the establishment of National and State Emergency Routine Immunization Coordination Centre (NERICC, SERICCs), quarterly primary healthcare planning and reviews, the PHC Under One Roof program (PHCUOR), bi-annual Maternal Newborn and Child Health Weeks (MNCHW) and the Midwives Service Schemes (MSS) amongst others.
However, despite all past and ongoing efforts, the implementation of PHC in Nigeria has been plagued by several challenges viz: Poor governance, inadequate financing, poor human resources for health and under-utilization of the PHC facilities by individuals and communities [4]. This article will discuss the challenges and propose recommendations to address them for improved PHC implementation in Nigeria.
Poor governance
Governance in health involves rule and decision making by the government to drive the achievement of national health policy objectives. It involves multisectoral collaboration to maintain and promote population health in a participatory and inclusive manner [5]. PHC in Nigeria is riddled with poor intersectoral collaboration without proper coordination and monitoring. Furthermore, there is a lack of political will amongst decision and policy makers with most leaders readily endorsing projects that favour their political agenda rather than approving funds to achieve national health policy objectives [4].
Inadequate financing
Another challenge the implementation of PHC faces is inadequate funding. Funds for PHC flow to the LGA level through multiple levels – the Federal Ministry of Health, National Primary Health Care Development Agency, the State Primary Health Care Development Boards, and then the LGAs. The allocation formula for sharing of funds keeps about 50% at the Federal level, 25% at the state level and the remaining 25% to serve all LGAs in the state [8]. Additionally, the Nigerian Health Budget has consistently remained less than the 5% against the 15% Abuja declaration target [5] with a consequent allocation of less than 15% of state and LGA budgets to health [6,7]. Although PHC in Nigeria is supported by international agencies through funding of health services, capacity building for staff and supply of medicines and commodities, this support alone is inadequate to meet the need [7]. To address the issue of poor funding of Primary Health Care, the National Health Act enacted in 2014 provides the Basic Health Provision Fund (BHCPF), a statutory provision financed predominantly through 1% of the Consolidated Revenue Fund (CRF). 50% of the BHCPF will be used to finance the provision of basic package of health services through the National Health Insurance Scheme (NHIS), 45% disbursed through National Primary Health Care Development Agency for infrastructural maintenance of PHC facilities, staff capacity building and operational expenditures; and the remaining 5% to be used by the Federal Ministry of Health (FMoH) for health emergencies. Although the Nigerian Senate approved 57.15 billion Naira for BHCPF in the 2018 Appropriation Bill (four years after the National Health Bill was signed into law), available evidence suggests that the fund is still inadequate for PHC financing [9].
Poor human resources for health
Human resources for health are one of the building blocks of health systems. No health system can function effectively without a good workforce. The implementation of Primary Health Care in Nigeria is also troubled by poor human resources for health. These problems range from inadequacy of trained personnel, poor distribution of available personnel to poor job satisfaction. Health worker distribution has been seen to be skewed to facilities in urban areas with health workers preferring to work in facilities in urban areas due to the lack of basic amenities like electricity, portable drinking water, separation from their families residential in urban areas, difficult working conditions from insecurity, and poor supply of essential health commodities constraining effective health service delivery in the rural areas. The dearth of health workers in rural areas is further compounded by the massive brain drain in medicine with health workers relocating outside the country in search of “greener pastures” and better working conditions [11-13].
Under-utilization of the PHC facilities by individuals and communities
PHC facilities in Nigeria are currently under-utilized with a utilization rate of less than 20% [15], attributed to perceptions of poor quality of services at PHC facilities and resulting in poor community participation in PHC [4]. Perception of services is essential to community acceptance and utilization. Generally in Nigeria, it is believed that PHC facilities are meant for the rural and under-privileged populace, that the staff at the PHC facilities as less qualified compared to their colleagues at secondary and tertiary facilities and therefore quality of service must be poor. Therefore, individuals and would rather patronize the secondary and tertiary health facilities for their health care needs [4]. Community participation is identified as one of the key ways to implement Primary Health Care successfully. The Alma Ata declaration defined it as the process by which individuals and families assume responsibility for their own health and welfare and for those of the community and develop the capacity to contribute to their community development [1]. To achieve community participation, the Government of Nigeria created Ward Development Committees (WDC) formed to work closely with the Local Government to monitor and improve PHC in their constituencies and to help mobilize individuals and households to utilize the PHC facilities optimally. However, the WDCs have largely been reported as either non-functional or used for political propaganda [4].
How do we go forward from here?
- Although the National Health Act is a good initiative towards improving governance and political will in the health sector, more commitment is required from political actors for proper implementation of policies, strategies, regulatory framework and financial commitments. Also, there is a need for intersectoral collaboration to avoid duplication of efforts and ensure optimization of resources.
- There is a need to increase the budgetary allocation to health in Nigeria to improve the financing for health services and to meet the set target of 15% in the Abuja declaration. Innovative means for health financing through effective resource mobilization from robust public-private partnership and tax returns would go a long way in increasing funds availability for PHC. Also, improvements in the public financial management system specifically in the cost estimation for health and health commodities, proper budget formulation, alignment of funding sources, transparency and accountability in budget implementations are essential to maximize outcomes from existing funds for PHC in Nigeria.
- Healthcare workers providing primary health services need to be trained regularly. Additionally, targeted health care worker recruitment per need is required to ensure adequacy of human resources for PHC services. Further, the government of Nigeria should improve the welfare packages of PHC staff and provide better working conditions.
- Health education should be improved at community and household levels to debunk the myths surrounding quality of health services at PHC facilities and improve perception of PHC services. The WDCs should be revitalized to further improve community health seeking behaviors.
References
- Alma Ata (1978). Primary Health Care, World Health Organization, Geneva.
- NPHCDA, National primary health care development agency: minimum standard for primary health care in Nigeria. 2012. Department of Planning, Research and Statistics, NPHCDA. Abuja, Nigeria.
- WHO, World health organization: Review of 40 years PHC implementation at country level
- Alenoghena et. al., Primary health care in Nigeria; Strategies and constraints in implementation: International Journal of Community Research, 2014.
- WHO, World Health Organization: Health systems governance
- NPHCDA, National primary health care development agency: Report of expert group on revitalization of primary health care in Nigeria, 2015. NPHCDA, Abuja, Nigeria.
- Uzochukwu et. al., Health care financing in Nigeria: Implications for achieving universal health coverage. Nigeria Journal of Clinical Practice, 2015.
- Budget office of the Federation 2014: Federation Appropriation Acts, 2011-2013. Federation Abuja, Federal Government of Nigeria
- Federal Republic of Nigeria 2014, 8th National Health Act. Official Gazette
- Onwujekwe et. al., Examining the financial feasibility of using a new special health fund to provide universal coverage for basic maternal and child health benefit package in Nigeria: Front. Public Health, 6:200. doi:10.3389/fpubh.2018.00200/
- Obembe et. al., Staffing situation of primary health care facilities in Federal Capital Territory Nigeria: Implications for attraction and retention policies: American Journal of Social and Management Sciences, 2014.
- O’Neill et. al., Causes of prolonged waiting time in public health facilities among health healthcare seekers in Calabar Municipal Council of Cross River State, Nigeira: Research on Humanities and Sciences, 2014.
- Abimbola et. al., How decentralization influences the retention of primary healthcare workers in rural Nigeria; Global Health Action, 2015.
- Enhancing the distribution and performance of primary health force in Nigeria: the case of Delta State. Center for Population and Environmental Development, 2014.
- Gupta et. al., Decentralised delivery of primary health services in Nigeria; Survey evidence from Lagos and Kogi States. The World Bank.
Reviewed by Folake Oni
