The concept of primary health care (PHC) was formulated by the 134 countries that met at the Alma-Ata conference in Russia on September 12, 1978 which was organized by the World Health Organization. Primary health care is a part of the three-tier system of health care in Nigeria. These are the tertiary health care, which the federal government is in charge; the secondary health care, under the auspices of the state government and the primary health care, controlled by the local governments. In the late 1980s there was a national initiative to overhaul the primary health care system through the adoption of a new national health policy, in the context of which the federal and state governments issued directives giving local government areas full jurisdiction over the delivery of primary health care services.1, 2 The local Government, the State Government and the Federal Government respectively are responsible for all financial aspects, including personnel costs, consumables, running costs and capital investment. The Federal government through the federal ministry of health sets overall policy goals, co-ordinates activities, ensures quality, training and implements sector programmes.
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“Primary health care according to the world health organization means essential health 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 which the country can afford to maintain at every stage of their development in the spirit of self reliance and self determination. It is the first level contact of the individual and community in the national health system, thus bringing health care as close as possible to where people live and work and contribute the first element of a continuing health care process”.3 It is essentially aimed to promote health, to cure diseases and to rehabilitate. Nigeria is one of the few countries in the developing world to have systematically decentralized the delivery of basic health and education services to locally elected governments.4
Nigeria has an enormous population of around 120 million in 20035, with a growth rate of about 2.9% per annum. It is hailed as the giant of Africa and yet ranked among the poorest nations of the world.6 The management of the health sector has been poor and this has affected the quality of services to the general populace. Although Nigeria has an extensive national health infrastructure, it lacks the resources needed to function effectively Nigeria is now decentralizing its health system and clarifying the responsibilities and services at each level, which should result in better management and coordination. In addition, its health policy has been guided by the Bamako initiative to encourage and sustain community participation in primary health care services.7
The evidence base for primary care orientated health care system
Primary care – that is, care from the viewpoint of the doctors who has been in contact exclusively to the patients appearing for care- has apparent limitation. From the evidence given by the World Bank table and world health report 2000. It shows that Nigeria is one of the very poor countries. It has a clear symptom of imbalance between resources in poor performance, deteriorating facilities and low working moral among staff. There a high mortality rate in child and adult. The structures of the economy have fallen from 2004, raised a little bit in 2005 and remain constant between 2006 and 2007. This shows that due to lack of adequate resources in will affect the orientation of the health care system.
The development of primary care in Nigeria
An effective primary care system is critical for any country, developed or developing, to maximize outcomes and minimize costs.8, 9 Accurate and relevant data gathering and information processing are necessary for any field of endeavour whether in health care or any other field. It has long been recognized that clinical issues in primary care in Nigeria are different from those in other types of care. For example, the predictive values of symptoms may be quite different in different settings and clinical evidence derived from other settings may have limited applicability to primary health care and delivery. This is due not only to differences in the prevalence of specific diseases, but also to the fact that patients in primary care have many problems and the clinician must prioritize the diagnosis and management of all of these together over time, often in a setting where continuity of care plays a crucial role.10
Primary care is the backbone of Nigeria health system. Primary care plays a vital role in deployment of all resources through appropriate channels in promoting, maintaining as well as improving health. All these confirm the definition of primary health care which states that “essential health care based on practical, scientifically sound, as well as socially acceptable methods and technology made universally accessible to individuals and families in the community by means acceptable to them and at a cost that community and country can afford to maintain at every stage of their development in a spirit of self-reliance and self determination. It forms an integral part of both the country’s health system of which it is the central function and the main focus of the overall social and economic development of the community. It is the first level of contact of individuals, the family and the community with the national health system, bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process”11. This implies that patients or individuals have a direct access to the appropriate source of care. It equally shows that it deals more with common and well defined problem in a community setting as well as affordable. Though, the development if primary care in Nigeria has improved immensely but it still shows some major defects.
Reasons for the current status of primary care within the health care system
- The coverage is inadequate: it is estimated that 54% of the population have access to the modern health care services. The rural communities and the urban poor are not well served due to inadequate staff and infrastructure.
- Lack of basic health data is a major constraint at all stages of planning, monitoring and evaluation of health services.
- The basic infrastructure and logistic supports are often defective owing to inadequate buildings maintenance, medical equipment and vehicles and unreliable supply water and electricity also poor management of medicines, vaccines and other supplies system.
- The financial resources allocated to the primary care services, especially to some priority areas are inadequate to permit them to function effectively.
Distribution of resources in Nigeria:
The Federal and State Government allocate 15% of the state budget to health services. Within the available resources, high priority shall be accorded to primary health care with particular reference to the less privilege areas and groups. Community and financial sector resources shall be mobilized in the spirit of self help and self reliance.
How the resource should be used in future:
- In the light of importance of health in socio-economic development: all the governments of the federation should review their financial allocation to health in relation to the requirements of other sectors of the economy. High priority programmes for primary health care should have the first consideration on any additional resources that may be available
- Within the health care system, effort should be made to redistribute the financial allocation among health promotion, preventive and curative health care services. This is to ensure that adequate emphasis and awareness are placed on health promotion and preventive services without comprising curative health services
- Governments of the federation should explore additional avenues for financing the health care system especially health insurance schemes and health development levies.
- The users should pay for curative services while the preventive services should be subsidized.
- Governments of the federation shall encourage employers of labour and the financial sectors to participate in the financing health care services.
Workforce and resource issues in Nigeria:
The workforce and resources issues have been a theme of discussion in the country. Earlier health services was focused primarily in the urban areas, this made them to be experiencing adequate health care delivery than rural areas. Even though health institutions such as leprosaria and dispensaries had been established for rural areas, these did not cater for the communities outside their immediate zones. The problem is that rural people were effectively overlooked in health care delivery, since the existing institutions were inaccessible to them due to cost and logistic constraints.
Another basic problem is the inadequate staff situation to meet the needs of the country. But after training the staff most of them get a job in urban area where they are paid more.
Quality of care issues in Nigeria:
Quality of care varies among patients, politicians, managers, clinicians and other actors within the health care system12. She stressed that quality occurs when good decisions regarding care are made so that resource are utilized effectively and better health outcomes are produced. Quality of health care is a multidimensional and multifaceted concept interwoven with value judgements about what constitutes good quality13. There have been several definitions of quality of health care. “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge”14.
Accessibility: assess to hospitals or medical centres from the rural areas can be problematic from the patients due to geographical or financial barriers. In some rural areas there are little infrastructure for primary care but there are no qualified doctors. This is due to the fact that most of the doctors are aboard or in the city trying to earn comfortable and decent living.
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Comprehensiveness: Nigeria health system can be categorized into the Public and the Private health services. The public health sector is further divided structurally into the Primary Health Care (PHC), Secondary Health Care (SHC) and the Tertiary Heath Care (THC). Though, World Health Organisation (1978) suggests that in order for primary care to be comprehensive, all development- oriented activities should be interrelated and balanced so as to focus on problems of the highest priority as mutually perceived by the community and the health system, and that culturally acceptable, technically appropriate, manageable and appropriately selected interventions should be implemented in combinations that meet local needs. This implies that single- purpose programs should be integrated into primary health care activities as quickly and smoothly as possible.11 In Nigeria, there are referrals but the problem the patients (either rich or poor, over 60 of age or not) faces is that they must pay part of their hospital bill before any treatment can be commence. In United Kingdom most of the treatment the NHS pays the bills.
Co-ordination of services: there is no co-ordination of services because of the way things are in Nigeria there is no accountability of the patient’s medical history. Patient can decide to move from one doctor to another without any referral. The system is not like in United Kingdom where the technology is computerized that you can pull out people medical records anywhere.
Equity: in Nigeria there is no equity. This is country full of corruption even in the hospital. For instance Jane to the hospital around 8.00am, then John and Amy went around 8.30am and 9.00am. Because they are related to the staff in that particular hospital they will see the doctor before Jane. In United Kingdom people wait for their turn unless is on emergency bases.
How could quality of care issues be made better in Nigeria over the next 10 years?
Quality of care issues can be made better by monitoring and evaluation of the health care system, with minimum categories of indicators as follows:
- Health policy: proper distribution of health resources, financial, manpower, physical facilities to reflect the degree of equity by geography and by urban/rural ratios; government should devise appropriate mechanisms for supporting and involving the communities in the planning and implementation of health services; an organizational framework for managerial process.
- Health status: proper documentation of patients’ health status for instance nutritional status as indicated by weight of babies, weight and height measurement of infants and children in relation to age.
- Socio-economical indicators related to health and living standard: such as sanitation, housing condition, work condition, food availability, and adult literacy.
- Provision and utilization of health care indicators: immunization this includes the percentage of children at risk who are fully immunized against the major childhood diseases; the incidence of the six diseases in children under 5 years of age and the mortality rate due to the six disease in children under 5years of age. Prevention and control of epidemic diseases indicators shall specify disease specific incidence and prevalence rate. Adequate provision of the essential drugs. The coverage by referral system indicators shall state the proportion of population in a given with access to the within 5 kilometres or 1 hour travel time, the proportion of the referred cases who made use of the services and availability of referral services. Promotion of health in school.
Recommendations for the development of primary health care:
- The national health policy: the aims are to achieve health for all Nigerians based on the national philosophy of social justice and equity. Therefore, a health system based on primary health care is adopted as the means of achieving the goal. Since health development contributes to and results from socio-economic development, the sectors should mutually be supportive and together contribute to the ultimate goals of the nation.
- All the governments of the federation should review their financial allocation to health in relation to the requirements of other sectors of the economy. High priority programmes for primary health care should have the first consideration on any additional resources that may be available
- More staff should be trained and an increase in wages for those who will agree to serve in the areas
- Facilitation of monitoring and evaluation data collection system within the nation.
Primary health care in Nigeria have evolved through a series of historical developments. Though, it is the backbone of Nigeria health system but has been judged to be unsatisfactory and inadequate in meeting the needs and demand of the public as reflected by the low state of health of the population. The population should abide by principles primary health care based on equity and justice. However, if the services are available accessible as well as acceptable to and affordable by every individual, community and the nation; if the masses concentrate on solving those health problems that take the greater toll of life.
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