Getting Primary Health Care Delivery Right for Universal Health Coverage in Nigeria

Ache's mother died a few months ago due to the absence of a primary healthcare centre (PHC) or health post in her community in Ibaji local government of Kogi State. The only PHC available in a nearby community cannot offer basic even health services. Therefore, the only option for many residents is to travel on motorbike or bicycle to Idah, a town in another local government over 30 kilometres away.

Ache said going to Idah is very difficult in the rainy season as the roads become inaccessible. "Because there is no functional primary health care centre around us, there is always delay in accessing care and many people die or their condition worsens before reaching Idah or Edo State," she said.

"Also, some people cannot travel to access health care because of the high cost of transportation apart from the rigours of the roads."

Shuaibu Maiangwa, 34, lost his wife to postpartum haemorrhage three days after she delivered their baby in Wukara community of the Federal Capital Territory (FCT).

"We don't have any health facility in this community and I didn't have money to transport her to Kuje General Hospital, which is far from our community."

During a visit to the Primary Health Care Clinic in Pasepa, a community in Bwari Area Council of the FCT, the reporter observed a dilapidated structure with two-thirds of its roof caving in and windows with broken or missing panes. A small, dirty room at the side served as the nurse's office while another even smaller, dirty adjoining room served as the injection room, with two cartons of drugs on the table at the side of the room.

The two small rooms have a bed space each, but without bed sheets and covered with cobwebs. When more than two patients are admitted, one has to lie on the floor. There was also no staff quarters.

Many residents of Pasepa and surrounding villages are said to have died or suffered complications because of the state of the Primary Health Care Clinic. The facility, also known as Primary Health Care Clinic, Zhiko, is meant to service 1,500 residents of Pasepa community and about 45,000 people from Pasepa and eight other communities.

Despite the critical role of primary delivery, and Universal Health Coverage (UHC), primary healthcare system in Nigeria is bedeviled with challenges. Some of the challenges are shortage and mal-distribution of healthcare workers, dilapidated infrastructure, weak referral systems and poor financing. This has further placed pressure on secondary and tertiary health institutions.

According to the State of Primary Health Care Service Delivery in Nigeria (2019 to 2021) Report, only 11 of the 36 states and the FCT have at least one functional PHC per ward and can fully utilise the Basic Health Care Provision Fund (BHCPF).

The report, which was conducted by Nigeria Health Watch, One Campaign and Public Private Development Centre, also revealed that at least one of the nine assessed public facilities owned are not equipped to offer basic medical services or require facility repairs.

Also, a national health facility assessment carried out by the National Primary Health Care Development Agency (NPHCDA) revealed that only 463 out of 25,843 primary healthcare facilities in Nigeria have the minimum number of required Skilled Birth Attendants (SBAs).

The immediate past Executive Director of the agency, Faisal Shuaib, said the findings of the report also showed that there is the problem of unequal distribution of available SBAs in the primary health care facilities.

Shuaib said to address the problem, NPHCDA came up with the Community-Based Research Innovative Training and Services Programme (CRISP), adding that the availability of skilled health workers in PHC facilities is critical to curbing maternal, perinatal, neonatal morbidity and mortality.

Access to quality and essential healthcare services is a fundamental human right. However, for many individuals and communities in Nigeria, it remains a luxury; and comes with untold hardships and death.

Experts say over 70% of Nigerians pay their health bills from out-of-pocket expenses making it difficult for many to access healthcare. This is driving millions of Nigerians into poverty, and death.

According to the World Health Organization, (WHO), UHC means that all people and communities can use preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship.

Dr Fejiro Chinye-Nwoko, General Manager of Nigeria Solidarity Support Fund (NSSF), a non-governmental organisation (NGO) said only about 20% of primary healthcare facilities across Nigeria are fully functional.

She said, "As a result, a large portion of the population does not have access to quality primary healthcare services which are essential for preventive and early intervention measures.

"In addition, only 3% of Nigerians have healthcare insurance leaving most Nigerians vulnerable to health emergencies- individuals and families face financial risks and barriers when accessing healthcare services."

The BHCPF and Primary Health Care Under One Roof (PHCUOR)

are some of the policies introduced over the years to improve service delivery but findings have revealed that they have not been fully implemented with pockets of challenges at national and sub-national levels.

Dr Walter Mulombo, WHO Nigeria Representative, stressed the importance of the primary Health Care (PHC) approach in achieving Universal Health Coverage globally.

He said "Rising from the international conference to celebrate the 45th anniversary of Alma-Ata and 5th anniversary of Astana declarations on primary health care in Astana Kazakhstan, countries have recommitted themselves to making a radical shift towards Primary Healthcare as the foundation of UHC and health security. This indeed entails shifting focus from mere concepts to actions with demonstrable results, for greater resilience in the health sector, even in the face of emergencies."

Addressing the challenges

A former Chairman of the Nigeria Governors Forum (NGF) and ex-Ekiti State governor, Kayode Fayemi, called for innovative solutions to ensure sustainable financing for primary healthcare in the country.

He said the ability of the country to guarantee this right for all Nigerians had been slow, largely due to how the health system is financed and delivered.

He called for the utilisation of the BHCPF to finance essential health services, especially for the vulnerable and to improve the country's capacity to address public health emergencies, consolidation of funding to address primary care and essential public health functions and the exploration of innovative ways to pool funds for non-contributory healthcare coverage.

Yobe State Commissioner for Health, Dr. Mohammed Lawan Gana said primary health care is the entry point to universal health coverage.

He said "Without primary health care, obviously, there is no way because it is the primary healthcare system that is closest to the people majority of whom live in rural areas. And of course, the whole idea of primary health care is at least getting health care to the doorsteps of the people where they live and work.

"We have seen repeatedly that primary health care drives improvements in immunisation, communicable and non-communicable diseases, maternal health, and nutrition. Rethinking primary healthcare investments can secure sustainable and more holistic development for the Nigerian health sector.

"We can move the brick by working together to build a safer and healthier Nigeria for all of us."

Dr Ngozi Azodo of the Federal Ministry of Health said limited financing for the primary healthcare (PHC) system stands out as a factor that has significantly limited the advancement of PHC in the country.

She said National Health Account reports published over the past decade indicate that expenditure on primary healthcare has been sub-optimal, with significant spending on curative healthcare.

She said robust primary healthcare financing in Nigeria would require collaborative efforts of both state and non-state actors.

The Registrar of MLSCN, Tosan Erhabor said, "We strongly believe that the PHC level is the foundation of any healthcare system. Therefore, if we get the capacity and service delivery at that level right, the health sector will inevitably be transformed. Based on the success achieved at the level of PHC, the partnership would move to the higher tiers of the health sector. "

Dr Emmanuel Alhassan , Nigeria coordinator Global Health Advocacy Incubator (GHAI) said it is not possible to have UHC without strengthened, functional, effective and efficient PHCS because PHCS are the closest to the community.

He said , "The idea is that when there is any medical issue, you should have what we call geographic and, easy physical access to a PHC which should be within a short distance to your vicinity.

"So that PHC must be well equipped, well staffed with trained and qualified health workers, have adequate drugs and commodities, and must follow the protocol of delivery of healthcare services."

The Special Adviser to the President on Health, Dr Salma Anas-Ibrahim, said the federal government is working towards establishing a minimum of two primary healthcare facilities per ward in order to ensure Universal Health Coverage (UHC) for Nigerians.

She said, "For Nigeria to achieve the UHC journey, the administration of President Bola Ahmed Tinubu is committed to ensuring that our primary health care functions at the sub-national and community level.

"We aim to achieve a minimum of two primary health care facilities per ward to ensure the population has access to the basic minimum package, especially the teeming population of vulnerable people who are mostly women, children, adolescents, the elderly and people living with disabilities."

The Coordinating Minister, Federal Ministry of Health and Social Welfare, Professor Ali Pate said, "We are redesigning the Basic Health Care Provision Fund (BHCPF), established by the National Health Act 2014, to become more effective and efficient in driving the strategic shifts and priority initiatives that will see us moving towards accomplishing our ambitious but achievable goals and objectives."

Speaking during the recent 64th National Council on Health he said, the health of the people is a fundamental human right. "It is a measure of our commitment to equity, justice, and the dignity of every individual.

"Achieving Universal Health Coverage (UHC) is not a choice; it is an obligation, a promise to provide quality healthcare to all regardless of their socio-economic status. It is the embodiment of our vision for a healthier and more prosperous nation and a strategic advantage for us as a nation."