The collapse of Primary Health Care - Guardian Editorial July 29, 2008 | posted by Nigerian Muse (Archives)

 

GUARDIAN

Friday, July 25, 2008

The collapse of Primary Health CareCollapse of primary health care threatens health care services in the country

While most facilities are in various state of despair, with equipment and infrastructure being either absent or obsolete, the referral system is almost almost non existent, Ben Ukwuoma, Ronke Olawale and Chukwuma Muanya, write that the Primary Health Care, is in doldrums and may worsen the already gloomy health profile of the country.

HE passionately promoted it and worked tirelessly to entrench it into the health care delivery system of the country.

He dreamt of a comprehensive health care system, that is not only promotive but protective, preventive.

He envisaged a system where patients with simple ailments such as immunization, malaria diarrhoea and pneumonia are well taken care of, while the pressure on the secondary and tertiary facilities is reduced.

That was vintage Professor Olikoye Ransome-Kuti, the late former minister of health who in March 1988 introduced the Primary Health Care.

The concept was unique and backed by many international donor agencies. It flourished.

In space of one year, it was introduced in more than 300 of 449 Local government areas. Health indicators shone brightly as most communicable and non-communicable diseases were put in check. Immunization coverage was not left as it jumped from less than 20 percent to 80 percent.

Tragically, 20 years after, the health system performance of the country does not give cause to cheer as the country is now ranked 187th among the 191member states by the World Health Organization W .H.O .

Even routine immunization coverage rate that reached over 80 percent in the early 1990s has nose-dived to an all time low.

The disease burden is nothing to cheer about. Malaria accounts for over 65 percent of out patient attendance and 10 percent death rate; tuberculosis is on the increase due to increase prevalence of HIV/AIDS.

Out breaks of vaccine preventable diseases like Measles; whooping cough; cerebrospinal meningitis have been reported. Frequent upsurge in cases of diarrhea diseases and cholera have also occurred. Life expectancy is about 45 years.

Maternal mortality is one of the highest in the world. In fact the first five years of the millennium, maternal mortality rose by 14 per cent from 704 to 800 per 100,000.

The under five mortality rate, which is already higher than the average for sub-Sahara Africa, rose from 97 to 110 per 1000, an increased 0f 13per cent The 2008 'Save the Children' report released last week ranked Nigeria lowest among 146 countries that have failed to stem maternal and child mortality ratio.

According to the report, under-five mortality is over 200 million, of which 10 million annual deaths occur due to treatable diseases like diarrhoea and pneumonia.

Health spending remains abysmally low; whereas the 2008 health budget is N138.2Billion, representing 5.6 per cent of total budget of N.748Trillion and 14.4 per cent above the sum allocated in 2007. This is clearly below 15 per cent Abuja declaration.

Human resources is also of inequitable distribution; 88 per cent of doctors practising in Nigeria work in hospitals, most of them (74 per cent) in private hospitals, with just 12 per cent of practising doctors working in private or public sector PHC services.

Funding for state and local hospitals, while increasing, is still only about 20 per cent of the overall government health funds in Nigeria, which is not enough to provide adequate staff, equipment, or medical training. Primary health care system,

Primary Health care, which is supposed to be the bedrock of the Country's health care policy, is currently catering for less than 20 per cent of the potential patients.

While most facilities are in various state of despair, with equipment and infrastructure being either absent or obsolete, the referral system is almost non-existent at all levels.

The goal of the National Health Policy is to bring about a comprehensive health care system, based on primary health care that is promotive, protective, preventive, restorative and rehabilitative to every citizen of the country within the available resources so that individuals and communities are assured of productivity, social well- being and enjoyment of living.

The health services, based on primary health care, include among other things: education concerning prevailing health problems and the methods of preventing and controlling them, promotion of food supply and proper nutrition material and child care, including family planning immunization against the major infectious diseases prevention and control of locally endemic and epidemic diseases provision of essential drugs and supplies.

The system encourages a three-tier system of health care: Primary Health Care, Secondary Health Care, and Tertiary Health Care. Primary Health Care __

The Provision of health care at Primary Health Care level is largely the responsibility of Local Governments with the support of sate ministries of health and within the overall national health policy. Private medical practitioners also provide health care at this level. _

Although it was said to have made much progress, its goal of 90 percent coverage was probably excessively ambitious, especially in view of the economic strains of structural adjustment that permeated the Nigerian economy throughout the late 1980s. But many international donor agencies such as UNICEF, World Health Organization (WHO) and the United States AIDS for International Development, (USAID) embraced the programme and participated actively in the design and implementation of programmes at that level. At a stage, most of the programmes were donor driven. It was not surprising that at the height of the political crisis in 1993, most of them withdrew their funding and the programme started experiencing hiccups.

With the return to democracy in 1999, however, primary health care system deteriorated to an unacceptable level.

Dr George Okpagu, former president Nigeria Medical Association, (NMA) puts it this way: "The system collapsed just like power and other things with the last administration of Obasanjo" He attributed it to inefficiency and corruption on the part of the people positioned to consolidate what Ransome-kuti started

Dr Dan Gana, also a former president of NMA agrees with him. He said: It has long collapsed."

According to him the system was very defective, thereby making useless the much -touted campaign to stem maternal and child's death

Gana said the government has paid lip service to the primary health care system for years, saying this has led to its collapse.

He said, "The secondary health care is in comatose. if we rely on available data, 70 per cent of all ailment could be treated at the primary care levels and just 20 per cent of ailment need to get to the secondary level and 5per cent to the tertiary level. So, if we strengthen the primary health care, there will be no pressure on the general Hospitals and the teaching hospitals. But as at now general hospitals are treating primary cases while teaching hospitals are treating malaria and diarrhoea."

Chief Medical Director of Lagos University Teaching Hospital (LUTH), Professor Akin Osibogun, told The Guardian that the major problem was that of pressure on the facilities as the number of facilities were grossly inadequate

"There is one PHC to 60,000 to 80,000 Nigerians. The Local Government Areas (LGAs) who are supposed to run the PHCs spend about 90 percent of their monthly allocation to pay salaries and there is nothing left for the PHCs."

"Also the quality of services at the PHCs do not encourage people to utilize them. The facilities are there but are poorly maintained. It is supposed to be maintained by the LGAs in addition to paying salaries," he said.

The premises of the Primary Healthcare Centre, (PHC), home to the Vaccine Cold Store serving the five PHCs in Mushin and Ilupeju parts of Lagos State, perhaps captures the state of deterioration of PHCs in the country.

Located on Palm Avenue, the supposed GRA of Mushin, the centre is doted with abandoned vehicles and refuse.

One of the nursing officers told The Guardian that she has spent two years at the centre and that it is only once that attempts were made to collect the garbage.

Whereas the centre would need at least six midwives to function optimally, it has three presently. To assist them on the 24 hour maternity services are some doctors on their one year compulsory National Youth Service Corps, NYSC.

Though there is no ambulance, there is however a Taxi Park right at the entrance of the centre to meet emergency needs.

"I have been here for two years now and I can only remember a truck coming in once, and even then, the truck could not pack up to half of the refuse because of blockage by several abandoned vehicles, some of which are said to have been there for up to six years. All these add up to make the place so unsightly that people are not attracted to come in to access care." She lamented.

"Indeed, there are some people who register but don't come to have their babies there as they complain of filth. The whole environment is infected with mosquitoes; there are no nets too. It then becomes difficult to encourage people to come in to have their babies and not be able to sleep at night because of mosquitoes or offensive odour from the refuse site." she added

Another headache, which the center has to battle with, is flooding each time it rains; a part of the ceiling has since given way due to continuous leakage.

Of course, that there are other challenges such as lack of adequate health personnel and drug shortage.

She continued: "most of the patients that come here are for routine immunization, while a few others who come for other ailments fall within the poor income earners which should not be. Our people still do not fully understand the place of Primary Healthcare Delivery System and I think we need a re-orientation.

"However, you cannot force them to come; government must first make the centres attractive by putting up clean structures and equipping them with the right tools, personnel as well as drugs. Imagine how this centre is now, what rich man or woman will come here for malaria treatment or any health services for that matter? There is need for total turn around of many of the PHCs but as a matter of fact, things are beginning to look up in Lagos State."

She observed that for now, most of the drugs, which they need to give the patients are not available hence she called on government to introduce a kind of Drug Revolving Fund.

"I will want to appeal to government to make many more drugs available, besides routine ones like paracetamol and multivitamins. There are situations whereby we have just two out of about eight drugs that we need to give a patient. What this means is that the patient has to go and buy the rest and this exposes him to the danger of fake/adulterated drugs."

Mr Segun Olaniyan,a Senior Community Health Officer, (CHO) confessed that health services at the local level have never been that same since the death of Olikoye Ransom-kuti.

He said: " Ransome-kuti had a strong passion for healthcare delivery at the primary level, hence he ensured that there were many programmes going on at that level. He gave priority to Community Health Workers, (CHW), Community Health Extension Workers, (CHEWs) as well as Community Health Officers, (CHO). Today however, there seems to be many forces that want to relegate their roles to the background. Prof Olikoye ensured that CHWs were trained; we have 'Standing Order' which serves as a consulting manual.

He identified what he called personality clash between Nurses and health extension workers as another issue in the deterioration of primary healthcare delivery in Nigeria.

"Nurses seem to be having personality problems with us." He added

The Guardian investigation showed a significant number of political wards and communities particularly in remote rural LGAs had limited physical access to health care.

In places where facilities existed, The Guardian learnt that most were in a state of dilapidation and neglect.

These reports were collaborated by findings from the Needs Assessment Survey conducted by the NPHCDA in 2001.

The Guardian investigations indicated that the poor state of PHC infrastructure could be attributed to a variety of factors, but centered mainly on the inability of the LGAs to fulfill their role of ensuring the provision of quality PHC infrastructure and services.

Indeed the main stated objectives of PHC included accelerated health care personnel development; improved collection and monitoring of health data; ensured availability of essential drugs in all areas of the country; implementation of an Expanded Programme on Immunization (EPI); improved nutrition throughout the country; promotion of health awareness; development of a national family health program; and widespread promotion of oral rehydration therapy for treatment of diarrhoea disease in infants and children.

Implementation of these programs was intended to take place mainly through collaboration between the Ministry of Health and participating local government councils, which received direct grants from the federal government.

Of these objectives, the EPI was the most concrete and probably made the greatest progress initially. The immunization program focused on four major childhood diseases: pertussis, diphtheria, measles, and polio, and tetanus and tuberculosis. Its aim was to increase dramatically the proportion of immunized children younger than two from about 20 percent to 50 percent initially, and to 90 percent by the end of 1990.

The government's population control program also came partially under the PHC. By the late 1980s, the official policy was strongly to encourage women to have no more than four children, which would represent a substantial reduction from the estimated fertility rate of almost seven children per woman in 1987. No official sanctions were attached to the government's population policy, but birth control information and contraceptive supplies were available in many health facilities.

The federal government also sought to improve the availability of pharmaceutical drugs. Foreign exchange had to be released for essential drug imports, so the government attempted to encourage local drug manufacture; because raw materials for local drug manufacture had to be imported, however, costs were reduced only partially.

For Nigeria both to limit its foreign exchange expenditures and simultaneously to implement massive expansion in primary health care, foreign assistance would probably be needed.

Despite advances against many infectious diseases, Nigeria's population continued through the 1980s to be subject to several major diseases, some of which occurred in acute outbreaks causing hundreds or thousands of deaths, while others recurred chronically, causing large-scale infection and debilitation. Among the former were cerebrospinal meningitis, yellow fever, Lassa fever and, most recently, AIDS; the latter included malaria, guinea worm, schistosomiasis (bilharzia), and onchocerciasis (river blindness). Malnutrition and its attendant diseases also continued to be a refractory problem among infants and children in many areas, despite the nation's economic and agricultural advances.

Among the worst of the acute diseases was cerebrospinal meningitis, a potentially fatal inflammation of the membranes of the brain and spinal cord, which can recur in periodic epidemic outbreaks.

Northern Nigeria is one of the most heavily populated regions in what is considered the meningitis belt of Africa, stretching from Senegal to Sudan and all areas having a long dry season and low humidity between December and April. The disease plagued the northern and middle belt areas in 1986 and 1989, generally appearing during the cool, dry harmattan season when people spend more time indoors, promoting contagious spread. Paralysis, and often death, can occur within forty-eight hours of the first symptoms.

In response to the outbreaks, the federal and state governments in 1989 attempted mass immunization in the affected regions. Authorities pointed, however, to the difficulty of storing vaccines in the harsh conditions of northern areas, many of which also had poor roads and inadequate medical facilities.

Beginning in November 1986 and for several months thereafter, a large outbreak of yellow fever occurred in scattered areas.

The most heavily affected were the states of Oyo, Imo, Anambra, and Cross River in the south, Benue and Niger in the middle belt, and Kaduna and Sokoto in the north. There were at least several hundred deaths. Fourteen million doses of vaccine were distributed with international assistance, and the outbreak was brought under control.

The presence of AIDS in Nigeria was officially confirmed in 1987, considerably later than its appearance and wide dispersion in much of East and Central Africa. In March 1987, the then minister of health announced that tests of a pool of blood samples collected from high risk groups had turned up two confirmed cases of AIDS, both HIV Type-1 strains. Subsequently, HIV-2, a somewhat less virulent strain found mainly in West Africa, was also confirmed. In 1990 the infection rate for either virus in Nigeria was thought to be below 1 percent of the population.

As part of efforts to revitalize the PHC sector and to facilitate the establishment of the Ward Health System, the Federal Government through the National Primary Health Care Development Agency initiated the construction of model health centres in various needy political wards across the country.

The process, which was executed in phases has so far resulted in the award of contracts for the construction of Six Hundred and Eighty-Four (684) units of Model Health Centres Nationwide from 2001 and 2007.

The constructed Model PHC centres were supplied with medical equipments and seed stock of Drugs for a drug revolving fund.

In addition, relevant trainings were conducted for the health staff posted to the centres and the communities organized to co-manage the provision of PHC services.

Experts told The Guardian that the critical challenges towards making all the health centers functional include staffing, apparent shortage of manpower and difficulty in retaining staff in rural areas

The critical number of staff of various cadres, required to man these center are expected to be deployed by the LGA PHC department.

However, apparent shortage of manpower and difficulty in retaining staff in rural areas has lead to understaffing, irregularity at work as well as absenteeism of staff in many of the model centers have also contributed to non-utilisation.

Lack of water, electricity and access roads to the center have created untold hardship to patientss and further discouraged the staff from remaining at their duty post.

Community restiveness and hard to reach terrains particularly in the south south zone has also hindered the completion of some health centers

Apart from signing a memorandum of understanding with LGAs for the provision of access roads, potable water and light for the health center, the NPHCDA has on numerous occasions advocated to LGAs to meet the agreements in MOU with poor response.

From 2001 to 2007 a total of 684 model health care centers have been for construction out of which 471 have been completed

All the completed centers have been provided with medical equipment and seed of drugs for drug revolving fund schemes, they have since been taken over by weeds.

In a bid to strengthened the primary health care, the Senate has also passed the National Health bill . The bill aims to establish a framework for the regulation, development and management of the national health system and underpins primary health care as the entry point into the national health system.

The bill also establishes a Primary Healthcare Development Fund, which shall see to the provision of basic health care to as many as possible through the National Health Insurance Scheme. The fund is to be administered by the National Primary Health Care Development Agency (NPHCDA).

The bill provides that funding for the Primary Health Care Development Fund shall come from "an amount not less than two per cent of the value of the Consolidated Revenue Fund as well as grants from international donor partners."

The bill stipulates a sharing formula in the utilisation of the fund to the effect that "fifty percent of the amount in the fund would be expended on basic health care for all citizens," while 25 per cent of the fund would be used to provide essential drugs for primary healthcare and 15 per cent of the fund would be used in providing and maintaining logistics used under the primary health care system.

The remaining 10 per cent of the fund would be utilised in the building of the capacity of human capacity used under the primary healthcare system.

The bill also sets guidelines for states and Local Governments to benefit from the fund. For the States, the bill provides that the State should provide at least ten percent of the cost of the project envisaged while Local Governments are to contribute 5 per cent of the cost of the project costs.

According to Osibogu, one of the ways of sustaining the PHC is through sustainable health care financing.

"The Lagos state government have just launched a Community based Health Insurance scheme (CBHIS) Wednesday. The system thrives in pulling of resources. You know it is not all in the scheme that will fall ill at the same time, so the huge funds are used to take care of the few that are ill.

Osibogun said the solution is for government to invest more in health and reorientate health workers, improve funding and support health workers.

He said LUTH has been very cognizant of the situation and offers PHC services. "We have a PHC at Ifo LGA of Ogun State at a village called Pakoto. We want to discourage people with simple ailment coming to our Accident & Emergency because it is over burdening us. However, we do not turn them back, but we need to concentrate more in offering specialized medical care".

The continued vertical structure of implementing individual disease control programmes like HIV/AIDS, TB and Malaria, as well as other programmes like reproductive health within a weak health system have had little impact on improving the health-related MDGs.

There is now a compelling need to adopt a sector-wide, service-wide approach to the delivery of primary health services in Nigeria.