BY JIDE AYOBOLU
The Minister of Health, Dr. Osagie Ehanire, says additional 10,000
Primary Health Centres (PHC) will be rehabilitated to boost healthcare
delivery across the country.
The minister made this known while addressing State House correspondents
at the end of the meeting of the Federal Executive Council (FEC),
presided over by President Muhammadu Buhari at the Council Chamber of
the Presidential Villa, Abuja, on Wednesday. According to him, the
Buhari administration has so far resuscitated 4,800 PHCs.
He said “at the inception of the current administration in 2015, less
than 20 per cent of PHCs were working, maybe about 1,000 were working.
As of now, 4800 are functional. “So many of the health centres have
been revitalised, they are working; not only are they working, the
government has provided the Basic Health Care Provision Fund with which
service can be paid at the primary healthcare centre for those who
cannot afford it for the poor. “The aspiration is to increase the
number from 4,000 to something near 10,000, one per political ward in
the country.’’ While reacting to a question on the identity of the
Covid-19 index case in Nigeria, the minister dismissed speculations that
the government was hiding the identity of the patient.
According to him, it is medically unethical to reveal the identity of
the Italian currently quarantined in a medical facility in Lagos. News
Agency of Nigeria (NAN) reports that an Italian, who is yet to be
publicly identified, tested positive for the virus on arrival in Nigeria
on Feb. 25. The minister said unlike the index case of Ebola, Patrick
Sawyerr who was known, the Italian could not be exposed because his
privacy must be respected.
In line with his administration’s vision to provide quality basic
health care services to Nigerians, irrespective of their location,
President Muhammadu Buhari PMB has pledged to revitalize 10,000 primary
health care facilities in the country, using a phased approach. Buhari
said the focus would be more on people living in rural areas and
vulnerable population in the society such as women, children under five
years of age and elderly in collaboration with national and
international partners.
According to him, provision of National Health Act, 2014 for Basic
Health Care Provision Fund is in the process of being implemented,
adding that his administration would fulfill all promises made to the
people. He said “Let me state clearly, that this revitalization
programme is in alignment with the agenda of our party, the All
Progressive Congress (APC). We did promise to provide succor to the poor
while at the same time providing for all other segments of the society.
I am aware that out of pocket payment for health constitutes over 70 per
cent of total health expenditure. This is more than the globally
recommended 30-40 per cent. “However, only less than 5% of the total
population is covered by any kind of health insurance or risk protection
mechanism which is against the recommended 90% coverage by the World
Health Organization. Our vision is to reverse this unsatisfactory
situation and better care for the poor and needy. “Our Administration
in recognition of this promised to revitalize one Primary Health Care
Centre in each of the political wards in the country. So far, we have
commenced the revitalization of one Primary Health Care in each
senatorial zone in the country. “Our vision is to revitalize 10,000
Primary Health Care Facilities in Nigeria using a phased approach. The
first phase of this approach is what we are flagging off today. It will
signal the revitalization of the first 109 Primary Health Care
facilities across the 36 states and the FCT.”
People turn to the primary health care system in their communities both
to stay healthy and to get care when they fall sick. From primary health
care providers they seek prevention of disease, management of chronic
conditions, access to treatment of various ailments and conditions, and
family planning. When the primary health care system performs well, it
meets the vast majority of people’s health needs, and that is
essential if we are to make progress toward our nation’s health goals.
The primary health care (PHC) facility is often all that rural
communities have in form of a formal health system. How then do we
improve the quality of care when attention has consistently been on
expanding the reach of PHC services to rural populations and hardly on
quality of services? The presence of a PHC facility does not guarantee
its use and there is a wrong assumption that a minimal level of input
(i.e. infrastructure and staff) is essential before one can discuss
quality. Even when quality becomes a real issue, it is often about
supervision; but supervision is a poor proxy for quality. The quality of
supervision itself is what matters. Handled poorly, this becomes a
vicious circle: poor supervision results in low quality of services and
low quality of services set a low standard for supervision. Health
services in Nigeria mirror political organization. The federal
government is responsible for tertiary care, state governments for
secondary care, and the local governments run primary care. The
financing of (but not the responsibility for) public health is tied to
the flow of funds from the federation account. Funds are shared between
levels of government according to an allocation formula that keeps about
half at the federal level, allocates a quarter to the 36 states, and
gives the other quarter to the LGs. These resources are not sectorally
earmarked and the states and LGs are not constitutionally required to
provide budget and expenditure reports to the federal government.
Nigeria thus leaves the most important and consequential level of health
care – primary health care – to the weakest level of government.
This results in poor coordination and integration between levels of
care, giving rise to a weak and disorganized health system, in which
widely varying patterns of outcomes depend on local situations.
The decentralization policy that makes local governments run primary
health care in Nigeria rests on the imported notion that services are
most efficient when governance is close to the people, an assumption
that is premised on the existence of a well-functioning participatory
democracy where the electorates are neither hungry nor ignorant. Most of
the rural people our PHC facilities serve have not been exposed to high
quality health services so they accept what they get as the norm or,
when they imagine it not to be the norm, without complaints. When they
cannot put up with low quality services they ignore the PHCs by staying
at home, and they consult quacks, only to present in the PHC or other
hospital in emergency, often too late for life-saving interventions.
This is not a new problem, and Nigeria has responded in two important
ways to the disjunction between finances and responsibility on the one
hand, and between communities and the political administration of health
on the other. The National Primary Health Care Developing Agency
(NPHCDA) is one such Nigerian innovation, albeit as usual, not
completely well thought out. NPHCDA is a federal government agency with
policy and oversight roles on PHC implementation at the state and local
government levels in Nigeria. The major drawback is that a federal
agency has no binding constitutional role to implement programmes or
policies at the state and local government levels. The governments must
be willing to cooperate or nothing happens, and cooperation often has to
come with financial commitments, which for every government are highly
contested grounds.
The second innovation, also poorly thought out for the short term, is
the creation of Ward or Village Development Committees (WDCs or VDCs).
An initiative of NPHCDA, they are designed to strengthen local
communities in the hope that they can advocate for themselves. The
committees are made up of influential community members who can help to
enhance community participation and ownership, and promote demand for
quality services. The problem here is that people can only demand what
they are really passionate about. People may be empowered by knowledge,
but it takes a deeper level of knowledge that can translate into passion
and commitment to get people to act and change their behaviour. It is
much easier to ignore community participation when the issue is
improving input — infrastructure and staff. But for quality, it is
clear that we either find a way to get communities actively engaged in
the health system that serves them, or we establish structures and
processes that will allow us to temporarily bypass community
participation on the road to improving the quality of care at the PHC
level in Nigeria.
Health professionals are often in the position to set the standards for
themselves, and then police themselves to ensure their practice is up to
those standards. Health workers in Nigeria as in many other countries,
rather than police themselves, are more likely to protect their
colleagues from complaints of negligence, malpractice that may lead to
litigation. In a situation where people are not empowered to detect poor
quality, speak up and fight, there is need for the health system to fill
that role on behalf of the people. This gap in behaviour means that the
solution to the quality issues in primary care has to be innovative. We
must think of structures, both government- and civil society-led, to act
on behalf of communities in the hope that by so doing, members of the
community can learn to make demands in their own voices. This may happen
through continuous supportive supervision through the use of
standardized checklists. It is also important to openness, while
discouraging a culture of blame and fault finding in quality assurance.
Nigeria lacks the technical, financial and political sophistication and
robustness required for a complete decentralization of health services.
To streamline the health system, it may be necessary to bring PHC under
the federal roof, and add tertiary care to the responsibility of state
governments. The role of supportive supervision can then be left to the
local governments who will function independently with verification of
their activities by civil society. I am afraid this proposal may only
look good on paper. Implementation in reality will be difficult, and
there are great political hurdles to reorganizing a system, especially
when such reorganization involves huge financial commitment by the
different tiers of government.
All said and done, it is commendable that the president has identified
critical areas in the healthcare system of the country and he has made
commitments to drastically improve the situation on ground, in the
overriding interest of all Nigerians, especially those residing in the
different rural parts of the country.