The 40th anniversary of the 1978 Alma-Ata Declaration on Primary Health Care was marked recently. The vision, principles and desirables of the PHC augury are pertinent to the hopes and strategies of the health-related trans-national frameworks that evolved later, namely, the Universal Health Coverage and the 2030 Agenda for Sustainable Development (the Sustainable Development Goals). These two global agenda also propagate the same fundamental principles and expectations as the PHC, that is, achievement of health and well-being for all. It is estimated that 80 – 90% of the health needs of an individual during their lifetime can be met within the PHC services.
This insight-sharing is a review of the meso-structural aspects of the Nigerian PHC system as it morphed during the last 30 years, using “lessons learned” parameters within four frames of reference in our PHC experience to guide reflection by stakeholders.
Between October 25 and 26, 2018, over 1,000 leaders from member states of the UN and global organisations met in Astana, Kazakhstan to renew commitment to the PHC and to develop people-centred PHC, building on the principles of the Alma-Ata Declaration. At least, the Declaration of Astana should stir up a renaissance in the PHC.
What are the prospects for fruitful PHC renaissance and revitalisation in the evolving political dispensation in Nigeria? In recent months, ostentatious actions and vocalisation on the PHC largely by state governments in Nigeria are remarkable in two thrusts:
Refurbishing of old and building of new PHC centres, and Setting up State PHC Development Agencies and Health Insurance Schemes, so as to qualify for drawing from the National Health Act-based Basic Health Care Provision Fund.
While the PHC has always been verbally proclaimed as a priority in major health fora in Nigeria all along, it is often treated as an orphan in the corridors of cash provision and priority pragmatisation at the three tiers of political will and governance. Furthermore, field workers who are acquainted with the local context do not find it easy to translate into practice, experts’ technical or mathematical intervention modelling which emanated from a process in which they, the field actors, did not participate. This tends to prolong the “storming and forming” stages of a new intervention, before arriving at the “norming and doing” stages that could progress to up-scaling.
(The statements reproduced here are lifted as they were expressed in the respective sources and frames of reference).
Frame of reference 1 (April 1995): Federal Government of Nigeria and UNICEF Strategy Paper for 1997 – 2001 Country Programme of Cooperation:
Lessons Learned From The Previous Programme of Cooperation:
It is very difficult to sustain achievements gained through vertical intervention which have not been integrated into the mainstream of the established minimum care package (MCP)
Community participation is just a hollow cliché if communities do not participate in the management of funds and other resources
Poly-pharmacy in diarrhoea and acute respiratory infection management is common
Unless women have access to emergency obstetric care when they develop complications, maternal mortality rate will remain high
Advocacy and education regarding “risks and complications” (during pregnancy) have limited benefit in the absence of adequate back-up support for case management.
Frame of reference 2 (April 1997): Federal Ministry of Health/WHO 3rd Global Evaluation of Strategies towards HFA 2000 Nigeria Country Report
The constraints highlighted in this assessment report are similar to those outlined in frame of reference 1.
Frame of reference 3 (November 2000): The UK Department for International Development document – “Better Health for Poor People; strategies for achieving the International Development Targets” –
Sustainable Services need better health Systems – A major lesson learned is that the early achievements of extending delivery of specific interventions (like childhood immunisation) cannot be sustained if they do not become integral part of national health systems;
Health Sector Reform: from Ideology to pragmatism – Early enthusiasm for the health sector reform agenda has been dampened to some extent by concern about the transferability of health reform models;
The reorganisation of the “supply-side” does not necessarily feed through more accessible and effective health care for poor people;
There is now more recognition that the health behaviour of individuals, social networks and community initiatives have an immediate and important impact on health risks and prospects;
Quality, participation, transparency and accountability of services are vital;
Focusing on poor people will target the concentration of ill-health, and those health problems for which there exists particularly cost-effective remedies;
For Aid Effectiveness, sector-wide approaches such as Comprehensive Development Framework hold out the promise of reduced transaction costs, reduced duplication and fragmentation of policies and systems and greater focus on the overall effectiveness of the sector.
Frame of reference 4 (May 2009): Federal Minister of Health Foreword (Final Draft): The National Strategic Health Development Plan Framework (2010-2015).
This frame poignantly summarised the shortcoming that despite remedial initiatives, much of the underlying weaknesses and constraints of the health sector persist.
Were the lessons actually learned? Collectively, the lessons determined but not learned encompass the following broad remedial courses of action: Adopting multilateral, system-wide approaches that would accelerate and sustain achievement of specific outcomes within the dynamic context of systems strengthening; Developing a community-and demand-side driven endogenous model of service delivery which would encourage community awareness of the social, environmental and other determinants of health as opposed to the exogenous “expert/mathematical model” of the PHC that responded primarily to disease epidemiology; Having mechanisms for eradicating superfluous medication prescriptions to reduce distressing out-of-pocket health expenses which may be a reflection of the shortcoming in the system relating to supervision and rational drug use, and probably also to coping strategy adopted by the health staff for salary augmentation.
The carrying power of the PHC through systems strengthening will be critical for expanding and sustaining the outcomes of government and international development partners’ initiatives to-date, mainly focused on communicable diseases. But the rising burden of non-communicable diseases and socially transmitted conditions together with the imperative of bridging to SDG3 will necessitate ongoing and long-term care to maintain well-being and quality of life. The prospect of such a desirable care continuum is weakened by rather fragile coordination and integration. Furthermore, when best practices are to be documented, the scenarios selected are often the externally supported project configurations; this predilection ignores locales of community initiatives. Also, community ownership will be vital for initiating and sustaining the much publicised community-based (social) health insurance movement which could leverage the UHC, with wide local stakeholder buy-in.
The frames of reference for lessons learned point to fact that reduction in morbidity and mortality and promotion of universal well-being in the general population at desired levels will need the integrated delivery of curative care and public health services (including health promotion) as well as on-going social care support on a scale provided through the spread of the PHC framework in terms of availability, accessibility and acceptability in the local context. Furthermore, a robust and resilient PHC system can contribute to dampening the strike impulse of staff in government-run hospitals, as well as making a difference in times of disease outbreak and other emergency situations. The PHC framework does not have such carrying power at present because “lessons learned” were not subsequently transformed to better ways of doing things.
Dr Inyang is a public health consultant based in Uyo, Akwa Ibom
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