Challenges Facing Nigeria’s PHC System and Possible Solutions

Nigeria’s PHC System: Challenges and Practices
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Nigeria’s PHC System: Challenges and Practices
Challenges Facing Nigeria’s PHC System and Possible Solutions
Nigeria's PHC system forms a central component of the country's health system and is an integral point for every Nigerian citizen's social and economic development. It is the first point of health service contact for communities, families, and individuals, and the country's health system as a whole. Since making PHC the cornerstone of health system development in 1975, the government has shown a remarkable commitment to PHC programmes, as demonstrated by the increased budget allocations and the numerous governance reforms aimed at streamlining PHC services. The country has also succeeded in ensuring a relative abundance of PHC centers nationwide, and there is reasonable geographical access to primary health care services at the community level. However, health gains at the grassroots level have been stubbornly slow, hinting at a possible underperformance in the country's PHC system. There are several reasons why Nigeria’s PHC system has failed to deliver quality health services at the community level. Some of these include inadequate funding for healthcare infrastructure and resources such as drugs, medical equipment, and vaccines at the facility level; fragmented supply chains; insufficient government commitment; poor engagement with the private sector; and inadequate health worker performance (Aregbeshola & Khan, 2017).
One of the biggest reasons for the poor performance of Nigeria’s PHC system at the community level is limited government funding which translates to higher out-of-pocket payments by health care consumers. Even though PHC coverage is comparatively satisfactory with sufficient facility density across the country, except for some isolated pockets where PHC services are limited, most families cannot afford the cost of public PHC visits. Most of the country's rural population resides within a moderate distance of a public PHC facility, but health care services continue to remain out of their reach. For instance, the average cost of visiting a PHC center is $2.30 for child patients and $3.20 for adult patients, sometimes going up to $8.00, which is taxing on 45% of the country’s population who typically live on less than $2.00 a day, and more so on 28% of Nigerians who live on less than $1.25 a day, as per World Development Indicators (Kress et al., 2016). Part of the reason PHC services are financially inaccessible for a majority of Nigerians stems from the fact that health care worker salaries are prioritized over health care supplies and other facility operational expenses. Because of financial constraints and the large workforce of community health workers, most budgetary allocations end up paying health workers at the expense of ensuring PHC facilities are stocked with essential drugs, modern equipment or that the facilities themselves are maintained. A large number of PHC facilities are under-resourced and cannot provide the high quality of healthcare services required by families and individuals at the community level.
This issue is largely the result of inadequate government expenditure on health care. Even though Nigeria is the largest economy in Africa, less than 4% of the country's GDP is spent on improving health care services in its PHC centers. Economic instabilities such as the collapse of oil prices, an economic sector the country is heavily dependent on, restrict the amount of money the government can spend on health care. Consequently, there is a perennial shortage of drugs in the majority of PHC facilities. Only a fifth of PHC centers have the required minimum health resources to provide the essential health services. While the government has made a sturdy effort to ensure better availability of vaccines, essential drugs and critical medical equipment such as stethoscopes, refrigerators, sterilizers, blood pressure cuffs, and refrigerators are largely unavailable. Because of the competing demands for the limited financial resources available, the infrastructure of most PHC centers has been largely ignored. More than three-quarters of health care centers lack electricity, toilets, and running water. Moreover, some of the PHC facilities are badly in need of maintenance. PHC centers have to rely on out-of-pocket payments to buy essential healthcare supplies, equipment, and vaccines (Ilesanmi & Babasola, 2017). Because the burden of supporting PHC centers is generally borne by health care consumers, citizens have to pay for nearly every health care service they access in public PHC centers. Currently, 73% of total health expenditure is financed from out-of-pocket payments.
Even then, these out-of-pocket payments are not enough to ensure PHC facilities have adequate health care resources, and it is not uncommon for drug stocks to run out for several weeks before the local government is able to provide the necessary replenishment. These centers also depend on comprehensive charger user fees (usually in the form of registration and consultation fees), which are typically high and more than what the ordinary Nigerian health care consumer can afford. As a result, affordable, integrative health care services continue to remain out of reach of poor populations, even with the relatively satisfactory coverage of PHC services. While the private sector is supposed to fill in these health care gaps, the Nigerian government has failed to leverage private medical services as a central facet of the country’s PHC provision. For instance, the country’s private sector is ineffectively regulated, and therefore the technical quality of health care services is variable and ineffective (Ogunseye, 2020). There is currently a large number of people without formal training retailing orthodox pharmaceutical drugs for profit in the pharmacy sector. Although these persons lack professional competence to provide diagnostic advice on complicated medical conditions and often refer patients to public PHC centers, the referrals are repeatedly delayed and irregular.
In addition to the inadequate partnership between Nigeria’s public and private health care sectors is the issue of inadequate health worker performance. The knowledge and capacity of health care workers in most PHC centers, as determined by diagnostic accuracy measures and capacity to deal with maternal and newborn complications, is insufficient. For instance, less than half of the health care workforce in Nigerian PHC facilities can correctly diagnose pneumonia, and only a slightly larger fraction is capable of prescribing efficacious antibiotics for the ailment. These incapacities speak to inadequate quality of care at the community level, especially since most healthcare services at the grassroots level are provided by community health workers. A majority of these community health workers do not receive any regular training or attend capacity-building workshops to ensure the health care services provided are up-to-date or evidence-based (Erchick et al., 2016). On the whole, the country's health workforce is largely unsupervised, and any clinical errors or poor health delivery practices are rarely documented or corrected. For instance, studies indicate that the average time spent by Nigerian health care professionals tending to patients during a visit is woefully inadequate. Although the Nigerian government has spent a huge amount of resources to ensure adequate distribution of PHC facilities and sufficient health care professionals to deliver services in these centers, the PHC systems are performing below expectations.
Even after building training colleges in every state to ensure a sufficient health workforce density, the PHC system is plagued by an unmotivated workforce. This challenge is demonstrated by the high absenteeism rates in most public PHCs. A significant proportion of health workers are often unavailable for consultations, although a majority of clinicians are usually on approved absence. Excused absence points to a largely unmotivated workforce, which is denying health consumers the critical health care services they require. In addition to insufficient budget allocations to PHC centers and an inadequately supported workforce, Nigeria’s PHC system is also challenged by a disjointed governance structure, which strongly ties to the previous challenge of financial constraints. Although the government has taken steps to streamline PHC governance through the Primary Health Care under One Roof (PHCUOR) policy strategy, which combines all PHC activities and policies under one administration, the governance of PHC activities, particularly financing and supply chains, are still highly fragmented (Tumba, 2017). The allocation of the health care budget is guided by the constitutional funding rule, which splits funds between the three tiers of the government. PHC system roles are also divided between the federal, state, and local government authorities, where the former is tasked with maintaining teaching hospitals and regulating medical training. The state governments are responsible for managing tertiary and secondary-care hospitals, whereas local government authorities are responsible for PHC.
Local government authorities are responsible for overseeing PHC centers and ensuring they provide essential health services and community education. The federation account, in conjunction with the local government joint account, provides the funds needed to support PHC facilities at the community level. Since budget allocations from the federal government flow first, to state governments, the governor essentially decides how much to allocate to local government authorities for health care (Reich, 2016). Generally, local government authorities receive funds from the federal government through the state, and therefore the state government's commitment to improving the quality of health care services provided by PHC centers is a critical factor. As is often the case, budget allocations from the state for health care are often limited, thereby restricting how much local government authorities can spend on PHC service improvement. The little that is received is often directed towards settling staff salaries, thereby leaving little to no funding for PHC operational expenses. Since local government authorities are incapable of generating sufficient resources to bolster the PHC centers under their purview, the lack of willingness by most state governors to allocate more funds to health care often means that local PHC centers have to make do with the bit of revenue generated through exorbitant and comprehensive charger user fees to cover operational costs and purchase health supplies. Even this is insufficient to guarantee actual service delivery and most PHC centers are incapable of providing outreach health services to at-risk populations.
Besides, only half of the overall capital budgets by state governors and local government author chairmen are ever executed. One of the reasons why both skilled and unskilled health workers are given first priority over PHC centers’ operational expenses is because of their strong bargaining power. Nigeria has one of the largest populations of health care professionals in the continent, and national health worker unions have enough power to dictate compensation rates. The country's PHC system is fragile, and the government often conceded to health worker demands since strikes tend to disrupt the limited health care service critically required by large vulnerable populations (Uzochukwu et al., 2018). On the whole, Nigeria's PHC system is dependent on cost recovery mechanisms and, to some extent, support from both domestic and international donors. The disintegrated governance structure of Nigeria's PHC system has cultivated a culture of poor management and accounting practices. Most PHC centers have one account that covers all facility expenses, and poor management of the little funds available often results in little or no money left for drugs. The disjointed PHC system governance structure is also evident in the supply chain, where PHC facilities have several uncoordinated supply chains. For instance, it is not uncommon for one PHC center to have five or more suppliers operating under different business models and implementing diverse business practices providing vaccines, essential medicines, family health commodities, and other health supplies. This disintegration extends to the storage and disbursement of essential drugs, where cold chain stores and medical stores are typically separated geographically.
The fragmented state of Nigeria's PHC system is not limited to financial or supply chain oversight but also in relation to the implementation of health care policies. For instance, the state governors receive direction from the National Primary Health Care Development Agency working together with the Federal Ministry of health. States governors are responsible for employing, managing, and compensating PHC administrators through the State Local Government Service Commission. However, the State Ministry of Local Government Affairs (SMoLG) has limited prerogative since power is shared conjointly with the local government authority chairman PHC department (Ottih et al., 2018). The latter is tasked with program coordination and management of PHC facilities at the community level, including budgeting, assessment, and supervision. The overlaps in jurisdictional power mean certain functions cannot be performed without the consent of the other. For instance, the local government authority chairman PHC department cannot fire senior PHC administrators since they are directly hired and compensated by the SMoLG. There is even greater disintegration at the community level where the ward, as well as the village development committees, are the major agents involved in the community improvement of PHC facilities. Unfortunately, these bodies are not always operative, and there is often little accountability on behalf of health care consumers.
The inability of Nigeria’s PHC system to provide adequate and quality health care services to communities, families, and individuals is mostly because of insufficient funds, fragmentation in the governance of PHC policies and activities, poor partnerships between the public and private health care sector, and insufficient development of the health workforce. These challenges can be easily resolved if the government devotes attention and resources to ensuring PHC facilities are well equipped and maintained, promotes partnerships between the public and private health sectors, eradicates overlapping functions among PHC agencies and actors, as well as provides regular training and capacity-building workshops for its health workforce. One of the first things the government requires to do to improve the quality of health care services provided by its PHC system is implemented stringent performance management where compensation of health workers is not assured but is based on job performance (Ekeigwe, 2019). At present, health workers enjoy an unparalleled level of bargaining power that has served to embolden poor skills, high rates of absenteeism, and limited service provision. There is a large population of unemployed and trained graduates who are willing to work in public facilities but are unable to join the workforce owing to the job security enjoyed by a largely ineffective workforce. Continued employment of currently employed health workers should be based on both quality and quantity of service delivery. Promotions should also be founded on performance, experience, and formal qualifications. Systematic evaluations of staff performance in every PHC facility should be conducted in order to eliminate non-performing staff whose lack of commitment is costing many vulnerable populations the critical care they deserve.
The Nigerian government should also work to improve the training and capacity of current health care professionals. The health ministry must promote regular workshops among clinicians to ensure that the workforce is sufficiently competent to provide evidence-based medicine. Regular supervision of all health professionals is also necessary to ensure that appropriate and quality health care services that conform to industry standards are provided. Moreover, training among private citizens operating pharmacies in Nigeria, over and above, enforcement of rigorous standardized referral systems, and quality assurance programs are critical. The Pharmacy Council of Nigeria can improve the quality of pharmacy services provided by the private sector by ensuring only competent pharmacists are given licenses to operate drug stores (Eboreime et al., 2015). Besides, explicit referral processes and quality assurance standards must be enforced to facilitate faster and regular referrals for at-risk groups, over and above, to ensure that the drugs sold in private pharmacies are safe and effective. In order to eliminate the still existing fragmentation of PHC service delivery, the government must place more emphasis on the PHCUOR policy, which seeks to consolidate all policy implementation processes and activities under one authority. All PHC activities must be brought under one administration body capable of overseeing all human and financial needs of PHC facilities spread across the country. Rather than having various PHC functions performed by the state in conjunction with the local government authority, it would be better to group all tasks and authorities at the state level.
Such a move would not only ensure faster and effective implementation of PHC policies and activities but would also encourage accountability. Instituting one supervisory system would put an end to the continued poor management of PHC finances by facility administrators. Further to this is the need to consolidate Nigeria’s PHC supply chain, over and above, integrate transport and storage capacities for diverse parallel supply chains. Local government authorities must mandate that all PHCs have a separate account for health care supplies. The current failure to ring-fence money for essential health supplies such as drugs, medical equipment, and maintenance of infrastructure has resulted in the misallocation of critical funds (Kress et al., 2016). Requiring PHC administrators to set aside money for operational expenses from that meant for drugs and other critical health supplies will promote better money management and greater accountability of all resources allocated to PHC centers. Most importantly, the Nigerian government needs to allocate more of its budget to health care, irrespective of economic fluctuations. The federal government needs to back its commitment to the PHC system by allocating more resources to operational expenses, thereby reducing the current heavy burden borne by citizens.
More funds are needed to ensure PHC facilities are adequately supplied with essential drugs, vaccines, as well health equipment and can conduct outreach health care programs. An increased budget allocation to the PHC system will ensure that all centers are well maintained and have sufficient utilities and amenities, including running water, electricity, and toilets. A funding program based on service delivery production will ensure that PHC facilities provide the best health care to the communities, families, and individuals they serve.
A Critical Evaluation of Nigeria’s PHC System In Relation To Kenya’s PHC System
Nigeria
The first attempt by the Nigerian government to incorporate PHC in its health sector reforms, which were framed within the broader national development plans, began with the Basic Health Service Scheme (BHSS). BHSS was founded in 1975 and focused on reducing health disparities between rural and urban regions, building training colleges, increasing accessibility of healthcare services, controlling the spread of communicable diseases, and utilizing community health workers to broaden health outreach initiatives. However, the program was not a success owing to poor policy frameworks, insufficient collaboration between the three tiers of the government, the non-involvement of local communities, prioritizing health worker training over improving health care services, and poor hiring practices (Welcome, 2011). However, the National Health Policy of 1987 was much more successful in formalizing the PHC strategy and developing an extensive healthcare system that was inclusive and geared towards improving the social and economic lives of all citizens.
This health care reform initiative succeeded in expanding preventive and curative medicine; increasing public health awareness on proper nutrition, family planning, and communicable diseases; increasing immunization coverage rates for target diseases; providing safe water and basic sanitation; and enhancing both maternal and child care services (Egwu, 1992). Health care was decentralized, and there was more participation at the individual and community levels, over and above, stronger collaboration between the three tiers of the government. On the whole, the National Health Policy of 1978 succeeded in reducing health disparities across the country by increasing the number of PHC centers at the community level as well as improving the ability of Nigerian citizens to take personal responsibility for their personal health. Over the years, Nigeria's PHC system has undergone several restructurings aimed at improving the implementation and governance of PHC policies and activities, including the institution of the National Primary Health Care Development Agency (NPHCDA) in 1992.
NPHCDA was founded to safeguard the PHC agenda, particularly the goals outlined by the Alma Ata Declaration of 1978. The body was tasked with overseeing the National Health Policy, providing technical assistance for the development and implementation of PHC, mobilizing resources at the local and international levels for the development of PHC, and facilitating the training of health workers, and developing policies for supervising and evaluating the National Health Policy. NPHCDA has been active in supporting PHC activities, including partnering with the National Programme on Immunization (NPI) to enhance immunization coverage rates, over and above, bringing more accountability and commitment at all health levels and among health workers (Amedari & Ejidike, 2021). Another significant development since the establishment of the National Health Policy was the more recent passing of the PHCUOR, which was aimed at reducing the fragmentation of Nigeria's PHC system. One of the consequences of decentralizing health care was the disintegration of PHC activities and policies brought about by poor governance and administration structures in all three tiers of the government.
Various entities had overlapping roles and responsibilities, resulting in inefficient delivery of equitable, high-quality healthcare services. PHCUOR brought all PHC functions and activities under one administration, thereby improving coordination of health efforts by various government actors towards meeting PHC goals. By clarifying roles, power, and responsibilities, the government hoped to bolster national commitment to enhancing universal health coverage of PHC services, reducing health disparities, improving the quality of healthcare services, and empowering citizens through public health education. Nigeria's PHC system's architecture is still founded on a three-tier structure of federal, state, and local government areas, each with distinct roles and substantial autonomy. The Federal Ministry of Health (FMoH) is tasked with overall oversight and leadership of health and provision at the tertiary level through the system of both teaching and specialist hospitals (Oyekale, 2017). However, several states assist in financing and administrating tertiary health care centers within their borders. Since Nigeria is a resource-limited nation, the government collaborates with development partners, who also provide financial assistance to the FMoH through the Federal Ministry of Finance (FMoF).
The State Ministries of Health (SMoH) are responsible for providing health care services via secondary health care centers, over and above, providing technical and financial assistance to the local government area health departments. State and local government areas distribute PHC functions between the Ministry of Health (SMOH) and the Local Government Health Department. However, the roles and tasks of each entity with respect to PHC are relatively unclear, and it is not uncommon for roles to overlap, resulting in either total neglect of PHC initiatives or wastage of resources (WHO, 2017). Local government areas own and finance PHC centers and are tasked with overall management for ensuring facilities at the community level provide equitable and high-quality essential health care services. On the whole, while PHC services are directly under local government areas, other state entities are also involved in policy implementation, including the SMoH, Ministries of Local Government Affairs (SMoLG), Civil Service Commission (CSC), Local Government Service Commission (LGSC), Ministry of Budget and Planning (MoBP), and State Hospitals Management Board (SHMB).
Other entities include nongovernmental organizations, faith-based organizations (FBOs), the National Health Insurance Scheme (NHIS), Zonal and State offices of the NPHCDA, FMoH, and development partners. The private sector often fills the health care gaps left by a fragmented and under-resourced PHC system, although partnerships between the public and private sectors are poorly leveraged. Nigeria's PHC system is mostly financed with out-of-pocket payments, while the smaller fraction is funded through tax revenue, health insurance, and international donor funding. The government spends a small fraction of its budget on healthcare, and much of it is spent on paying its large health workforce. Consequently, families and individuals remain the major source of health financing through out-of-pocket spending, which caters to most of the operational expenses of PHC centers. Revenue collection and disbursement are highly consolidated, with the federal government collecting the majority of national revenues (mostly from oil) in place of other tiers of the government (Abdulraheem, 2012). Federal revenues are generally mobilized under the value-added tax (VAT) pool, Federation account, and Treasury Single Account (TSA). These funds are then distributed between the federal, state, and local government area governments in accordance with the constitution.
Although local government areas have their separate revenue streams, they can only generate a small proportion of funds needed to support community PHC centers. Consequently, a sizable proportion of national revenues in the VAT pool and Federation Account are used to support local efforts at bolstering health care. In 2006, the FMoH instituted the National Health Financing Policy, which aimed at ensuring equitable and health care through a transparent and sustainable financing system. The National Health Act (NHAct) was also developed to increase universal coverage through a well-organized PHC system availing the essential services in community PHC facilities. To this end, NHAct instituted the Basic Health Care Provision Fund (BHCPF), which combined federal revenues and donor funds from international partners. Unfortunately, the federal PHC budget as a fraction of the total federal health budget has been gradually decreasing over recent years, thereby hampering PHC efforts geared towards combating malaria, improving public health awareness, and increasing immunization coverage rates (Ekenna et al., 2020). Even though states are supposed to allocate reasonable health care budgets to PHC facilities through the local government areas, the disbursement of funds is often limited and irregular.
At the local government level, most of the funds received from the federal government through state ministries of health are often consumed by health worker salaries. Furthermore, the management and accountability of health care funds for PHC centers at the local government level is very weak compared to other levels of the national public finance system. Despite the density of PHC centers in Nigeria, there are still health disparities in terms of the quality of health services between rural and urban areas owing to imbalances in the distribution and skill ranges of clinicians (Mohammed et al., 2010). Poor attraction and retention of community health extension workers, doctors, health assistants, laboratory staff, community health officers, midwives, nurses, and public health nurses by the public sectors has resulted in a bigger concentrati...