Historical Development and Roles of PHC in Nigeria Situating it in Alma Ara Declarations

PHC Programmes in Nigeria
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PHC Programmes in Nigeria
The Basic Health Services Scheme (BHSS) (1975-1980)
Efforts to establish and increase healthcare infrastructures with a particular focus on curative medicine instead of preventive medicine started as early as 1960 in Nigeria. During this post-colonial period, health sector reforms were framed within the perspective of national development plans. The first National Development Plan (1962-1968) contained the underpinning for expanding hospitals in major cities, healthcare centers, and maternity homes in rural villages and towns. On the other hand, the second National Development Plan (1970-1974) concentrated on correcting some of the challenges in the health delivery service system founded in the first plan. The health sector was required to pursue the objective of expanding, protecting, restoring, and enhancing the health of all Nigerian citizens (Anaemene, 2016). There were efforts to come up with a comprehensive national health policy that addressed such issues as health workforce development, disease control, improving medical research, provision of comprehensive health care as stipulated by the primary health service scheme, health planning, and management, as well as efficient implementation of healthcare resources.
This second National Development Plan performed relatively well compared to the first one concerning the expansion of healthcare facilities. For instance, substantial funds were allocated at the federal level to run the University Teaching Hospitals at Enugu, Ibadan, and Lagos. For instance, the Lagos University Teaching Hospital managed to expand its dentistry and radiotherapy specialties and complete the mobile theatre and physical medicine units. Adequate sums were also set aside to expand specialist hospitals in Ilorin, Benin, and Enugu (Odutolu et al., 2016). Moreover, there was marked improvement at the state level, where significant progress was made in restoring healthcare centres in the three Eastern States. Hospitals in the Mid-West and Kwara states also saw a marked increase in bed capacities. On the whole, more than 300 health centers, maternity wards, and dispensary units were created during the second National Development Plan period. However, the plan failed to structure a system of sharing responsibilities between the three levels of government.
However, it was not until 1975 that the third National Development Plan started a health system development initiative that applied primary health care (PHC) as the foundation stone. The Basic Health Services Scheme (BHSS) was founded in 1975 as Nigeria’s first concrete attempt at putting PHC into practice (Aregbeshola & Khan, 2017). This PHC programme focused on increasing accessibility of healthcare services for the entire population from 25% to 60%, training health workers, correcting healthcare disparities between rural and urban regions for all preventative and curative care, and utilizing community social workers to increase health services. Other objectives included integrating basic health units and combining prevention and health promotion services with curative services. This last objective involved controlling the spread of communicable diseases, over and above, promoting nutrition, environmental health, and family health.
Every basic health unit had four categories of health facilities: one comprehensive health facility capable of serving a population of 50,000; four PHC centres capable of serving a population of 10,000 each; twenty health clinics capable of serving a population of 2,000 each; five mobile clinics capable of serving a population of 40,000 each. The BHSS programme was elaborated in its health reform attempt. Substantial funds were set aside for the National Malaria Programme and the implementation of widespread smallpox vaccination campaigns through collective efforts with local and global voluntary organizations. There was also a rapid increase in federally managed teaching hospitals to train various healthcare staff, including doctors, nurses, technicians, and midwives. Schools of health technology were set up to ensure an adequate workforce of intermediate-level staff for community health (Anaemene, 2016). However, the BHSS programme did not achieve most of its objectives owing to poor policy frameworks and implementation constraints. For instance, there was still the problem of how the three levels of government were to share the responsibilities of resource generation and providing the necessary healthcare workforce.
Most states refused to comply with the PHC programme directives because it required constructing twenty-five health facilities in one local government area. There was little involvement of local communities. After spending up to N200 million by 1983, most healthcare centres remained unfinished all over Nigeria. Some of the reasons why the first attempt at implementing PHC failed to include dependence on untenable frameworks and equipment, inadequate inter-sectorial partnership, workers integration challenges (a majority of staff preferred urban postings to rural ones, thereby impeding efforts at bridging health disparities in the country), over and above, focusing too much on training health workers as well as providing health facilities while neglecting other critical facets (Lambo, 1982). The federal government concentrated on building teaching and specialist schools at the expense of other BHSS objectives. In sum, the primary reasons for the failure include selecting programme officials based on political expediency rather than merit, institutionalizing the training of health staff, poor inter-government collaboration, and giving little attention to community involvement and application of applying modern technology.
National Health Policy (1987-1988)
In 1987, the federal government formally adopted the PHC strategy and established the National Health Policy in the context of the five national objectives (making Nigeria: a free and democratic society; a just and egalitarian society; a united, strong, and self-reliant nation; a great and dynamic country; and a land full of opportunities for all citizens) as well as the principles of social justice, equity, freedom, and opportunity for all. The primary objective of the National Health Policy was to provide healthcare founded on PHC, as defined in the Alma Ata Declaration of 1978, which aimed to enhance community health while lowering child mortality rates (WHO, 2021). Within the general essential obligations of the governments of the Federation and the nation's socio-economic development, the National Health Policy aimed to create an extensive healthcare system that was founded on primary health care and was also protective, restorative, and rehabilitative to every Nigerian citizen.
The health services based on the PHC programme had to include at least: public education on prevailing health issues and the ways of both preventing and managing them; promotion of proper nutrition as well as food supply; provision of safe water and basic sanitation; maternal and child care; as well as family planning. This last part included providing culturally and religiously appropriate health services geared towards spacing pregnancies, preventing unwanted pregnancies, availing abortion services, and adjusting family sizes according to socio-economic status and family health (Aregbeshola & Khan, 2017). Other health services under the scope of the National Health Policy included immunization against transmittable diseases, preventing and managing endemic and epidemic infections, availing essential drugs and supplies, and providing appropriate treatment of specific diseases and injuries.
Under the National Health Policy, PHC was to be provided by local government authority via health centres staffed by physicians, community health officers, nurses, midwives, health technicians, community health extension workers, and health technicians. However, the local government has to deliver PHC services in compliance with the National Health Policy framework. The health services to be provided at the community health centres include public health education, immunization, prevention and treatment of infectious diseases, environmental health, family planning, maternal and child health services, and the gathering of statistical information on health-related events (WHO, 2016). Healthcare delivery at the local government area was to be directed by a supervisory councilor with the help of PHC coordinators and deputy coordinators. The PHC co-coordinator answers to the supervisory counselor, who sequentially reports to the local government authority chairman. The various facets of the local government area PHC were now administered by personnel of different specialties.
The PHC programme, under the stewardship of Professor Olikoye Ransome-Kuti (the minister of health then), was initially successful in meeting the stated health services objectives. Some of the notable successes by the National Health Policy included a widespread emphasis on healthcare services and preventive medicine at the community level, endorsed exclusive breastfeeding practice, established free countrywide immunization and vaccination programs, made it compulsory for healthcare facilities to report maternal deaths, established an effective HIV/AIDS campaign, and increased the use of oral rehydration therapy among nursing mothers. One major reason for the program’s success was the cultivation of community participation. The federal government devolved the national healthcare delivery system, and health services were widely inaugurated and bolstered at the grass-root level (Odutolu et al., 2016). For instance, the local government area comprises several wards, thereby maximizing healthcare services by allowing more people at the local level to participate and participate in the PHC processes.
The implementation of the PHC approach had several ramifications, particularly increased budget allocation to healthcare services compared to previous health sector reforms. The PHC programme allocated healthcare responsibilities to the various governments of the federation. It allowed citizens to contribute both individually and collectively in the development and administration of health and social services. Moreover, health resources were equally distributed, reducing health disparities, especially among under-served communities and high-risk populations. Self-reliance was also encouraged among citizens, communities, and the country as a whole. The PHC programme ensured that health information was dispersed to all communities, allowing individuals to take personal responsibility for their health (Federal Ministry of Health, 2004). After the National Health Policy institution, greater importance was given to preventive and promotive healthcare services by integrating the two with treatment and rehabilitation in a multi-sectoral and multi-disciplinary manner.
Since the policy was geared towards availing health services to improve citizens' social and economic productiveness, all social and economic sectors started collaborating towards enhancing overall public health. Moreover, the PHC programme encouraged "scientifically sound" healthcare measures and technologies that were determined to be safe, effective, and appropriate (Lambo, 1982). Overall, the National Health Policy successfully dramatically increased the proportion of immunized children, improved the availability of pharmaceutical drugs, and availed birth control information and services. Other areas the PHC programme excelled in include mitigating against transmittable diseases, providing pure drinking water supplies in rural villages, accelerating the collection and monitoring of health information, and improving nutrition throughout the nation.
Roles of Federal, States, and LGAs in Operational PHC
Roles of the Federal Government
Implementing the national health policy and achieving PHC goals necessitates clear elaboration of federal, state, and LGAs. Governments of the federation are generally responsible for interpreting the national health policy into well-defined strategies and targets. On the whole, the federal ministry of health is responsible for:
* employing necessary steps to ensure that the national health policy is reviewed and implemented by the federal government;
* coming up with a comprehensive strategy that ensures collective action by the federal, state, and local governments in the implementation of the national health policy as per the provisions of the constitution;
* presenting an extensive financial plan to the federal government for approval in order to give effect to the federal elements of the PHC strategy;
* submitting for the consideration of the federal government necessary national health legislation;
* serving as the coordinating entity on all nationwide health operations in place of the federal government with the aim of making sure the national health policy is implemented;
* evaluating the nation’s health status and developments by conducting related epidemiological investigations and reporting the findings to the government;
* facilitating public health campaigns to ensure an informed nation on matters pertaining to health;
* aiding the government, and by extension the local government, in creating strategies as well as plans of action relating to the national health policy;
* assigning federal resources to specific activities to be implemented by states and LGAs in executing their health strategies;
* providing principles to guide states in the preparation, administration, and evaluation of healthcare strategies and related programmes, institutions, and services;
* developing health technology, supplies, equipment, biological products, drugs, as well as vaccines standards and ensuring acquiescence with them all in conformity with WHO’s criteria;
* developing training and licensing standards as well as ethical guidelines of various categories of health staff ;
* encouraging research that is pertinent to the execution of the national health policy and developing suitable strategies for guaranteeing sufficient coordination between scientists and research institutions involved;
* facilitate collaborations between healthcare professionals, scientists, and non-governmental organizations in line with the objectives of the national health policy; and
* monitor as well as assess the execution of the national health policy in place of the government and present the findings of the investigation.
Roles of the States
On the other hand, the states are responsible for administrating and coordinating the management of health activities within the state. The functions of the state ministries of health include:
* ensuring political commitment to the national health policy by:
* taking steps to ensure the collective commitment of their governments to the strategy for health, over and above, solicit the support of public figures and institutions including civic, religious, and political leaders as well as powerful non-governmental organizations;
* propose strategies to the government on ways to ensure all relevant economic and social sectors are involved in the implementation of the healthcare policy;
* advise the government on healthcare reforms and even assist in legislation by defining the rights as well as responsibilities of various health workers and the public with regard to their health.
* ensuring economic commitment by capitalizing on all opportunities of acquiring the aid of economic institutions and planners, over and above, ensuring that all health activities are a critical part of development projects;
* gaining the support of relevant professional groups by convincing them of their social responsibility in the implementation of the national healthcare policy;
* developing methodical administrative procedures for health development;
* conducting public information and education by determining the best way to disseminate information on the state health strategy to the desired target audiences as well as liaise with local governments in ensuring the message reaches everyone at the grassroots level;
* facilitating inter-sectoral collaboration concerned with the national healthcare policy including cultural, education, housing, public works, finance, information, and agriculture sectors;
* encouraging cooperation between different health disciplines, services, and institutions with regard to allocation of responsibilities and resources;
* delegating primary health care resources and responsibilities, over and above, providing guidelines as well as necessary practical support to communities;
* developing effective logistical systems to ensure prompt and regular delivery of healthcare resources to communities;
* collaborating with the federal government to ensure sufficient training of healthcare workers and availability of necessary manpower in rural regions;
* liaising with LGAs to ensure equitable distribution of healthcare facilities to improve the accessibility of healthcare services to citizens; and
* mobilizing all available financial and material resources by;
* reviewing the allocation of state resources to primary, secondary, and tertiary healthcare institutions;
* allocating all extra resources to marginalized and at-risk populations;
* considering the cost benefits of various health projects and selecting the most effective one;
* conducting an economic analysis of the cost of developing and maintaining all health infrastructure;
* securing additional funding for critical health activities;
* identifying those strategies that might attract external funding;
* presenting to the government a plan for the use of all human, financial, and material resources.
Roles of the LGAs
The ministries of local government are responsible for implementing the national healthcare policy at the grassroots level. Some of the functions of the LGAs include:
* collaborating with state health ministries in implementing the strategy for health depending on the health needs of the local community;
* sustaining public health awareness campaigns;
* facilitating community support for health strategies using formal and informal leaders, including religious and cultural leaders as well as traditional leaders;
* tailoring health activities to meet the needs of the local population;
* mobilizing resources to aid health strategies and achieve community health goals;
* ensuring that critical health infrastructure for PHC programmes are accessible and well maintained;
* gathering relevant data about the community’s health trends, health behaviour, and utilization of health services;
* identifying necessary support action for every aspect of the PHC program; and
* implementing mechanisms for ensuring individual and collective participation in the provision of health services.
History and Development of EPI, NPI, and NPHCDA in Nigeria and Their Roles
Extended Programme on Immunization (EPI)
The Extended Programme on Immunization (EPI) was introduced in Nigeria in 1974 as a widespread attempt to provide routine immunization to children below two years old. Some of the target diseases of the EPI initiative included diphtheria, poliomyelitis, whooping cough, tuberculosis, measles, and yellow fever. The primary goal was to ensure that every child received all doses of vaccines for the killer diseases before their second year of life. Other objectives of the EPI programme included enhancing disease management as well as introducing new vaccines, tools, and technologies. The core activities of the EPI policies are: evaluating the effectiveness, safety, and quality of immunization system using indicators; appraising both existing and future burdens of vaccine-preventable diseases concerning disability, sickness, death, and overall economic burden; conducting epidemiological surveys accompanied by reliable laboratory studies to determine the effect of vaccination strategies; assessing national immunization policies, especially the type of vaccines used and immunization schedules; as well as evaluating overall immunization coverage in all districts of the country (Alakija & Anakhu, 1983).
National Programme on Immunization (NPI)
The National Programme on Immunization (NPI) (previously known as the Expanded Programme on Immunization (EPI)) was launched in 1996 with the same goal as EPI, which was to achieve Universal Childhood Immunization. The primary objective of NPI was to ensure that 80% of all children below two years had been vaccinated against the six target diseases. Unfortunately, the NPI programme has suffered stiff opposition from various ethnic and religious groups. Other problems encountered by the program include insufficient awareness and government response to the seriousness of target diseases, poor programme administration, inadequate skills and capacity for vaccine handling and storage, limited monitoring capacity as reflected by decreasing immunization coverage rates and increasing incidence of target diseases (Adedokun et al., 2017). Even though its predecessor (EPI) recorded initial but intermittent success, even reaching an optimum level by the early 1990s, with a universal childhood immunization coverage rate of 81.5%, the same cannot be said of NPI. The country has recorded a steady decrease in immunization coverage from the unprecedented highs of the 1990s, and by 1996, reports indicated less than 30% coverage for all target diseases. An even lower coverage rate of 12.9% was recorded in 2003, one of the lowest in the world and the worst in the West African sub-region (Ophori et al., 2014). However, the country has recommitted itself to the United Nations General Assembly Special Session (UNGASS) goals of polio eradication, maternal and neonatal tetanus eradication, and measles mortality reduction.
National Primary Health Care Development Agency (NPHCDA)
The National Primary Health Care Development Agency (NPHCDA) was founded in 1992 to safeguard the PHC agenda and ensure its continued sustenance. Implementing PHC using the National Health Policy framework has proven successful. The government wanted to capitalize on the healthcare achievements and sustain federal government assistance to LGAs through NPHCDA. It is parasternal of the federal ministry of health, with the goals of managing preventable diseases, increasing accessibility of critical health services, and enhancing the quality of care. Some of the responsibilities of the agency include:
* overseeing the National Health Policy, especially the development of PHC;
* availing technical support for the development, administration, and execution of PHC;
* mobilizing resources nationally and globally for the expansion of PHC;
* developing guidelines for the monitoring and assessment of the National Health Policy;
* coordinating the training of health workers required for PHC through orientation and ongoing education;
* supporting rural health systems by training community health workers;
* facilitating health system research by financing and guiding problem-focused health system studies;
* stimulating collaboration between various healthcare institutions, including non-governmental organizations, higher learning institutions, and global agencies; and
* preparing yearly reports on the standing of PHC execution countrywide.
The domestic development agency for health in Nigeria recently partnered with NPI to help increase immunization coverage rates, particularly concerning polio eradication, bolstering the routine immunization (RI) system, and revitalizing PHC in Nigeria (Sambo, 2010). For instance, NPHCDA has played an enormous role in providing technical, human, and financial resources towards interrupting poliovirus transmission in all states and LGAs. The agency has also assisted in strengthening healthcare leadership and transparency at all levels, over and above, deploying motivated and highly trained healthcare personnel in high-risk regions.
Operationalizing PHC under One Roof and Establishment of State Primary Healthcare Development Agency (SPHCDA)
Primary Health Care under One Roof (PHCUOR)
The Primary Health Care under One Roof (PHCUOR) is a policy strategy by the federal government that aims at uniting the administration of Nigeria's PHC. This initiative was established in conjunction with development partners to reduce the country's disintegration of the PHC system. The PHCUOR policy was endorsed by the National Council of Health in 2011 and has been enforced in over thirty states. Owing to the fragmented state of PHC, there were systemic weaknesses in the delivery of healthcare, including insufficient human resources, inadequate healthcare supplies and equipment, as well as infrastructural decay (Eboreime et al., 2018). Moreover, poor governance and administration structures in several facets of the health system, particularly in coordinating PHC activities at the state and LGA levels, were rampant. For instance, it was not uncommon for the various administrative frameworks at the state level to have concurrent roles for PHC: The Local Government Service Commission, State Ministry of Health, State Ministry of Women Affairs, State Ministry of Local Government & Chieftaincy Affairs, the Office of the Executive Governor, and even the Local Government Service Commission would have overlapping responsibilities that impeded the delivery of efficient, equitable, and high-quality healthcare services.
Therefore, the concept of bringing PHC under one roof was necessary to overcome poor governance at the state and LGA levels, over and above, overcome endemic challenges in translating PHC principles into practice. Bringing PHC under one roof helped streamline the responsibilities of several ministries, agencies, and departments towards results while reinforcing political will as well as the commitment to national health strategies. The major elements of the PHCUOR policy initiative are: instituting a single administration body with managerial oversight of healthcare services as well as both human and financial resources; implementing the principle of one management body, one plan, one supervising and assessment system; establishing a legislative structure; decentralizing power, responsibility, and transparency with an adequate span of control; installing an integrated supportive managerial system controlled from one point; combining all PHC services under a central authority; as well as implementing an operative referral system across diverse levels of care (Eboreime et al., 2017).
Executive implementation of these elements has resulted in an efficient healthcare delivery system comprising of well-organized participants in ways that allow the government to attain optimal universal health coverage (UHC) of PHC services across Nigeria. A robust PHC system is critical to accomplishing the aims of UHC and reducing health disparities, increasing healthcare accessibility, and improving the quality of healthcare services (Eboreime et al., 2018). On the whole, the PHCUOR helped clarify how responsibilities, power, and roles would be assigned and coordinated between the various entities in order to improve PHC outcomes.
State Primary Healthcare Development Agency (SPHCDA)
The State Primary Healthcare Development Agency (SPHCDA) is an administratively separate and self-accounting PHC entity established under the PHCUOR to manage PHC activities in the state. It ensures one managerial framework and administrative processes for PHC in the state. The SPHCDA was established to provide managerial oversight of PHC activities of the local government health authorities; enhance the allocation, distribution, and utilization of healthcare resources; avail sufficient technical and management training for PHC administrators and different levels of health staff; provide healthcare delivery standards and supportive monitoring to ensure compliance; as well as supervise and assess various programmes in the state (Eboreime et al., 2018).
Every state has one PHC board whose responsibility is to manage the execution of the state ...