For decades, the Nigerian health system has been weak, dysfunctional, and inequitable. Political actors have expressed dissatisfaction with the deplorable state of the health sector . Key challenges include emigration of Nigerian physicians to developed countries. Although this has always occurred, the rate accelerated in the 1980’s when the financial crises occurred, leading to the implementation of the Structural Adjustment Programme (SAP) .
The wave of medical emigration has now reached an unprecedented level. Medical tourism has become the order of the day among the privileged elite. Nigeria loses about US$1.2 billion dollars annually to medical services sourced abroad by the higher income portion of the population [3, 4]. There is a need to shift to a health system based on a prevention model.
Treatment versus prevention
Although the National Health Policy states that primary health care (PHC) should be the bedrock of the health system in Nigeria [5, 6], the Nigerian health system has favoured curative services rather than preventive services. The focus on sickness and treatment rather than the promotion of prevention now sees the country burdened by numerous diseases. This has led to an increase in health care costs. This burden manifests in a failure to meet the health needs of lower income population.
As part of efforts to promote curative services over preventive services, the bulk of public health sector resources is allocated for the running of tertiary and secondary health facilities that are technically inefficient [7, 8]. Consequently, PHC is funded through extra-budgetary means, complemented by donor funding, which focus on specific diseases and conditions.
Basic Health Care Provision Fund
To address the issue of poor funding of PHC, the National Health Act (No. 8, 2014) established a Basic Health Care Provision Fund (BHCPF) with 50% to be used to provide a basic minimum package of health services to all citizens in eligible primary and secondary health facilities .
Four years after the signing of the National Health Bill into law, the Nigerian senate approved 57.15 billion naira (US$ 158,75 million) for BHCPF in the 2018 Appropriations Bill . However, evidence suggests that the BHCPF is an inadequate health financing mechanism .
Efforts to revitalise the PHC system include A Plan To End Preventable Newborn Deaths in Nigeria (2016), including initiatives such as the National Health Insurance Scheme (NHIS), the Free Maternal and Child Health (MCH) Programme, the Midwives Service Scheme (MSS), the Subsidy Re-investment & Empowerment Programme, Maternal and Child Health (SURE-P MCH), Saving One Million Lives (SOML), PHC Under One Roof (PHCUOR), and Basket Funding. However, these are yet to achieve the desired impact.
Health for all: Primary health care
The international Alma-Ata Declaration of 1978 identified PHC as the key to the attainment of Health for All . Forty years later, “health for all” has not been achieved in many countries, including Nigeria. According to the World Bank and World Health Organisation (WHO), at least half of the world’s population still lacks access to essential health services .
The failure of many countries to achieve health for all led to the 2018 Declaration of Astana. It is a global commitment that aims to strengthen PHC systems as an essential step towards achieving universal health coverage (UHC) . The PHC approach is the most effective way to sustainably solve health and health system challenges.
The inability to successfully implement comprehensive PHC in low-and-middle income countries (LMICs) is due to the belief that PHC is too large an ambition to be practical . However, investment in PHC over the decades has improved life expectancy and reduced mortality globally . This recognition has prompted greater support for a comprehensive PHC approach that ensures better health outcomes for all.
The Declaration of Astana 2018 therefore reaffirms comprehensive PHC as the key to achieving UHC. That being said, many LMICs still lag far behind in this goal . The majority of these countries have not fully developed their PHC system. This is in spite of the ability of PHC to address the majority of health problems and reduce health care inefficiencies .
Health challenges in Nigeria
Nigeria is experiencing a dual epidemic of communicable and non-communicable diseases (NCDs). In 2017, the top ten causes of death in Nigeria were lower respiratory infection, neonatal disorders, HIV/AIDs, malaria, diarrheal diseases, tuberculosis, meningitis, ischemic heart disease, stroke and cirrhosis .
Communicable, maternal, perinatal, and nutritional conditions account for 63% of total deaths, while NCDs, such as cardiovascular disease, cancer, diabetes, chronic respiratory diseases and other NCDs accounts for 30% of total deaths in Nigeria .
A PHC framework is capable of providing 80-90% of people’s health needs across their lifetime . A selective PHC approach that focuses on specific diseases and conditions will not effectively address the dual epidemic of communicable diseases and NCDs.
Expanding health care
Vertical health programmes have helped to address some of the public health challenges in LMICs, including Nigeria. However, they undermine the successful implementation of PHC . Unless vertical health programmes are integrated into the national health plan. Comprehensive PHC is preferred to selective PHC because disease specific health interventions place an enormous burden on weak health systems in LMICs [15, 22].
Expanding access to quality health care for poor and vulnerable populations requires:
- the expansion in the utilisation of community-based health workers (CHWs);
- the equitable distribution of health workers;
- the development of a cadre of primary care and family physicians;
- the establishment of PHC as a policy focus;
- and the pursuit of PHC focused on UHC.
Such efforts would reduce the rising burden of diseases and health care costs in Nigeria. Countries such as Sri Lanka, Thailand, Cuba, Brazil, Chile, Ethiopia, and India have been able to strengthen their health system with a focus on PHC. This has been achieved through heavy investment in PHC and development of policy innovations leading to improved population health outcomes at lower costs and a reduction in health inequities [15, 21, 23].
Primary health care and disease prevalence in Nigeria
Under the leadership of Professor Olikoye Ransome-Kuti, between 1986 and 1992, Nigeria adopted PHC in 52 local government areas (LGAs) as models and subsequently expanded PHC to all LGAs, seeing improvements in population health outcomes [18, 24]. Professor Olikoye Ransome-Kuti was able to achieve this feat due to his focus on PHC.
Evidence suggest that Nigeria has over 30,000 PHC facilities across the 36 states and the Federal Capital Territory (FCT) . However, only 20% of these PHC facilities are functional . Studies have shown that health systems based on strong PHC improve the management of NCDs, reduce mortality from NCDs, reduce infant and under five mortality, reduce maternal mortality and increase life expectancy at birth .
Recommendations going forward
Nigeria needs to shift from the present curative model to a preventive model that keeps the population healthier rather than waiting for them to fall sick before they have an encounter with health care providers. The curative model and selective PHC approach have proven to be ineffective in addressing the public health challenges that Nigeria faces and in meeting the health needs of the low income population.
The time is ripe for public hospital reform that ensures the funding of curative services through:
- public private partnerships;
- the establishment of a gatekeeper system to seeking health care;
- altering the upfront payment system in public hospitals;
- the reorganisation of the hospital governance structure;
- and the realignment of physician incentives (see the Sanming model in China) .
This shift from a curative model to a preventive model will require strong political will and sacrifice on the part of all stakeholders, including the private medical establishment, to ensure that PHC is made the cornerstone of the Nigerian health system. This will be a major step towards achieving UHC and the Sustainable Development Goals (SDGs).
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