Organization And Financing Of Primary Health Care In Nigeria: Problems, Issues And Alternative Approaches
Primary Health Care (PHC) provides the most viable route towards achieving health related sustainable development goals (SDGs) and is crucial to the achievement of other SDGs. Given the importance of primary health care, nations across the world devote considerable effort and resources towards establishing and maintaining effective PHC systems. In Nigeria, domestic spending on the health sector has been declining while foreign donations towards improving primary health care have been on the increase. However, recent global trends and the imminent expiry of deadlines for a number of foreign donations point toward a not too distant future without foreign donations for health care system improvements. This constitutes a development challenge. Even though foreign donations have yielded some positive health outcomes, the effect of foreign donations on the primary health care system is unclear. The study set out to examine the problems, issues and alternative approaches of organization and financing of primary health care in Nigeria. The paper combined qualitative methodology and analysis of literature to investigate the present state of primary healthcare, identify the setbacks to full development of primary healthcare in Nigeria and examined the effects of foreign donations on the primary health care system in Nigeria. The paper found that foreign donations have been increasing but have also led to the perpetuation of a non-committal attitude towards increasing domestic spending on health and the neglect of health system strengthening. Therefore, the paper recommends timely and steady increase in domestic funding for health along with the strengthening of the health system towards creating an effective primary health care system with or without foreign donations.
1.1 Background To The Study
The health sector in any country has been recognized as the primary engine of growth and development. But despite the laudable contributions of the health sector to economic development, the Nigerian health sector has witnessed various turbulence that has negatively revised the progress recorded at various times.
Nearly 15 percent of Nigerian children do not survive to their fifth birthday. Two leading causes of child mortality are malaria (30 percent) and diarrhea (20 percent). Malnutrition contributes to 52 percent of death of children under five. A household survey conducted by the government in 2003-2004 showed that 54.4 percent of the population is poor, with a higher poverty rate in rural area of 63.3 percent (HERFON, 2006). The incidence of poverty in Nigeria is widespread and increasing with some of the worst poverty linked health indicators in Africa. There has been a sharp increase in poverty from 1992 to 1996, with an estimated third of the population living below $1 per day and nearly two thirds below $2 per day (FMoH, 2005).
Some of the factors that affect the overall performance of the health system include; inadequate health facilities/structure, poor human resources and management, poor remuneration and motivation, lack of fair and sustainable health care financing, unequal economic and political relations, the neo-liberal economic policies of the Nigerian state, corruption, illiteracy, very low government spending on health, high out-of-pocket expenditure in health and absence of integrated system for disease prevention, surveillance and treatment, inadequate mechanisms for families to access health care, shortage of essential drugs and supplies and inadequate supervision of health care providers are among some of the persistent problems of the health system in Nigeria.
The right to enjoy the highest attainable standard of health is one of the most fundamental human rights in the constitution of the World Health Organization (World Health Organization, 2008). Therefore, all member countries of the United Nations (UN) have the mandate to provide basic, affordable and universal healthcare for their citizens. Primary Health Care (PHC) provides the most viable route towards achieving the aforementioned mandate. Primary Health Care is defined as a whole-of-society approach to health and well-being based on the needs, peculiarities and preferences of individuals, families and communities. (WHO, 2019). PHC serves as the first contact of individuals, families and communities with the national health system. Accessibility to and closeness to the poor and hard to reach populace makes the primary health care system the most relevant, unique and important in the three-tier health system in Nigeria, as indeed stressed by the World Health Organization (WHO, 2018). Primary healthcare is a deliberate and systematic effort to develop a health care system that caters to the needs of majority populations and poor citizens, at an affordable and sustainable cost and with a guarantee of quality health care service through government primary health care centres and faith-based clinics in rural and suburban areas, while secondary and tertiary health facilities serve urban populations. The primary healthcare system is designed to be cost effective and designated as the first point of call for all, irrespective of the social or economic status.
PHC provides healthcare from the cradle to the grave for the individual by focusing on broad and inclusive determinants of health and through the provision of comprehensive care, promotion of health friendly practices through health education, prevention and treatment of infectious and non-infectious diseases, public health management as well as rehabilitation and palliative care for all persons. Primary health care is extremely important for the continued existence of humankind in general and for the growth and development of nations. By treating people and communities as stakeholders and duty bearers in their well-being and total health outcomes, the PHC systems is capable of responding locally and promptly to rapid economic, demographic and technological changes with proven potential to yielded massive benefits across the world (WHO, 2008).
PHC has also been found to be highly effective and efficient in treating the main causes and risk factors of health deficiencies. It is also capable of tackling emerging threats to public health and wellbeing into the future. Primary health care is crucial for the realization of health-related Sustainable Development Goals (SDGs) which are in turn inextricably linked with the other SDGs such as ending poverty, inclusive education, work and economic growth, reducing inequality and climate action.
Given the importance of Primary health care, nations across the world devote considerable efforts and resources towards establishing and maintaining viable PHC systems. As a signatory to the United Nations’ Charter and member of the World Health Organization (WHO), Nigeria has the mandate to do same and indeed has made efforts to provide primary healthcare to its citizens. It is worthy of note that the success of efforts to provide effective primary healthcare depend on a good choice and combination of adequate and efficient method (s) of financing and on a sound framework for the organization and delivery of health services (Drouin, 2007). Healthcare financing in Nigeria currently involves a combination of tax revenue, out-of-pocket payments, foreign donations, and health insurance (Olakunde, 2012). Singly or in combination, these financing methods yield differing outcomes on the success of PHC in Nigeria. This paper examines the effects of foreign donations on the success of PHC in Nigeria and points the way forward towards better health outcomes for primary healthcare in Nigeria.
1.2 Statement Of The Problem
In spite of huge government spending, coupled with bilateral and multilateral assistance in the health sector, the patterns of health status in Nigeria mirror many other Sub-Saharan African nations but are worse than would be expected given Nigeria’s GDP per capita. The health system is in shambles, policy somersault and reversals tends to have under-mined several reforms in the health sector over the years. Poor human resources and policy management have led to unprecedented brain drain in the health sector as health professionals in search for better conditions of service abroad often vote with their feet in droves (FMoH, 2005). (Federal Ministry of Health).
The Nigerian health system is in comatose, few hospitals with few drugs, inadequate and substandard technology and a lack of infrastructural support, including electricity, water and diagnostic laboratories resulting in misdiagnosis. Medical record keeping is rudimentary and diseases surveillance is very poor. Delivery of health care becomes a personal affair and dependent on ability to pay for basic laboratory and physician services. These have exacerbated the disease burden (FMoH, 2004). Health care financing is worse hit especially in the poor continent where health care faces serious problem of acceptability with out-of-pocket expenditure accounting for over 70% of total private health expenditure is enough to dent the little progress of the health system made. Hence, the increasing out-of-pocket expenditure due to high disease burden on most poverty-stricken households has kept them in the vicious cycle of the poverty trap. Risk pooling in the form of private/commercial health insurance is often lopsided while the much-touted social insurance is limited to those in Federal government service (HERFON, 2006).
1.3 Objective Of The Study
The broad objective of the study is to assess the problems, issues and alternative approaches of organization and financing of primary health care in Nigeria as it is expected to provide an important role in national economic development strategy.
Specifically, the study will address the following major issues:
- The problems confronting the Primary Health Care sector in Nigeria
- The measures to reverse the trend through reforms
- The impact of reform on the health sector and the challenges
- Health care financing and organization for economic development
- Make recommendation on the way forward
- HO1: There is no significant relationship between organization and the primary health care sector output in Nigeria
- HO2: There is no significant relationship between financing and the primary health care sector output in Nigeria
- HO3: There is no significant impact ofchallenges and approaches on the organization financing of primary health care in Nigeria
1.5 Significance Of The Study
The provision of accessible and affordable health care services on a sustainable basis in any country, including Nigeria, is an important obligation of government and the fundamental right of the citizens, through direct participation in health delivery system and good legislature on health. The government of Nigeria, through the Federal Ministry of health, has been undertaking this responsibility, but with abysmal result (FMoH, 2005). In economic parlance it is believed that health and education are the two important prerequisites for human capital development, and have been demonstrated to be the basis of individual’s economic productivity. Health is the basis for job productivity, the capacity to learn in school, and the capability to grow intellectually, physically and emotionally. As with economic wellbeing of individual households, good health is a critical input into poverty reduction, economic growth and long-term economic development at the scale of whole societies. This study will be significant to health professionals, researchers and the academic community as the findings address these issues.
5.0 Conclusion And Recommendation
The paper investigated the problems, issues and alternative approaches of organization and financing of primary health care in Nigeria. Primary health care in Nigeria is currently inefficient and is incapable of achieving health related sustainable development goals. Given the low level of government funding of health sector, particularly the PHC system over the years, foreign donations have been increasing and have become essential for the development of a functional and sustainable primary health care in Nigeria. This challenge becomes more urgent against the background of projected declines in foreign donations towards improving healthcare because of a number of socioeconomic factors. Foreign donations have created two major spillover issues: weakening of commitment to domestic funding and neglect of health system strengthening. Foreign donations cannot be a replacement for increased domestic spending on public health. Increased domestic funding must be made a prerequisite for foreign funds. Increase in domestic funding for health along with the strengthening of the health system in Nigeria will ensure that when donor funds are no longer available, Nigeria’s primary health care system would be ready, and able to deliver quality health care to Nigerians.
The Federal Government should explore ways towards improving access to primary health care:
Extending the reach of primary health care and improving its performance requires action on several fronts’ simultaneously-including new delivery models to increase access, a greater role for nonprofit and private organizations in service delivery, and the introduction of performance incentives to improve it.
Better mind-sets and behavior:
Pay-for- performance bonuses and other incentive programs would motivate health workers to provide high-quality care efficiently. Improved delivery of supplies would reduce frustration. Better management capabilities would help ensure that workers were paid on time. To further improve the attitudes of health workers, the system should give them management training and other skill-development opportunities and a more supportive working environment. A mind-set shift among patients is needed as well so that they seek needed treatments more promptly. The presence of community health workers in each village may help change the mind-sets by making patients see that the health system is addressing their immediate needs. Experience in other sub-Saharan countries suggest that many of them face similar problems.
Strategic and progressive leadership in health delivery service:
At a time when much is being made of foreign reserves that are being built up and the general improvement in Nigerian economic indices, it is perhaps time to re- examine the systems that will be needed to deliver results to the Nigerian people from the funds that have been stock piled through prudent economic management. We owe a duty to the people of Nigeria to utilize the windfalls from the increases in oil prices to effect changes in their lives. One way we can do this is through ensuring that these funds are used to eradicate preventable diseases and despair.To achieve this, the Federal Ministry of Health will need to provide strategic, progressive leadership.
Effective monitoring and evaluation (M&E) of performance and tracking the use of resources, health policies and reforms:
The Government should appoint a committee or set up an agency in the monitoring and evaluation (M&E) of performance and tracking the use of resources, health policies and reforms continuously to enable technical efficiency in the delivery of their services. Implementation of health financing policies and actions need to be monitored and evaluated at regular intervals. Monitoring and evaluation exercise are needed for building evidence for future policies and for the assessment of whether the policy objectives have achieved the expected results. Monitoring and evaluation strategies contribute to the assessment of MDG, child and maternal health and other national and international development goals. The evidence will be useful for better targeting of donor action on MDG. The amount of investments in health is expected to increase with the provision of evidence to justify the magnitude of investment. It is also necessary to ensure the effectiveness of public health expenditure through the institutionalization of performance-based budgeting and other mechanisms for preventing fraud.
Building a fairer economic relation with the world:
There should be concerted effort to “build a fairer world” that limits the health damaging consequences of the unjust economic and political relation between the developed and the developing countries, to which Nigeria belong. In this regard, the power of the World Bank, the IMF and WTO in forcing programmes on the poor countries that exacerbate poverty and endanger the health of the population must be addressed. The current WTO agreements on intellectual property rights, which effectively limit the access of the poor countries to essential medicines and cheap drugs, must also be opposed by the governments and peoples of the poor countries. The framework of unequal economic and political relations between Nigeria and the advanced capitalist countries -unequal trade, the ecological debt, the external debt, has to be addressed.
Increased funding to the health sector:
Government should massively increase investment and public spending on health. The health system currently relies on mixture of government budget, health insurance, external funding and private sources including non-governmental arrangements and out of pocket payments. Despite the variety of financing sources, the level of health spending is relatively low.
Implementation of integrated model for community-based chronic and communicable disease control in health services delivery:
The FMoH should promote the implementation of integrated model for community-based chronic and communicable disease control in health services delivery. Government should develop guidelines for the practice of traditional medicine and facilitate the retraining and registration of traditional medical practitioners to improve their skills and effectiveness and thus, help promote their integration with the primary health care system. Also, government should strive to promote the development of industries and relevant manpower to enhance local capabilities in the production of drugs, including ARV and laboratory reagents, medical equipment and spare parts to improve supplies and maintenance capabilities so as to reduce cost and improve efficiency.
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