CHAPTER ONE
INTRODUCTION
1.1 Background
of the Study
The concept of primary health care has had a significant
influence on the populace in many less-developed countries. However, there is
little understanding of the origins of the term. Even less is known of the
transition to another version of primary health care, best known as selective
primary health care. During the final decades of the Cold War (the late 1960s
and early 1970s) the US was embroiled in a crisis of its own world hegemony—it
was in this political context that the concept of primary health care emerged.
By then, the so-called vertical health approach used in malaria eradication by
US agencies and the WHO since the late 1950s were being criticized. New
proposals for health and development appeared, such as John Bryant’s book Health
and the Developing World (in 1971), in which he questioned the
transplantation of the hospital-based health care system to developing
countries and the lack of emphasis on prevention. According to Bryant, “Large
numbers of the world’s people, perhaps more than half, have no access to health
care at all, and for many of the rest, the care they receive does not answer
the problems they have ,the most serious health needs cannot be met by teams
with spray guns and vaccinating syringes.
Another important influence for primary health care came from
the experience of missionaries. The Christian Medical Commission, a specialized
organization of the World Council of Churches and the Lutheran World
Federation, was created in the late 1960s by medical missionaries working in developing
countries. The new organization emphasized the training of village workers at
the grassroots level, equipped with essential drugs and simple methods. In
1970, it created the journal Contact, which used the term primary
health care, probably for the first time .By the mid-1970s, French and Spanish
versions of the journal appeared and its circulation reached 10 000. It is
worth noting that John Bryant and Carl Taylor were members of the Christian
Medical Commission and that in 1974 collaboration between the commission and
the WHO was formalized. In addition, in Newell’s Health by the People,
some of the examples cited were Christian Medical Commission programs while
others were brought to the attention of the WHO by commission members. A close
collaboration between these organizations was also possible because the WHO
headquarters in Geneva were situated close to the main office of the World
Council of Churches. Another important inspiration for primary health care was
the global popularity that the massive expansion of rural medical services in
Communist China experienced, especially the “barefoot doctors.”This visibility
coincided with China’s entrance into the United Nations (UN) system (including
the WHO). The “barefoot doctors,” whose numbers increased dramatically between
the early 1960s and the Cultural Revolution (1964–1976), were a diverse array
of village health workers who lived in the community they served, stressed
rural rather than urban health care and preventive rather than curative services,
and combined Western and traditional1
The landmark event for primary health care was the
International Conference on Primary Health Care that took place at Alma-Ata
from September 6 to 12, 1978. Alma-Ata was the capital of the Soviet Republic
of Kazakhstan, located in the Asiatic region of the Soviet Union. According to
one of its organizers, the meeting would transcend the “provenance of a group
of health agencies” and “exert moral pressure” for primary health care.A
Russian co-organizer claimed that “never before [have] so many countries
prepared so intensively for an international conferences. Three
key ideas permeate the declaration: “appropriate technology,” opposition to
medical elitism, and the concept of health as a tool for socioeconomic development.
Regarding the first issue, there was criticism of the negative role of
“disease-oriented technology. The term referred to technology, such as body
scanners or heart-lung machines, which were too sophisticated or expensive or
were irrelevant to the common needs of the poor. Moreover, the term criticized
the creation of urban hospitals in developing countries1
When the country gained its independence in
1960, healthcare was not among the first things government officials thought
about. They focused more on the medicine that cured rather than prevented
illnesses. However, 15 years later, National Basic Health Services Scheme
(NBHSS) was created, where primary health care served as the basis for the
whole idea. It was meant to provide medical training and healthcare facilities,
although it neglected the use of new technology and community cooperation.
Unfortunately, NBHSS remained just an idea, as there were problems with
implementing it. Consequently, until 1985, Nigeria remained without primary
health care. In 1985, Nigerian government chose a new Minister of Health,
OlikoyeRansome-Kuti. And that was when thing started to look up. During his
time in office, he managed to introduce primary healthcare into all of the
government areas, ensure immunization of children by making it free, create a
national health policy, emphasize the importance of preventive medicine, encourage
vaccination and introduce a nationwide campaign against HIV/AIDS. He also
relocated responsibility for primary healthcare to the local governments. That
way, secondary healthcare fell onto the shoulders of the state government, and
tertiary health care became the federal government’s responsibility. To control
the implementation and continuation of the idea of primary healthcare, creation
of the National Primary Health Care Development Agency was done in 1992.
Judging from his achievements, he would have done so much more for the
healthcare system in Nigeria. However, in 1993, after seven successful years as
the Minister of Health, OlikoyeRansome-Kuti was removed from the post during
the military takeover. The era of effective and innovative primary healthcare
then came to a close. Twenty-four years after the leadership of Professor
OlikoyeRansome-Kuti, the need to strengthen the PHC in Nigeria is relevant as
ever before.2
In 1992, the National Primary Health Care Development Agency
(NPHCDA) was established to ensure that the PHC agenda is continued and
sustained. The establishment of NPHCDA and the 30,000 PHC facilities across
Nigeria provide an opportunity for the effective implementation of PHC in
Nigeria. Therefore, governments have to maximize the opportunity provided by
existing PHC facilities to make PHC sustainable in order to strengthen
Nigeria’s health-care system. The running of PHC facilities would be more
effective if federal and state governments took over their administration from
the local governments. The Primary
Health Care Under One Roof (PHCUOR) policy was formulated in 2011 to address
the problem of fragmentation in PHC and ensure the integration of PHC services
under one authority. Its impact is yet to be felt on health status and
utilization of PHC in Nigeria since PHC under one roof became a national policy
only few years ago. The inability of
PHC centers to provide basic medical services to the Nigerian population have
made both secondary and tertiary health-care facilities experience an influx of
patients. This has had its toll on the secondary and tertiary levels of care.2
1.2 Statement of the Problem
The current state of
PHC system in Nigeria is appalling with only about 20% of the 30,000 PHC
facilities across Nigeria working. Presently, most of the PHC facilities in
Nigeria lack the capacity to provide essential health-care services, in
addition to having issues such as poor staffing, inadequate equipment, poor
distribution of health workers, poor quality of health-care services, poor
condition of infrastructure, and lack of essential drug supply2. Nigeria allocated 4.6%
and 3.5% of the total gross domestic product (GDP) to health in 2009 and 20010
respectively, although health allocation was increased to 5% in 2012, it is
still way below the 11% GOP recommended by WHO and like most allocations, it is
badly managed and is nothing near what is necessary to clear the back log in
health investment carried out through the years. In 2005, the federal ministry
of health estimated a total of 23,640 health facilities in Nigeria of which 85%
are primary health care facilities, 14% secondary and 0.2% tertiary. Wide
regional variations exist in health indicators across the zones. Infants and
child mortality in the north, west and eastern zone are in general twice the
rate in southern zone while maternal mortality in the northwest and northeast
is over six times the rate recorded in the southwest zone. There are also wide
variations in the rate across regions, socio economic, rural urban residence.
These indicators does not converge toward achieving the MDGs in Nigeria3.
Primary health care in
Nigeria has suffered a setback since the failure of the basic health service
scheme (BHSS) of 1975-1980. Failure of
BHSS were for many reasons such as poor commitment of federal ministry
of health bureaucrat, Poor budgetary allocation to scheme, non involvement of
community participation, the scheme was politised, the principle of primary
health care were not applied, refusal of new cadre of health staff (community
health workers, comm. health assistants, comm. Health supervisors and community
health officers), failure in equipping schools of health technologies with man
power with the skill to set up of PHCs.. Enormous quantity of sophisticated
equipment were contrary to principle of self reliance and appropriate
technology. Most of the buildings were not complemented, medical equipment were
delivered but remained unused for many years (if ever). Individuals and
companies were paid for equipments that were never delivered and work that was
never done, to mention but a few.4
1.3 Justification of the Study
THE ROLES OF NATIONAL PRIMARY HEALTH CARE DEVELOPMENT AGENCY (NPHCDA) ON PRIMARY HEALTH CARE UNITS IN NIGERIA
