Scaling up primary care to ensure universal coverage, SDGs

*Nigeria will require over N2.5tr to fund PHC interventions in 10,000 wards from 2021 to 2030 to cover target
*Country to avert 3.1m under-five, 110,540 maternal mortalities in 10 years through revitalisation of PHC delivery
*To achieve UHC, country needs to set aside 5% of GDP for sector, ensure 90% of population covered by health insurance

Several studies have shown that Nigeria has continued to under-perform in terms of its health indicators. Nigeria failed to achieve the Millennium Development Goals (MDGs) and is not on course to attain the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC) by 2030.

Stakeholders insist that this situation is largely caused by under-resourcing and inefficiencies in the Primary Health Care (PHC) system.

Little wonder Nigeria has now overtaken India as the country with the highest number of under-five mortality. Data from World Health Organisation (WHO) indicates that one out of every five Nigerian adults is likely to die prematurely from Non-Communicable Diseases (NCDS). Most of these will happen near a PHC facility that will not be able to save the life.

Also, Nigeria has one of the highest rates of out-of-pocket spending (75 per cent) and one of the lowest rates of health insurance coverage (4 per cent). This, coupled with a fragmented and poorly resourced PHC system, makes accessing even basic care an insurmountable challenge for most Nigerians.

Despite political commitments and ambitious policies to improve and expand primary healthcare, Nigeria’s PHC system remains broken. The inefficient system has persisted years after the government first unveiled its effort to improve the coverage and quality of PHC throughout the country, called Primary Health Care Under One Roof initiative (PHCUOR).

In 2014, as part of the National Health Act, the Basic Health Care Provision Fund (BHCPF) was born. This effort, which seeks to remove financial barriers to accessing PHC, particularly for the poor and vulnerable, alongside PHCUOR is finally getting traction. Overseen by the three “gateways”—the Federal Ministry of Health (FMoH), the National Health Insurance Scheme (NHIS), and the National Primary Health Care Development Agency (NPHCDA)—the fund is now being rolled out to address demand-side barriers to accessing basic health services. Meanwhile, PHCUOR is being implemented to address supply issues—primarily access, quality, infrastructure, and commodities.

It is believed that if BHCPF and PHCUOR are sufficiently resourced and implemented they ill offer the promise of essential healthcare for all Nigerians, regardless of geography or their ability to pay.

But despite these efforts, stakeholders have highlighted the major challenges with PHC implementation in Nigeria, the funding requirements, availability and proposed recommendations to bridge the gaps

What is wrong with the current PHC model? A recent paper titled, “Transforming PHC from Ground Zero,” produced by stakeholders in the health sector identified poor funding, weak PHC, and no UHC. It noted that over 60 per cent of PHCs were without the minimum infrastructural requirements for basic PHC operations.

On human resources for health (HRH), the researchers said at least 78 per cent of required staff were not available in the country. They said there is lack of institutional accountability framework. “Poor service and weak accountability. Too many vertical projects implemented by government and partners,” they said.

The researchers insisted there was poor PHC financing in Nigeria. “There is lack of dedicated funds for drugs, commodities etc. Basic Health Care Provision Fund (BHCPF) is a good start, but grossly insufficient,” the paper noted.

What must we do differently? “To provide quality services, deliberate investments in PHC are necessary to ensure availability of HRH in well-equipped PHC facilities,” the researchers said.

On the human resources needed for each facility, the researchers recommended: “Eight clinical staff, 22 non-clinical, two health attendants, one lab technician, one pharmacy technician, health records officer, one driver, two cleaners, two security personnel, ten Community Health Influencers, Promoters and Services (CHIPS), and two Community Engagement Focal Person (CEFP).”

They recommended infrastructure Model Type 2 PHC with full complement of staff, medical equipment and ambulance: Perimeter fencing, security post, accommodation for midwives and other workers, labour and consulting rooms, and ambulance for referral, 24 hours operation.

They said despite tremendous efforts by governments and partners to revitalise PHCs, approximately 7,000 health facilities still need to be either constructed or upgraded to achieve one PHC per ward based on national standards for revitalisation.

On the scope of funding infrastructure for PHC delivery, the paper recommended: capital investment, quasi-capital investment and operational services.

The researchers said capital investment on one Type 2 PHC infrastructure includes; secure perimetre fence, solar alternate power, borehole as well as general equipment, lab equipment, clinic equipment, personnel equipment, and general items.

They recommended one tricycle ambulance per PHC per ward with maintenance and operation costs.

The paper noted quasi-capital investment involves human resource including two midwives per PHC, six other clinical staff, non-clinical staff and Local Government Area (LGA) level clinical staff that support the PHC facility.

On operational services, the researchers recommended: service delivery- Ward Health System (WHS) package; operating expenses (OpEx)- daily maintenance based on current BHCPF Decentralized Facility Financing (DFF); and Monitoring and evaluation (M&E)/governance- governance system, engagement, M&E and supervision (Institutional cost Discounted from PHC cost).

The researchers warned that the country might not be able to achieve UHC and most of the SDGs by 2030 due to funding gaps for PHC centres in the country.

The paper titled, “Transforming PHC from Ground Zero” said Nigeria would require about N2.5 trillion to fund PHC interventions in 10,000 Wards from 2021 to 2030 to cover the target populations, significant amount of which will be on Human Resource for Health (HRH).

The researchers said assuming steady and consistent income from donors and partners, an estimated N1 trillion ($2.6 billion) is required to meet the funding gap over the next 10 years.

They said the BHCPF, which averages N55 billion plus yearly, represents capitation for only 1.2 million Nigerians and does not solve infrastructure and human resources for health challenge.

They said the N1 trillion would be used for: infrastructure upgrades; human resource hiring, training and salaries; PHC services and operational costs; and ambulances and emergency medical treatment (EMT).

According to the paper, the Federal Government (FG) would raise N500 billion out of the N1 trillion funding gap and would support the advocacy for donors, partners and private sector to raise another N500 billion to transform PHC as well as support and galvanize various stakeholders towards the planned Primary Healthcare System Summit in Spring of 2021.

Also, the Federal Government has said that 3.1 million under-five deaths could be averted in 10 years if the ongoing revitalisation and optimal scale up of the PHC delivery is fully implemented.

It added that its plan to improve PHC delivery in the country could significantly improve maternal mortality rates over the next the 10-year period with up to 110,540 lives saved.

Meanwhile, a revised Guideline for Administration, Disbursement and Monitoring of the BHCPF, approved by the National Council on Health, has been launched to reset implementation processes for better alignment with the National Health Act.

These were disclosed at a media engagement organised by the Federal Ministry of Health (FMoH), on Monday, in Abuja. A document presented at the event noted: “With an ambitious scale-up of PHC, a total of 110,540 additional women could be saved over the course of 10 years reflecting improvements in health systems delivery – a 92 per cent improvement in the current projection.”

The document is titled “Strengthening PHC towards achieving UHC in a Post- Polio, Peri-COVID19 Era: An agenda for 2021 – 2030.”

It noted that this is compared with a projected 9,561 lives saved if PHC delivery remains the same adding that this benefit is in additional to the potential impact of the deaths averted is significant when you consider the “multiplier effect” of a single maternal death on the household and negative implications for child survival.

“An additional 2.05 million under five deaths and an additional 1.03 million neonatal could be averted over the next 10 years if the optimal scale-up of PHC was implemented and this represents a significant leap from the projected 69,819 lives saved if things remain the same.”

According to the document, to achieve the UHC, Nigeria needs to set aside, four-five percent of its Gross Domestic Product (GDP) to the health sector and ensure that 90 percent of the population are covered by health insurance and with not more than 30-40 percent out of pocket expenditure.

It noted that out-of-pocket spending presently stands at 77 percent of total health spending while only five-seven percent of the population are covered by pre-payment and risk pooling.

It stated that a highest-level political decision and commitment is needed to make investments in PHC to ensure equity, justice and productivity as well as ensure the development of the PHC system at all levels.

The document further stressed the need for strategic plan to have a well-performing health system with regards to equity, efficiency, quality, responsiveness, resilience and a commitment to implement people-centered programmes that ensure more people have access to care, and more services are covered.

Meanwhile, a study published in the Journal Health Systems & Reform and titled, “Donor and Domestic Financing of Primary Health Care in Low Income Countries” noted that well-functioning PHC systems also require ‘system-wide’ investments to assure effective priority setting; sound management, administrative and financial planning; up-to-date ‘health management information systems’ for resource tracking; and appropriate regulatory and accountability mechanisms. For our purposes, we refer to such expenditures as being most relevant to ‘Health System Strengthening’ (HSS) in support of ‘PHC Delivery.’

The researchers concluded: “Finally, we applaud efforts to better leverage domestic public funding for PHC in LICs and improve the efficiency of health spending. Increasing government financing for health, as a share of total government expenditure, should be a first priority, especially among aid-dependent LICs. Expanding collective public and private financing, through prepayment, is also critical to reducing high reliance on private, out-of-pocket spending and contributing to a more sustainable financing base for PHC.”

Former Minister of Health, Prof. Isaac Adewole, had said that Decentralised Facility Financing (DFF) was the best financing model for PHCs if Nigeria must achieve UHC by the year 2030.

He also pointed out that 80 percent of health problems in Nigeria could be solved at the PHC level of the health system if adequate attention was given to service delivery at the state and local government levels.

According to a study published in the journal BMC Public Health and titled, “Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries: a scoping review”, NCDs are the largest cause of mortality both globally and in the majority of low- and middle- income countries where approximately 80 per cent of the global deaths from NCDs occur.

The researchers said there is strong evidence that primary care is one of the most cost-effective strategies in curbing morbidity, disability and premature mortality of hypertension and diabetes.

Indeed, the need for effective primary care interventions was stated in the Alma Ata Declaration in 1978, which emphasised effective healthcare systems as a reflection of social determinants rather than hospitals and doctors alone. The Declaration proposed a focus on PHC, which challenged the view of biomedicine, dominated healthcare system. PHC conceptualised healthcare as scientific, socially acceptable and universally accessible and based on the principles of equity and community participation. PHC has again been in the spotlight with the 40-year anniversary of the Alma-Ata Declaration and the global community reasserting its principles in the Astana Declaration, which emphasised the importance of PHC in achieving universal health coverage and the sustainable development goals, and on the prevention and management of NCDs.

Recognising the importance of PHC, the WHO has developed the Package of Essential Non-communicable Disease Interventions (WHO PEN) for Primary Care in low-resource settings. The WHO PEN has a special focus on hypertension and diabetes and their integrated management given their burden.

Consequently, research and policy-making efforts are underway in many countries including Nigeria to revitalise PHCs to tackle hypertension and diabetes.

According to the WHO, the SDGs highlight the global community’s commitment to achieving a rigorous standard of UHC as a means to promote the right to health. However, before achieving UHC, a strong PHC system needs to be in place.

Almost forty years ago, the Alma-Ata Declaration elevated the profile of PHC as pivotal to delivering health for all. Evidence has shown that a health system based on high-quality, equitable PHC delivers better health outcomes including longer life expectancy, decreased infant mortality and decreased under-five mortality.

A high-functioning PHC system helps individuals and families build connections with locally based health care workers and facilitate access to high-quality essential health services. When PHC works, it is the first point of contact for people accessing the healthcare system. As such, it plays an important role in preventative care, including early diagnosis and treatment, and is the first line of defense against communicable diseases. Although PHC is one of the most important facets in a country’s health care system, it is often the weakest link, faced with insufficient funding and staffing. Limited support for PHC services has resulted in a lack of access to quality services at the basic level of care for an estimated 400 million people around the world.

Current health financing focuses on vertical funding for specific health programmes and diseases, an approach that can drive significant progress for some health areas but can leave the underlying health system starved for support. Household out-of-pocket expenditure is one of the largest contributors to financing PHC, which limits access to health care services.

A strong primary health care system is the first step toward achieving UHC and Nigeria must address the funding shortfall as well as develop innovative financing strategies.