How council autonomy will guarantee functional primary health care

Medical experts have hailed the Supreme Court’s landmark judgment granting financial autonomy to Local Government Areas (LGAs) as a catalyst for functional primary health care centres, social health insurance schemes and ultimately universal health coverage (UHC.) They say there is need for the federal and state governments to expedite action on implementation of the provisions of judgement to guarantee UHC by 2030.

Until now, several studies have shown that primary health care (PHC) is a whole-of-society approach to effectively organise and strengthen national health systems to bring services for health and wellbeing closer to communities.

PHC enables health systems to support a person’s health needs – from health promotion to disease prevention, treatment, rehabilitation, palliative care and more. It is essential health care that is based on scientifically sound and socially acceptable methods and technology. This makes universal health care accessible to all individuals and families in a community.

PHC initiatives allow for the full participation of community members in implementation and decision making. Services are provided at a cost that the community and the country can afford at every stage of their development in the spirit of self-reliance and self-determination. In other words, PHC is an approach to health beyond the traditional health care system that focuses on health equity-producing social policy.
 

PHC includes all areas that play a role in health, such as access to health services, environment and lifestyle. Thus, primary healthcare and public health measures, taken together, may be considered as the cornerstones of universal health systems.

The World Health Organisation (WHO) elaborates on the goals of PHC as defined by three major categories, “empowering people and communities, multisectoral policy and action; and primary care and essential public health functions as the core of integrated health services.” Based on these definitions, PHC cannot only help an individual after being diagnosed with a disease or disorder, but can actively contribute to preventing such issues by understanding the individual as a whole.

   This ideal model of healthcare was adopted in the declaration of the International Conference on Primary Health Care held in Alma Ata, Kazakhstan in 1978 (known as the “Alma Ata Declaration”) and became a core concept of the World Health Organisation’s goal of Health for all. The Alma-Ata Conference mobilised a “Primary Health Care movement” of professionals and institutions, governments and civil society organisations, researchers and grassroots organisations that undertook to tackle the “politically, socially and economically unacceptable” health inequalities in all countries. There were many factors that inspired PHC; a prominent example is the Barefoot Doctors of China.

In Nigeria, PHC is supposed to be funded and operationalised by the Local Government Areas (LGAs) but unfortunately the latter was not autonomous. They have been for several decades run by the state governors. The governor receive their allocations from the Federal Government and spend it as they wish. Until now, PHCs had been run by the Federal Government with uncoordinated support from the states.
Consequently, there has been gross neglect of PHCs. Investigations reveal that over 70 per cent of PHCs in Nigeria are not functional. There have been so many efforts by the Federal Government to refurbish over 10,000 PHCs nationwide, but with little progress.

 According to Nigeria Health Watch, while the Supreme Court judgement is predicted to drive grassroots development, primary healthcare is one area that will be impacted positively when local governments are financially empowered.

Beyond quality, accessibility is an important consideration while accessing healthcare.
This is why primary healthcare is critical to any successful healthcare system because it is close to people. Up to 90 per cent of health services needed during someone’s lifetime can be provided at the primary healthcare level.

Primary healthcare, being closest to communities, should be overseen by local government area councils. This is especially so because healthcare is on the concurrent legislative list, meaning the three tiers of government — federal, state, and local — all have roles to play in ensuring its full functionality. The 1999 constitution lists healthcare provision as one of the responsibilities of local governments. Healthcare at any level requires resources, however, when it is unavailable or inadequate, it becomes difficult to operate optimally. This has been the reality of most local government area councils for nearly two decades as they have become almost defunct, with state government receiving and disbursing funds on their behalf from the federal account. Now that this situation is about to change, these three areas will potentially be positively impacted when the judgment takes full effect.
   

Reaching a health facility and receiving adequate care are two of the three delays that contribute to maternal deaths. This can happen when local governments lack the human and financial resources needed to operate PHCs effectively. There are examples where young midwives are trained to provide care for pregnant women in their communities, however, many of them are reluctant to work often due to the working conditions of the community facilities.

With more resources at their disposal, local governments should be better able to improve the quality of care in health facilities and employ skilled healthcare workers. This reduces the need for women to visit secondary or tertiary facilities, unless there are complications. Should skilled healthcare workers at primary health centres identify any complications, an effective referral process should ensure that pregnant women are directed to secondary or tertiary health facilities.
With additional funding, local governments will also be able to equip PHCs with necessary medical supplies and essential medication, such as uterotonics, to address cases of post-partum haemorrhage as well as ambulances for critical patient referral movements. 

   The issue of zero-dose children is a prevalent public health challenge caused by a range of factors. These children are vulnerable to deadly diseases because they have not received a single vaccine shot in their lives. Often, they are in communities that can be reached by local governments if they are working at their full potential. Unprotected children in communities increases the risk of disease outbreaks in communities.

PHCs need the vaccines, adequate storage to preserve them and finances to reach every child in their catchment areas. Having financial autonomy will enable local government administrators to do this for their citizens without waiting for the state, which also has other competing priorities.

  Well-resourced PHCs can help reduce zero-dose children and, in turn, improve local health security. However, when public health events occur, they can detect them quickly and escalate for investigation using already established protocols like the Surveillance, Outbreak Response Management and Analysis System (SORMAS).

   According to Nigeria Health Watch, effective governance is one of the pillars of the Nigeria Health Sector Renewal Initiative, and the financial autonomy of local governments can help achieve this. By reducing layers of bureaucracy at the state level, LGAs should be able to prioritise healthcare initiatives based on local needs and provide oversight, minimising opportunities for corruption and mismanagement, a major challenge in Nigeria’s health sector.

In addition, accountability mechanism should enable communities to be more involved in monitoring how their funds are used, ensuring greater transparency and accountability.

This enhanced governance framework can foster trust and confidence in the healthcare system, encouraging more people to seek care at local health facilities.

  Indeed, realising this vision is not going to be easy. There are already mixed reactions following the judgement. Several hurdles need to be overcome before Nigerians will start reaping the dividends of local government financial autonomy. First, state electoral commissions must conduct credible, free, and fair elections to elect local government chairmen. With Nigeria’s history with elections, it’s important to ensure the elections produce candidates that citizens will not question the legitimacy of their mandates. This is important because everything falls on good leadership.

 Prof. Obinna Onwujekwe, Coordinator of the Health Policy Research Group and Professor of Health Economics at the University of Nigeria, said the judgement giving financial autonomy to local governments will “have a positive impact with serious and results-oriented chairpersons.”

 Also, while LGA autonomy will promote transparency and accountability because community stakeholders and gatekeepers who are close to the local governments will be more involved, it is not guaranteed.

Accountability will require intentional efforts and active citizen engagement to ensure fiscal openness and funds for the people, work for the people. Nigeria is part of global initiatives that seek to make governance more open, such as the International Budget Partnership and Open Government Partnership. However, can this be stepped down to the local government level?

To be continued tomorrow.

Muanya is a freelancer, public affairs analyst and media consultant. He can be reached via:[email protected]