PRIMARY HEALTH CARE SERVICES IN NIGERIA: CRITICAL ISSUES AND STRATEGIES FOR ENHANCING THE USE BY THE RURAL COMMUNITIES
CHAPTER TWO
REVIEW OF RELATED LITERATURE
2.1 INTRODUCTION
This chapter reviews the literature on the primary health care in Nigeria critical issues and strategies for enhancing the use by rural communities. It discusses issues arising from the topic of interest as viewed from different perspectives.
CONCEPT OF HEALTH CARE SYSTEM
Good health is one of the fundamental human rights everybody is entitled to enjoy. And the onus rests on the healthcare system to provide health services at the three tiers of the government (federal, state and local government). A health system can then be said to be an organization of people, institutions, and resources that deliver health care services to meet the health needs of target populations. Health system planning then should be distributed among market participants, governments, trade unions, charities, religious, or other coordinated bodies to deliver planned health care services targeted to the populations (Frenk, 2010). World Health Organization [WHO] (2000) identified three basic goals of a healthcare system which include:
1. Good health (improvement and protection of the health of the populace)
2. Fair financial contribution (receiving the services paid for)
3. Responsiveness of the healthcare providers (living up to the people‘s expectation) Achievement of these goals is dependent on how the healthcare systems carryout the following functions:
a. Rendering of efficient health services
b. Resources generation such as healthcare financing (raising, pooling and allocating)
c. Health investment such as material resources
d. Stewardship such as human resources.
Other dimensions for the evaluation of health systems include quality, efficiency, acceptability, and equity. They have also been described in the United States as "the five C's": Cost, Coverage, Consistency, Complexity, and Chronic Illness (Brody, 2007).
SITUATION ANALYSIS
The Federal Republic of Nigeria has an estimated population of 150 millions of which 49% are female and 51% male. The country operates a three-tiered governance structure – a Federal Government, 36 semi-autonomous State Governments grouped into six geopolitical zones, the Federal Capital Territory and 774 Local Governments, with wide regional, socio-cultural, economic and geographical diversities existing across the country (National Planning Commission [NPC], 2008). States and LGAs revenue, contributing to funding for health care are largely dependent on allocations from the federal government as their internally generated revenues are usually low. Nigeria has enjoyed a period of economic growth with the Gross Domestic Product (GDP) rising from 2.5% in the 1990‘s to 6% during the period 2004 – 2007 with average annual inflation rates falling from 20.6% to 11.6% over the same period. Although in recent times, the global economic recession has adversely affected the country‘s economy with a GDP of over $181 billion (Central Bank of Nigeria [CBN] (2008). It is also estimated that more than half of Nigerians (54.4% or 76 million) live in poverty with 70.8% of this living below the poverty line of less than $1 per day. Poverty is found to be predominant in the rural areas than urban areas and deepens from the southern to the northern part of the country (United Nations Development Program [UNDP], 2007). In Nigeria, life expectancy at birth as at 2005 was 46.6% compared to 77.8% in developed countries (UNDP, 2007). Still in 2005, maternal mortality rate was 110 per 100,000 live births (UNDP, 2007). In 2003, neonatal mortality rate was 48 per 1,000 live births (National Bureau of Statistics [NBS], 2008). Infant mortality rate in 2005 was 133 per 1,000 live births as against 41 per 1,000 live births in developed nations in 1970 and 9 per 1,000 live births in 2005 (UNDP, 2007). In 2003, under-five mortality rate was 257 per 1,000 live births as compared with 54 per 1,000 live births in developed countries in 1970 and 11 per 100,000 live births in 2005 (UNDP, 2007). Again, 11,854 deaths from notifiable diseases were reported in Nigeria in 2006 and 15,680 in 2007. HIV/syphilis sero-prevalence rate in 2005 in Nigeria was 11.4% and just 1% in developed countries (NBS, 2007b). All these happenings in Nigeria are largely due to inadequate immunization coverage, unawareness of the public, poor nutrition, unsafe water and poor sanitation exercises (Eneh, 2011). Eneh simply captured what is really prevalent in the rural area of the country, which is occupied by about 70% of the country‘s population. Corroborating Eneh‘s submission, UNDP (2007) affirmed that, only 48% of Nigerians had access to improved water and 44% good sanitation in 2004.
HEALTH CARE SYSTEM IN NIGERIA
Nigeria as a nation operates a pluralistic health care delivery system (orthodox and traditional health care delivery systems). Orthodox health care services are provided by private and public sectors. However, the provision of health care in the country remains the functions of the three tiers of government: the federal, state, and local government. The primary health care system is managed by the 774 local government areas (LGAs), with support from their respective state ministries of health as well as private medical practitioners. The secondary health care system is managed by the ministry of health at the state level. The tertiary primary health care is provided by teaching hospitals and specialist hospitals. The secondary and tertiary levels, also work with voluntary and nongovernmental organizations, as well as private practitioners (Adeyemo, 2005). In 2005, the Federal Ministry of Health (FMoH) estimated a total of 23,640 health facilities in Nigeria of which 85.8% are primary health care facilities, 14% secondary and 0.2% tertiary. 38% of these facilities are owned by the private sector, which provides 60% of health care in the country. In spite of the availability of this huge number of healthcare facilities and advancement in technology the health sector in Nigeria has witnessed various turbulent with its attended negative effects. As affirmed by Obansa and Orimisan (2013), with the country‘s teeming population now estimated at over 150million, it is still struggling with the provision of basic health services. And according to HERFON (2006), health facilities (health centers, personnel, and medical equipments) are inadequate in the country, particularly in rural areas. This of course clearly explains the high mortality rate in children, maternal and even adults over the years. Nearly fifteen (15) percent of Nigerian children do not survive to their fifth birthday. The major causes are malnutrition that accounts for fifty-two (52) percent of the deaths, malaria thirty (30) percent and diarrhea twenty (20) percent (Federal Ministry of Health [FMoH], 2004). Maternal mortality reported as being is extremely high. In 2008, between 3million and 3.5million people were estimated to be living with HIV/AIDS. Nigeria has the fourth highest number of TB cases in the world, with a 2004 estimate of 293 new cases per 100,000 population and 546 per 100,000 total cases (Obansa & Orimisan, 2013). Another key issue linked with health indicators in Africa is poverty and in Nigeria, the incidence of poverty is widespread. Between 2003 – 2004, a household survey was conducted by the government and results revealed that 54.4 percent of the Nigeria population is poor, with a higher poverty rate of 63.3 percent in rural areas. Over half of the population live below the poverty line, on less than $1 a day and so cannot afford the high cost of health care (HERFON, 2006). Obansa and Orimisan (2013) identified the following among others as the factors affecting the overall performance of the Nigerian healthcare system:
Inadequate health facilities/structure
shortage of essential drugs and supplies
Inadequate supervision of the healthcare system
Poor human resources, management, remuneration and motivation
Lack of fair and sustainable health care financing with very low per capita health spending
Unequal economic and political relations
The neo-liberal economic policies of the Nigerian state and corruption
High out-of-pocket expenditure in health by citizens
Absence of community-based integrated system for disease prevention, surveillance and treatment
It became very necessary to brainstorm and come up with plans and strategies that will checkmate the aforementioned factors that militate against effective health care system in the country. Obansa and Osrimisan (2013), highlighted some strategies among others which will help to tackle the health sector challenges in the country as follow:
- improved access to primary healthcare
- Strategic and purposeful leadership in health delivery services
- Increase fund to manage the health sector
SUSTAINABLE HEALTH CARE SYSTEM IN NIGERIA
In 2000 according to World Health Organization (WHO), Nigeria‘s overall health system performance was ranked 187th position among 191 member States. Primary Health Care (PHC), which forms the bedrock of the national health system, remains comatose due to gross under funding, mismanagement, corrupt practices andlack of capacity at the local government level.
CHALLENGES OF SUSTAINABLE HEALTHCARE SYSTEM IN NIGERIA
Some of the major factors that affect the sustainability of the health system and invariably, the economic growth and development in Nigeria include the following:
1) Counterfeit and adulterated drugs – For many years Nigeria was plagued by counterfeit and substandard drugs. WHO ( 2006), reported 70% of substandard drugs in Nigeria and the National Agency for Food and Drug Administration and Control (NAFDAC) estimated 41% of fake drugs (Yankus, 2006; Akunyili, 2007). These counterfeit drugs have led to the loss of several lives and heavy cost in economic terms. According to Reef (2008) a total of 109 children in 1990 were reported dead after the administration of fake paracetamol.
2) Poor health care financing and sustainability – In Nigeria, the federal government health spending increased from the equivalent of US$141 million in 1998 to the equivalent of US$228 million in 2003. State spending on health estimate was about US$420 million or US$3.50 per capita in 2003. Majority of the spending by both the federal and state governments is concentrated on the teaching hospitals, federal medical centres and state owned hospitals respectively. (World Bank CRS, Nigeria, 2005). Once there is problem with the budgeting system in a country where little resources is allocated to the health care system, there is bound to be an increased out-of-pocket expenditure by the consumers of the services. To ensure sustainability of the system, the financing system of the country according to Obansa and Orimisan (2013) should be able to protect its populace from exuberant health services expenses when they are ill and encourage the service personnel to offer effective preventive and curative services.
3) Increased out-of-pocket expenditure – Payments made for health services at the time of illness are referred to as out-of-pocket expenditures. These payments are for consultation, treatments, transportation to the facilities, laboratory charges and/or hospitalization charges (which is more costly). When communities are denied access to essential drugs, facilities and necessary equipments and personnel due to uneven distribution and allocation of resources, sick members have no option but to seek for help in private sectors. Payments for consultation, treatments and/or hospitalization (which is more costly) will however constitute a burden for the sick person and his/her entire household. In 2004, the Nigeria Living Standard Survey (NLSS) surveyed 19,159 samples of households in the country. Data generated revealed that, the estimated average annual per capita out-of-pocket spending on health is #2,999.00 (Nigeria naira), equivalent to about $22.50 (US dollars). This then accounts for 8.7% of household expenditures on health which includes expenditure on outpatient care, transportation to healthcare facilities and treatment/medication (Obansa & Orimisan, 2013). Furthermore, it has been found that one of the largest proportions of total health expenditure in the country is private healthcare spending. Of total health expenditures, government covers 25.5%, while private expenditure comprises the remaining 74.5% of which 91% of the private expenditures are out-of-pocket (WHO, 2006). Again in the same 2004, out-of-pocket health expenditure in private health sector was nearly 70% of total health expenditure. Government total health expenditures were equal to 30.4% (WHO; 2004). In other words, about 4% of households spend more than half of their total expenditures on healthcare (Federal Republic of Nigeria[FRN], 2004).
4) Inadequate basic infrastructure and equipments – The heart of the Nigerian health policy is the provision of universal health services to all citizens. Section 17(3)(d) of the Constitution states that ―The State shall direct its policy toward ensuring that there are adequate medical and health facilities for all persons.
Again in 1999, the Nigeria government during the last days of the military regime headed by president Olusegun Obasanjo established the National Health Insurance Scheme (NHIS) by Act 35 of the constitution. The objectives of the scheme include; the provision of access to good health care services; protection of families from the financial hardship of huge medical bills; and ensuring equitable distribution of health facilities throughout the country (Akinnaso, 2014). Availability of basic infrastructure and equipments at the different levels of health facilities enhance good health services provision. Inequitable supply and distribution of available resources, unavailable buildings, electricity, equipments and drugs have been found to be common in the country (Obansa & Orimisan, 2013). They further noted that in some communities, the habitants have ―to travel over 5 km to access health care because sitting of structures is often based on political expediency rather than perceived need‖ (p.223). In another development, WHO Country Cooperation Strategy: Federal Republic of Nigeria 2002-2007, showed that, the proportion of households residing within 10 kilometers of a health centre, clinic or hospital is 88% in the southwest, 87% in the southeast, 82% in the central, 73% in the northeast and 67% in the northwest regions.
5) Inadequate supply and inequitable distribution of essential drugs – Provision of drugs that are evenly distributed is essential for the essential for the delivery of effective health care. In Nigeria, drug supply especially in the primary health centres (PHCs) is inadequate. FMoH in 2001 conducted a survey and reported that, out of the available 674 PHCs in 202 local governments, 46% had less than half of the essential drugs and 54% had experienced out-of-stock in the preceding three months. Again in 2002, FMoH conducted another survey and found out that, 64% of the PHCs have not been supplied any drug from the government since the year 2000. Absence of these essential drugs including vaccines for curative and preventive services, needed personnel, facilities and equipments in the healthcare system would mean pushing the affected populace to sought alternative care to promote their health and well-being. Some however resort to private sectors, unqualified health personnel and even traditional healers. The poor drug supply and distribution system has led to problems of drug resistance such as resistance to anti-malaria drugs (HERFON, 2006 & FMoH, 2004),
6) Unawareness and participation in healthcare services – It has been observed that most consumers of healthcare services are unaware of available healthcare services and their rights regarding health service delivery. This can be attributed to the lack of ―a bill of rights for consumers (claim holders) and providers (duty bearers)‖ (Obansa & Orimisan, 2013.p.223). Sensitization of the various communities to create more awareness and encourage community mobilization and participation in issues concerning their health is required.
7) Poor remuneration, compensation and other push factors – Poor compensations, remunerations, working conditions and/or career opportunities could make healthcare workers to be dissatisfied with their work and consequently relocated from their home country to other countries, most times from developing countries to developed countries. In Nigeria for instance, it is an obvious fact that several health personnel are engaged in strenuous work in the different facilities which is not commensurate with the salaries there are being paid. According to Obansa and Orimisan (2013), some even work in unsafe/insecure environments. Again among the African countries, Nigeria is one nation where majority of the health personnel sought for greener line in developed nations. Lambo (2006) reported that, over 21,000 Nigerian doctors are practicing abroad. Between April, 2001 and March, 2002, 432 Nigerian nurses legally migrated to work in Britain out of a total of about 2000 nurses that legally emigrating Africa. United Kingdom work permits were approved for 1510 nurses from Nigeria in 2003, and 850 from Ghana (UK Department of Health, 2001). The Nigerian government however sees this trend as a threat to sustainability of her healthcare system.
8) Bribery and corruption – Corruption through the embezzlement of healthcare budgets, health insurance fraud, fraudulent drug procurement or bribes extorted from healthcare consumers at delivery level have negative effects on the healthcare system both in developed and developing countries (World Bank, 2009). It also includes bribery of health professionals, regulators and public officials, stealing of medicines and medical supplies by the health personnel, overbilling for healthcare services, absence from work, and informal payments (Transparency International 2004; Vian, 2007). In Nigeria, corruption in the healthcare sector occurs among different actors which include; healthcare personnel and some government functionaries working directly or indirectly in the healthcare system. Akinbajo (2012) noted arbitrary inflation of unit price of drugs purchased by the ministry of health as part of efforts to help in the treatment of HIV aids victims. In 2008, a former minister of health, Adenike Grange, a former federal legislator, Iyabo Obasanjo and their gladiators were alleged to be involved in corruption where the sum of ₦300 million was misappropriated in the ministry of health (Ogbu, 2008). Today, while the likes of Grange and Iyabo walks the streets of the country freely without being called to account, most of the poor masses who could have benefitted from the ₦300 million have met with untimely death.
9) Shortage of healthcare personnel – The shortage of healthcare personnel is a global issue. According to WHO report (2006) there is a global shortage of 2.4 million doctors and nurses and midwives. Africa has an estimated 817,992 shortage (WHO report, Part 2). In Nigeria, there are 13 doctors, 92 nurses/midwives, and 64 community health workers (CHWs) working in the public sector per 100,000 population (Chankova et al, 2007).
Again in 2012 according to the Nursing and Midwifery Council of Nigeria (NMCN) there were 148,129 registered nurses to care for the approximated Nigeria population of above 150 million with a nurse-to-population ratio of approximately1:1013 persons. The physician-to-population ratio was 1:2536 persons in 2007 in Nigeria (National Bureau of Statistics [NBS], 2007a) as compared with developed nation that has physician-to-population ratio of 1:410 persons in 2007 (Jhingan, 2007). Birth attended by skilled personnel in 2005 is just 35% as compared with developed nations of 95% in same 2005 (UNDP, 2007). This acute shortage is as a result of inadequate infrastructure and poor compensation packages and massive immigration of doctors, nurses and other medical professionals to developed countries in search of fulfilling and lucrative positions (Raufu, 2002; Awofeso, 2008).
3.2 Health financing mechanisms in Nigeria
The NHIS established in 2005 by Decree 35of 1999 of the Federal Government of Nigeria [Laws of the Federation of Nigeria. 1999] was targeted at improving health care financing, by reducing the health care cost borne by individuals. Health financing mechanisms used in Nigeria are mainly user fees and social health insurance schemes. The schemes benefit mainly people in the formal sector (civil servants and those in organized private sector), with a vast majority of the people in the informal sector (farmers, traders, other self-employed and the unemployed) left out [Palmer N, 2004]. Donor agencies like the WHO, UNICEF and USAID played active role in health financing in Nigeria. For comparison, China overall achieved its articulated goals for 2009-2011; extending basic health insurance coverage to 90% of the population, among others [Eggleston K. 2012].