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