Theophilus Abbah and Ben Atonko
4 January 2009
Though the primary health care system has received government's attention for over 20 years, there are not many encouraging things about it.
Newly appointed Executive Director of the National Primary Health Care Development Agency, Dr Muhammad Ali Pate, a Nigerian who has a wide-range of experience as World Bank consultant on health, explains why. Excerpts:
Recently, you executed the measles campaign programme which took you round the rural areas in the country. You must have observed the state of health care at that level. What could you say is the state of the primary health care in Nigeria?
We have significant challenges in our primary health care system in this country. The development of the primary health care system has been an ongoing thing for the last 20 or more years. We have been trying to develop a primary health care system that would develop essential basic health service at the frontline. And given the health needs we have in this country, I don't think we can be satisfied with the level of performance.
In terms of maternal mortality -the death of women through child-birth, pregnancy and child-birth related complications we are among the highest in the world and on the average, in Africa. But even if you aggregate it by state, by local government areas, there's a huge variation - in some places, it's twice as high in some places. That's a problem in itself.
But if you look at access to ante-natal care services, over half of women ever go to any health centre before they are delivered of their babies. And a third of them actually show up for delivery-on average, in some places, much less. So most of our women are delivered outside health facilities and when complications arise, they just die and they are buried.
When you come to health of children who are the future of society, one in 10 of children born in this country would die before the age of one. And one in five would die before the age of five. So only four out of five reach the age of five and nine out of 10 would reach the age of one. And if you look at the distribution in the country, some parts of the country have twice worse health outcome regarding childrens health than other parts of the country.
We have got many primary and secondary health facilities spread all over the country, but many people stay at home because either the facilities are too far or they don't have the money to go there. The secondary and tertiary health facilities are visited by people who can afford to do so, who live in urban areas.
The reality in this country is that the poor segment of our population is the one more likely to visit primary healthcare facilities. If you work in Abuja or any capital city in this country, most people you'll see, when they're ill or any member of their families is ill, they're not likely to attend a primary health care facility.
The poorest of our population are the ones who rely on these primary health care facilities. That is why it's important for us to make it work. So, in my opinion, we have a health care system that is inequitable. Secondary and tertiary health facilities that serve the smaller population have more resources than the primary health care facilities that ought to serve the most of the population.
The second problem we have is impoverishing state disease. There is evidence that a lot of families, especially the poor families, when somebody is ill, there is a lot of cost on the family on the household that makes them further impoverished. So you have someone who's already poor and then sick, and he takes five or six days trying to access care. He pays for it out of his pocket. He sells some of his assets. So he comes out of that illness even poorer. So the impoverishing aspect is very important.
The third problem is the fragmentation in the way we offer services-the system between the primary care-different levels of it, and a secondary and tertiary and even within one facility. When you go, you see one doctor today, he gives you something, tomorrow, you go, you see another one-this is fragmentation!
Another thing I have experienced within my short stay here is the quality of the health care we receive. There're concerns about the quality of care in the facilities, meaning that while health workers are doing their best with the limited resources they have, there's still a gap between what the people get and the optimum care that they should get.
This problem isn't limited to the primary health care. If you go to the secondary and tertiary levels, you could notice this. If you go to a teaching hospital, there're concerns about quality - people wait for too long. They're not treated nicely, they get complications. It happens in every country in the world. But the extent it occurs varies from one place to another. It's ideal that we improve the quality of care in the country.
Finally, I would say some of the care may be misdirected in the sense that you've got the continuum from prevention to cure. It costs you N2, N3, for example, to prevent measles with a vaccine which is what we start with. But if you don't get an immunisation, and you get measles, and the child gets malnourished, he gets admitted for five days. You end up spending N500!
So if you do this around hospitals, you're tackling the problem before it gets compounded. On the preventive part, diabetes for instance, if the people are aware that they have to exercise, eat well and take their medications so they don't suffer complications, even if they have diabetes , they can manage it. If they don't and nobody tells them, they'll end up with kidney problem, eyes problem, hypertension. It's much more expensive!
That's the picture I get in terms of the state of our health care and within that, the primary health care can play a significant role to improve things, especially for the most vulnerable population: the poor, women, children and those in the rural areas.
If one looks at the death toll in Nigeria compared with some African countries, it's said that maternal and child deaths are more in Nigeria. But is this true considering the relative population in Nigeria and other African countries?
You can't compare Nigeria's maternal mortality fairly with that of the UK and America because they have different income levels. But if you compare Nigeria with countries that have similar income level, per capita GDP and you look at the outcome they're able to accomplish, it's more realistic. If you compare for the level of spending, there's a lot of spending on healthcare.
Do we spend more here?
The health care spending in this country comprises of about five different components: there's the federal government spending, the state government spending and the local government spending, which amounted to $9 per person annually, on average, a few years ago. Plus $1 or $2, if you add what all the development partners bring. And if what households in Nigeria spend is put at about $20 per capita on health care out of pocket mostly. There's no insurance. So the bulk of healthcare spending in this country is on households and individuals and then government is the largest public sector spender. With that level of spending, the system ought to deliver services that would lead to some outcome.
And if you compare the spending of other countries with ours, you'll find out that there's room for improving our effectiveness as well as efficiency. It has to do with how health care is organised, how the different layers, in terms of maintaining relationships among the federal, state and local governments on the issue of health. On the issue of primary health care, it is how the system is organised, and the fragmentation contributes to inefficiencies, and the complexities in our system.
Take, for instance, the case of polio, which is more of a symptom of the failure of the primary health system. If you have a good primary health care system: we deliver routine immunisation, we might have fewer outbreaks. We need to boost efforts. It doesn't mean we don't have campaigns, but campaigns won't be the only thing. There will be supplemental. If you look at other countries in the world, they've been able to get rid of the polio virus. Some are poorer than us, some have gone through conflicts, Sierra Leone, Congo have been able to do a lot more on polio.
Nigeria is the only country on the African continent that is polio virus endemic. And it's the only one in four countries in the world that are considered endemic: Afghanistan, Pakistan - you know they're having conflicts - and India which is far bigger than us, but they're not doing poorly in terms of efforts.
There was a time we almost succeeded in stopping the transmission and then, we had a rebound in the polio virus. Now we're to quickly make progress to in the long term, improve the situation. Countries that are even poorer and have been in war, have been able to do better. We are a fortunate country in the sense that, we have good people, we have incredible amount of natural resources and other things that when put together, we should be able to deliver good quality services. But there's still a lot of room for improvement.
In the rural areas, many are aware of the need to immunise children against polio, against measles. But facilities aren't available. Between publicity and the real coverage, which do you think should be emphasised?
It isn't either...or. There's the demand and the supply. You produce beds. You produce all the beds that you want to produce. Somebody is willing to buy them. That's the demand and someone is willing to pay. But when you come to the health sector, it's very complicated. There's also the demand and supply sides. The supply side is making sure that we have the facilities. Physical facilities should be where people can access them all-year round, there should be people who'll receive patients, there should be drugs, the vaccines and communication and transport facilities in times of emergency are there - all this is on the supply side but there's a huge gap there.
On the demand side, even if you have the facilities, if people don't know of them it is not useful. So one has to tackle that side.
I'll give an example, I went to a rural missionary hospital in one country. I saw that they had very good buildings, they had maternity ward but the doctors told me that women refused to come and be delivered. They said the women come for ante-natal care but they don't come for delivery. We wondered what happened. Then we understood the problem. Traditionally, they are delivered in huts, with a rope hanging from the top and they hold the rope and squat. Traditionally, that's how they are delivered. They weren't comfortable coming to be delivered on flat bed facing up.
"We then built a hut separately and put the same rope. And what happened? Women started coming to be delivered there. So when you supply these things, you've to be sure that you're also meeting a demand. When we provide health services, workers have to make sure that people realise that they're relevant to them and they come out to use them. There's conflict between orthodox medicine and traditional beliefs. So you don't just sit back and say "They're not coming." Try to provide incentives to them. Take the National Health Insurance Scheme, for instance, that is working on midwifery angle. On the demand side, they're trying to improve demand for health services.
But even if you have the demand, they come out saying "Oh, we need health care but there're no facilities, where will they go? That means there will be demand but no supply.
What are the cultural barriers that affect demand?
They are diverse. Explanation will differ from one country to the other. But generally, there's a difference between knowledge and understanding. You can know something without really understanding it. You can tell people something but they may not understand. You'll have to go to another level of making sure that they understand. That's something that deals with communication, it has to do with health promotion, health education.
In the last few years, many had structures built in so many parts of the country. But many of them don't have drugs and equipment. Can you really tackle this?
It's a very difficult situation. The agency has put together a database-it's been fine-tuned and should be completed the coming month. All the primary health care facilities in the country, both public and private, where they're located, the workers they have, the kind of services that are delivered will be captured. By this, we'll be able to tell some of those infrastructures that we have and then take them up to the next level.
I think, in terms of buildings, we have many that haven't been completed. So with the little resources at our disposal, we'll think of what we can do. It's not just the agency that builds facilities. Many other arms of government at the federal, state and local levels build these facilities.
Ultimately, state and local governments have the responsibilities to build, staff and maintain these facilities. What we may do is pool the resources to successfully channel them, tackling some of the infrastructural gaps.
But you have to deal with politicians. What plans are always there to this?
I believe that politicians are leaders. And leadership comes with a lot of responsibilities. Accountability is there. If primary health is demand-driven, if the people in a local government area go to the council chairman and say this our building is falling, it needs renovation, it's demand-driven. I believe the politician will do what he can to solve the problem.
How effective can the Health Insurance Scheme be in the rural areas?
The National Primary Health Care Development Agency is not a home for the National Health Insurance Scheme so the National Health Insurance Scheme is in the better position to say that.
What is your vision for the primary health?
We have been working on the primary health for over 20 years. And the agency has been here for 16-17 years. That's a long time but see where we are. So I don't want to give the impression that every problem will be solved.
For the time that I'll be here, hopefully, we'll lay the building blocks for the future. We're fortunate to have a Public Health practitioner appointed Minister of Health. We hope to collaborate with relevant agencies to reposition the primary health system to be the cornerstone of Nigeria's health system.
For the agency to improve its effectiveness as a player in the health system, it must be a coordinator of primary health care development. We're not the ones delivering those services but we'll be the coordinators for a comprehensive package of services to be delivered at the frontline all over the country.
How do you collaborate?
There're many types and levels of collaborations: state, local government, NGOs, private sector. But it doesn't matter. Coordination is what is needed. For us, we want to be the coordinator of the various actors involved in delivering primary health services. We want to have one common programme that takes into account the different sets of activities in the different parts of the country and channel resources to target areas.
What's the relationship between you and the primary health system at the local government area?
By the structure we have in this country, the local government system is independent. We would like to provide a platform and something of benefit to them in terms of technical and financial assistance. We'll be the advocate. With our database, we can say who's doing well and who's not.
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