LECTURE NOTE ON PRIMARY HEALTH CARE

Definition of Health

The World Health Organization defines health as “a state of complete

physical, mental and social well-being and not merely the absence of disease
or infirmity”

HISTORICAL BACKGROUND OF THE NIGERIAN HEALTH SYSTEM

It is important to study and understand the past; this is because it is an

aid to a better understanding of the present and helps in planning for the
future. The planning of the Nigeria health system took the following
sequence:

First Health (Harkens-walkers 10 year (1946-1956) plan:

The first attempt at planning ahead for the development of health care
services in Nigeria was the 1946-1956 Health Plans. The plan was not an
integrated development plan. Its focus was on a segmented development
like provision of portable water, environmental hygiene, and expansion of
hospitals, maternities, child welfare and dispensaries.

First National Development Plan (1962-1968): This was the first

National Development Plan. It was designed following the Nigerian
independence in 1960. It aimed at the improvement of health of the
populace. Training of medical manpower and construction of health centers
were emphasized.

Second National Development Plan, (1970-1974): This aimed at

correcting the deficiencies in the 1 plan, e.g. neglect of preventive health
care and rural dwellers. Reconstruction of health structures following end of
the Nigerian civil war was carried out. Environmental sanitation and
development of medical personnel were emphasized. The National objective
of this plan was to make Nigeria:

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1. A free and democratic society

2. A just and independent Society

3. A limited, Strong and self-reliant-nation

4. A great and dynamic economy

5. A land full of bright opportunities for all citizens

Third National Development Plan (1975-1980):

The National Basic Health Services Scheme (NBHSS) based on the principles
of PHC was designed at this period. The scheme aimed at increasing
coverage from 25% to 60% by providing a comprehensive health care that
would ensure community mobilization, involvement, participation and
disease prevention; using appropriate technology, as well as planning and
management.

Fourth National Development Plan, (1981-1985):

The health policy content for the 4th National Development Plan was
reflected in the National Health Policy document which states that, ‘The goal
of the National Health Policy shall be to establish a comprehensive health
care system, based on primary health care, that is, promotive, Protective,
Preventive, restorative and rehabilitative to every citizen of the country
within the available resources so that the individual and communities are
assured of social welfare and economically productive lives”.

In this plan a design of an integrated primary health care system was

made. Various government of the federation is to participate. Community
participation and self-reliance, equity and a multicultural approach are to be
pursued.

In Summary; the development of health system in Nigeria could be

discussed under the following:

Pre-independence

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1946-1956 - emphasis was on development and welfare Post independent
1962- 1974-curative health care was emphasized

1975-1985-Preventive care was emphasized but money and energy were

spent on construction of health care facilities and purchase of equipment
1985 to the present-the National health policy was established, and health
matters have since then been based on the national philosophy of social
justice and equity of achieving health for all.

BASES (LEVELS) OF THE NIGERIAN HEALTH SYSTEM

The Nigeria health system operates under 3 (3-tiers) inter related levels,
namely; federal, state and local government.

Fig. 1: Organizational Structure of the 3 tiers of the Health

System in Nigeria Federal Level

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Health care delivery in Nigeria is therefore rendered as follows:

 Primary level
 Secondary level and
 Tertiary level

Functions of the 3- Tiers (Level) Of Health Care

a. The local Govt. (primary) level

This is the level providing primary health care services to the local
community. It emphasis preventive care.

The functions are:

 Mobilize, motivate and community members through their chiefs,

traditional rulers, religious leaders and other avenues in identifying
and taking decisions and planning solution to their health problems
using their own available resources.

 Recruit, train and promote the delivery of PHC services by disciplined

staff

 Plan and organize local strategies to deliver PHC services in the LGA.

 Enforce and supervise environmental health laws

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 Implement PHC services such as MCH/FP, health education, treatment
of minor ailment, immunization

 Facilitate referral services

 Liaise with state and federal govt. on primary health issues in the area.

Members of the health team at this level (LGA) are:

 Medical officer of health - chairman

 Community health officers

 Community health Extension workers (Junior & Senior)

 Voluntary Village Health workers (VVHW) and TBAs

 Registered Nurses and Midwives

 Environmental health Officers

 Medical laboratory and Pharmacy Technicians

 Dental therapist, medical health record officer and others as relevant.

This level of operation takes place at health facilities, such as, health
post, health clinics, primary health centers, comprehensive health centers

b. The state government (secondary) level

This level provides services for more serious cases referred from the primary
health centers

Functions:-

 Establishes secondary health facilities

 Organization and management of health training institutions - nursing,
midwifery, health Technology.
 Formulates the state health policies
 Translates and execute federal health policies
 Recruitment and discipline of staff

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  Setting of standard for private hospitals and Clinics
 Liaise with international agencies on health issues
 Carry out research activities
 Offers in-patients and out-patients services such as diagnostic, medical
and surgical interventions, blood transfusion services, maternal and
child health / Family Planning services and referral to tertiary
institutions when necessary.

Members of the state level health team are: -

 Medical Doctors
 Registered Nurses/Midwives
 Pharmacists, Laboratory Technologists
 Radiologists and other supportive staff.

Facilities used are the specialist and general hospitals.

c. The federal government (tertiary) level

This is the apex of health care delivery in Nigeria.

Functions are as follows: -

1. Formulate national health policies

2. Provide funds for manpower training, establish specialized training and
research institutions, e.g. medical schools,
3. Teaching hospitals and research units
4. Provision of funds for capital projects for the states and
5. Local government levels health department respectively.
6. Monitor and supervise projects and programmes at the state and local
govt. health departments
7. Set standards for state and local govt. health departments
8. Liaise with international organizations on health care matters
9. Organize tertiary institutions, accepting referrals and providing
specialized care like rehabilitative services.

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 Members of the team are:

Specialists like:

 Ophthalmologists
 Ortholaryngologists
 Gynaecologists
 Obstetricians
 Consultants, Professors
 Pharmacists
 Laboratory Scientists
 Radiologists
 Psychiatrists
 Dermatologists
 Statisticians
 Nurses/Midwives, (specialists in all branches of medicine). They
operate in teaching and specialist hospitals like orthopedic, psychiatry,

Rational for the 3-tiers:-

1. To ensure prevention and treatment of common problems from the

grass-root level.
2. To facilitate the referral and treatment of more serious cases to a more
specialized centre.
3. To avoid waste of resources

FACTORS AFFECTING HEALTH IN NIGERIA

which are:
1. Cultural factors
2. Environmental factors
3. Geographical factors
4. Socio-economic factors
5. Personal factors.
Cultural factors that affect health are:

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a. Customs: This is the particular way in which people do certain things in
their society, e.g marriage.
b. Belief: This is what people hold in their mind to be cause or solution to a
particular thing in their society, e.g. Religion.
c. Taboo: This is a certain thing which people regard to be an abomination in
their society, e.g eating of snails.
d. Practices: This is a way people behave, act and respond to a particular
situation in their life activities, e.g female genital mutilation.
Environment factors that affect health:
1. Air pollution
2. Inadequate safe and wholesome water supply
3. Poor housing
4. Poor road network
5. The presence of industrial waste
6. Inadequate refuse and excreta disposal
Geographical factors that affect health:
1. Topography of the soil, rivers, mountains e.t.c
2. Deserts
3. Weather
4. Forest vegetation
5. Draughts
Socio-Economic Factors that affect Health:
1. Education level
2. Poverty
3. Ignorance of health matters
4. Low income
5. Socio –economic status
Personal factors
1. Lack of personal hygiene
2. Educational level
3. Awareness of health system

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4. Attitude of the health system
5. Genetically or biological factors
Various cultural theories of disease / illness causation in Nigeria

The cultural belief of a people has great influence on their health status.
Health workers should understand how the people in their target area view
illness, disease and health in order to make impact in health care delivery. In
traditional African societies, Nigeria for instances, there is the belief that
factors other than those put forward scientifically are responsible for the
causation of diseases and ill health.

They believe in two (2) major causations of illness - Natural and

supernatural:

 The natural causes could be accidents, bad food, and headache from
long exposure to sun, scabies from dirt, bad blood.
 The supernatural causes are attributed to:
o God
o Ancestral spirits
o Evil spirits
o Witches and wizards (witchcraft)
o Sorcery

Religion as part of culture also play important role on how members view
and manage illnesses. They employ prayers and incantations. Some religions
would not accepting blood transfussion eg. Jehovahs Witness.

Actions that people take to get well (Cultural Practices to Present or

Cure Illness)

i. Divination—Consultation to find Out cause of the illness

(which is usually attributed to any of the above).
ii. Herbs-used to cure diseases
iii. Charms - to protect and pre cut misfortune

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 iv. Sacrifices- to appease the gods
v. Prayers fasting and abstinence including exorcism — to
plead for mercy from God and to deliver victims from the
oppression of the devil.
vi. Incantation and other forms of rituals to invoke spiritual
powers and to purify selves.

Sources of Health Care Delivery

 Traditionalist - Dibia, Babalawo, Buka.

 Spiritualist - exorcists, Pastors, Imams.
 Orthodox - Hospitals, clinic, Pharmacies and Chemist

What is Primary Health Care (PHC)?

The World Health Organization, (1978) defined primary health care as

“essential health care based on practical, scientifically sound and socially
acceptable methods and technology, made universally accessible to
individuals and families in the community through their full participation and
at a cost that the community and country can afford to maintain at every
stage of their development in the spirit of self-reliance and self-
determination”.

 Primary health care reflects and evolves from the economic

conditions and socio-cultural and political characteristics of the
country and its communities.
 Addresses the main health problems in the community providing
primitive, preventive, curative and rehabilitative services.
 It includes education concerning prevailing health problems and
the methods of preventing and controlling them.
 It involves, in addition to the health sector, all related sectors
and aspects of national and community development example,
Agriculture, education ,housing etc.

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Primary health care requires a change in socioeconomic status, distribution
of resources, a focus on health system development, and emphasis on basic
health services.

Aims/Purpose of Primary Health Care

Making essential health care services (Water, Food, Sanitation,)

available and accessible to the people wherever they live and work

To provide services using technology that the people can use

themselves and are able to maintain hence eliminating waste Involve the
community in planning, implementation and evaluation of health services
concerning them thereby enhancing self-reliance.

Ensure prompt attention to problems in order to reduce mortality and

morbidity among vulnerable groups Create awareness through health
education on prevention of diseases.

BASIC PRINCIPLES OF PRIMARY HEALTH CARE

The practice of PHC is based on the following principles:

1. Community participation

2. Intersectoral collaboration

3. Integration of health care programs

4. Equity

5. Self-reliance.

COMMUNITY PARTICIPATION

This is the Hallmark of primary health care, without which it will not succeed.
Community participation is a process by which individuals and family assume
responsibility for their own health and those of the community and develop
the capacity to contribute to their/and the community development.

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Participation can be in the area of identification of needs or during
implementation.

The community needs to participate at village, ward, district or local

government level. Participation is easier at the ward or village level because
the issue of heterogeneity is eliminated.

ADVANTAGES OF COMMUNITY PARTICIPATION

 -It addresses the felt health needs of the people

 -It ensures social responsibility among the community
 -It ensures sustainability
 -It ensures cost sharing
 -It ensures enhancement of knowledge
 -It encourages intersectoral collaboration

INTER SECTORAL COLLBORATION

This is the coordination of health activities with other sectors; such sectors
include Education, Finance, Agriculture, Information etc. There should be a
working relationship these bodies and the health ministry.

ADVANTAGES

 -Overall human development

 -It ensures economic development
 -It ensures affordability

INTEGRATION OF HEALTH SERVICES

This is defined as coordination of various primary health care components

into a whole programme and made available at all times including referrals.

ADVANTAGES

 -It ensures efficient use of all resources and removes areas of wastage.

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  -It ensures sustainability of programme
 -It ensures bye pass phenomenon
 -It reduces opportunity cost
 -It grantees clients confidentiality

EQUITY

The health care resources available in a given community should not be in

the handle of a few. And resources should be accessible and affordable to all.
Addressing the issue of equity in Nigeria It is divided in 3 components:

1. Decentralization of health services into federal state-local government-

ward levels.

2. The essential drug services and the national drug formulae, making
drugs available at all levels and at low cost.

3. National health insurance scheme-where people contribute to the

health services of those who don’t have or cannot afford.

SELF RELIANCE

This involves the use of technological methods and scientifically sound and
maintain by the community .It can be in terms of human resources, money
or materials. Human resources in Nigeria-medical officer of health,
community health officer, nurses midwives, community health extension
work, community health Aid etc

Money-Is to ensure that there is financial backing.

Material- can be in form of physical facilities, drugs or other biological.

ADVANTAGES OF SELF RELIANCE

 -Affordability
 -Sustainability

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  -Acceptability
 -Authenticity

COMPONENTS OF PRIMARY HEALTH CARE

Initially eight (8) components of PHC were issued. These could be increased
depending on the country and its health needs.

They are: -

1. 1. Education concerning prevailing health problems and the methods

of identifying, preventing and controlling them.
2. Promotion of food supply and proper nutrition
3. Promotion of adequate supply of water and basic sanitation
4. Prevention and control of locally endemic diseases
5. Immunization against major communicable diseases
6. Maternal and child health including family planning
7. Appropriate treatment of common diseases and injuries
8. Provision of essential drugs
Additional components
9. Community mental health
10. Dental health
11. Primary eye care
12. Promotion of occupational health
13. Care of the handicapped
14. Care of the aged
15. Care of the school child
16. Care of the adolescents

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Primary health care elements

PROBLEMS OF IMPLEMENTATION OF PRIMARY HEALTH CARE

PROGRAMME AT LGA LEVEL IN NIGERIA.

To achieve primary health care in Nigeria, Nigeria was divided into wards of
10.000 people. This ward is the same as political ward that makes up district
and then local government. However problems experienced during
implementation of primary health care in Nigeria include the following:

1. Shortage of funds

2 Lack of materials and equipment

3. Shortage of appropriate staff

4. Lack of commitment which can be at the individual or government

level.

5. Lack of incentive

6. Lack of information

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 7. Inadequate community participation

8. Inadequate intersectoral collaboration

9 .Rapid turnover of policy makers

10. Lack of manpower training and development

11. Inadequate utilization of services

12. in appropriate staff recruitment

13. Ill defined responsibilities that is poor job description

14. Ill defined authority.

Role of Primary Health Care in the Current National Health Policy

The health policy adopted in a particular country is derived from politics.

Unlike the capitalist societies where health provision is governed by the
market forces, in Socialist country it is governed by the need for it. This
therefore is the reason for the adoption by the Federal Ministry of Health a
new system of health care delivery “the primary health care”. It is such that
health care services can be extended to individuals, families and the entire
community members wherever they live or work with their full participation
and at a cost that they can afford. Primary health care has been declared by
the World Health Organization (WHO) in Sept., 1978 as the key to attaining
the stated objective of the World Health Assembly, that is, “the attainment
by all the people of the world by the year 2000 a level of health that will
permit them to live a socially and economically productive life”. This strategy
of the PHC is to be adopted by all member states of the World Health
Organization. It has since been adopted by most countries of the world in
order to ensure equity and social justice in the distribution of health care
delivery.

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PRIMARY HEALTH CARE APPROACH OF THE NIGERIAN HEALTH
SYSTEM

In pursuit of the goals of the Nigerian health system, primary health

care adopted the following approaches in order to achieve them. They are: -

1. Down-up (bottom-up) approach

This implies planning, implementation and evaluation of primary health care

services from the grass-root (community) level. That means that the
processes would proceed from the community to the local government, to
the state and then to the federal government level.

2. Preventive approach

Primary health care emphasizes more on preventive services e.g.

immunization, health education, rather than the curative of the previous
system. It therefore focuses on primary (preventive), then secondary
(curative), and lastly tertiary (rehabilitative) health care delivery.

3. Cost recovery

This is necessary if out of stock syndrome is to be averted. The drug

revolving fund scheme is geared in this direction. Seed money used on the
initial purchase of drug is recovered through issuing of the drugs to patients
on affordable rate. It is not aimed at making profits but rather to recover and
re-use in ensuring constant drug supply.

4. Quality assurance

Primary health care emphasizes a qualitative health care delivery. It should

be of standard, scientifically sound, uses appropriate technology and
acceptable to community members.

Quality assurance by definition is the systematic evaluation of care

based on pre-determined standard and the systematic correction of
deficiencies.

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THE NIGERIA HEALTH TEAM

THE HEALTH TEAM

A team is a group of people who have been chosen to work together

for a common goal. As a tree cannot make a forest, an individual cannot
single-handedly and skillfully render all the services of health care delivery to
the people. As a result there is the need for a joint effort of various cadres
specialized in different skills. Health team therefore can be defined as a
group of people working together to give health care to individuals and
families in the community.

The World Health Organization (WHO) define health team as a group of

persons who share a common health goal and common objectives,
determined by community needs and towards the achievement of which
each member of the team contributes in accordance with his/her
competence and skills and respecting the functions of the others (WHO,
1981).

Composition of a health team

There is no single structure of a health team because its requirement

depends on the public health problem identified. A health team could be
hospital based health center or community health workers team. Health
center team could be composed of the following: -

 -Medical doctors
 -Community health Officers
 -Community health extension workers (CHEW and JCHWS)
 -Environmental Health Officers
 -Pharmacists
 -Nurses
 -Midwives
 -Voluntary Village health workers and traditional birth attendant
 -Medical laboratory scientists
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  -Other paramedics like health information officers.

Characteristics of a health team

o Team spirit
o Goal oriented
o Cooperation among members
o Task distribution (division of labour)
o Clear line of communication
o Sound Organizational management

Functions of health team

The functions of a health team are that of providing to the community

members a comprehensive health care according to their health needs.

This care could be broken down into the following:

 Promote adequate delivery of health care services like immunization,

ANC.,
 Promote community participation in health care delivery.
 Identify diseases in the community and manage as appropriate
 Promote adequate supply of potable water and sanitation
 Give health education on prevailing health problems in the community
 Facilitate referral Services
 Mobilize and motivate community members to find solution to their
health problems.

Advantages of team work in health care delivery

 It facilitate smooth running of the health system

 Promotes achievement of the goals of the health care system
 Promotes understanding and cooperation among workers
 Enhances interaction and exchange of ideas

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  Enhance learning, specialization, accountability and high productivity
 Allows for a shared responsibilities
 Saves time and make service delivery easier
 It promotes effective and efficient work delivery
 It ensures a comprehensive patient-centered care
 Minimizes waste and redundancy at work
 Promotes staff morale

INTEGRATED PRIMARY HEALTH CARE SERVICES

Integrated services are a process by which all component services are

rendered to a client within a reasonable period of time. Integrated primary
health services are the delivery of all the components of primary health care
services at the same time under the same roof and on daily basis.

Advantages

1. It offers a wide range of services to the community

2. It facilitates quality of care

3. It is convenient for clients

4. It boosts staff morale

5. It harnesses PHC resources leading to increased productivity.

6. Prevents duplicating and wastefulness

7. Economizes on resources (money, manpower and materials)

8. Assists in effective management of resources

9. It enhances coverage

10. It saves patients\clients time and cost, hence providing satisfaction.

11. Enhances sustenance and utilization of services.

Reasons for possible failure of integrated services

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1. Incompetent and inadequate staffing

2. Inadequate materials, equipments, drugs and logistics

3. Lack of commitment, acceptable behavior and motivation of existing staff

4. Poor planning e.g. organizing services where and when farm work and
other activities in the community will deter attendance

5. Communication gap among staff and clients

6. Cost, rumors and ignorance

Facilitators for integrated health services

 Cohesive health team

 Advocacy
 Drug revolving fund
 Supply of essential Drugs
 An operational 2-way referral system Functional community
development committees
 Effective and efficient information system
 Community participation
 Outreach services.

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