Issues is a new NT series in which academics and policy experts write on their areas of expertise. If you would like to contribute to the series send an email to Olumide (his email address is on the page under the link).
The columnist this week is medical doctor and health policy analyst Seye Abimbola.
The primary health care (PHC) facility is often all that rural communities have in form of a formal health system. How then do we improve the quality of care when attention has consistently been on expanding the reach of PHC services to rural populations and hardly on quality of services? The presence of a PHC facility does not guarantee its use and there is a wrong assumption that a minimal level of input (i.e. infrastructure and staff) is essential before one can discuss quality. Even when quality becomes a real issue, it is often about supervision; but supervision is a poor proxy for quality. The quality of supervision itself is what matters. Handled poorly, this becomes a vicious circle: poor supervision results in low quality of services and low quality of services set a low standard for supervision.
Health services in Nigeria mirror political organisation. The federal government is responsible for tertiary care, state governments for secondary care, and the local governments run primary care. The financing of (but not the responsibility for) public health is tied to the flow of funds from the federation account. Funds are shared between levels of government according to an allocation formula that keeps about half at the federal level, allocates a quarter to the 36 states, and gives the other quarter to the LGs. These resources are not sectorally earmarked and the states and LGs are not constitutionally required to provide budget and expenditure reports to the federal government. Nigeria thus leaves the most important and consequential level of health care – primary health care – to the weakest level of government. This results in poor coordination and integration between levels of care, giving rise to a weak and disorganised health system, in which widely varying patterns of outcomes depend on local situations.
The decentralisation policy that makes local governments run primary health care in Nigeria rests on the imported notion that services are most efficient when governance is close to the people, an assumption that is premised on the existence of a well-functioning participatory democracy where the electorate are neither hungry nor ignorant. Most of the rural people our PHC facilities serve have not been exposed to high quality health services so they accept what they get as the norm or, when they imagine it not to be the norm, without complaints. When they cannot put up with low quality services they ignore the PHCs by staying at home, and they consult quacks, only to present in the PHC or other hospital in emergency, often too late for life-saving interventions.
This is not a new problem, and Nigeria has responded in two important ways to the disjunction between finances and responsibility on the one hand, and between communities and the political administration of health on the other. The National Primary Health Care Developing Agency (NPHCDA) is one such Nigerian innovation, albeit as usual, not completely well thought out. NPHCDA is a federal government agency with policy and oversight roles on PHC implementation at the state and local government levels in Nigeria. The major drawback is that a federal agency has no binding constitutional role to implement programmes or policies at the state and local government levels. The governments must be willing to cooperate or nothing happens, and cooperation often has to come with financial commitment, which for every government are highly contested grounds.
The second innovation, also poorly thought out for the short term, is the creation of Ward or Village Development Committees (WDCs or VDCs). An initiative of NPHCDA, they are designed to strengthen local communities in the hope that they can advocate for themselves. The committees are made up of influential community members who can help to enhance community participation and ownership, and promote demand for quality services. The problem here is that people can only demand what they are really passionate about. People may be empowered by knowledge, but it takes a deeper level of knowledge that can translate into passion and commitment to get people to act and change their behaviour.
It is much easier to ignore community participation when the issue is improving input — infrastructure and staff. But for quality, it is clear that we either find a way to get communities actively engaged in the health system that serves them, or we establish structures and processes that will allow us to temporarily bypass community participation on the road to improving the quality of care at the PHC level in Nigeria.
Health professionals are often in the position to set the standards for themselves, and then police themselves to ensure their practice is up to those standards. Health workers in Nigeria as in many other countries, rather than police themselves, are more likely to protect their colleagues from complaints of negligence, malpractice that may lead to litigation. In a situation where people are not empowered to detect poor quality, speak up and fight, there is need for the health system to fill that role on behalf of the people.
This gap in behaviour means that the solution to the quality issues in primary care has to be innovative. We must think of structures, both government- and civil society-led, to act on behalf of communities in the hope that by so doing, members of the community can learn to make demands in their own voices. This may happen through continuous supportive supervision through the use of standardised checklists. It is also important to openness, while discouraging a culture of blame and fault finding in quality assurance.
Nigeria lacks the technical, financial and political sophistication and robustness required for a complete decentralisation of health services. To streamline the health system, it may be necessary to bring PHC under the federal roof, and add tertiary care to the responsibility of state governments. The role of supportive supervision can then be left to the local governments who will function independently with verification of their activities by civil society. I am afraid this proposal may only look good on paper. Implementation in reality will be difficult, and there are great political hurdles to reorganising a system, especially when such reorganisation involves huge financial commitment by the different tiers of government.
Seye Abimbola is a health systems strengthening project manager and research fellow at the National Primary Health Care Development Agency, Abuja, Nigeria