Charting a Healthier Course: The State of Nigeria's Primary Care
Primary healthcare is the cornerstone of any national healthcare system. In Nigeria, the primary healthcare space is a complex, paradoxical environment where the nation's PHC system grapples with obstacles while simultaneously holding the potential for transformative change.
According to the Federal MoH Health Facility Registry, Nigeria currently has a network of just under 33,000 operational primary healthcare facilities, constituting 85% of all healthcare establishments nationwide, with most being publicly owned. However, juxtaposed with a population exceeding 220 million, this statistic reveals a stark reality - there are only 15 primary healthcare centres per 100,000 individuals. For context, some European nations have almost 20 times that amount, with almost 240 PHCs per 100,000 people. Additionally, more than 550 primary healthcare centres are in different stages of development, either pending operation or under construction, raising questions about the extent to which the previous administration's pledge to renovate 10,000 PHCs across the nation has been realised.
With such a stark disparity between the number of PHCs and the size of Nigeria’s population, the question of governance becomes paramount, and the role of the National Primary Health Care Development Agency (NPHCDA), established in 1992, becomes even more critical. The NPHCDA oversees and coordinates primary healthcare services nationwide, including essential areas such as immunisation and maternal and infant health. Notably, the NPHCDA played a significant role in executing Nigeria’s COVID-19 vaccination program and may now be gearing up for a new vaccine rollout following the WHO's approval of the effective and scalable malaria vaccine developed by the University of Oxford and the Serum Institute of India.
So, why is primary healthcare important? Primary healthcare is the most inclusive, equitable, cost-effective and efficient approach to enhancing the physical and mental health of the general population. According to Dr Faisal Shuaib, the Executive Director of the NPHCDA, 70% of Nigerians rely on primary health facilities, so the health of the PHC sector is pivotal for the health of the population as a whole.
On a more global scale, nearly 930 million individuals worldwide face the risk of sliding into poverty due to out-of-pocket health expenses consuming 10% or more of their household budgets. The scaling up of primary healthcare interventions in low and middle-income countries presents an opportunity to save 60 million lives and extend the average life expectancy by 3.7 years by 2030. However, achieving these PHC targets requires substantial investments, with an estimated annual expenditure ranging from US$ 200-370 billion. This allocation is necessary to provide a more comprehensive package of healthcare services to all.
The Challenges
Despite this, Nigeria’s PHC sector is riddled with challenges that undermine the ability to provide the basic, minimum health service package to its citizens.
While the NPHCDA has established a comprehensive set of guidelines outlining the minimum standards for primary healthcare centres in the country, including infrastructure, medical equipment, staffing, essential drugs, and services, a recent WHO report paints a concerning picture. The report reveals that only a quarter of PHCs in Nigeria have more than 25% of the minimum required equipment package. Additionally, only 20% of PHC facilities have the capacity to provide basic emergency obstetrics services. Even the NPHCDA acknowledges challenges within the PHC system, as it has observed a noticeably high incidence of stock-outs of essential drugs in most PHC facilities, as well as instances of expired drugs and wastage, undermining the ability to deliver basic healthcare services.
Chronic underfunding of primary healthcare in Nigeria has persisted as a significant issue. The primary funding source for the National Primary Health Care Development Agency (NPHCDA) comes from the Basic Healthcare Provision Fund (BHCPF), designed to offer free basic healthcare services to Nigeria's most vulnerable citizens. However, the BHCPF's implementation has been slow since its launch in 2014 and its inclusion in the national budget in 2018. This delay in releasing funds, coupled with issues like fund misappropriation and corruption, hampers effective utilisation at the state level. But the greater challenge lies at the federal level, where the BHCPF's primary funding source, a 1% allocation from the Consolidated Revenue Fund (CRF), has dwindled over the years due to shrinking government revenue. In 2021, 1% of the CRF amounted to approximately ₦35 billion, down from ₦56 billion in 2018. Without additional revenue sources, chronic underfunding remains a looming concern.
Furthermore, the federal budget has seen a steady decrease in allocations for primary healthcare facilities, encompassing critical programs such as the National Programme on Immunization, the Roll Back Malaria initiative, the Midwives Service Scheme, PHC, and community and environmental tutor programmes. These allocations have decreased from 8.4% of total health sector spending in 2012 to a mere 4.7% in 2015. There's a widespread perception that funding for healthcare, particularly primary healthcare, is insufficient, adding to the enduring challenge of resource constraints in the Nigerian healthcare system.
And this chronic federal underfunding has trickled down to the state level. The number of primary healthcare centres (PHCs) in each state is closely tied to population size and healthcare budget allocation. For instance, Katsina, with a 2022 healthcare budget allocation of ₦39.95 billion, has nearly 2000 PHCs, while Kaduna, with an allocation of ₦40.97 billion, has close to 1300 PHCs. On the other hand, states like Bayelsa, with a 2022 healthcare budget of just ₦12.56 billion, have fewer than 300 PHCs, and Ekiti, allocated ₦6.35 billion, has less than 500 PHCs. This trend is particularly concerning, given that more than a third of Nigerian states reduced their healthcare budget by an average of 27% between 2020 and 2022, with some cutting it by almost 70%.
The insufficient insurance coverage in Nigeria has a profound impact on the accessibility and utilisation of primary healthcare. With over 70% of healthcare expenses being paid out-of-pocket, individuals often bear a significant financial burden, discouraging them from seeking timely healthcare, including primary healthcare services. This delay in seeking care limits the preventive and early intervention benefits of primary healthcare. Furthermore, with only about 10% of Nigerians having health insurance coverage, many people are vulnerable to unexpected medical costs, leading to tough choices like forgoing essential medical appointments or delaying necessary treatments due to financial concerns. This, in turn, worsens health conditions and strains secondary and tertiary healthcare facilities, as patients arrive with more advanced and costlier health issues
In Nigeria's healthcare system, the distribution of healthcare workers varies by region, with some areas experiencing lower doctor-to-population ratios and different nurse and midwife ratios. For instance, although the national average for doctors per 100,000 population stands at approximately 12, specific zones, notably the North West and North East, have ratios as low as 4. Similarly, while the national ratio of nurses and midwives to 100,000 population averages at 21, the South West, North West, and North East zones report ratios of 16, 11, and 18, respectively.
Additionally, the primary healthcare sector predominantly relies on community health workers (CHEWs), while medical doctors and other healthcare professionals are primarily found in non-primary healthcare settings. However, a case study conducted by the WHO and the Alliance for Health Policy and Systems Research highlights significant challenges within the primary healthcare sector, including unclear job descriptions, inadequate training, and high patient-to-staff ratios, especially in rural areas, compounding the workforce shortage in primary healthcare facilities across the country.
The Impact
This myriad of challenges has a significant impact on healthcare delivery in the country. The Northwest and Northeast regions, marked by the lowest primary healthcare centre density, consistently exhibit the poorest health outcomes, including high rates of under-5 mortality, low immunisation rates for diseases like TB and polio, and limited antenatal coverage with skilled personnel. For instance, the proportion of primary healthcare facilities providing immunisation services varies widely, from a mere 0.5% in the North East to a robust 90% in the South West. A January 2023 report from the National Primary Health Care Development Agency (NPHCDA) underscores the gap: while Nigeria's primary healthcare system is designed to serve at least 70% of the population, it currently caters to just around 20%. Conversely, the secondary healthcare systems, originally designed for a minimum of 27% coverage, are shouldering the healthcare burden for over 70% of the population, highlighting a systemic disconnect.
The Path Forward
Investing in primary healthcare in Nigeria offers a range of compelling advantages that can transform the healthcare landscape and have far-reaching positive effects. A robust primary healthcare system in Nigeria is vital in enhancing preventive care. Numerous studies have shown that preventive care can significantly reduce premature mortality and improve the overall quality of life of the population. By providing accessible and affordable preventive care services, primary healthcare centres contribute to the early detection and management of health issues, reducing the overall burden on the healthcare system and enhancing the well-being of the population.
A comprehensive network of primary healthcare (PHC) clinics and physicians significantly alleviates the patient burden at secondary and tertiary health centres. By acting as the first point of contact for patients, PHC centres serve as gatekeepers, filtering out cases that can be handled at this level, ensuring that only complex and severe cases reach secondary and tertiary centres. This not only reduces overcrowding but also ensures that patients receive the most appropriate level of care, ultimately leading to better health outcomes.
Moreover, implementing and revitalising primary healthcare centres allows for effective patient tracking and data management. Tracking a patient's journey and referrals is crucial for optimising healthcare services and improving outcomes and primary care physicians typically serve as a central data hub for each patient. If managed appropriately and effectively, this data would be invaluable for fueling the growing health tech ecosystem in Nigeria, addressing one of the biggest challenges in the industry: accessing comprehensive and up-to-date patient data. With accurate patient information, startups and healthcare companies can make better-informed business decisions and tailor their services to the specific needs of the population.
From an economic standpoint, the primary healthcare system is ripe for private investments. Primary healthcare centres require relatively low initial capital investment, as they mainly need basic infrastructure and equipment. This makes them a cost-effective and efficient way to expand healthcare infrastructure in the country and presents significant opportunities for healthcare real estate investment. Investors can quickly and efficiently scale the establishment of primary healthcare centres, creating new opportunities for economic growth, job creation, and improved healthcare access for the Nigerian population.
The combination of these factors demonstrates the substantial benefits of investing in primary healthcare in Nigeria, with a potential for positive social and economic impact.
Key Takeaways for TC Health: Despite stark imbalances in healthcare facilities, chronic underfunding, workforce gaps, and poor insurance coverage, the importance of a robust primary healthcare system cannot be overstated. Looking forward, investing in primary healthcare offers a transformative path. It's the linchpin for preventive care, efficient healthcare delivery, robust data management, and a promising avenue for private investments.
