Reinventing primary care in Nigeria


By Dr. Ola Brown, CEO, Flying Doctors Nigeria

With a total population of approximately 182,200,000, Nigeria has some of the poorest healthcare outcomes in the world. For example, the under-five mortality rate has been reported by the World Health Organization at 117 per 1000 live births. In other words, 1 in 10 Nigerian children under the age of 5 die annually. A stratification of the causes of mortality amongst them reveals some of the chief causes, which are as follows - Malaria, Acute Respiratory Infections and Diarrhoea. These causes of mortality are worth deliberating, as they are preventable.

Child mortality is not our only problem. From the number of people that die from road traffic accidents, to the number of mothers that die during child birth to malaria deaths to malnutrition; the statistics paint an abysmal picture of Nigeria’s healthcare system. As our population continues to grow at rates as high as 4 per cent the need for healthcare reform has never been more urgent.

In this article, we will be reviewing the current primary healthcare model in Nigeria, as well as the impetus to change to address these unsettling indices.

The ‘McKeown thesis’, was an original and inventive idea proposed by the eminent physician-historian Thomas McKeown between 1950 and 1980. He postulated that the population growth in the post-industrialisation era was primarily attributable to improvements in overall standards of living such as diet and nutrition, sanitation and vaccinations rather than life-saving advancements in medicine.

McKeown’s postulation resonates strongly with Nigeria. Only 3.7 per cent of its GDP is utilised on health expenditure. In stark contrast, developed countries such as the U.S. and the UK utilise 17.1 per cent and 9.1 per cent of their GDP on health expenditure respectively. This cost constraint imposed on the treatment of preventable diseases can be alleviated by long-term social improvements that focus on prevention rather than treatment. This will not only translate to reduced morbidity and mortality rates, but also relieve the burden of patient load in Nigerian hospitals.

Hospitals are a big part of Nigeria’s problem. Our politicians love to launch them, celebrate them, we are sentimental about them, we constantly order expensive equipment for them, but in the grand scheme of things; they don’t really matter. Nigeria’s hospital-dominated health system overemphasises medical interventions at the expense of public health and primary care.

Hospitals tend to focus on the very sick, sometimes using very expensive interventions to extend or improve life for a small number of individuals. This means that their potential to actively promote health is limited.

As a developing country, Nigeria has much untapped potential with regard to social reforms. Comprehensive vaccination programmes, health education, institution of basic sanitation and water-provision infrastructure are not novel ideas and have been employed with great success in other developing countries. Our focus should be on emerging technologies and social reforms which Nigeria can tap on even at this stage to achieve modest morbidity and mortality rates. These include telemedicine, remote support for paraclinical healthcare staff, institution of robust systems to manage patient journeys, protocolisation of common and easily preventable disease management guidelines and efficient referral systems.

A preventative health system would be primary, and community-care led, and hinge on the shift in resource allocation from tertiary institutions (hospitals) to community and primary care facilities. This philosophy has recently been re-endorsed by the World Health Organisation in 2003 by means of the Declaration of Alma-Ata, which states categorically that all governments should formulate national policies, strategies and plans of action to launch and sustain primary healthcare as part of a comprehensive national health system and in coordination with other sectors. To this end, it will be necessary to exercise political will to mobilise the country’s resources and to use available external resources rationally.

Costa Rica – A case study
Costa Rica is a developing country in South America, and its citizens have access to one of the most effective primary health care systems in the world. The country’s unique, team-based model of primary care service delivery successfully combines preventive and curative care to provide comprehensive primary healthcare to nearly all Costa Rican citizens. The system produces better health outcomes, while spending less than most other countries in the world. In fact, Costa Rica has achieved the third-highest life expectancy in the Americas — behind only Canada and Bermuda, and well ahead of the U.S. Its infant mortality rate that is half the average of the Latin America and the Caribbean region.

Health reform in Costa Rica was conducted in deliberate and targeted pursuit of the country’s vision of achieving equal healthcare for all. Reforms were implemented in an iterative fashion — supported by strong measurement and monitoring — which allowed for ongoing adaptation and continuous improvement and refinement. The result of the reforms is a robust primary healthcare system, rooted in public provision of care, that supports comprehensive, continuous, coordinated, and equitable care for the entire population.

What about hospitals?
The number of hospitals in Nigeria need to reduce, not increase. The main expansion should be in primary care centres. This may seem counter-intuitive but allow me to explain why.

As healthcare advances, more can be done to treat patients that have what were previously disabling or life-threatening conditions like burns, severe injuries or strokes. But, in order to provide complex healthcare safely, professional teams need to see sufficient volumes of patients with a particular condition. The potential benefits from specialisation are greater for some life-threatening conditions like heart attacks and major injuries, but the safest treatments cannot be provided at small general hospitals because there are not enough patients for teams to maintain their skills. More lives can be saved if advanced services are centralised in more specialist hospitals.

There is further evidence that bypassing smaller hospitals for more central, high volume hospitals produces better outcomes for trauma patients also.

The importance of focusing on determinants of health that lie upstream from hospitals cannot be overstated. Health systems in Nigeria should focus on optimising resource allocation to focus on reducing the disparity in health-access and quality of health within the majority, rather than extending life for the minority.

The quality of tertiary healthcare is critical, but it should not come at the expense of public and primary healthcare.

References available on request.

Dr. Brown will be a panellist at the ‘Keynote panel: 2020 and beyond - top concerns for healthcare leadership and how to address them’, as part of the Africa Health Leaders Forum on May 30 at the Africa Health Exhibition and Congress.