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NIVERSAL HEALTH COVERAGE:
Things
to consider in achieving Health for All through Primary Health Care
It is note worthy to
bring our memory back to Alma Ata Declaration in 1978 in discussing this issue,
after which I will briefly talk about the present situation to the best of my
knowledge in my country Nigeria before I discuss possible interventions
(actions) and the challenges.
Primary Health Care is an
essential health care which is practical,
scientifically sound and socially acceptable to individuals and
families in the community through their full
participation and at a cost that
the community and the country can afford to maintain at every stage of
development in the spirit of self
reliance and determination. The key
words that make effective primary health care are;
1.
Inter-sector
approach and
2.
Community
participation
Primary Health Care is
practiced in Nigeria. Administratively, there are governmental bodies called
National Primary Health Care Development Agency (NPHCDA), State Primary Health
Care Development Agency (SPHCDA) and Local Government Authority Primary Health
Care Department (LGA PHC) at federal, state and local government level
respectively. Their responsibilities are
to provide regulations, over sights, technical supports and capacity building
for Basic Health Centers (BHCs).
The agency get funds
and grants from the government and donors like the World Bank, IMF, Bill Gates foundation
fund, UNICEF, WHO etc. Consequently, their interventions are horizontal and
vertical. Referral system is also in place although the effectiveness of it is
questionable.
Even with all these, I
can say we are not yet there; we need interventions that are scientifically
designed to help improve limitations that we have in the system. Hence, I identify three specific actions that contribute toward
achieving Health for All through Primary Health Care.
·
Action
1:
Community mobilization
·
Action
2:
Health Financing
·
Action
3:
Health determinants consideration
Action
1:
Community mobilization
Community mobilization
is defined as a capacity-building process through which community
individuals, groups, or organizations plan, carry out, and
evaluate activities on a participatory and sustained basis to improve
their health and other needs, either on their own initiative or stimulated by
others.
It can be
deduced from the above definition that community mobilization goes beyond
gathering community members and just passing information. Community
participation is a subset of community mobilization. Community health interventions that will work
effectively will have the traditional health workers and other community
members trained and it will involve them through the planning and
implementation of the project. How much
of health interventions set up by the government considers the community
people? The answer is not farfetched, it can be easily said that if most of the
project had fully involved community members, we should hear more of success
stories than the failures recorded even at pilot phase.
According to the
Alma Ata Declaration, Primary health care: “relies, at local and referral
levels,
on health workers, including physicians,
nurses, midwives, auxiliaries and community workers (applicable), as well as
traditional practitioners as needed, suitably trained socially and technically
to work as a health team and to respond to the expressed health needs of the community”. “Health services, no matter how efficient,
cannot change the condition of the marginalized people unless they are helped
to become self-reliant and the root problems addressed. People who are poor and
illiterate are like uncut gems hidden under the dirt and stone. Given the opportunity,
they can reach their full potential and live as responsible, sensitive human
beings, possessing self-reliance and the liberty to shed those old customs and
traditions that impede health and development.” Arole and Arole, 1994
Health
programmes today often identify empowerment rather than participation as an
objective. Empowerment can be defined as the process and outcome of those
without power gaining information, skills, and confidence and thus control over
decisions about their own lives, and can take place on an individual, organizational,
and community level. Community mobilization, by it definition, is a way to
support this empowerment process and reach this empowerment outcome. All the successful projects like; Nepal,
Jamkhed etc. have the component of ‘capacity building’. Also, the choice and the voice of the community
people must be empowered. Community members should be able to talk with an
action following their voices when they decide how their health centers should
be. Their opinions should be highly respected.
·
Action
2: Health Financing
The importance
of health financing at the country level to the community level cannot be over
emphasized. A good financing system is
however essential for effective and efficient delivery of primary health
care. Health
financing policies from the perspectives of the basic financing are functions
of collecting revenues, pooling resources, and purchasing services. It evaluates these
functions for their capacity to improve health outcomes, provide
financial protection, and ensure consumer satisfaction in an
equitable, efficient, and financially sustainable manner. For primary health
care delivery to function effectively for all, the available scarce resources
should be efficiently distributed.
The
importance of efficient distribution of scarce resources can be seen well
practiced in Brazil health interventions.
The country was known to be a very poor country in the 1940’s and 50’s on the par
of countries in Africa. And during that time it created a special service for
public health that was focused on improving the public health in rural isolated
areas giving priority to immunizations, maternal and child health, and
improving water and sanitation. Their projects clearly demonstrated cost
efficiency. The very sparse distribution of health centers created only had
minimal resources, but is was well administered and the staffs who worked in it
were well paid, it had a good management structure.
Action 3: Health determinants
consideration
The
Alma Ata Declaration in 1978 also illustrated that Primary health care reflects
and evolves from the economic conditions
and socio-cultural and political characteristics of the
country and its communities and is based on the application of the relevant
results of social, biomedical and health services research and public health
experience. Health according to WHO is defined as a state of complete Physical, Mental and Social
well-being and not merely the absence of a disease or infirmity. The Alma Ata
declaration involves, in addition to the health sector, all related sectors and
aspects of national and community development, in particular agriculture, animal husbandry, food industry,
education, housing, public works, communications and other sectors; and
demands the coordinated efforts of all those sectors. Most of the notable
health programs focus on health care alone, leaving behind other health
determinants such as quality water supply, hygiene and sanitation. For an
effective program, inter-sector approach is highly needed. Ministry of health is not the only agency
that should be active in achieving health for all, other ministries like;
agriculture, finance, environment etc. should be effectively involved.
CHALLENGES RELATING TO
THE SPECIFIC ACTIONS
Top
– down approach (hindering effective community mobilization)
Most of the Primary health
care interventions in Nigeria are done without considering the community
members that will enjoy the program; this could be as a result of their selfish
interests. Top-down approach is mostly sought. The governments are the
dictators and they single handedly plan and execute the projects. Asides that, minority
groups in the community can show lack of interest in participating, they might
not be carried along in the project and this could affect the project
sustainability.
Cost
Inefficiency
Ineffective allocation
of resources is a frequent occurrence in most primary health projects. This
mostly accompanies poor management, unclear institutional role. If the management is controlled well, then
will we have efficiency in primary health care programs, we can see a demonstration
of cost efficiency in Brazil intervention where financial resources from
federal, states and municipals are pooled and judiciously used.
Conflict
of interests between sectors
This could be as a result of unclear description
of agencies’ roles. Most agencies do not want to approach health programmes in
horizontal manner but in vertical. For instance, Ministry of Health would want
to claim the superior over ministry of agriculture when talking about tetanus
eradication, forgotten that the bacteria that cause tetanus, Clostridium tetani, are
found in soil, dust and animal feces. They should work together on the same
level.
In
conclusion, the
three specific actions and three specific challenges identified
above can make or mar the achievement of Health for All through Primary Health
Care but it is not only limited to the factors aforementioned.
REFERENCES
Howard-Grabman L, Snetro G.
How to mobilize communities for health and social change. Baltimore, MD: Health Communication Partnership/USAID,
2003.
Rifkin S, Pridmore P.
Partners in Planning. London: MacMillan, 2001.
Declaration of
Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
Pablo Gottret, George Schieber. Health Financing Revisited A Practioner’s Guide. 2006
Arole,
M., Arole, R. (1994). Jamkhed: A Comprehensive Rural
Health Project (1st
ed.). Macmillan.
.
