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Roles of PHC and Community Health Workers in Universal Coverage

By Abu Menyanga

The development of people oriented health care system in Nigeria started as far back as 1976 through the development and introduction of Basic Health Services Schemes (BHSS) . This scheme i.e. BHSS seemed not to provide that health care services that meet the health needs of the population. Following the Alma Ata declaration of 1978, Primary Health Care (PHC) system was adopted as a strategy to bring health care services closer to the people at the grass root levels and rural communities. The concept of PHC is promotive, protective, preventive, curative, restorative, and rehabilitative to every citizen of Nigeria within the available resources. The components of PHC are immunization against major infectious diseases, health education and community mobilization, maternal and child survival including family planning, nutrition, prevention of non-communicable diseases, and control of communicable diseases like malaria, TB, STI and HIV/AIDS, safe water and basic sanitation, treatment of diseases and injuries, promotion of oral health and programs on maternal health, provision of essential drugs and other health commodities and prevention and control of local epidemics and endemic diseases.

 The Nigeria health system, as it is and has been, is networked between primary, secondary and tertiary health services featuring many partnering actors. The PHC is the largest in terms of its policy scope and coverage, expected to provide preventive and basic health care services for about 70% Nigerians residing in the rural and semi-urban areas. The goal of PHC is to improve and ensure sustainable health care services with full and active participation of people at the grass root level – rural community -. Community as we all know plays important role in the production and consumption of health care services. Community system is complimentary to and closely connected to health system and care services delivery. Advocacy, community mobilization and sensitization, accountability, demand creation and linking community to appropriate health care services plays key roles in health promotion and delivery as well as in monitoring health system for equity and quality of services. Strengthening community system will no doubt promote the development of informed, supportive- community and community-based structures that enable them to contribute to longer-term sustainability of health programmes and other interventions at the community levels.  PHC is the main entry point into the health care system by the rural communities but today it is characterized by inadequate human resources, poor infrastructures and insufficient supply of equipment and essential drugs and health commodities. The provision of health services at the PHC level is largely the responsibility of the LGAs with the support of state ministries of health and within the overall national health policy.

 Today the state of PHC facilities across the country is that of understaffing with obsolete, decayed and outdated materials and structures. A visit to some of the PHC facilities will make one sad and weep for Nigeria Health Care System as most of them are overgrown by weeds and grasses, infected with reptiles and pests.  Those that seem alive lack staff, drugs and other health commodities as such no community patronage. As earlier mentioned, functional PHC facilities are crucial to the achievement of universal health coverage. The achievement of universal health coverage (UHC) in Nigeria is hinged on the availability and consumption of quality health care services especially at the peripheral health care – PHC -.  The achievement and non-achievement of UHC lie at the PHC door- steps because PHC is the strategy that brings health care services closer to the masses in the rural communities housing over 70% of Nigeria population. The introduction of midwives services scheme (MSS) at primary health care facilities across the country sometimes ago was a good development towards reducing maternal and child mortality. But then what happened to this programme, I still insist that this programme should be strengthened and given a face lift. Improving maternal health and reducing the maternal mortality rate at the grass root level is surest means of improving children’s and the family health in general because women are the first-line providers of care within the family and the key to human development and well being.

The primary health care development agency, in order to strengthen and bring health care services closer to the rural community for the achievement of UHC should as a matter of urgency develop, popularize and strengthen the concept of ward health system (WHS) within the domain of the PHC system. This is because the ward is more homogeneous politically and could create ideal opportunity for co-operation between people in laying the foundation for strong PHC system. The concept of WHS is to improve and ensure sustainability of PHC services with full active participation of the people at the grass root level for the achievement of universal health coverage.  The ward health system (WHS) should be well defined and designed to strengthen the PHC and address causes of previous failures in the designs and operations of a functional PHC system.

Community health workers (CHWs) on the other hand are a crucial link between communities and formal health systems. They are trusted members of their communities who are well trained on how to care for the sick with supervisory support and linkages with formal health centers for referrals. CHWs are the foundational first tier of the health system. They were called foot doctors by China in the era of Chinese poor health status – in the 30s when China was called the weeping child of Asia. The introduction and implementation of the foot-doctors (CHWs) scheme by China led to significant improvement in their alarming health indices. Today Chinese health story has become a model to study. CHWs, if well positioned can work across sectors, connecting efforts in health to those in education, agriculture, transportation, water, sanitation and governance. If the CHW health scheme is well designed and managed, it can cover the health care service gaps that stubbornly persist across socio-cultural and rural settings in Nigeria. CHWs training should be tailored towards performing tasks to underserved communities and the homebound by effectively relaying health information through local languages and culture and working where they live. These community-based health workers can provide access to preventive, curative, rehabilitative, basic health education, family planning services and palliative care to rural communities if well positioned. They can ensure that children are immunized and women deliver in the presence of skilled birth attendants, treat common ailments and also provide a link to health facilities to facilitate the continuum of health care services.

Effective and functional CHWs programme can serve as a good tool for monitoring maternal, neonatal and childhood development because they (CHWs) who speak the local language and identify with the local community can easily follow-up women during pregnancy, delivery and the postnatal period.  Properly trained, equipped, empowered and supported CHWs can take on a range of tasks that otherwise depend on mid-level health workers. They stand to enhance community access to health services and promote people’s trust and demand for such services as well as helping service users avoid trips to far-to-reach health facilities, which translates into saved transportation costs and time. Effective CHWs scheme as integral members of the health team can go beyond the provision of health care services to foster community-based actions. As the MDG era has come to an end and a new era focusing on UHC begins, Nigeria has a unique opportunity to develop implementable CHW programme that will create lasting health improvements. By supporting relevant stakeholders committed to scale-up of CHW programme in the context of primary healthcare systems, the CHW scheme can significantly improve access to essential health services for the rural dwellers in Nigeria. It is expected that this will significantly cut down the burden of disease in the country. It is important to point out that CHWs should not however be left to serve on their own but rely on both the community and the formal health system for supervision, supplies, communications and referrals so as to avoid  the temptation of creating a monster vertical programme that neglects broader human resource for health. CHW subsystem should be implemented within broader strengthening of human resources for health that emphasizes effective collaboration among all cadres of health workers and never a replacement for highly skilled health workers but can complement them in order to make quality healthcare available to people at the grass root levels.

Strengthening the linkage between PHC and community health workers will no doubt scale up universal health coverage. If the PHC facilities and community health workers across the country are given proper orientation, strengthened, trained and empowered enough to provide quality health care services to meet the health needs of the masses at the grass root level where 70% of Nigeria population resides, there will be no doubt that universal health coverage could be achieved to a measurable level. Such achievements will positively affect the level of productivity and other economic activities that could raise many above the poverty line.  Functional primary health care (PHC) facilities with well trained and empowered community health workers are the hubs of health care services at the peripheral level of health care – grass root level – where over 70% of Nigerians resides. The synergy of PHC activities and CHW services are crucial to the achievement of UHC, so all efforts should be directed at strengthening them whatever the cost in the country.

• Menyanga Abu is an Abuja-based Development and Health and System Consultant.

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