Forty years ago, world leaders converged in Kazakhstan to adopt the Alma-Ata declaration which called for all actors – leaders, health sector workers, communities to secure access to primary care as an essential health service. This declaration mobilized leaders around making primary care services available for populations across the world. The principles include: universal access to care, a commitment to health equity, community participation and intersectoral approaches to health.
Forty years later, how are we doing on primary healthcare? Let’s profile Nigeria.
According to the CDC, life expectancy at birth for a Nigerian woman is 54 and 52 for the men. The top ten causes of death in Nigeria are malaria, respiratory infections, HIV, diarrheal disease, road injuries, malnutrition, cancer, meningitis, stroke and tuberculosis in that order. Note that many of these causes of death can be managed and/or their risk significantly reduced through ensuring safe and hygienic living conditions and effective and affordable primary care.
Current estimates are that only about 20% of 30,000 primary healthcare centres in Nigeria are working. Those which work do not have the optimal staff size and capacity, the right equipment, infrastructure and essential drugs. They are not distributed relative to population size or need, and some of them do not have infrastructure as simple as boreholes. Given that urbanization is happening at a rapid rate across Africa and that so many aspects of the urban environment are related to health outcomes in a city like Lagos for example, investments to build intersectoral cooperation, and to ground urban governance in equity and ultimate to improve urban health outcomes for all are still inadequate.
We also need to remember something – most of our people are poor. We cannot change this fact if we do not confront it. As far back as 2009, 53.5% of Nigerians were estimated to be below the poverty line and the World Bank indicates that that number is most likely to have risen given the economic contraction in 2016. It is not the fewest but most Nigerians who can be driven deeper into poverty from having a long-term illness. It is not the fewest but several Nigerians that are living in precarious housing conditions.
So what does this mean? The number of people living in poverty in Nigeria is rising and when this population gets sick, they will not have the only form of care that should have been accessible to them. It is not just poverty as in how much income people have in their pockets, but also their ability to bounce back from challenges. Most Nigerians will be knocked out financially, socially, probably mentally by the toll a bout of illness or another emergency will take on their resources if they even survive it.
It means that we start looking at the data differently. We start breaking it down beyond averages to really see those who tend to be left behind. Sometimes policy is the biggest innovation. Simply having institutional backing for public health and policy incentives for private sector investment in challenges facing the poor will do wonders.
Does this mean we should not invest in frontier ideas not driven by utilitarian ideals? No it does not. But what it means is that for us to make the biggest difference, we need solutions that work for the majority of the people. We need to go back to basics.
Think of a city like Lagos. Just imagine if most of the population who does not own a car can have access to safe transportation and be safe when they walk and cross the road. This means road infrastructure that accommodate those who do not have cars. Streetlights, signs, sidewalks. This means making sure that bikes and buses are safer. This involves making sure that the environment is clean so people don’t contract diseases and increase their risk of cancer simply by breathing and infectious diseases simply by walking. New specialist hospitals are good but imagine if all Nigerians lived in health promoting environments, and close to affordable primary health services, which is what they will need for many of their health challenges anyway.
There is nothing new here and it is perhaps common sense, but this is what we still need in this SDGs era. What do we have to gain from this? We gain a workforce that can get the care they need, return to work and create ideas that will make our countries proud. We reduce the losses to economic productivity due to preventable deaths. We gain a society where people have the resources to bounce back from the vagaries of life – whether it is the loss of a job or a bout of illness. We have children who are set up to succeed instead of hawking on our streets, suffering from malnutrition and being exposed to physical, sexual and psychological harm from living in precarious conditions.
I am not despondent. What use will that be? Besides, in the same meeting a colleague shared a case study of how Sao Tome and Principe, a small African island, was able to improve life expectancy from 47 to approximately 70 years simply by investing in basic health and social needs like immunization, clean water and sanitation. It is doable, but we need to build strong will for it. We need to go back to basics and take our leaders and all actors along with us.