Rural health in Nigeria, reality or mirage?

Lack of access to primary healthcare remains the bane of Africa’s healthcare delivery system. In this report by Sade Oguntola, experts say ensuring access and affordable primary healthcare requires much more than funding.


Primary healthcare (PHC) refers to “essential health care” that is based on scientifically sound and socially acceptable methods and technology, which make universal health care accessible to all individuals and families in a community.

A strong, accessible PHC system reduces pressure on hospitals by supporting people to manage their health issues in the community. It is the cornerstone underpinning population health outcomes and key to ensuring we have a high-quality sustainable health system into the future.

Yet, despite its critical importance, decades after PHC was accented to in Nigeria, many challenges had made it fail in tackling the “politically, socially and economically unacceptable” health inequalities, especially at the rural communities.

Improving the rural healthcare was the thrust of the 30th memorial of Chief Obafemi Awolowo organised by Dideolu Specialist Hospital, Ikenne and held at his Ikenne residency. It was sponsored by Obafemi Awolowo Foundation.

Chief Obafemi Awolowo believed that the state should channel Nigeria’s resources into education and state-led infrastructural development; hence he introduced free education for all as well as free health-care in the Western region to cater for the health needs of the people. He believed that a healthy man or woman will contribute positively to the development of the region.

Having a rethink on the state of PHC, Dr Olatokunbo Awolowo Dosumu, Executive Director, Obafemi Awolowo Foundation and Vice Chairman, Dideolu Specialist Hospital said was critical since rural dwellers still constitute a significant percentage of Nigeria’s total population and their access to quality healthcare must be a concern to all stakeholders.

Is PHC clearly understood by those working outside the system? “Chief Obafemi Awolowo’s concept of free health was misconstrued and misunderstood by the government after. The slogan was lashed on, but consideration was not paid to the structures that could make it work,” said Professor Temitope Alonge, Chief Medical Director, University College Hospital (UCH), Ibadan, Oyo State.

As designed, the primary health care system was the responsibility of the local government, but the Federal Government had picked up its responsibilities alongside tertiary healthcare delivery.

According to Professor Alonge: “Now, the tertiary health institutions are bugged down by health problems like uncomplicated malaria that the primary and secondary healthcare levels were supposed to look after rather than the tough cases.”

Professor Alonge, however, suggested making all tertiary health facilities adopt PHCs to ensure they could provide quality services and improve people’s access to care in the locality.

“If every tertiary hospital can be mandated to adopt at least 10 PHCs, they will then be responsible for their growth and ensure their manpower oversees what goes on in these PHCs,” he declared.

Given the importance of having medical officer of health, environmental health officers and health councillors for a functional Primary Healthcare delivery, Professor Alonge suggested the Federal Government adopting medical doctors under the National Youth service Corps as medical officers of health in all the local government areas to improve healthcare service in the rural areas.

According to him, having a full complements of medical officer of health, environmental health officers and health councillors to do the job will avert many epidemics, like cerebrospinal meningitis before they become  disastrous.

A functional PHC, however, is only achievable with proper and adequate funding. “We have given the biggest part of the healthcare delivery that most Nigerians need to the weakest level of governance. The best of time we have ever had for PHC in Nigeria was when Professor Olikoye Ransome Kuti decided to invest Federal Government’s resources in PHC,” said Dr Babatunde Ipaye, Ogun State Health Commissioner.

A situation, where Nigeria invests about 120 dollars per capital per annum to its health system notwithstanding its huge population of about 200 million, and expects similar results like South Africa that does 558 dollar per capital per annum, is not realistic.

Nonetheless, what needs to done differently to improve rural healthcare, he said was community health insurance. According to him, “About seven per cent of healthcare spending in Nigeria is out of pocket spending. So what we need to do is to have a mechanism that pulls household resources  so that this can be used to help finance health properly.”

A dysfunctional local government system, however, Emeritus Professor Theophilius Ogunlesi noted will continue to deprive people of good rural health services.

Aside many people lacking proper education on issues that can affect their health such as okada riding, Professor Ogunlesi said improving rural health would also require taking healthcare to the door step of rural dwellers as well as improved infrastructure in our communities.

A rural health care delivery that does not take care of children and elderly, a group most vulnerable to illnesses, Professor Tanimola Akande, a community health physician from the University of Ilorin, opined would not be efficient.

Also, Professor Akande said attention would also need to be given to traditional cultural practices that make it difficult for rural dwellers to seek health care.

Ensuring philanthropists and non-governmental organisations support rural dwellers to access community-based health insurance, he said is equally important.

He stated: “People opted out of the Kwara State Community-based health insurance scheme that was funded by Netherlands when they were required to pay N500 rather than N200. Some cannot afford to pay N500.”

Professor of Community Medicine and Public health, University of Benin, Obehie Okojie stressed the need for inclusion of rural training in curriculum of doctors-in training to prepare them for provision of medical care, especially in the rural areas.

Taking healthcare to their doorsteps rather than remaining in the built PHC centres, Professor Okojie, said will make primary health care functional and take care of more than 60 per cent of ill health problems of people in rural communities.

In her submission, head, Department of Community Health and Primary Care, University of Lagos, Professor Olayinka Abosede said challenges of PHC, even after many years, had remained poor political commitment, non implementation of many health policies, dearth of health workers, lack of two-way referral system, and non-implementation of the National Health Act.

“Funding the PHC would continue to be a challenge if we do not tap into the National Health Act that was signed into law in 2014. It is the way forward,” she said.

Also, Dr Doyin Odubanjo, Chairman, Association of Public Health Physicians of Nigeria, Lagos Chapter, stated that ensuring a functional PHC in Nigeria is achievable considering the political support seen in the fight against Ebola.