Primary health care is the first level of healthcare that forms the foundation for the formal health care system. Provision for this can be through a variety of settings from community clinics to private practices. Primary health care helps to promote health and prevent illness. It also helps to identify, treat, and refer patients to specialists when appropriate.
What is primary health care?
The term “primary care” is mainly used in the UK and North America to describe medical care or family practice. In our part of the world- Nigeria to be exact, we adopt the wider definition of primary health care. We define healthcare as determinants of health that play an important role in the provision of services.
Primary health care is a “whole of society approach to health and well-being, centred on the needs and preferences of individuals, families, and communities. It addresses the broader determinants of health and focuses on the comprehensive and interrelated aspects of physical mental and social well-being” WHO 2019.
The importance of primary health care
According to the World Health Organization, primary health care can address most of an individual’s health needs throughout their life. This includes prevention, treatment, rehabilitation, and palliative care. With proper usage, primary health care is also able to provide empowering education. This ensures that people are able to take timely health-related decisions about themselves and their family members. Also, it reduces deaths and disability.
Universal Health Coverage-UHC- simply means that all people have access to the health services they need. This includes prevention, promotion, treatment, rehabilitation, and palliation without suffering financial hardship.
Ensuring access to primary health care in Nigeria, therefore, is the way to ensure that as a nation, we achieve universal health coverage.
Primary Health Care in Nigeria
Both private and public (Government) health care providers give health care services. Access to most healthcare services in Nigeria is often through the private sector, and this applies to primary healthcare services as well. Unfortunately, most Nigerians still fail to access primary health care services.
The prevailing issue is the lack of access to finance and the cost barrier they perceive. Other reasons include distance, lack of awareness of the availability of services. On the supply side, the reasons are the attitudes of healthcare workers and poorly equipped facilities or the legacy of these which does not make it easy to trust.
However, primary health care is the least expensive form of health care and can defray significant costs. This is because it provides community-level screening, health education, and prevention advice at a significantly lower cost than, for example, a hospital will give.
Primary health care as a means of prompt intervention
Primary healthcare also allows for prompt intervention in cases with fewer complications that present early due to good health-seeking behaviour on the part of the patient. One way many Nigerians have received primary healthcare services involves outreach healthcare. Although this may have been a contribution to our collective poor health-seeking behaviour. The reason is that most of the time, we do not accompany outreaches by appropriate follow-up.
Outreach health services are successful at getting people to access services on one or perhaps, several occasions. Provision for these services is best in rural locations where geographic access to healthcare services is an issue. This is in opposition to our more usual practice of outreach services in towns and cities where health facilities are available within a relatively shorter distance.
Why are outreach services provided in rural areas?
We make provision for outreach services to people in rural areas because proximate services are not available, and we want to ensure they get those services. Although it is advisable that permanent structures and locations for healthcare replace this. When outreach is practised in rural areas, we send the message that they are an alternative to existing services.
This has shaped the behaviour of some urban dwellers who consider this as a sustainable means of accessing healthcare. Thus, outreach has done great damage to the concept of continuity of care. This is an important component of primary healthcare service provision but we often ignore it. Especially in pregnant women, newborns and young children, adolescents, and people with chronic diseases. Or people at risk of developing the same.
Effectiveness of outreach services in rural areas
Everybody in the population would significantly benefit from continuity of care. Importantly, the opportunity to provide continuing care that they can trust is lost when we “helicopter in” and provide some services. We do not emphasize the need for follow-up or provide referral services.
We also lose the opportunity to address the ongoing critical needs of adolescents and the elderly who will not or cannot go to an open outreach event. For this set of people, we need to carefully curate primary care services.
Inadequacy of primary health care in Nigeria as exposed by COVID
Overall, the gaps in primary healthcare service provision became obvious during the early days of the COVID pandemic and the ensuing lockdown. Patients could not access their usual healthcare providers. They could not reach them via telemedicine or telephone. Many had emergencies but were also afraid to go to the hospital. With the exception of a small number of facilities, most patients were unable to get answers to their questions.
This was especially evident and alarming for women receiving antenatal care and infants who could not get their immunizations. If primary health centres had already been established as medical homes, connections, and relationships, things might have been different. It is very likely that we would have been able to manage medical emergencies and urgencies better. People would not have become as anxious as they did during the lockdown.
In a post-pandemic world, how might primary healthcare evolve in Nigeria?
Looking forward, the post-pandemic outlook for primary health care in Nigeria could be a net positive.
It became apparent during the lockdown that there's a need for people to have a “medical home” they can trust. Somewhere their history was known and their medical needs coherently documented. A place they could call to ask questions and receive telemedicine support.
The fall out of the pandemic on primary healthcare could therefore be positive. It could result in more people signing up for primary care services. Ultimately, it could lead to health maintenance organizations (HMOs) taking this component of care more seriously.
This is because the overall effect on primary health care would be progressive as outlined below.
Benefits of post-pandemic primary health care evolution in Nigeria
1. Opportunity to engage more primary healthcare providers
Health Maintenance Organizations (HMOs) and sub-specialists who would benefit from earlier referrals and a wider pool of referrals should seize the opportunity. They should see this as an opportunity to engage more primary healthcare providers. This would drive down costs as well as improve outcomes. With the increase in need comes the additional need for timely appointments to reduce the overcrowding of clinical facility waiting rooms.
2. Increase in uptake of digital health and digital health platforms as telemedicine is embraced.
An example is the explosion of chat groups that focuses on specific health education to support pregnant women and mothers of young infants through a most turbulent period. In order to always ensure access to healthcare providers, many more digital health platforms have doctors available at the click of a button.
Our pre-pandemic approach to primary healthcare with crowded waiting rooms, megaphones, and crowds for public education, has to change. We can no longer safely convene crowds in the post COVID world.
Existing solutions include one-on-one care and education, virtual consults using telephones and video calls, and other digital health solutions. This could include the least formal chat groups which actually allow for many people.
The need for 24-hour primary care facilities remains to be seen. This is because most primary care services involve non-emergent ambulatory care which can be provided during daytime hours. This will reduce overheads and the cost of care by eliminating overnight power and staffing costs.
Nurses and community health officers can also make provision for staffing for primary healthcare depending on locale and availability of providers. Home-based primary care may also soon be possible – at a premium, supported by easy to deploy handheld tools and technology. This will allow for virtual visits or concierge services.
Primary care infrastructure will likely change, and it is important for state governments to consider policy flexibility. This is in a bid to accommodate these expanding opportunities for primary care. Some of which are already adopted, tested and trusted in other parts of the world. And some of which we, in Nigeria, would be at the forefront of innovating.
What's the way forward?
Undoubtedly, there remains room for face-to-face primary care visits, because babies still need to take their immunizations. Also, there's a need to carry out screenings for early intervention purposes. The options available to us today indicate that healthcare providers provide these specific services.
However, there are new opportunities to infuse some other elements of care into the basic care interactions of primary health care in Nigeria. We are poised to test some of our assumptions and interrogate some of the possibilities that the pandemic has thrown up. This includes scheduled visits, one on one interactions, anticipatory guidance in young children, co-located screening for mothers and children, virtual consultations, and digital health records.
As some of these have taken off in the private provider spaces, it is also time for us to consider them as possibilities for the public providers' spaces, and it is certainly time for these services to scale.
Dr Orode Doherty writes from Lagos and is the Founder of Ingress Health Partners, a primary healthcare franchising organization