How primary health systems can help Nigeria’s fight against coronavirus

While the Nigerian government has been shuffling various strategies to curtail a catastrophic outcome from the coronavirus pandemic, it has failed to chart a clear role for the Primary Health Care (PHC) level of the health system, health experts have said.

Despite President Muhammadu Buhari’s approval of a gradual easing of lockdown measures in the capital, Abuja, Lagos and Ogun states from Monday, Nigeria’s COVID-19 ordeal is still unfolding and its eventual casualties remain unknown.

The number of infections has been increasing exponentially – from one case in Lagos on February 27 to more than 2,000 as of Saturday morning, after the Nigeria Centre for Disease Control (NCDC) reported 238 new cases on Friday night, the nation’s highest daily tally.

The federal government’s plan relies heavily on ramping up its daily testing and tracing of contacts, expanding the capacity of isolation and treatment centres with sustained training and protection of frontline health workers.

Though these measures have proven critical, the Partnership for Advocacy in Child and Family Health at Scale (PACaH@Scale) in a statement on Thursday said the PHC facilities have been “under-emphasised and relegated to the background in the scheme of things.”

It said the current approach highlights how much the primary healthcare system has been neglected even though it is considered the first line of defense during pandemic outbreaks by the World Health Organisation (WHO).

This can be largely attributed to the multiple challenges with Nigeria’s PHC system but PACaH@Scale, a leading health advocacy group believes Primary Health systems still have an important role to play.

“While infectious disease control requires highly specialised interventions with facilities removed from communities there is still an important role for PHCs in infectious disease prevention,” the statement said.

“Primary Health Care centres in Nigeria, even if equipped poorly, are the hub for healthcare in the community and well positioned as the primary point of care under the Primary Health Care Under One Roof (PHCUOR) National Policy. The fight against Covid – 19 should not be one which trades off PHCs against a specialised and central command system of service delivery.”

Four point agenda

Below is a four-point agenda on how the PHC system can help in the fight against COVID-19, according to PACaH@Scale and a coalition of other 24 Civil Society organisations on public health:

1. The Government of Nigeria and the National Centre for Disease Control (NCDC) in particular, should pivot and leverage PHCs as centres for community-based trainings and sensitisation engagements on hand washing and behavior change communication on social distancing for local communities, especially in rural geographies.

Under the PHCUOR National Policy, the PHC health system has already been entrusted key social and behavioral change communication roles in areas of nutrition, polio and routine immunisation as well as prevention of diarrhea and pneumonia of infants and children. In regions with limited access to the internet where videos of hand-washing can be demonstrated, PHC staff are well placed to demonstrate proper handwashing and social distancing protocols.

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2. Across Nigeria’s 36 states and in the FCT, PHCs are struggling to respond to the demands of the National and State Primary Health Development Agencies to continue providing services. Experiences from the Ebola outbreak in West and Central Africa provide the evidence base for not disrupting PHC services during an epidemic outbreak and no doubt underpin the expectation of the National and State PHCDAs.

The enlightenment campaign of the National Primary Health Care Development Agency (NPHCDA) to reassure all Nigerians that PHC services will continue must be seen in this light. PHCs struggling to provide services for a mass clientele during this hot season or routine immunization services are in dire need of clear guidelines of how to remain active while not inadvertently spreading COVID-19.

As the hot season approaches many states are coordinating Meningitis vaccinations programs within the PHC system; routine immunization has not stopped; women are giving birth; and research is being conducted in states with where new Vaccine-Derived Polio Virus type 2 (cVDPV2), cases have emerged. While PHCs are providing on-going public health services a strategic opportunity is being missed to incorporate COVID-19 protocols in their on-going services. Therefore, if PHC services are to remain undisrupted, critical questions must be asked about whether state governments have provided enough Personal Protective Equipment (PPE) to staff and whether they have received updates in hand-washing protocols?

3. Nigerian civil society community have been grumbling their under-presentation in National and State governments COVID-19 situation rooms and coordination points. They ask – “where are the Market Women Associations? Where are the health professional associations? Where is the Guild of Nigerian Actors? Where are representatives of Nigeria’s numerous religious and traditional leader’s councils in these coordinating agencies and situational rooms”? Maybe if they sat in situation rooms our Imams and Pastors would not continue to curate their flock for religious worship and our Actors and Actresses will realize the seriousness of COVID-19 and lend their voice to the campaign. While we agree that Infectious Disease health professionals must take the lead in testing and treatment; and that Epidemiologist are vanguards for contact tracing, there is also an important role for civil society groups to mobilize communities for behavioral change to prevent the spread of the virus.

The PHC level provides an effective opportunity to engage civil society groups, including traditional and faith leaders and their communities of faith at the local level. Traditional/Religious leaders served as gatekeepers, key influencers, and guiding voices to most Nigerian communities. PHC centres can and should be positioned to serve as the NPHCDA/SPHCDA and the NCDC agents for interfacing with the Traditional/Religious leaders with regularity to support the process of community engagement, contact tracing, and subsequently, referrals and reporting back to the NCDC.

Despite their well-known limitations, one critical success factor of PHC centres all over Nigeria is that they have well-established lines of coordination with community-based associations, traditional and faith leaders on issues related to disease outbreaks, to complaints of poor service, to social welfare for indigent patients. This asset can and must be pivoted and leveraged in the fight against COVID-19.

4. The government’s initiative to recruit 774,000 new sanitation officers in the fight against COVID-9 is commendable and has great potential for readdressing falling sanitation and hygiene standards in our over-crowded and infrastructure overburdened urban, peri-urban and rural centres across Nigeria. For hand-washing to be effective in the fight against COVID-19 there must be water; for water to be utilisable; it must be clean; for the 774,000 new sanitation officers to fulfill their role; they must be anchored within a PHC system. Within the PHC system their knowledge and skills will be stepped-down and reinforced. Water, Sanitation, Hygiene and Health are all interlinked and should not be separated in the fight against COVID- 19.