Primary Health Care Under One Roof - An Overview

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OUTLINE Background on PHCUOR Governance Structure Policy Structure The need for PHCUOR Principles of PHCUOR Step by Step Approach for implementing PHCUOR

Background on PHCUOR PHC is the first level of contact of individuals, thefamily and the community with the national healthsystem, bringing health care as close as possible towhere people live and work. Access to primary health care is the foundation ofgood health. Considerable achievements in Nigeria as a result ofimplementation of the Primary Health Care.

Background on PHCUOR Cont. There has been systemic weaknesses due to gapsranging from infrastructural decay, inadequacy inhuman resources, essential drugs and other supplies The existence of a well-functioning health system anda timely access to services is critical for attaining UHC. Unsatisfactory governance system stands out as amajor constraint that has continued to undermine thedelivery of primary health care.

Background on PHCUOR Cont. Though some challenges have been blamed onlack of effective governance system, much has todo with poor management, especially in theorganization of PHC at the state and LGA level &the difficulties faced in translating PHC principlesinto practice. Significant challenges continue to exist despiteseveral laudable initiatives, including inequity inhealth care delivery.

GOVERNANCE STRUCTURE Nigeria operates a Three Tier Health System in a Federal SystemStrong Central Federal Government : Responsible forTertiary Health Care & Elements of PHCStrong State Governments: Responsible for SecondaryHealth Care & PHC manpower developmentState PHC Agencies: Now on board, pushing PHCUORRelatively Weak Local Governments: Responsible forPHC Service DeliveryPolitical Ward: Organisational unit for PHC Delivery

POLICY STRUCTURE The National Health Policy still identifies PHCas the corner stone of National Health System. National institutions such as NPHCDA, andcurrently, the SPHCDAs have been establishedto translate policies for PHC into action Various national strategies/plans such NSHDPhave been established over the years.

NEED FOR PRIMARY HEALTH CAREUNDER ONE ROOF (PHCUOR) Weak Governance and management structures, invarious aspects of the health system, especially in theorganization of PHC at the State and LGA levels. Concept of bringing “Primary Health Care Under OneRoof” (PHCUOR) was introduced to improve theimplementation of PHC. An integrated approach using the principles of oneManagement, one Plan and one Monitoring andEvaluation.

PHCUOR Cont. PHCUOR policy was based on resolution 29 of the 54thNational Council on Health meeting of May, 2011. It is also backed by the National Health Act of 2014. Under this policy, states are to establish anadministratively autonomous and self-accounting PHCBoard/Agency (SPHCB) to manage PHC. States/LGAs to fast-track the organization of LocalGovernment Health Authorities (LGHA) to managePHC.

Principles of “PHC Under One Roof”. The "PHC under One Roof" is modeled onguidelines developed by the World HealthOrganization for integrated district-basedservice delivery and on the following keyprinciples:1. Integration of all PHC services deliveredunder one authority, at a minimum consistingof health education and promotion, maternaland child health, family planning,immunization, disease control, essential drugs,nutrition and treatment of common ailments.

Principles of “PHC Under One Roof”Cont 2. A single management body with adequatecapacity to control services and resources,especially human and financial resources. Asthis is implemented, it will requirerepositioning existing bodies.3. Decentralized authority, responsibilityand accountability with an appropriate“span of control” at all levels. Roles andresponsibilities at the different levels willneed to be clearly defined.

Principles of “PHC Under One Roof”Cont “three ones”: onemanagement, one plan and onemonitoring and evaluation (M&E)system.5. An integrated supportive supervisorysystem managed from a single source.4. Principle of

Principles of “PHC Under OneRoof” Cont 5. An effective referral systembetween/across the different levels of care.6. Enabling legislation and concomitantregulations which incorporate these keyprinciples.

“All PHC-related Functions under one roof”SPHCB maintains and coordinates allPHC activities in the StatePHC Services Coordinates plansbudgets andmonitors all PHCservicesHuman Resources Recruits, disengages,promotes, disciplines,transfers and retiresall PHC staff Pays salaries andallowances of all PHCstaff Maintains personnelrecords of all PHCemployeesNPHCDA - Making Nigerians Healthy.PHC advisoryservices Advicescommissioner andlocal government onall mattersconcerning PHC


STEP BY STEP APPROACH FOR THEIMPLEMENTATION OF PHCUOR Step 1: Establishment of a TechnicalCommittee for PHCUOR: PHCUOR likeany other health sector reform requires amulti-stakeholders buy-in and strongpolitical will.

STEP BY STEP APPROACH Cont The committee should includerepresentatives of government Ministries,Departments and Agencies (e.g. SMoH,MOLG, LGSC, MOF, MOJ, State CSC,MOWA); legislators; LGA council chairmen,council and management; partners, CBOs,professional groups; traditional andreligious leaders; private healthprofessionals

STEP BY STEP APPROACH Cont Step 2: Advocacy, stakeholders’engagement and building strongconsensus around PHCUOR: Keystakeholders to be consulted about the planto consolidate PHC structures anddecentralize roles.

STEP BY STEP APPROACH Cont Policy dialogue involves workshops,meetings, retreats, study tours and one-onone dialogue to discuss existing situation ofPHC and advocate for reform options - frankdiscussions to ensure sound reasoningtowards any consensus that will be reached.

STEP BY STEP APPROACH Cont Step 3: Establishment of a technicalsubcommittee to draft the SPHCB bill, facilitateprocess of passage into law, assent by theExecutive Governor and publishing of its gazette.:This subcommittee should include those technicallyskilled in drafting of health legislation and those witha sound knowledge of the PHCUOR policy. Although,a subcommittee of the technical committee to bringPHCUOR, the ministry of justice and healthcommittee of the state house of assembly can providevaluable inputs.

STEP BY STEP APPROACH Cont Step 4: Development of SPHCB Regulations,Policy Document and Annual Work Plan: It isessential for the SMOH to develop regulations thatwill enhance the effective implementation of the law.Regulations provide less legal jargon of the law formanagers and staff to read, understand, and follow.When setup, the SPHCB management team can thendevelop its policy documents including annual workplan, implementation and monitoring systems toguide its operations.

STEP BY STEP APPROACH Cont Step 5: Establishment of SPHCBGoverning Board and ManagementTeam: The establishment of the governingboard and management team is under thepurview of the governor however, there arealways vested interests which must betactically guarded against.

STEP BY STEP APPROACH Cont Step 6: Reposition MDAs to transfer PHCresponsibilities in the State to SPHCB:The SPHCB takes over all responsibilities forPHC service delivery in the State. It isessential to reposition the SMOH, bycollapsing its existing PHC department andall programmes into the SPHCB.

STEP BY STEP APPROACH Cont Similarly, all PHC related functions in theState Ministry of Local Government andLocal Government Service Commissionshould be transferred to the SPHCB. The LGA PHC department becomes theLGHA in line with the PHCUOR Agenda.

STEP BY STEP APPROACH Cont Step 7: Allocate well-equipped officebuilding at State capital and all LGAs forSPHCB and LGHAs respectively. Releaseof take-off grant for the SPHCB: The Stategovernment should adequately equip theSPHCB and LGHAs to commence theirduties.

STEP BY STEP APPROACH Cont Well-equipped office building and a take-offgrant should be provided for theiroperations at the State and LGA level.Systems for managing staff and assetsshould be developed to ensure smooth andsustained growth and development of theSPHCB.

STEP BY STEP APPROACH Cont Step 8: Establishment of LocalGovernment Health AuthorityManagement Team and AdvisoryCommittee: The Governing Board andManagement Team of the SPHCB shouldestablish Management Teams and AdvisoryCommittees for all the LGAs.

STEP BY STEP APPROACH Cont The key principles for establishing theLGHA are single lines of accountabilitybetween this level and the SPHCB, wellestablished accountability lines upwardsfrom LGHA to SPHCB, creation of LGHAstructures.

STEP BY STEP APPROACH Cont Step 9: Build Capacity of GoverningBoard and Management Team of SPHCBand LGHAs: It is also critical to build thecapacity of new managers in the system onPHCUOR policy, guidelines and their newroles.

STEP BY STEP APPROACH Cont A structured management capacity buildingprogramme needs to be developed andimplemented - Guideline on PHCUOR, TheNational Guidelines for Development ofPrimary Health Care in Nigeria (PHC GreenBook) are readily available resources apartfrom other resource materials that focus onspecific capacity in systems management ina decentralized setting.

STEP BY STEP APPROACH Cont Step 10: Orient and ReorientStakeholders and SPHCB/LGHA Staff onPHCUOR Policy, new roles andresponsibilities: As proposed PHCUORreform begins to produce a unified anddecentralized PHC system, more attentionshould be shifted to improving PHC servicedelivery.

STEP BY STEP APPROACH Cont This attention should focus on theorientation and reorientation of key policymakers and managers from the MOH,MOLG, SPHCB and LGHA staff, stateassembly and other PHCUOR 'champions'of the reform system to deepen theirunderstanding and practice of the PHC lawand regulations.

STEP BY STEP APPROACH Cont Step 11: Adoption and Utilization of theWMHCP approach: A key technical step is forthe new SPHCB management team to focus onimproving PHC services. The Ward MinimumHealth Care Package (WMHCP) approach isappropriate step towards achieving this andguidelines for its implementation are available asresource materials from the NPHDCA and theNHAct.

Conclusion THANK YOU

GOVERNANCE STRUCTURE Nigeria operates a Three Tier Health System in a Federal System Strong Central Federal Government : Responsible for Tertiary Health Care & Elements of PHC Strong State Governments: Responsible for Secondary Health Care & PHC manpower development State PHC Agencies: Now on board, pushing PHCUOR Relatively Weak Local Governments:

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