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Management of Primary Health Care in Local Government in Nigeria

Management of Primary Health Care in Local Government in Nigeria: Between Community and Environmental Health Officers

The term ‘Primary Health Care’ was used to mean the care given to the patient by the health worker who saw him first. It was also called ‘first contact care’; but if the patient was referred to the hospital it was called ‘secondary care’.
Following this in May 1978, an international conference was headed by World Health Organization [WHO] member states in town in former USSR [now Russia ] called Alma-Ata , where 134 nations including Nigeria declared that Primary Health Care [PHC] is the key to attaining health for all.
At the conference, it was agreed and concluded that Primary Health Care [PHC] is essential health care made universally accessible to individuals and acceptable to them, through their full participation and at a cost the community can afford [WHO/UNICEF 1978].

Bamigboye [2001] see PHC as people oriented service built on the axiom of health of the people, by the people and for the people, and [Lambo 2005] not perceived as the exclusive prerogative of health professions. Its components include Maternal and Child Health [MCH]; provisions of essential drugs; appropriate treatment of common diseases; prevention and control of locally endemic diseases; food nutrition, dental health; environmental health; and health education.
Any discerning listener will quickly realized that there is more to the issue of interpreting correctly the definition and concept of PHC than its implementation. There are underlying disagreements over how PHC problems are defined, their degree of seriousness, who is responsible for solving them, and how amenable they are to solution.
In Nigeria , every health worker talks about PHC, but if you ask them to define or explain the term, they often offer funny explanations. This shows that as important as the programme is, it is still not well understood even by those expected to plan and implement the programme [Ojewale 2003]. Instead of the stakeholders to work as a team, they tend to fight each other on professional bias.
Recently PHC programme clock 30 years, and Nigeria, under Health Reform Foundation of Nigeria [HERFON] reviewed Nigerian Health [System] Review 2007 titled, ‘Primary Health Care in Nigeria: 30 years after Alma ata’, which according to touches issues as the historical review of the major milestones in the development of PHC in Nigeria from the pre-colonial period to the recent attempts at health reforms; overview of the essential concepts and features of PHC and a review of the major challenges confronting and constraining its implementation in Nigeria; and analyses of the social, cultural, economic and political issues which affect the functioning and performance of PHC in Nigeria and suggests measures for bringing about change and improvement. It also x-rays the challenges presented by human, financial and material resource constraints; weaknesses and deficiencies in specific elements of PHC including services for women and children are examined in several chapters; role of important stakeholders in achieving national PHC objectives; and vital managerial issues which must be confronted if equity, effectiveness and efficiency are to be achieved in the provision of PHC in Nigeria.

Though I do not have the book, but got some information in the HERFON website on the last year review of Nigeria Health Review, this writing will look at one silent issue which is being bypassed and regarded as non issue at all [perhaps it was not touched in the book], which is critical to the success of PHC programme, but inadvertently is adversely affecting the smooth running of Primary Health Care programme at local governments level, which is the backbone of its implementation at grass root level. This issue is non other than professional conflict or bias that is blinding many health practitioners to regard themselves as the alpha and omega in Primary Health care, which if not them no one knows anything. Though this is common [but bad] within health practitioners, nevertheless my main concern here is at the local government level, where the main practitioners that held sway are Community and Environmental Health Officers, with few others.
The conflict is arising over which practitioner [between Community and environmental Health Officers] shall occupy the position of Primary Health Care Coordinator/Head of Department, and the role[s] each should play in the discharge of their duties. These disagreement run deep, they are either based on different professional training, moral principle, or different values, different assumptions and even personal egocentrism. I will use Kano state as a case reference, where these inter-professional conflict is more pronounced, to the extent that some Community Health Officers see Environmental Health Officer as an enemy that must be eliminated or incapacitated and vice versa, so that they alone leads and determine what becomes the priority needs of Primary Health Care at local government level from their professional perspectives. More so, what is happening in Kano is also happening in most or all states of Nigeria . This writing is not done to hurt anybody, but just to raise awareness on the implication of professional conflict of health practitioners toward rendering their services to the public; and it is not an attempt to write what happened since 1978 to date, but to gives an insight of this problem which had shaped and still shaping the way PHC programme is implemented by usinf recent instances.
Before then, let us know who is an Environmental Health Officer [EHO], and the Community Health Officer [CHO], their duties, limitation and others.

Environmental Health Officer

I quoted "Preventing disease through proper environmental management in the 21st century in Nigeria" [2001], published by the then Professional Association of Environmental Health Officers of Nigeria [PAEHON] and now Environmental Health officers Association of Nigeria [EHOAN].
"This cadre of public health workers came into existing during the colonial era, their statutory function was purely sanitary inspection then as sanitary assistants to the colonial masters.
"In the 19th century, the colonial masters who executed the sanitary duties of our environment in Nigeria were known as sanitary inspectors while the African/Nigerians attached to them were known as sanitary attendants. These attendants acted as aides to their masters to discharge various sanitary inspection activities like marking of tall trees, service of abatement notice etc. under their masters’ directives and close supervision.
"As time went on these sanitary attendants were given more responsibility such as routine sanitary inspection, collection of water samples, survey for breeding places of mosquitoes, as well as acting as guides and interpreters.
“During the early 20th century, with improved educational background, these attendants gathered enough experience from their colonial masters, they were assigned duties such as cutting down tall trees that were close to the residential buildings, identification of infectious disease cases, disinfection and disinfestations, liaison between the colonial masters and villagers, verification of notices issued by their colonial masters [sanitary inspectors], retention of daily, weekly and monthly returns.


"Dr Isaac Ladipo Oluwole brought about changes in the status of Nigeria health workers. In the 1920s, when Dr. Isaac came back from Britain as public health physician, he was the first African Medical Officer of Health [MOH] in the Lagos colony. He pioneered with vigour, school health services using the then sanitary attendants, including inspection of schools and vaccination of schoolchildren in their school. He started the first Nigerian School of Hygiene at Yaba Lagos in 1920, where qualified persons from all over the Nigeria trained as sanitary inspectors and obtained the Diploma of the royal institute of health [RIH] London, which was later, changed to Royal Society of Health {RSH} diploma, London.
"The first problem that faced the modern day Nigerian sanitary inspectors as early as the 1920 was the outbreak of bubonic plague in 1924. The professional was actively involved in the control of the plague epidemic. Dr. Oluwole revamped port health Duties and made sanitary inspection a vital instrument for the control of communicable diseases using entirely the Nigerian sanitary inspectors.

"All these brought recognition to the sanitary inspectors among other cadre of health workers in Nigeria . They were referred to as "Wole-wole" among Yoruba’s, "Nwaole-ala" among the Igbo’s and "Duba-Gari" among the Hausas. They were a force to reckon with in that colonial era in the area of preventive health services in Nigeria .
"In the 1930s, the educational qualification and training of sanitary inspectors had greatly improved. Thus, the colonial government assigned them the following statutory functions: routine sanitary inspection of houses, markets, schools and communities; waste disposal and environmental sanitation, pollution control and industrial sanitation; water sampling and sanitation; port health duties [air, land and seaports]; ccontrol of communicable disease [infectious diseases].
Other duties were, building and urban planning; vvector and pest control e.g. Malaria control; pprosecution of public health offenders in the court; meat and food inspection; the disposal of the dead [corpses]; ooccupational health and factory inspection; vvaccination/inoculation of both schoolchildren and adults; and health education on personal and public hygiene was also included.
“The establishment of the World Health Organization [WHO] in 1948, brought about changes in the profession, thus many people with higher educational qualification were recruited into the profession and enhanced curriculum to accommodate the need of the society.
“This was evidenced in their immense role in the eradication of Yaws and Smallpox in the late 1940s and early 1970s respectively.

The 1980- to the present day

“In 1988, the name of the profession was changed to Environmental Health officer [EHO] in line with the internationally accepted name of practitioners of the profession and also to accommodate members of the profession who graduated from the university with a degree in public health, environmental health and epidemiology.
“Apart from the general environmental health duties which had hitherto been mentioned this cadre of officer has been very useful in the implementation of primary health care services in the country at all level of government [federal, state, and local government]”.
There are 3 categories of practitioners within the profession in order of superiority, Environmental Health Officer [EHO], Environmental Health Technician [EHT], and Environmental health Assistant Technician [EHAT], so where I used Environmental Health Practitioners [EHPs], I mean all of them, and or EHO, I mean in particular.
Their work include but not limited to the following; administration, inspection, education and regulation in respect of Environmental health; surveillance over health related environmental conditions, including necessary monitoring activities………; act as a public arbiter of environmental health standard, maintain close contact with community; carry out the well established duties of Sanitarian, including inspection of housing and food hygiene, monitoring and control of new hazards due to intensive industrialization; and application of professional standard in his work in relation to non-professionals involved in environmental health, and relate professionally with other health professionals [Journal of Environmental Health June 2006].
The profession has council that regulates it by virtue of act no 11, 2002.

Community Health Officer

According to The Accessible, the publication of Community health practitioners association of Nigeria , Kano chapter Vol. 1 no 1, the history of community health started around 1943. It continues “A missionary medical officer in western part of the country started training community health personnel in part of Ile-Ife present Osun state to take care of some medical problems of its members in order to augment their man power need”.
Community health practice comes as a result of yawning gap in those that will man the Comprehensive Health centre [CHC], Primary Health Centres [PHC] and Local health Centres [LHC] built during Gen Yakubu Gowon.
At that time an attempt was made to put basic health services in the 3rd national development plan [1975-1980], the aims of the scheme was a], to increase the proportion of the population receiving health care from 25-60%; b] to correct the imbalances in the location and distribution of health institution between preventive and curative medicine; c], to provide the infrastructure for all preventive programme such as control of communicable diseases, family health, treatment of minor ailments, nutritional health and others; and d], to establish health care system best adapted to the local conditions and to the level of health technology.

According to National Health Review 2006, “Under the Plan, each local government in the country was to build 25 physical health facilities consisting of one comprehensive health centre, four primary health centres, and 20 health clinics, as well as own and operate five mobile clinics. Different cadres of auxiliary health workers were to be trained, including four levels or types of generalist health workers (community health aids, assistants, supervisors and officers), as well as laboratory, dental and environmental health workers. However, the Plan became financially impossible and difficult to execute in the different parts of the country”.
The 4th National plan succeeded the 3rd plan, which covered the period of 1981-1985. It was during this during period that health as a sector receives a paltry 5% of the national budget and makes Primary Health Care to at least make an impact. Also, “…… that time, the range and training of the generalist auxiliary community health workers was
reduced to three, the junior and senior categories, the community
health extension workers and community health officers (CHOs).
and many of these were produced……’ [National Health Review 2006].
All these plans and the ones that followed them gave rise to the emergence of community health practitioners in Nigeria .
The community health worker is rural based, as s/he is expected to spend 50% of his time on community based functions and 50% in the clinic.
His/her community based functions are, but not limited to the followings: explain to the community the primary health care approach of the Nigerian health system and his role as a member of the health team to link the community with health care system; carry out community mobilization for health action; participate in, and supervise primary health care house numbering and placement of home-based records; initiate and work with the community and other health workers to carry out general community survey, social and cultural characteristics of the community; and work with other health workers and the community to identify major health problems of the community.
The clinic based functions include: provide integrated primary health care services, collect and collate monitoring and evaluation data for the National PHC from the community and health facility and forward to the district; and carry out day to day administration of health services in the target population.
Right now, there are 3 categories of practitioners in community health in order of superiority, Community Health Officer [CHO], Senior Community Health Extension Worker [SCHEW], and Junior Community Health Extension Worker [JCHEW], all of them are called Community Health Practitioners [CHP]. It has board which regulated its activities under the supervision of department of public health, federal ministry of health, Abuja .

PHC is a programme set to provide health services at the door step of the communities, which encompassed ten components which no any profession [alone] can claim it has the exclusive power or competence to determine who, where and how the programme should run; this is because, among the principles of the programme, there is multisectoral approach, which requires the joint effort of health sector [of which it is an integral part] and other health related sectors, viz education, food and agriculture, social welfare, animal husbandry etc.
But in Nigeria , medical practitioners [precisely doctors] at federal and state levels, and community health practitioners at local governments level regards themselves as alpha and omega of PHC. Anything[s], no matter how good it is, if it does not comes from them or from the perspective they believe, will not scale through, whoever you are, whatever your health qualification, as if you have no input in the programme, whether or not it is within the territory of their professional discipline.
Community health practitioners have been in the forefront at local governments’ level in making sure all other health practitioners are relegated to the background unless you have a certificate in community health course. They are doing all they can, with their collaborators at National Primary Health Care Development Agency [NPHCDA], to stop every health practitioners in becoming Head of Department, Primary Health Care at local government without being a ‘Community health Officer’.
Their effort in making their ambition to be fruitful was further boosted, when NPHCDA compounded the situation by releasing a circular stating those eligible to head PHC departments in local government in Nigeria; the circular was dated 10th August, 2005 with ref no NPHCDA/380 and signed by Dr Shehu Mahdi, the then Executive director. The circular limit those that would be PHC head of department to either be a qualified medical practitioner, qualified nurse/midwife with certificate in public health, qualified nurse/midwife with community health certificate, and community health officer. It also added professionals like environmental health officers, health educators, have a place in the health team but cannot lead the team. This where the partiality of NPHCDA comes, as it considered the other professionals whom are also stakeholders in PHC programme as too inferior to head PHC department at local government.
Kano, considering it has the highest number of environmental health practitioners; the circular can be said has created a crisis which only compounded the already frosty relationship that exists between them and community health practitioners. As at the time the circular was released, some states like Katsina, Edo, etc were said had implement it, and all covert and overt moves are going place in Kano to make sure the enemies-environmental health practitioners are nail and removed, by their supposedly brothers at work-community health practitioners. In fact, Kano members of the later profession went as far as Katsina to jubilate with their colleagues over the new development, and hoping to get the same in Kano .
When the above circular was released, Environmental Health Officers Registration Council of Nigeria [EHORCN]-a regulatory body of environmental health practice, got wind of it; it visited the then minister of health informing him of the development, and the minister claims ignorance, and promised to reverse the circular.
As the above struggle is taking place, Kano community health practitioners were happy and in good mood over the opportunity they have been yearning for long [to push environmental Health practitioners to irrelevancy], now that it is available and emanated from Abuja , they fine tune their strategy to act more aggressively. In fact, they had gone extra mile in preparation to the implementation of the circular by Kano state ministry for local governments, but unfortunately, environmental health practitioners discovered the move, hence they put pliers and unscrew the entire bolt and nuts they screwed, hence the circular was not affected. This coupled with the moves earlier stated of EHORCN which makes sure the circular was render irrelevant and of no effect at all.
Also when it comes to issue of immunization, CHP see themselves as the only people to provide the service, while in an ideal situation, the work is collaborative between preventive health practitioners as epitomize by EHP, and curative health practitioners as represented by other health practitioners. That is why in any local government area where the HOD is CHP, he tends to favour his professional members in all undertakings, to the disadvantage of others.
Considering the role of environmental health in determining the health status of a community, state or nation, on assumption of Ibrahim Shekarau to office as governor Kano state, he ordered for the employment of environmental health workers [aka sanitary inspectors] in each local government in the state. The circular was dated 10th January, 2005, with ref no MLG/OR/CIR/26/vol 1/131, and for record purposes it only stated that graded sanitary inspectors are the ones to be employed in the ratio of 50 in the eight metropolitan local governments and 30 in the remaining 38 local governments.
Though the circular specified who shall be employed, no sooner had it reaches local governments secretariat, than the HODs, whom are over 50% CHP, disregard it and favour their professional members to the disadvantage of those whom the circular meant for, it took a long time battle before the issue was resolved with the intervention of EHP that government should consider others, and the government made a provision, that other health practitioners should be employed. Yet instead of CHP to appreciate the gesture and accommodation of EHP, they re-sharpen their sword for the battle ahead.
These inter fighting is not only in Kano, but applicable in most Nigerian states, where they have substantial number of the practitioners, but only differs in nature, context and perhaps vision [if any].
But if I should ask, when does even community health practice come into being? Who were at local government’s level providing health services before their coming? Do they really know the historical evolution of public health in Nigeria ? Are they the only health practitioners in Nigeria ? Why their arrogance and proud more prominent? Are they indispensable in PHC programme? When PHC does become synonymous with community health workers? The questions are endless.
Even though PHC programme need every profession’s participation [not only CHP], nevertheless, the challenge of EHP in PHC implementation is more daunting than any other profession. By ignoring the artificial but loose boundaries created between the components earmarking them for specific health cares, it is obvious that ‘environment’, i.e. the total sum of the conditions within which organism live directly, or by implication embraces all the components of PHC, as such, it is logical to assert that all the components are source of challenge to EHP.
As health is defined by world Health organization [WHO] as ‘state of complete physical, social and mental well being of person, not merely absent of disease or infirmity’, many see this definition as an idealistic goal rather than realistic definition. There are other definitions from various perspectives, like biomedical, ecological and others, as such, no one or any profession can provide health to anybody alone.
No single person can deliver the entire range of health care services to the people. The practice of modern public health service has become a joint effort of many groups of workers, both medical and non-medical, viz, physicians, nurse, social workers, public health engineers, sanitarians, and host of others. Hence, no any profession is island unto itself, medical doctors need pharmacist, microbiologist/laboratory scientist, nurses, labourer, as much as they need him, hence, community health practitioners, nutritionist need environmental health practitioners, as much as he also need them in his services.


Based on these, we can understand that, PHC, which is the centre point of health care in Nigeria, it is not a prerogative of anybody or profession, there should be a joint support for the programme to succeed, as such all the fighting on whom control PHC at local government is uncalled for and unfortunate.
The essence of any health services be it preventive, curative, promotive or rehabilitative is to ‘attain the goal of an acceptable level of health that will enable every individual to lead a socially and economically productive life’ [WHO 1981], hence, this should be the guide line, not personal interest.
Even though inter professional conflict could not be eliminated at all, nevertheless, CHP should understand they are not, and can not alpha and omega in PHC, they should regard each other as partner toward the upliftment of health services; their bias and hatred, enmity toward EHP should be stop, for if environmental health services would be given much attention by all the levels of government, the load on curative health services [which CHP are integral part of], would be reduced and in some instances, eliminated.
CHP should also know that, without environmental health control, no any progress of any health service can scale through, that is why due to the relegation of the later by PHC coordinators at LG level, whom are more of CHP, and medical practitioners at state and federal levels, policy makers inclusive, the progress achieved in the last 30 years of PHC programme is not satisfactory.
The open battle of NPHCDA to delist EHP and others from heading PHC departments in our local governments was unfortunate, bias and selfish. Instead of the organization to carry every profession along, they rather become partial and do injustice. It is even flabbergasting that a supposedly regulatory body is doing what is causing a great havoc towards the running of smooth PHC programme, which at last, those that the services is meant for, are the one affected.
NPHCDA should be alive to its responsibilities, by siding with truth and carrying everybody along, for it is not only the ones it likes that has something with PHC, all have roles to play. The issue of PHC is not only building PHC centre, provision of drugs and those that will man them, but each center, should at least have all the necessary professionals to make it fully operational.
What stated in this article notwithstanding, medical practitioners, CHP, EHP, Pharmacist, etc are all partners in the delivery of health services, as no one is an island unto himself; the inter fighting would only further deviate them from doing their works, which the people they supposedly work for are the ones affected. As such there should be understanding, collaboration and commitment, so that these intra fighting be eliminated.

June 1,2008
source;  Sani Garba -Karaye local government area, Kano state

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