Defeating tragedy of commons: Providing social purpose for primary healthcare in Nigeria

That healthcare is an inalienable right has become a common narrative used at health systems and policy frontiers. Yet the reality of this assertion has remained debatable, especially in countries where health inequities hold sway. The Health Equity Assessment Toolkit (HEAT) of the World Health Organisation shows that in Nigeria, those with more money tend to have better health outcomes than those with less. The same HEAT, when applied to Algeria based on wealth quintile, shows that the poor and rich enjoy almost the same positive health outcomes, accounting for Algeria’s place among top-70 healthcare systems in the world, while Nigeria is rated among the least 12.

The leveller in healthcare across the world is primary health care. It provides a melting point for the rich and poor to access basic quality healthcare. When this is not possible, it becomes clear that the social purpose of primary health care is lost. The essence of social purpose is the prioritisation of people, ensuring that everyone reaches his/her full potential based on the provision and preservation of inalienable rights such as healthcare. Absence of social purpose becomes a tragedy, mostly suffered by the commons who already are limited in resources and opportunities, hence completely reliant on the dividends of the social contract.

Why social purpose?

In the words of Herbert Spencer – “society exists for the benefit of its members …”. The structures that make society should ordinarily tend toward advancing the safety and prosperity of man. Edwin Markham spoke about how society remains a vain concept if man is not the essence. We understand how capitalism has deepened the rich-poor dichotomy, with grave effects on social purpose. The world’s history is characterised by man’s inhumanity in several forms and spaces. And the more we scream for a turnaround, the more situations take turns for the worse.

Healthcare has not been spared of man’s inhumanity, and just maybe, healthcare in Nigeria might have seen enough of such inhumanity. We may want to ponder about how a country like Indonesia about the same size as Nigeria in population and economy, and about the same healthcare budget, fares better in health outcomes. The fact remains that countries with an increasing understanding of social purpose for health will certainly ace vital health indicators because the safety and prosperity of humans are at the centre of the existence of the health institutions. In the absence of this, tragedy becomes the order.

The tragedy of commons – an ugly experience

The manifestation of tragedy of the commons in Nigeria is that there is a clear demarcation between the institutions that serve the interest of the public from those that serve interest of elites. Elite-serving institutions continue to progress in funding and sometimes in standards, while public-serving institutions diminish remarkably on most counts. For instance, while around 37 billion naira was a no-go-area for budget cuts during the pandemic, primary healthcare was put forward for about 40 percent cut. Also, no less than 67 billion naira have been budgeted for renovation of the complex of Nigeria’s National Assembly between 2020 and 2024, while public health facilities continue to beckon for attention.

As a researcher with remarkable experience in primary healthcare, I have documented several cases of abandonment of health facilities to insecurity, chronic scenarios of corruption among health policymakers and providers, lack of pro-poor approach to primary health services, neglect of primary healthcare facilities by community people due to gross inefficiencies, and the disinterestedness of elites in building and/or equipping primary healthcare facilities across the 774 local government areas in Nigeria that meet the minimum standards. I worry about how easy it is to set standards without plans to ensure that such standards are met. These experiences drive home the need for health authorities in Nigeria and the overall leadership to do a deep reflection on ‘social purpose’, accentuating how the wellbeing of humans must be the essence of the existence of institutions.

Returning to the path of social purpose for primary healthcare

First, primary healthcare in Nigeria needs a mantra. The powerful effects of mantras cannot be overstated, especially in the direction of focus, mental energy, and accountability. We need a mantra that emphasises the nothingness of the entire primary healthcare institution if one human loses trust in it.

This mantra must be the bedrock of the entire system, well known in public domain, and used as a reminder of social purpose for primary healthcare. Mantras such as ‘the cry of one human pains us all’; ‘we are here because we care’, etc., should resonate with the ideals and ambitions of the system. The more this mantra is soaked in the fabrics of the system, both at frontline and policymaking, the more concerted energy toward social purpose we will realise, and the more accountable the system will be before the public.

Second, I must restate what research evidence has shown about the extent of accountability, social justice, and social protection in primary healthcare in Nigeria. I recall undertaking a study where we asked primary healthcare providers about rules and regulations. I was treated to a surprise when the majority of the health workers said they do not have context-specific rules guiding them, and the managers said they rely on negotiations for moral behaviours, as they find it hard to point to documents containing rules and sanctions.

We further enquired about if the health workers had an orientation toward efficient service delivery, and responses were in the negative. The same negative responses greeted supervision, efficient complaint mechanisms for service users, as well as functional mainstreamed protection of service users from injustices and other harms. I began to imagine what kind of services to expect from practitioners who are not prepped to be accountable, who are short in understanding of how to achieve a successful and efficient organisation, and what to make of a system that is without mainstreamed protective measures for service users.

A system designed with the intent of social purpose will be focused on absolutely prioritising the people. This must be clear in its mantra that is well-communicated and imbibed by all, a mainstreamed structure that protects service users (my previous column reports on the absence of qualified social workers who are trained social care and justice professionals in primary health care. See https://www.businessamlive.com/what-social-welfare-in-nigerias-new-health-ministry-should-mean/), rules and mechanisms that elicit accountability from healthcare actors, and absolute prioritisation of healthcare among other public goods for strategic funding by the government.

Indeed, the current health ministry in Nigeria has made some notable efforts in recognition of these gaps, evidenced by the Health Sector Renewal Plan (HSRP). However, such a lofty agenda will only achieve little or nothing if it fails to anchor ‘social purpose’ and vehemently defeat the tragedy of commons. Until the rich and poor enjoy the same amount of positive health outcomes from one health system in the country, we will remain a case in point for the ‘tragedy of commons’. 

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