Trust Renewal in Healthcare (TRHc) Blog Series
WHY THE ORIGINAL PHC VISION REMAINS UNFINISHED
By Dr Abdullahi Jibril Mohammed
PHC Consultant,
Convener/CEO,
Initiative for Health Accountability and Transparency
More than four decades after the Alma-Ata Declaration of 1978 proclaimed Primary Health Care as the pathway to “Health for All,” the original PHC vision in many countries, including Nigeria, remains only partially realised.
The vision itself was ambitious and transformative.
It was not merely about building clinics or expanding basic medical services. It represented a broader philosophy of health system development rooted in:
Equity;
Community Participation;
Prevention;
Intersectoral Collaboration;
Appropriate Technology;
Social Justice;
And People-Centred care.
PHC was envisioned as the foundation of national development and not simply the lowest level of healthcare delivery.
It aimed to bring healthcare closer to communities while simultaneously addressing the broader social, economic, and environmental determinants of health.
The original PHC vision therefore sought transformation at multiple levels:
Better Access To Care;
Stronger Prevention Systems;
Community Ownership;
Equitable Distribution Of Resources;
Integrated Service Delivery;
Local Participation In Decision-Making;
And Health Systems Designed Around People Rather Than Institutions Alone.
Yet despite decades of reform efforts, this vision remains unfinished.
One major reason is that implementation gradually became narrower than the original philosophy itself.
In many settings, PHC became reduced primarily to selected programmes, vertical interventions, or basic facility-based services rather than functioning as a fully integrated system approach to national health development.
Over time, attention often shifted toward disease-specific interventions driven by urgent global priorities such as immunisation, HIV/AIDS, tuberculosis, malaria, maternal health, and polio eradication.
While these programmes produced important gains, they sometimes unintentionally weakened the broader integrated PHC philosophy by creating parallel systems, fragmented funding streams, separate reporting structures, and programme-specific operational cultures.
As a result, health systems frequently became programme-driven rather than system-driven.
Another reason the PHC vision remains unfinished is the persistence of fragmentation within governance and implementation structures.
The original PHC model assumed coordinated systems operating across different levels of government and sectors. However, in practice, institutional fragmentation often weakened coherence between federal, state, and local structures.
Responsibilities became divided across multiple agencies and actors with varying priorities, financing arrangements, and operational approaches.
This fragmentation affected:
Service Continuity;
Resource Allocation;
Workforce Deployment;
Supervision;
Referral Coordination;
And Accountability.
Communities therefore experienced uneven and inconsistent service delivery rather than one integrated system of care.
Weak implementation culture has also contributed significantly to the unfinished PHC vision.
Nigeria has developed numerous policies, strategic plans, and reform frameworks over the years.
Yet implementation discipline often remains weaker than policy ambition.
Facilities may possess guidelines without operational adherence.
Supervision systems may exist without regular follow-through.
Data systems may generate reports without influencing decisions.
Community structures may exist formally without meaningful participation.
This persistent gap between policy intention and operational reality has slowed sustainable transformation.
Financing limitations and inefficiencies equally play important roles.
The Alma-Ata vision required sustained investment in frontline systems, prevention, workforce development, community engagement, and equitable access.
However, PHC financing has often remained inadequate, unpredictable, fragmented, or poorly protected. In many cases, tertiary and curative services continue to attract greater visibility and political attention than preventive and community-based care.
As a result, frontline PHC systems frequently operate with constrained resources despite carrying the largest population health burden.
The PHC workforce crisis further explains why the original vision remains incomplete.
Frontline workers remain central to PHC effectiveness, yet many continue to face:
Staff Shortages;
Poor Working Conditions;
Limited Career Development;
Inadequate Supervision;
Uneven Distribution;
Burnout;
And Low Motivation.
A system built on prevention, continuity, and community trust cannot function effectively without a supported and motivated workforce.
Importantly, the original PHC vision also depended heavily on community participation and ownership.
Communities were meant to become active partners in planning, monitoring, prevention, and accountability.
Yet in many situations, participation became symbolic rather than functional. Health systems often evolved into institution-driven structures where communities remained recipients of services rather than co-creators of health system performance.
This weakened trust, accountability, and responsiveness.
The unfinished PHC vision also reflects insufficient attention to the “software” dimensions of health systems:
Trust;
Leadership Culture;
Ethics;
Accountability;
Responsiveness;
Communication;
And Patient Experience.
Infrastructure and equipment alone cannot sustain PHC effectiveness where communities experience disrespect, neglect, weak complaint systems, or unreliable services.
Ultimately, the original PHC vision remains unfinished because building people-centred, equitable, accountable, and integrated health systems is far more complex than expanding infrastructure alone.
It requires continuous political commitment, implementation discipline, sustainable financing, institutional coordination, workforce investment, community ownership, ethical leadership, and trust-building sustained over many years.
Yet despite these challenges, the original PHC vision remains profoundly relevant.
In many ways, today’s global calls for:
Universal Health Coverage;
Health Equity;
People-Centred Care;
Community Engagement;
Integrated Service Delivery;
Health Security;
And Resilient Health Systems
Are Reaffirmations Of The Same Principles Articulated At Alma-Ata Decades Ago.
The vision therefore remains unfinished, not because it was wrong, but because it has not yet been fully implemented consistently and coherently.
And perhaps the future of PHC in Nigeria depends not on abandoning that vision, but on finally completing it.
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