Primary Healthcare Under One Roof: Way Out of Primary Healthcare Dilemma

: The adoption of the Primary Health Care Under One Roof (PHCUOR) initiative serves as a crucial approach to tackle the complex challenges encountered by primary healthcare systems worldwide. This paper explores the historical background, present difficulties


INTRODUCTION
Primary health care (PHC) is an essential part of healthcare systems globally and has its origins in the influential Alma Ata Declaration of 1978.The concept encompasses a comprehensive approach to providing healthcare, with a focus on delivering critical services that are easily available, comprehensive, and centred around the community (WHO, 1978).The primary healthcare (PHC) acts as the initial interface between individuals and the healthcare system, providing a wide array of services that encompass health promotion, disease prevention, treatment, and rehabilitation (Starfield, 1994).This comprehensive range of healthcare services not only focuses on the physical well-being of individuals but also takes into account the wider social factors that influence health, such as education, housing, and employment (WHO, 2008).
The importance of Primary Health Care (PHC) in public health systems is emphasised by its role in advancing health equity and attaining universal health coverage.Primary healthcare (PHC) plays a crucial role in minimising health disparities among various population groups by offering care that is easily accessible in terms of location, culturally suitable, and financially cheap (WHO, 2018).Furthermore, primary healthcare (PHC) functions as an economically efficient method of providing healthcare, as it prioritises preventative measures and timely intervention, thereby decreasing the necessity for pricier and more intense treatment options (Macinko et al., 2019).
The notion of "Primary Health Care Under One Roof" signifies a strategic advancement in the structure and provision of basic healthcare services.The concept promotes the incorporation of diverse healthcare services into a unified institution or network of facilities, with the objective of enhancing the coordination, continuity, and comprehensiveness of care (Kringos et al., 2020).This concept aims to overcome the fragmentation and isolation of traditional healthcare systems by integrating medical, dental, mental health, maternal care, and other services in one location.By doing so, it improves the overall patient experience and health results (Veillard et al., 2012).This paper aims to examine the reasoning behind the implementation of primary health care under one roof and its capacity to tackle the difficulties encountered by conventional primary health care models.The researchers want to enhance the understanding of primary health care consolidation as a potential solution to the primary healthcare challenge

Historical Context of Primary Health Care in Nigeria
The evolution of primary health care (PHC) in Nigeria has been shaped by a combination of international initiatives and local circumstances.Gaining a deep understanding of the historical backdrop is essential for fully grasping the difficulties and possibilities in the present delivery of primary healthcare.The primary health care concept originated from the Alma Ata Declaration of 1978, in which global leaders recognised health as an essential human right and identified primary health care as the crucial means to achieve "Health for All" by the year 2000 (WHO, 1978).This significant proclamation highlighted the significance of community involvement, cooperation between different sectors, and fair availability of crucial health services, establishing the basis for primary healthcare systems globally.
In Nigeria, the Alma Ata Declaration stimulated initiatives to enhance primary healthcare (PHC) provision, resulting in the implementation of different policies and strategies with the goal of increasing availability of crucial health services.An important undertaking was the creation of the National Primary Health Care Development Agency (NPHCDA) in 1992.Its main responsibility is to coordinate primary health care efforts at the national level (NPHCDA, n.d.).The government's dedication to primary health care (PHC) as a means of improving health outcomes for all Nigerians was reinforced by subsequent programmes, including the Bamako Initiative in 1987 and the National Health Policy of 1988 (FMOH, 1988).
Nevertheless, despite these endeavours, conventional primary healthcare (PHC) models in Nigeria have encountered a multitude of obstacles.A significant obstacle has arisen due to insufficient funding and distribution of resources, resulting in a scarcity of infrastructure, equipment, and supplies at primary healthcare institutions (Oladipo et al., 2018).Furthermore, there have been concerns regarding the unequal allocation of healthcare professionals, resulting in significant deficiencies of skilled individuals in rural regions (Uzochukwu et al., 2015).In addition, inadequate governance, underdeveloped health systems, and cultural obstacles have impeded the successful execution of primary healthcare programmes in Nigeria (Onwujekwe et al., 2012).
Essentially, the historical background of primary health care in Nigeria is influenced by worldwide efforts such as the Alma Ata Declaration, together with local policies and tactics designed to enhance the availability of vital health services.Notwithstanding these endeavours, obstacles endure, underscoring the want for continuous dedication and inventive strategies to enhance primary healthcare provision and enhance health results for all Nigerians.

Current Challenges in Primary Health Care in Nigeria
The efficiency of primary health care (PHC) in Nigeria is hindered by various problems, which prevent it from delivering important health services to the people.Comprehending these difficulties is essential for policymakers and healthcare stakeholders to create specific interventions and enhance the quality and availability of primary healthcare services throughout the nation.Many Nigerians, especially those residing in rural and underdeveloped regions, have a considerable obstacle in obtaining primary healthcare services.Geographical obstacles, such as extensive distances to healthcare facilities and inadequate transportation infrastructure, frequently impede persons from promptly obtaining medical attention (Okeke et al., 2018).Furthermore, economic obstacles, such as the need to pay for consultations, drugs, and diagnostic tests, present considerable difficulties, particularly for households with low incomes (Uzochukwu et al., 2010).The presence of these access restrictions has a greater impact on vulnerable populations, such as women, children, and the elderly, which worsens health disparities throughout the country (Onwujekwe et al., 2016).
The issue of providing high-quality care continues to be a long-standing problem in numerous primary healthcare facilities in Nigeria.Inadequate infrastructure, outdated equipment, and drug stockouts are contributing factors to the inefficient delivery of services (Oladipo et al., 2018).Furthermore, inadequacies in the training and supervision of healthcare providers, along with inconsistent compliance with clinical guidelines, undermine the quality and safety of the care being delivered (Uzochukwu et al., 2015).Inadequate communication between patients and healthcare providers, extended waiting periods, and disrespectful behaviour contribute to a decline in trust in the healthcare system, resulting in reduced utilisation of primary healthcare services (Oleribe et al., 2017).
The fragmentation and absence of coordination among primary healthcare service providers present considerable obstacles to the provision of comprehensive treatment in Nigeria.The presence of numerous vertical health programmes, each with their own financing sources, reporting systems, and service delivery platforms, frequently results in redundant efforts and ineffective allocation of resources (Uzochukwu et al., 2018).The fragmented approach impedes the integration of services and weakens the continuity of care, especially for individuals with intricate health requirements (Eboreime et al., 2017).In addition, inadequate referral systems and restricted information exchange among primary, secondary, and tertiary healthcare facilities worsen fragmentation and hinder the coordination of patient treatment (Ogundipe et al., 2020).
The scarcity of human resources, particularly in the form of skilled healthcare professionals, presents substantial obstacles to the provision of primary healthcare services in Nigeria.Rural and isolated regions often experience severe deficiencies in medical personnel such as doctors, nurses, midwives, and other crucial healthcare experts.As a result, primary care institutions in these areas become overwhelmed and understaffed (Aregbeshola et al., 2017).The unequal allocation of healthcare professionals in urban and rural regions worsens the discrepancies in healthcare accessibility, with rural communities experiencing the greatest scarcity (Uzochukwu et al., 2010).In addition, the significant emigration and attrition of healthcare workers exacerbate the already strained primary healthcare workforce, hence impeding efforts to enhance service provision (Okeke et al., 2018).
To effectively tackle the existing issues in primary health care in Nigeria, it is essential to adopt a comprehensive approach that focuses on enhancing accessibility, improving the quality of care, facilitating coordination and integration of services, and addressing the shortage of human resources.To enhance the primary healthcare (PHC) system and promote the health and well-being of all Nigerians, policymakers and healthcare stakeholders must tackle these concerns.

Primary Health Care Under One Roof Model in Nigeria
The Primary Health Care Under One Roof (PHCUOR) model is a strategy approach to healthcare delivery that aims to integrate and harmonise primary health care services within a single administrative and operational framework.This concept aims to tackle the issues of fragmentation, inefficiency, and ineffectiveness that are inherent in conventional primary healthcare systems by integrating different services into a single structure.

Definition and Key Principles of the Model
At its core, the PHCUOR model entails the consolidation of primary health care services, including preventive, promotive, curative, and rehabilitative services, under one administrative authority at the subnational level, typically the state government (Ng'andu et al., 2013).This integration extends beyond organizational structures to encompass financial, managerial, and service delivery aspects, ensuring a coordinated and comprehensive approach to primary health care provision (Onwujekwe et al., 2016).Key principles underlying the PHCUOR model include 1. Decentralization: The model emphasizes decentralized decision-making and management, empowering subnational authorities to adapt primary health care services to local needs and priorities (Atun et al., 2015).2. Governance and Leadership: Strong governance structures and leadership are essential for effective implementation and oversight of the PHCUOR model, ensuring accountability, transparency, and stakeholder engagement (Eboreime et al., 2017).3. Integration of Services: The model promotes the integration of various health services, such as maternal and child health, immunization, family planning, and disease prevention, within a single facility or network of facilities (Uzochukwu et al., 2016).4. Human Resource Development: Capacity building and training of healthcare workers are central to the success of the PHCUOR model, enabling them to deliver a wide range of services and adopt a holistic approach to patient care (Oleribe et al., 2015).

Case Studies/Examples of Successful Implementation
Multiple states in Nigeria have used the PHCUOR concept with different levels of achievement.An example worth mentioning is the adoption of the model in Anambra State, where the state government established the Anambra State Primary Healthcare Development Agency (ASPHCDA) to supervise the incorporation of primary health care services (Eboreime et al., 2017).Anambra State has achieved notable progress in boosting access to vital healthcare services, decreasing rates of maternal and child mortality, and promoting community involvement in health-related decision-making, as documented by Uzochukwu et al. (2018).A notable example of a successful case study is the implementation of the Primary Health Care Under One Roof (PHCUOR) in Lagos State.This initiative involved the revitalization of primary health care facilities and the enhancement of the primary health care referral system, as documented by Okeke et al. in 2019.The implementation of this strategy has resulted in enhanced health outcomes, heightened utilisation of primary health care services, and improved efficiency in the allocation of resources and delivery of services (Oladipo et al., 2018).

Benefits of Integrating PHC Services Under One Roof
Integrating primary health care services under one roof offers several benefits for both healthcare providers and patients: 1. Improved Access: By consolidating services within a single facility or network of facilities, the PHCUOR model enhances access to essential health services, particularly for underserved and marginalized populations (Eboreime et al., 2017).2. Enhanced Coordination: The model promotes better coordination and collaboration among healthcare providers, resulting in improved patient care, reduced duplication of efforts, and streamlined service delivery (Uzochukwu et al., 2016).3. Cost-effectiveness: By rationalizing resource allocation and reducing overhead costs associated with fragmented service delivery, the PHCUOR model enables more efficient use of healthcare resources and improved cost-effectiveness (Onwujekwe et al., 2016).4. Comprehensive Care: Integrating various health services under one roof allows for a more comprehensive approach to patient care, addressing not only medical needs but also social determinants of health and preventive measures (Oleribe et al., 2015).
The PHCUOR model has great potential for enhancing the delivery of basic health care in Nigeria.This approach presents a practical answer to the difficulties encountered by conventional primary health care systems by combining services, improving coordination, and advocating for comprehensive treatment.Ultimately, it leads to improved health outcomes and increased fairness in accessing crucial health services.

Components of Primary Health Care Under One Roof
The Primary Health Care Under One Roof (PHCUOR) concept offers a holistic approach to healthcare provision, incorporating multiple vital components to meet the health requirements of individuals and communities in Nigeria.At the core of this paradigm is the delivery of extensive healthcare services, which include preventative, promotive, curative, and rehabilitative interventions (WHO, 2018;Nutbeam, 1998;Starfield, 1994;WHO, 2020).The PHCUOR model seeks to enhance health outcomes for populations of all ages by providing a diverse array of services that facilitate early intervention and alleviate the burden of disease.
The effectiveness of the PHCUOR model relies on the cooperation of diverse healthcare teams consisting of doctors, nurses, community health workers, and allied health professionals (WHO, 2010;Perry et al., 2014;World Confederation for Physical Therapy, 2019).These teams collaborate to provide comprehensive and patient-focused care, utilising their combined knowledge and abilities to successfully address the many health requirements of patients.The PHCUOR model facilitates the integration of different health services into a single administrative and operational structure, allowing for easy access to comprehensive care.This includes medical, dental, mental health, and maternity and child health services (WHO, 2020;Kassebaum et al., 2017;WHO, 2008;UNICEF, 2019).
The PHCUOR model is built on the fundamental concepts of community involvement and participation.It acknowledges the significance of involving communities in decision-making, planning, and implementation of primary health care services (WHO, 2016;Bhutta et al., 2010;Jaskiewicz & Tulenko, 2012).The concept utilises health education, community health committees, and community health volunteers to empower individuals and communities to assume responsibility for their health, advocate for their health requirements, and actively engage in health promotion initiatives.
The PHCUOR model provides several advantages, such as increased availability of services, improved organisation of care, cost efficiency, and complete delivery of care (Eboreime et al., 2017;Uzochukwu et al., 2016;Onwujekwe et al., 2016).The PHCUOR model shows great potential in enhancing health systems, enhancing health outcomes, and promoting health equity in Nigeria through its focus on addressing the varied health needs of populations, fostering collaboration among healthcare professionals, integrating services, and engaging communities.

Implementation Strategies in Nigeria
To successfully implement the Primary Health Care Under One Roof (PHCUOR) model in Nigeria, it is necessary to engage in strategic planning, coordinate efforts, and provide supportive policy frameworks.There are several important techniques that can help ensure the successful adoption and implementation of PHCUOR nationwide.Policy Frameworks Supporting Integrated PHC An essential initial phase in the implementation of PHCUOR in Nigeria involves creating and accepting policy frameworks that provide support at both the national and subnational levels.The policy frameworks should clearly define the objectives, principles, and standards for integrating primary health care services into a single administrative and operational structure (Eboreime et al., 2017).To ensure the efficient implementation and sustainability of the PHCUOR model (Atun et al., 2015), policies should give priority to decentralisation, governance reforms, and multisectoral collaboration.In addition, policies should encourage community involvement and participation, encouraging communities to assume responsibility for their health and actively contribute to decision-making processes (WHO, 2016).

Infrastructure Requirements
Infrastructure development is crucial for the establishment and functioning of primary health care facilities according to the PHCUOR model.This encompasses the process of building, refurbishing, and furnishing primary health care facilities with necessary facilities, medical apparatus, and provisions (Oladipo et al., 2018).It is important to prioritise infrastructure improvements in disadvantaged and marginalised populations to ensure fair and equal access to high-quality health services in both urban and rural locations (Uzochukwu et al., 2018).Moreover, utilising technology and digital health solutions can improve the efficiency and efficacy of service delivery, allowing for telemedicine, electronic health records, and health information systems (Okeke et al., 2019).

Training and Capacity Building for Healthcare Workers
Enhancing the skills and abilities of healthcare professionals is crucial for providing excellent, comprehensive primary healthcare services within the PHCUOR framework.Training programmes should prioritise the improvement of clinical skills, fostering interprofessional collaboration, and promoting patient-centered care (World Health Organisation, 2010).Providing continuous professional development and mentorship opportunities can enhance the ability of healthcare personnel to adjust to changing roles and responsibilities within multidisciplinary teams (Perry et al., 2014).Furthermore, community health workers have a vital role in the effectiveness of PHCUOR and should be provided with sufficient training and assistance to provide necessary healthcare services and promote health education among communities (Jaskiewicz & Tulenko, 2012).

Financing Mechanisms and Sustainability
Establishing sustainable financial channels is crucial for ensuring the long-term viability and scalability of the Primary Health Care Under One Roof (PHCUOR) concept in Nigeria.It is crucial for governments to give sufficient resources to primary health care, with a focus on investing in infrastructure, human resources, and service delivery (Onwujekwe et al., 2016).In addition, the exploration of novel financing structures, such as community-based health insurance schemes and public-private partnerships, can enhance the variety of funding sources and enhance financial sustainability (Uzochukwu et al., 2010).Ensuring the financial stability and sustainability of PHCUOR implementation requires the strengthening of health finance systems, optimising resource allocation, and enhancing revenue production and collection procedures (Oleribe et al., 2015).
To successfully implement the PHCUOR model in Nigeria, a comprehensive approach is needed.This approach should include supportive policy frameworks, infrastructure development, capacity training for healthcare personnel, and sustainable financing methods.Nigeria may enhance its primary health care system, enhance health outcomes, and promote health equity for all its residents by implementing these methods.

Recommendations
Nigeria is making progress in enhancing its primary healthcare system and implementing the Primary Health Care Under One Roof (PHCUOR) model.To improve health outcomes and promote health equity nationwide, there are various potential initiatives and recommendations that should be considered.Expanding established models of integrated primary healthcare delivery is crucial, based on the success of pilot programmes and initiatives.States that have effectively implemented Primary Health Care Under One Roof (PHCUOR), such as Anambra and Lagos, can serve as models for other regions in Nigeria (Oladipo et al., 2018).By replicating and modifying effective tactics like as governance structures, service integration mechanisms, and community involvement approaches, we may speed up the process towards achieving universal health coverage and enhancing health outcomes across the entire nation (Eboreime et al., 2017).
Several crucial future directions and recommendations arise in Nigeria's efforts to enhance its primary healthcare system and implement the Primary Health Care Under One Roof (PHCUOR) concept.First and foremost, it is imperative to expand successful models that have demonstrated effectiveness in pilot programmes.States such as Anambra and Lagos, where the implementation of the Primary Health Care Under One Roof (PHCUOR) has been successful, can be used as models for other states to follow.Nigeria may expedite progress towards achieving universal health coverage and enhancing health outcomes countrywide by duplicating and modifying effective initiatives, such as governance structures, service integration mechanisms, and community involvement approaches.
Policymakers have a crucial influence on the efficacy of primary healthcare in Nigeria.Leaders must show unwavering political dedication to reforming primary healthcare by giving sufficient resources and prioritising efforts to strengthen the health system.Implementing supportive laws and policies at both the national and subnational levels is crucial for establishing the PHCUOR model as a permanent part of the institutional framework and guaranteeing its long-term viability.Furthermore, it is essential to establish alliances and cooperative relationships with different entities, such as government agencies, civil society organisations, academia, and international partners, in order to maximise resources, knowledge, and exemplary methods in the provision of primary healthcare.Implementing strong monitoring and evaluation systems is essential for effectively monitoring progress and making informed decisions to consistently enhance primary healthcare services.Sustained research is crucial for the progression of knowledge and the implementation of evidence-based practices in integrated primary healthcare.Important research areas include conducting rigorous impact evaluations to evaluate the effectiveness, efficiency, and fairness of PHCUOR implementations, examining health system factors that promote or impede successful implementation, exploring creative methods to improve community engagement and participation, and studying the role of health information systems and digital health technologies in supporting integrated PHC delivery.

CONCLUSION
The process of enhancing Nigeria's healthcare system by adopting the Primary Health Care Under One Roof (PHCUOR) model is complex yet crucial.By carefully analysing the main discoveries, it becomes clear that expanding effective models, implementing supportive policies, and promoting research are crucial measures for improving health outcomes and promoting health equity nationwide.The significance of integrating primary healthcare services in a facility to tackle healthcare challenges cannot be emphasised enough.The PHCUOR model provides a holistic approach to healthcare delivery by integrating primary healthcare services under a unified administrative and operational framework.This model effectively serves the different health requirements of individuals and communities.By working together, organising efforts, and involving the community, PHCUOR not only enhances the availability of high-quality healthcare services but also supports the ongoing provision of care, decreases divisions, and improves the overall efficacy and efficiency of the healthcare system.
It is our responsibility as stakeholders, including policymakers, healthcare providers, civil society organisations, academics, and international partners, to actively promote and give priority to integrated primary healthcare (PHC) programmes.A comprehensive strategy to enhance primary healthcare in Nigeria necessitates unwavering political dedication, legislative backing, cooperative partnerships, and vigorous monitoring and evaluation, along with ongoing research.
Hence, the researchers urge all parties involved to join forces in promoting integrated primary healthcare (PHC) initiatives, giving priority to investments in basic healthcare, and striving to attain universal health coverage and enhanced health outcomes for the entire Nigerian population.Collectively, we have the ability to construct a more robust and adaptable healthcare system that guarantees the health and welfare of future generations.