MEDICAL LABORATORY SERVICES IN PRIMARY HEALTHCARE: Dr. Chris Elemuwa

BACKGROUND INFORMATION/MILESTONE ON PRIMARY HEALTHCARE:

The term Primary Health Care was used initially to describe the first care given to a person poor in health, irrespective of where the care was given. Things, however, began to change in 1952 when the WHO Expert Committee on Public Health Administration defined Public Health as “’ the Science and art of preventing disease, prolonging life and promoting mental and physical health and efficiency through the organized community efforts for sanitation of the  environment, the  control communicable infections, the education of the individual in personal hygiene, the organization of medical  and nursing services for early diagnosis and preventive treatment of disease and the development of social machinery to ensure to every individual a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity’’

In 1953, the Committee met again and took a closer look at the available strategies for extending public health services to the rural areas and came up with the idea of ‘’Basic Health Service’’. The package included:

• Maternal and child health
• Communicable disease control
• Environmental sanitation
• Maintenance of records for statistical purposes
• Health education of the public
• Public health nursing and medical care

In search of a solution to the growing demand for improved health, the idea of Health for All by the year 2000 was initiated by the former Director – General of WHO. The goal was accepted and endorsed by the 30th world Health Assembly in 1977. In 1978, under the auspices of WHO and Uncief, an international Conference on Primary Health Care was held in Alma Ata. The meeting which was well attended by 134 countries and many international agencies had declaration called Alma Ata Declaration, defined Primary Health Care as:  ‘’Essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self- reliance and self –determination’’

The conference also identified PHC as strategy for achieving HFA 2000.

The Alma Ata Declaration stressed health as a fundamental human right and stated that health care must accessible, affordable and socially relevant to meet the needs of the people. The concept of Primary Health Care is based on four major pillars:

• Political commitment
• Intersectoral  cooperation
• Community participation
• Use of appropriate technology

In 1992, Nigerian Government showed full commitment by establishing the National Primary Health Care Agency (NPHCDA) through the Decree 2, with Prof. Ransome  Kuti as the  Hon. Minister of  Health. NPHCDA operated with some deficiencies and challenges.

MINIMUM HEALTH PACKAGE:

As many countries started experiencing downturn in their economies, the minimum health care package was muted considering the fact there is need to provide cost – effective health services which have the potential for addressing the major health problems of the people. Based on the components of the Primary Health Care, services under the package would therefore ensure child survival, safe- motherhood and healthy workforce at the least.

The minimum health package was endorsed by member countries of African Region of WHO at a meeting held in Yauonde, Cameroon from 5th -9th February, 1994. The package was classified into three:

• Priority Health Interventions
• Health centre services
• Health related interventions

It is expected that the implementation of the minimum health care package at the District (LGA) level would facilitate the achievement of the Health for all goal. The multisectoral effort will undoubtedly contribute to the socio- economic development of the people.

In 2001, the Nigerian Government in its drive to reform her healthcare system decided to repackage the minimum health package making the ward, the unit of PHC implementation. The ward is the smallest political unit which is more homogeneous than the LGA as each ward is represented by a councillor in the LGA.  The minimum healthcare package was finally endorsed for implementation by the Nigerian Government in 2007.

MEDICAL LABORATORY SERVICES IN PRIMARY HEALTHCARE: Structure and operation

We know that preventative care, primary health care and acute care are all intertwined and interdependent elements of our health system – and our reform agenda acknowledges that interconnection.

Health is higher on the international agenda this decade than at any time in recent memory. Good health for a society is recognized to be not only a result of socioeconomic development but also a precondition for such progress. Three of the eight Millennium Development Goals (MDGs) are directly related to health, a clear sign of its importance. It is also increasingly recognized that strong health systems based on the values of primary health care (PHC) are the best way to organize a health system to maximize the health gain relative to the amount of funds invested in all societies, not just in the developing world.

Structurally, of the 684 NPHCDA Model Health Centres across the country now,the Medical Laboratory infrastructural build-up are there, but there are little or no manpower to operate them. The Minimum Health Care Package only captured  the Laboratory Technician as one of the the component personnel but , saw it as typological as the equipment and the infrastructural build up as wrll as the quality of services required now is more than the scope of a medical laboratory technocian. This needs to looked into.

Improvements in primary health care are critical to improvements in the overall health system. In particular, primary health care is vital in turning our health care system more towards keeping people well and participating in life and work, rather than just looking after people when they are sick.

We need to have a primary health care system that enables people to see the right health professional for their needs, in an appropriate place at the right time.

WHY IS MEDICAL LABORTORY CRITICAL IN PRIMARY HEALTH CARE
Laboratory support is critical for disease surveillance and control programmes. Before an outbreak, laboratory-supported surveillance allows early detection of cases and during an outbreak; cases are confirmed in the laboratory to assess changes in the etiological agent(s) to guide decisions about interventions and the allocation of resources. Laboratory makes management of cases cost effective and more directional. It makes the Minimum Ward Healthcare package practicable and realistic.

The coordination of Polio laboratories in Ibadan, Maiduguri and Measles laboratories is also critical for effective Case-based efficacy in the country. The integrity of the country disease control surveillance, and periodic evaluation of vaccine potency and infrastructure depends on maintaining a complementary network of medical and public health laboratories, and a national system for coordination is needed.

The existence of National Primary Healthcare Development Agency (NPHCDA) perpherial laboratories as well as laboratory components in all the model health centres in the country and their activities can not be over- emphasized. Of these laboratories and their activities, littile or no appropriate coordination and monitoring system have been put in place resulting in uncoordinated collation and inadequate utilization of data generated from these segments for effective planning. 

More so, in line with the Minimum Ward Health Care Package (MWHCP) of the Agency, laboratory is a major component of the package.

Quality of laboratory infrastructure, care and data should be regularly ascertained through the laboratory system hence, the NPHCDA is expected to provide this leading role in the health care delivery system in Nigeria. Health related MDGs will not be achieved in developing or poor countries without accessible and reliable laboratory services. The diagnosis of tuberculosis requires microscopic examination of sputum smears. HIV status needs to be confirmed by a laboratory test before treatment and response monitored with CD4 counts. Since the introduction of combination therapy the over diagnosis rates of malaria associated with presumptive clinical diagnosis cannot be justified. Laboratory confirmation by microscopy or rapid test is cost-effective for adults and older children in high transmission areas and also probably in children under 5 years old. Anaemia affects over half of all pregnant women and children in poor countries. Accurate haemoglobin measurement, not Conjunctival pallor, is the best way to confirm all but the most severe cases.

Adequate supplies of safe, accurately matched blood are essential to prevent deaths from severe anaemia.
Despite overwhelming evidence that laboratory services are absolutely critical for achieving the MDGs, they remain one of the most neglected components of health systems.

The reasons why laboratories have been so neglected range from failure to engage laboratory staff in key decisions to a limited focus on technology rather than on effective management systems. Marginalization and chronic neglect of laboratory services means that results are inaccurate or unknown.

Consequently patients are mismanaged, drugs are wasted and surveillance data is unreliable. Until poor countries develop laboratory services they can rely on, they will continue to be dependent on externally funded and therefore unsustainable, laboratory technology to monitor disease burden and the impact of disease control programmes.

Laboratory services are essential health care services. In developed countries, laboratory-aided preventive, diagnostic and prognostic testing plays a central role in modern medicine. Similar advantages should be possible in developing countries, but this will require the application of appropriate technologies that optimize the use of limited resources. In Bangladesh, diagnoses made at the primary health care (PHC) level are mainly based upon presenting complaints, history taking and clinical examination (1). The extent to which this is aided by laboratory tests is largely unknown. Unlike the case for essential medicines, there is no consensus among experts as to what constitutes an essential laboratory service that stems from applied research and evidence-based reviews of effectiveness and efficiency (2

RECOMMENDATIONS:
It is therefore proposed that NPHCDA be strengthened through medical Laboratory services that would provide the following primary functions:

• Effective Coordination and monitoring of all the peripheral laboratories within the NPHCDA domain in line with the Minimum Ward Healthcare Package.
• Regular evaluation of laboratory network
• Collaborate with all stakeholders on Relevant operational research and publications
• Knowledge sharing/Continuous learning/ capacity building
• Credence to the  National Surveillance system
• Results-based programme development and management
• Analytical and strategic innovations
• Develop and maintain National data base for effective references.
• A  Comprehensive healthcare can be assured at the communities as common ailments can easily be diagnosed and appropriately managed at the primary healthcare.
• Drastic reduction on the heavy dependence on the secondary healthcare level would be assured.
• Pivotal to achieving the relevant MDGs

In this connection therefore, it is further proposed that a division for Laboratory services whose functions shall be the coordination of network laboratories involved in disease surveillance nationally and internationally, this division should be coordinated by a medical laboratory scientist who shall be a Deputy Director. Other staff compliment should include Assistant Director (Polio Laboratories), Assistant Director (Measles Laboratories), Assistant Director (Diagnostics and Peripheral Laboratories) and other supporting staff. At the peripheral laboratories in the model health centers, qualified Medical Laboratory Scientists should also be saddled with task of ensuring quality of Laboratory results to add value to the quality of health care delivery.

Functions of a Primary Healthcare Laboratory Services
The main functions of this division are to provide effective coordination and monitoring of laboratory activities and laboratory personnel in the primary healthcare settings, provide quality assurance, periodic training and evaluation of the laboratory network as well as relevant operational research. It will also develop laboratory national data base for effective referencing. The imperative of this division when established will be obvious with its multiplier effects overtime on the general activities of the agency moreso as the country is getting ready for the polio – free certification stage.

Conclusion:
It is imperative therefore, that Proper surveillance with a sound and efficient network of laboratories is essential to meet the preventive, promotive, diagnostic, therapeutic and rehabilitative components of health care. At present, laboratory support at the primary health care level is not fully developed in most developing countries like Nigeria hence, a more radical approach has to be adopted to ensure that the quality of healthcare at the communities are equitable, guaranteed, scientifically proven and of course cost -effective. If a comprehensive primary healthcare team is established, the needed services to cope with the different treatment well financed vertical programmes need skilled local health personnel. Medical laboratory services can strengthen maternal and child- health services, HIV/ AIDS, malaria, Tb, blood and blood products, parasitic diseases, diarrhoeal diseases to mention but a few.

To aid health care delivery planning, further clarification of the health benefits to a population of a basic package of essential laboratory services would be useful. 

Using a consensus list of essential services and supplies, this survey of NSDP laboratory facilities found they were lacking physical infrastructure, essential equipment and quality control procedures. No standard operating procedures for conducting the tests performed were available at any of the laboratories. A record keeping system should contain all the requisite information related to test procedures. The lack of procedures to prevent dangerous infections is particularly worrying as poor practices have resulted in the spread of blood-borne infections in other settings.  

Primary health care clinics would benefit from the availability of appropriate tests, but this should coincide with improved quality control, waste control and training of laboratory staff.

Medical laboratory services in Primary Health Care are therefore a sine quanon!

Email: elemuwachris@yahoo.com