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Journal of Community Medicine & Primary Health Care
Association of Community Physicians of Nigeria
ISSN: 0794-7410
Vol. 16, Num. 1, 2004, pp. 1-3
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Journal of Community Medicine & Primary Health Care, Vol. 16, No. 1, June
2004, pp. 1-3
COMMENTARY
The necessity for a health systems reform in Nigeria
M. C. Asuzu
Department of Community Medicine College of Medicine, University College Hospital,
Ibadan
Correspondence to: Dr. M. C. Asuzu Department of Community
Medicine College of Medicine, University College Hospital, Ibadan
KEYWORDS: Reforms, Health systems, Nigeria
Code Number: pc04001
Definition
A health system is an organizational framework for the distribution or servicing
of the health care needs of a given community. It is a fairly complex
system of inter-related elements that contribute to the health of people
- in their homes, educational institutions, in work places, the public
(social or recreational) and the psychological environments as well as
the directly health and health-related sectors.
The organization of health services in Nigeria
The health system in Nigeria is structured along the now universal three levels
of the primary, secondary and tertiary levels of care. The system is
run concurrently such that all the three levels of government - local,
regional/st ate and national/federal, even though they hold primary responsibility
for only one level of the system each, can exceed it and provide services
at any of the other two levels of care. One of the effects of this fluid
system, in the face of the many social and infrastructural problems facing
the nation, is that the pursuit of the politically attractive tertiary
health care can remain the only attractive area of the health system,
to the detriment of the other levels of care. The neglect of the primary
health care system, its maldistribution as well as the secondary health
care, will result in an inverted health care pyramid. This will not produce
any health for the people but will always have the threat to collapse
on itself.
Past and present needs for a health system reformin Nigeria
The Nigerian health care system can be said to have experienced five past reforms
(or attempts thereof, conscious or otherwise) from the traditional health
care system that existed in the individual Nigerian communities and ethnic
groups before our western (British) colonization till date. Thus, while
the system naturally had to develop in the wake of the British colonization,
the first Nigerian Colonial Development Plan of the 1940s gave some limited
framework for the health system. It was a unitary health service system.
Then came the era of regionalization in the 1950s. Even though no specific
documentation or specific effort at such a reform exists, the national
health system stopped being unitary; and the regional governments started
to run independent and sometimes parallel health systems with the federal
government. Then came the Second National Development Plan of the immediate
post independence era in the 1960s. Again the plan did not articulate
a system with clear levels, or the assignment of responsibilities to
the three levels of government. The Third National Development Plan of
the 1970s was a rather ambitious plan with the Basic Health Services
Scheme as its focus. It was quite elaborate in its health reform attempt.
It was far too heavy in infrastructure and auxiliary health manpower
development. It however failed to share responsibilities between the
three levels of government for resources generation, manpower development,
the services to be delivered, and especially on the health professional
manpower for the services. All these happened in the absence of a clear
policy framework.
Following the Alma Ata Declaration, serious attempts had been made at a health
systems reforms in the 1980s. Thus the National Health Policy (1988)
based on the principles of primary health care and primary health care
implementation were the results of that era.
The current need for a health system reform
The reason that we have needed health systems reforms all along is because the
systems we had prior to that time were not working or producing the optimal
health status possible and deserved by the people. The 2000 World Health
Report ranked Nigeria as the 187th of the 191 member nations for its
health systems performance. That speaks a whole lot about the fact that
our health system is not working.
There are many things that are responsible for our health care system not working,
the most important of which is the inadequacies of the community or primary
health care services. The whole international community had agreed both
at the Alma Ata and the following Riga Conference, that primary health
care is the only viable way to go in order to produce optimum health
for the people. So what is wrong with the Primary Health Care System
in Nigeria for which a reform will be important? I will list some of
the items here. They will be the most important ones as the full list
will indeed be too numerous. However, if we begin with these few critical
ones, the rest will be expected to come along in due course.
- Revision of the National Constitution to actually share responsibility for the
primary, secondary and tertiary health care. A separate National Health
Bill will also be needed to give more details to this and to require
the three levels of government to not wade outside of their primary
responsibility if they have not substantially fulfilled it first.
- Involvement of appropriate community health professionals - nurses (as community
health nurses) for community nursing zones operating from medically
manned health centers or community hospitals or district nurses manning
theirs districts in the absence of immediate community physician support;
and physicians as medical officers of health for every local government
area in the country.
- Emphasis for state governments to staff and equip district hospitals as the
major aspect of their secondary health care services for which they
hold primary responsibility. This, according the Riga Conference, is
the first part of the primary health care support (i.e., referral)
system; without which PHC will not work.
- The training and retraining of health professionals and auxiliary primary health
care workers in situations that engender team work, rather that intra-sectoral
division and in-fighting that is currently the case in the country.
- The orientation, reorientation and continuing education of the political class
and community leaders, especially the local government chairmen and
councilors for health, for political will and ongoing support for PHC
and secondary health care.
Consequences of a health system involving theabove reforms
The consequences of a health system that involves the above five items will
be as follows:
- The current over-emphasis on tertiary super specialist health care will
be moderated as necessary. State governments will focus on and develop the
currently ailing or even hardly existing secondary health care system and
minimize or eliminate any unnecessary involvements in tertiary health care.
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Community nursing and medical care will be developed properly as the only real
basis for raising the health status of the country. Community involvement
and participation will be automatically developed as each community
is uniquely able to give. Auxiliary health workers as community health
officers or health extension workers who show particular talents for
community medical or nursing care may be sent to be fully trained into
the professional cadres. The Philippines is the best example of a third
world country that has developed this system of community health professional
development.
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In the face of inability of local governments to employ, pay and equip the primary
health care system, the state government may assist them there at,
as many are already doing so by employing the professional health cadre
under the Local Government Service Commission. The Federal Government
may also do so by requiring the youth corps doctors in each state to
be primarily deployed for PHC work. In this regard, it will be obvious
that without self owned and administered transport system with enough
recurrent budgets by the medical officer of health to do so, no reasonable
community health work may be achieved by the PHC system. The orientation,
reorientation and continuing education of the state and local government
political class will improve the above requirements for an effective
PHC. The other issue such as health information, health insurance,
intersectoral collaboration and healthy relationships between the western
and traditional health practices will be able to be implemented properly
and smoothly because full fledged health professionals are involved
at the apex of the health system at all its three crucial levels.
Community physicians in the country have a responsibility to work for the production
of enough critical mass of their members in this country and for their
deployment and devoted work to produce the needed change in the health
care system in this regard.
BIBLIOGRAPHY
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Alakija W. Essentials of community health, primary health care and health management.
Medisuccess Publications, Benin City. 2000
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Federal Ministry of Health (1988). National Health Policy and Strategy to achieve
health for all Nigerians. Lagos
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World Health Organization (1978). Primary Health Care. Health for all Monograph
No 1. Geneva 4.
-
World Health Organization (2000). World Health Report 2000. Geneva
-
Shehu U (2000). Health systems reforms: the challenges for community physicians.
Paper delivered at the Annual Conference of the Association of Community
Physicians of Nigeria, Jos 2002.
-
World Health Organization (1988) Health for all by the year 2000: reflections
at midpoint. Geneva.
-
Ransome Kuti O., Sorungbe O and Bamisaiye A. (1990). Strengthening primary
health care at local government level: the Nigerian experience. Academy
Press Ltd, Lagos.
Copyright 2004 - Journal of Community Medicine & Primary Health Care
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