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.

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.

The consequences of a health system that involves the above five items will be as follows: