Monday, August 11, 2008

A Brief Anthropology of the Nigerian Healthcare Tier System and Her Primary Healthcare Exigency.

Let it be known from the outset that this discourse is not an attempt to fully elucidate the origins and subsequent evolution of Nigeria’s health system. Such a comprehensive undertaking is beyond the limit of this post. This chronicle of events is intended to rouse that idling quest for improved health outcomes especially as it relates to primary healthcare development, first in Nigeria, and then, in the rest of the developing world.
Nigeria was colonized by Britain. Nigeria had no formalized planned health services until the end of the Second World War. Before the war, provision of health services was by the British Army Medical Services. The subsequent integration of the British Army and the colonial government gave birth to the Colonial Medical Service. The Colonial Medical Service provided free health services only to the British Army and the colonial service officers. Nigerians at that time only benefited incidentally. Nigerians were served primarily by a handful of mission and private hospitals sparsely scattered throughout the country.
In 1946, the colonial government promulgated a ten-year National Development and Welfare Plan. There was no separate national health policy at that time but the ten-year plan integrated all aspects of government endeavors, including health activities. The euphoria of independence, the devastation of the Nigerian civil war and the nuances of neocolonialism distracted Nigerian leaders after the expiration of the First National Development Plan. It was not until 1970 and 1975 respectively that the Second and Third National Development Plans were birthed. Although these subsequent development plans did not address the specific issue of a national health policy, the Basic Health Service Scheme evolved as part of the Third National Development Plan. The scheme attempted to put the semblance of a primary healthcare service in place. The scheme had the following objectives:
1. To increase coverage from 25 to 60 percent of the population receiving healthcare;
2. To correct the imbalance between preventive and curative medicine and in the distribution and location of health institutions;
3. To provide the infrastructures for all preventive health programs such as family health, environmental health, nutrition and control of communicable diseases; and
4. To establish a healthcare system best adapted to the local conditions and to the level of health technology.
The first national health policy was promulgated in 1988. The health policy content of the Fourth National Development Plan was in harmony with the first national health policy. At that time, the feverish agitation for Health for All by 2000 was at its peak worldwide. It was not surprising that the first national health policy set out to achieve health for all by 2000 through emphasis on primary health care.
At the moment, Nigeria has a three tier system of government comprising of local, state and federal governments. The Federal government at the center oversees the 36 State governments (and the Federal Capital Territory) and 776 Local Government Areas. The Local Government Areas are equivalents of districts in other countries. Each tier of government has its responsibility thus: the Federal Government oversees all health activities in addition to taking care of tertiary level healthcare at the Teaching Hospitals and Federal Medical Centers; the State Governments supervise health activities at the Local Government level and is solely responsible for secondary healthcare at the General Hospitals; and the implementation of primary healthcare has been devolved to Local Governments. The primary healthcare system is the first point of contact with the healthcare grid. The primary healthcare system in Nigeria is meant to ensure the:
1. Provision and maintenance of health infrastructure;
2. Planning and implementation of strategies to meet community health needs;
3. Provision of the ten primary healthcare components to the community;
4. Training of personnel and logistic support for community mobilization and participation; and
5. Management of health information system.
It should suffice to state that the Local Governments are presently ill-equipped to dispense the much needed primary health care to millions of Nigerians. In other developing countries, this bottom-up primary healthcare approach has successfully improved health outcomes.
Is it out of place to suggest that the government at the center should pay more attention to primary healthcare? Is it not true that the Federal Government has the most resources? Has it not been proven that improved primary healthcare delivery equates improved national health indices? Did Paul Farmer and colleagues not establish that sustainable quality healthcare delivery is possible even in resource-poor settings? Is it not true that most African governments scorn the promise to commit 15% of their budgets to health as contained in the Abuja Declaration? Have wealthy countries complied with the United Nations target of raising overseas official development assistance to 0.7% of their gross national product? Are the patents on medicines by developed economies not adversely affecting primary healthcare development in resource-poor settings? And is it not true that certain policy prescriptions by world bodies such as the World Bank and the IMF deter increased investments in primary healthcare?
These questions beg for answers.

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