Dr. Michael C Asuzu (Professor of Public Health & Community Medicine, CoM, UI)

1. Federalism and Nigeria’s healthcare system – an appraisal of the primary and secondary healthcare systems Dr. Michael C Asuzu (Professor of Public Health & Community Medicine, CoM, UI) (Consultant Community & Occupational Physician, UCH) Dept. of Community Medicine, University College Hospital, Ibadan. NIGERIA. (A presentation at the NMA Oyo State Annual Conference, October, 2013 at NMA House, Agodi, Ibadan)

2. Presentation outline • Gratitude and confessions • Clarification of the key items of the discussion: federalism and federating units/states and responsibilities; health care system and systems; 10, 20 and 30 healthcare systems • PHC as the singular basis for any would-be healthy national healthcare system since 1978; and Nigeria (& few other people)’s problems with it’s understanding and practice • SHC and Nigeria’s problems with it, one and all! • Quo vadis?

3. Gratitude and confessions • It is gratifying that I keep getting invitations to talk on issues like this; which even though appear to be enjoyed while we speak of them in such halls, nothing has come of it thereafter!; people like to be “abused” repeatedly?, never tire of hearing what they have heard before, even if they had done nothing about the previous ones? Reason I still come • The pride, elegance and beauty of (well done or even otherwise) surgical and acute care medicine; yet the humbling wisdom and even superiority of PMC & PHC; and the greatest one of learning and balancing them all out beautifully; also of PH & CM; & even worse (explain) • The responsibility of Com. Med. therefore; & of us!

4. Clarification of the key issues in the talk 1 • A federation – as a country (& federalism as a method of governance) by a system of units which themselves are proper and adequate to be countries of their own and so whose relationships must respect those multi-nationalities in very clear terms. • The number of the federating units or states need to be clear as well as meet the requirements thereof; their capacities and responsibilities • Does Nigeria, outside of 1952 – mid-1966 bear any resemblance of any such thing?

5. Clarification of the key issues in the talk 2 • Primary health care as the level of health care that covers all that is essential for health and well being – promotive, preventive, curative, and rehabilitative as well as (ideally all the essential health professions) empowering the individuals and people to do the most that they can do in those regards by themselves – home, work place, dispensary or health post, clinic, HC, PHC or CHC (PHC & SHC may meet here) – responsibility of the lowest level of public governance • Secondary health care as level of health care that covers all that any well functioning state should provide for its people – usually 80 or more % of the diseases found in the place and presenting promptly for such care - at all sorts of hospitals right up to regional ones – responsibility of states/federating units

6. PHC & peoples’ problems with it – especially Nigerians • Sounds so simple that everybody thinks that s/he knows everything about it • Yet Nigerians have NEVER seen it practiced anywhere and just keep regurgitating their daydreams about it even with all the failures of all their pasts in it staring them in the face! • Agreed since 1978 as the only basis for going to achieve health for all in any country • Formal health services contribute only 25% of Health • Only 25% of people who need clear/formal health care go to physical health facilities (90% balance!!!)

7. PHC as the ideal community health care • Community health care as health services given to people where they live and work • Ideally is disciplinary, statutory and ethically holistic; both of persons, diseases and health; in clearly defined communities all of the time and professionally; & until ALL the communities are served! • The key person & producer of PHC/HFA is the district or zonal/area community nurse-midwife but supportively coordinated and lead by the statutory community physician for the entire D/LGA – as A PROPER Medical Officer of Health!

8. Delivery of PHC services 1 • Begins by statutory demarcations and totally covered assignment of professional personnel • Auxiliaries of the nurses and physicians only for places “where there are no such nurses or doctors” – i.e., where such professionals are unable to be found for. Auxiliaries do not have Councils created for them!!! • Actual professional jobs delegated to the auxiliaries by very specific individual protocols for such diseases; not an ‘akampo’, “Mr. do all” as in the Nigerian “Standing orders”!

9. Delivery of PHC services 2 • Work starts by a de-jure census of his/her statutory community and the establishment of all the denominator populations for all the services involved in the (P)HC services; establishment of all the at risk people, their at risk registers, home care nurse family members and life-long health care plan. • 3 days-a-week community health rounds, primarily of the at risk people but also oversight on EVERY other health and related matters in the community such that at the minimum two rounds of the statutory community is completed yearly

10. Delivery of PHC services 3 • Early and late of each of the 3 community health rounds days are used for emergency health care only; the mornings of the other 2 working days per week are used for the integrated preventive, curative, promotive and rehabilitative health care of the statutory community (with some window for the external vertical public health candidates) and the afternoons primarily for the record updating of the services. Good salaries and field costs paid very promptly and above all else. • This situation is slightly different for zonal/area community health nurses who are usually 2 or more and may have other clinical nurses and midwives at the PHCs or CHCs that they are based.

11. Delivery of PHC services 4 • Obviously only countries which are unitary, proper federating units and responsibilities, social justice and equity, minimal corruption, respect of the people and good governance can have PHC; FUs must be viable, well governed; and take responsibility for all the social needs of her citizens • In contrary countries the best effort (usually through institutes of PH & CM) may only expect to establish one or two small or moderate models of such a thing as a prophetic sign for such country’s peoples – either ways.

12. What PHC is not • It is NOT “Primary Care”, Primary Medical Care, Community-oriented health care or outreach health services. The latter two are community-foraying vertical public health services which even though sometimes useful are most times abusive and problem creating for authentic Community/PHC. PHC is Bottom-up CH but not mere PH! C-OHC vs CHC using cataract services! • Parts of “PC” and/or PMC are one of the minimum components of essential PHC; but full-blown “PC” or PMC as medical specialization (with the “all essential surgeries” involved as specialist GP) is the heart of the SHC system. In sociologically and technologically advanced countries, they would invariably seem to serve same purposes for them as PHC, but not quite completely! See Lord Dawson’s Report of the UK, 1920 and its eventual implementation in the British National Health Act, 1948 and aftermath CGMP, etc.

13. The 6 broad (sine-qua-none) principles of PHC • Political will at all levels of human community • Orientation of health professional and institution to PHC • Intra-sectoral and inter-sectoral integration and cooperation • Community mobilization and involvement up to self ownership and self-reliance (++++++++) • Appropriate technology for PHC • New management methods, including new cadres of (auxiliary) health workers as needed

14. Illustration of PHC using Oyo State • MoH for every of the 31 LGAs but not merely replacers of the PHCCs for corruption & “cooperation” with the LGA chairman, etc • Proper supplies and CoS, including drugs, housing, transportation, annual accounting meetings with LGA professional report in March • Statutory division and staffing for effective and properly supplied CN-M • CHOs and CHEWs for only where the respective professionals cannot be found but with their regular oversight and supportive visits and assisted care

15. The actual deterioration in PHC over the years in Nigeria • Remember all of Ibadan and the follow-up “1st generation medical schools” all tried to practice C/PHC as it was understood then; what about now? • NYSC in our time (from the beginning) up to about mid 1985 when I also supervised it in old Gongola State and its nature; contrast now! • The effects of security allowance, constituency allowance, etc; “one of many LGAs that I know”. • What of here? The endless story!

16. Asuzu 1: Mobile community health service in Ankpa LGA 1978, Nigeria

17. Asuzu 2: Pictures of community health day at a village in the Fiji Islands 1999

18. Asuzu 3: Pictures of community health day at a village in the Fiji Islands, 1999

19. Asuzu 4: Pictures of community health day at a village in the Fiji Islands, 1999

20. Secondary health care 1 • SHC as all the essential clinical medical and health care that a state ordinarily owes its citizens if the health system is properly organized and the people avail of the services as their earliest needs for it; should cover 80% or more of the diseases seen in such a country because even with such best organizations, some people will still not attend the services as needed until they had developed beyond normal care. • It is the primary responsibility of the federating units/states in a federal government • PC, PMC, SGMP or family medicine is the heart of it

21. Secondary health care 2 • May be practiced from cottage to district to general hospitals as the heart thereof, but also to regional or provincial hospitals where generalist single organ system or population group specialist doctors may also be found. • Non-federating nations (i.e., small countries) may then need to build a national tertiary hospital for the rest of their tertiary medical problems; or they become the primary responsibilities of the federal governments in large and federating nations.

22. Problems of SHC in Nigeria • While the problems of PHC in Nigeria are of many aetiologies with the worst being that of ignorance that problem of SHC is more of the political matter of lack of nationhood and political corruption. • Where there are much noise and many activities largely of the wrong types in PHC at least, in SHC, there is simple deadly silence and “siddon-look” • This is what has produced for us in Nigeria, a health care system of staff, facilities and activities that yield the “ugly hour glass” syndrome of a larger upper triangle emptying into a smaller lower triangle with easily predictable outcomes!

23. Some funny Nigerian issues with PC • Squabbles in the medical schools with community physicians who do not know what the specialty is and so afraid of family medicine and family physicians who confuse the entire issues and create trouble all over the place; hence resistance or even rejection in many schools – by community physicians, surgeons, etc. • The AFPON vs AGPMP issues and no desire for state government service or even education, challenge, engagement of same in the interest of the SHC services

24. Quo vadis? 1 • Can we produce a country where the medical doctors understand the nature of their profession, its ethics and grandeur and respect it themselves? • Can we produce a country where the medical doctors understand the need for, the importance, peculiarities and special needs of their various specialties and protect and work for them all, irrespective of their various narrow or wide specializations and practice settings?: PH is all of us in the public services; surgeon-generals at national & state levels, MoH at every LGA & the appropriate nurse-midwives (& “the others) as appropriate?

25. Quo vadis? 2 • Can we produce a country where medical doctors are aware of the negative and very destructive interests in the health professions, their contribution to its worsening, repent of it and become positively and non-partisanly political enough to stem the tide and repair the enormous damage already – only 4 councils in the health sector – medical & dental, nursing & midwifery, pharmacy, and “health professionals, only; real medical and health TEAMS everywhere as needed; clinical pharmacy vs clinical pharmacology; pathology and medical laboratory services; etc.

26. Quo vadis? 3 • Can we produce a true federating nation of mutual respect and universal nationality in this country? • Can we reduce the cost of governance (No of political offices, security allowances for only a few, constituency allowance for non-executive political persons, etc), tribalism, corruption, do-or-die political brigandry and impunity & inherent disrespect for the polity; so that there will then be money, accountability, social justice necessary for the ideal country of our heritage?

27. Thank you for your esteemed audience!