THE NEW HEALTH HIERARCHY

The Fourth National Development plan (1981- 1985) addressed the issue of preventive health services for the first time.

The policy statement contained in this plan called for the implementation of the Basic Health Services Scheme (BHSS), which provides for the establishment of three levels of health care facilities; namely 1) Comprehensive Health Centers (CHC) to serve communities of more than 20, 000 people; 2) Primary Health Centers (PHC) to serve communities of 5000 to 20, 000 persons; and 3) Health Clinics (HC) to serve 2000 to 5000 persons. Thus, a CHC would have at least 1 PHC in it catchment area (ideally 4) and a PHC would have at least 1 HC in its catchment area (ideally 2). These institutions were to be built and operated by state and local governments with financial aid from the federal government. By this policy, the provision of health services would be the joint responsibility of the federal, state and local governments. In its outlook, this policy is not different from the one published in 1954 by the Eastern Nigerian Government previously mentioned.

Nigeria is currently made up of 36 states and over 500 local government areas. Each local government area (LGA) is made up of between 150, 000 to 250, 000 people. By the scheme proposed in the Fourth National Development plan, each LGA would have a minimum of 7 PHCs and 30 HCs with at least one CHC at the apex of the health care services. The larger LGAs would each have, at least 12 PHCs and 50 HCs feeding into one or more CHCs.^[4] Nigeria has not come close to achieving this lofty objective. As a matter of fact, services that existed were deteriorating hopelessly, leading to various industrial actions by all classes of doctors in the 80's. This has continued even today.

On the last day of 1983, a new Military Government came into being in Nigeria and one of the reasons it gave for the Military intervention was the state of health services, declaring "our teaching hospitals have been reduced to mere consulting clinics." One of the government's first efforts was to revise the Fourth National Development Plan. The health strategy under this revised plan gradually shifted emphasis to primary health care. Although this has always been the ultimate goal of the plan, the political will did not seem to exist for its implementation. The adoption of the WHO target of Health for All by the Year 2000 by the federal government was marked by shifts in emphasis and structural changes in health care administration.

At the federal level, the Directorate of National Health planning had the function of coordination and implementation of the national health policy. It also had the function of developing plans for national health. At the state level, were state health advisory councils whose function it was to give general advice to the Commissioner of Health in the performance of his functions. At the local government level, the State Ministry of Local Government in consultation with the State Ministry of Health established Local Government Health Committees covering their area of authority for the purposes of formulating policies for providing health services to the communities. At the community level, several small communities had evolved small community primary health care services with active community participation.

In more recent Nigeria, this lofty goal has not been achieved. The capacities of the facilities that emerged from previous efforts have been stretched and infrastructure broken beyond repair. Primary health care services now exist only in name. The common man has reverted to the herbalist and traditional healers for care because of access and affordability issues. The elites have perfected medical tourism to India, Singapore, South Africa and even Ghana. This is in the face of a rapidly changing disease patterns in which infectious diseases have been replaced by behavioral, environmental and poverty-related diseases.

The record shows that in 1979, there were 562 General Hospitals, 16 Maternity and Pediatric Hospitals, 11Armed Forces Hospitals, 6 Teaching Hospitals and 3 prison Hospitals and they all accounted for 44, 600 hospital beds. In addition to these, there were estimated 600 Health Centers, 2740 General clinics, 930 Maternity Homes and 1240 Maternity Health Centers. By 1985, 13% of the hospital beds were provided by 84 Federal Institutions while 47% of the hospital beds were provided by 3, 023 hospitals owned by the State Governments. The rest of the beds were provided by 6331 health facilities owned by Local governments ( 11% of the beds) and 1, 436 private hospitals ( 14% of the beds).