Chapter one
Introduction

1.1 Background of the Study

Health is an important indicator to measure development. It is indeed a prerequisite for development. No society can develop if the health of its population is poor. Therefore, any nation that seeks to develop should pay attention to health issues. Good health is one of the fundamental human rights everybody is entitled to enjoy. And the burden of proof is on the health care system to provide health services in the three levels of government (federal, state and local government). A health system can then be seen as an organization of people, institutions and resources that provide health care services to meet the health needs of target populations. The planning of the health system , and should be distributed among market participants , governments , trade unions, charities , religious or other organizations coordinated to provide planned health care services targeted to populations ( Frenk , 2010). Clearly, health has been included in the transformation program of the outgoing government of Nigeria. Then government officials hailed their own efforts and achievements in relation to the agenda of transformation while public opinion differs strongly. Although, a transformation took place in the health sector, but it is not quite clear to the general public especially those in rural areas, because it is negligible. Therefore, the delivery of health care is still considered by many as the poor.

Primary health care service has become a dream come true for the first time in Nigeria in 1975 when Yakubu Gowon, Nigeria leader announced the Basic Health Services Program (BHSS ) as part of the Third Plan national Development ( 1975-1980) . The program objectives were to increase the proportion of the population receiving health care between 25 and 60 percent, correct imbalances in the location and distribution of health facilities and provide the infrastructure for all preventive health programs such as control of communicable diseases, family health, environmental health, nutrition and other and establish a health care system best suited to local conditions and the level of health technology (Sorungbe, 1989). The goal of primary health care (PHC) was to provide accessible health for all by the year 2000 and beyond. Unfortunately, this has not yet been reached in Nigeria appears to be unrealistic in the next decade. The SSP aims to provide people in the world with the basic health services. Although the PHC centers were established in rural and urban areas in Nigeria with the intent of fairness and easily accessible, unfortunately, the rural population of Nigeria are underserved compared to their urban counterparts.

In addition, the Nigerian national plans, commitments and programs in recent decades have reflected the government understands that the basic health of Nigerian citizens is essential for growth and prosperity. While total per capita health spending has not increased proportionally to the growth of the country’s GDP, it has nevertheless increased 103 % from $ 102 in 2000 to $ 207 in 2013. The financial barriers to care seems to decrease ; the percentage of women who reported problems accessing care because of cost , for example, fell by 56% in 2008 to 42 % in 2013. However, it was noted that the provision of health care in Nigeria is a concurrent responsibility of the three levels of government in the country. The federal government has the onerous functions for the direction of policy, planning and technical assistance, coordination of implementation at the state of the national health policy and establishing systems of health management information systems. Moreover, the federal government reserves the right to disease surveillance, drug regulation, vaccine management and experts in the training of health. The federal government also coordinates the business of education, psychiatric and orthopedic hospitals and also manages some medical centers.

In Nigeria, the delivery of health care cannot be discussed without a proper understanding of the national health care delivery strategy. The provision of health services is the responsibility of federal, state and local and religious organizations and individuals (National Population Commission, 2000). This means Nigeria operates a three-tier health care system. The first level is the tertiary health care is in the field of both federal and state governments. This level of care provides highly specialized reference services to both the first and second levels (primary and secondary) health care delivery system. The second level is in the area of ​​state governments. It is the secondary care. It offers specialized services to patients referred by primary health care. The third level is the primary health care. This is in the area of ​​local government, but with the support of the Ministry of Health. It essentially provides health care for people at the base. Over the years, the national government has developed several policies and programs; all aimed at improving health care services in the country. The Fourth National Development Plan (1981 – 1985) established a government commitment to provide adequate and effective primary health care was promotion, protection, prevention, repair and rehabilitation of the entire population by the year 2000. Consequently, the Nigerian government in 1988 adopted a national health policy to provide a formal framework for the management of the country’s health system (Obionu, 2007). The policy was approved by the military to power in 1987 Governing Council and launched in 1988. Its objective was to provide the population with access not only to primary health care, but also secondary and tertiary care, as required by a functional reference system. It was revised in 1997. The revised national policy includes related policies of the major health problems such as health management information against HIV / AIDS, malaria, tuberculosis, reproductive health, etc., Clearly, primary health care has become a major component of the national health policy. In fact, current national health policies for primary health care as framework for achieving better health for the population. With this focus, we can say that the national health policy becomes aware of the health needs of both urban and rural peoples.

However, facilities management and health programs is a function shared by the ministries of health, recommendations hospital management of the state and local government areas. Specifically, the state governments run secondary health facilities (general hospitals), sometimes tertiary hospitals and primary health care facilities. The training of nurses, midwives, health technicians, etc. is the responsibility of the State. States also provide technical assistance and support to health programs and local government facilities. Local governments are in charge of the management of primary health care facilities in their areas of competence. The 774 local governments in Nigeria in specific terms ensure the provision of basic health services, community health hygiene and sanitation. The deplorable situation of the public health system in the country has led to the emergence of private health sector as well as traditional and spiritual healers.

The general health status in the country was found to have fallen below the standards of the WHO agreed. According Oyebanji (2013), the state of health in Nigeria is deplorable. He argued that the most common diseases in Nigeria are malaria, Guinea worm, pneumonia, measles, gonorrhea, typhoid, tuberculosis, chicken pox, diarrhea, polio and more recently AIDS. He said that while cases of significant diseases were about 1.78 million in 1991, this figure rose to about 2.06 million by 1995. According to WHO (2002), malaria, diarrheal diseases, vaccine-preventable diseases and acute respiratory infections are responsible for approximately 95% of morbidity and nearly 90% of mortality in children under five in Nigeria. WHO (2014), said that malaria accounts for 30% of infant mortality. He added that AIDS, lower respiratory infections and diarrheal diseases are among the leading causes of death in the country. According to the report, the most recent figures for maternal mortality and under-five child mortality is 630 per 100,000 live births and 124 per 1000 live births respectively. There are large disparities in health status across the states and geopolitical zones in Nigeria. Etiology of the disease is linked to social determinants such as socioeconomic status, education, gender inequality, and poor access to water, sanitation and hygiene (WHO, 2014).

The poor state of Nigerian healthcare system is generally attributed to several factors such as organization, leadership, infrastructure, financing and delivery of health services (Federal Ministry of Health, 2000). The above problems have been compounded by other socio-economic factors and environmental policies.

Similarly, Umeha (2015: 1) succinctly presented the problems of the Nigerian health sector in the following lines – They range from the lack of funding by the government, which are reflected in the inadequate or in some cases, lack of equipment and facilities in hospitals across the country, unhealthy rivalry between the doctors and other professionals leads to a lack of industrial harmony to the brain drain. Some analysts say that the area was literally brought to their knees by international professional quarrels and fighting for supremacy. While doctors say that, by virtue of their training and responsibilities, they are the natural leaders of the sector, other health care workers, including nurses, pharmacists, laboratory technicians / technologists, radiologists and virtually all other members of the non-medical staff say the opposite. As this rivalry rages, the provision of health care is the worst for it. Another major challenge for the Nigerian health sector is the acute shortage of qualified health care providers. This ugly situation is usually due to inadequate infrastructure and poor remuneration. The Federal Ministry of Health (FMOH) lamented that the major challenge its ugliness is how to ensure the availability and retention of adequate pool of skilled human resources. The shortage of health workers were widespread, health professionals and other service providers are inadequate; the unequal distribution of skilled health workers deprives a large number of services and the migration of health workers exacerbates the situation of health (FMOH, 2007). In a related development, there is a challenge of appropriate incentive schemes for health personnel.

This largely gets frustrated and therefore, a negative impact on productivity. In most cases, the unmet health workers show an ugly behavior which include among others –

• Lack of courtesy to patients.
• Failure to turn up at work on time and high level of absenteeism.
• Failure to conduct proper patient examination and failure to treat patients in timely manner (Nnamuchi,

2007).

In 2000, according to World Health Organization (WHO), the performance of the overall health system in Nigeria was ranked 187th among the 191 positions of the Member States. Primary Health Care (PHC), which is the basis of the national health system, remains in a coma due to gross under funding, mismanagement, corruption and lack of capacity at local government level.

Nigeria as a country has a pluralistic health care delivery system (delivery orthodox and traditional health care systems). Orthodox health care services are provided by private and public sectors. However, the provision of health care in the country remains the functions of the three levels of government: federal, state, and local government. The primary health care system is managed by 774 local government areas (LGA), with support from their respective Ministries of Health State and private medical practitioners. The secondary health care system is managed by the Ministry of Health at the state level. Tertiary primary health care is provided by teaching hospitals and specialized hospitals. The secondary and tertiary levels, are also working with volunteers and non-governmental organizations and private practitioners (Adeyemo, 2005). In 2005, the Federal Ministry of Health (FMOH) estimated a total of 23.640 health institutions in Nigeria, of which 85.8% are primary health care, secondary and tertiary 14% 0.2%. 38% of these facilities are owned by the private sector, which provides 60% of health care in the country. Despite the availability of this large number of health facilities and the progress of technology in the health sector in Nigeria has witnessed various turbulent assisted with negative effects. As stated Obansa and Orimisan (2013), with the teeming population of the country now more than 150 million, it is still dealing with the provision of basic health services. And according HERFON (2006), health facilities (health centers, staff and medical equipment) are insufficient in the country, especially in rural areas. Of course, that clearly explains the high rate of maternal mortality in children, and even adults over the years.

Nearly fifteen (15) percent of Nigerian children do not survive to their fifth birthday. The main causes are malnutrition representing fifty-two (52) percent of deaths, the malaria thirty (30) percent and diarrhea twenty (20) percent (Federal Ministry of Health [FMOH] , 2004). Maternal mortality is reported to be extremely high. In 2008, between 3 million and 3.5 million people were estimated to be living with HIV / AIDS. Nigeria has the fourth largest number of TB cases in the world, with a 2004 estimated 293 new cases per 100,000 and 546 per 100 000 Total number of cases (Obansa&Orimisan, 2013). Another key issue related to health indicators in Africa is poverty and Nigeria, the incidence of poverty is widespread. Between 2003 -2004, a household survey was conducted by the government and the results showed that 54.4 percent of Nigeria’s population is poor, with a higher poverty rate of 63.3 percent in rural areas. More than half of the population lives below the poverty line, on less than $ 1 a day and so cannot afford the high cost of health care (HERFON, 2006).

In the Ward Minimum Health Care Package [WMHCP] (2001); Global Health Initiative [GHI] (2010 – 2015) and the National Strategic Health Development Plan [NSHDP] (2010 – 2015) the under listed visions to sustain the Nigeria health care system were projected:

• Attainment of Health For All Nigerians through the Primary Health Care
• Strengthening the national health system through the primary health care (PHC) approach
• Increasing economic productivity
• Sustaining national development and gender equality
• Improving access to commodities
• Strengthening partnerships and research for health as the building blocks of a functional health system

1.2 Statement of the problem

Regardless of taking steps to prioritize and improve health care, however, and has experienced unprecedented growth over other lower middle income countries of the region, the health outcomes at the national level in Nigeria are relatively poor. For example: While Nigeria’s under-five mortality rate has improved since 2000, it nonetheless remains very high (at 109 per 1,000 live births in 2015). The median U5M rate in sub-Saharan Africa is 80, and the Sustainable Development Goal target is <25 U5M rate by 2030. Adult mortality from non-communicable diseases in Nigeria has remained largely unchanged in the last decade; it was 22% in 2000 and 20% in 2012. DPT3 immunization coverage of 66% in 2014 falls well short of the 90% coverage the UN called for during its 27th Session).Women receiving the recommended four antenatal care visits declined 5.5% from 2011 to the 2013 rate of 56.6% – far from the SDG target of universal access to reproductive health care services.

It is expected that More worrying is the poor overall performance of the healthcare system in Nigeria, especially compared with other less affluent countries in Africa. For example, in 2005, Uganda has allocated 11% of its total budget to health care, while Nigeria, in 2006, only 5.6 % budgeted. Despite its high percentage of HIV + citizens, Uganda was ranked 149 of 191 countries and 39 came ahead of Nigeria to 187/191 in the 2000 World Health Report.

Low level of health care spending per capita in Nigeria seems to exclude it short of the SDGs 4 and 5, wherein the effective implementation of the strategy IMNCH require a greater commitment from all levels Nigerian health care system.

However, Obansa and Orimisan (2013) identified the following among others as factors that affect the overall performance of the Nigerian health care system: Inadequate health facilities/structure; shortage of essential drugs and supplies; Inadequate supervision of the healthcare system; Poor human resources, management, remuneration and motivation; Lack of fair and sustainable health care financing with very low per capita health spending; Unequal economic and political relations; The neo-liberal economic policies of the Nigerian state and corruption; High out-of-pocket expenditure in health by citizens and Absence of community-based integrated system for disease prevention, surveillance and treatment . It has become very necessary to reflect and propose plans and strategies that Checkmate the above mentioned factors militating against effective health care system in the country. Obansa and Osrimisan (2013) highlighted some strategies among others that will help meet the challenges of the health sector in the country as follow:  improved access to primary healthcare; Strategic and purposeful leadership in health delivery services; Increase fund to manage the health sector

The abject failure of public health care system in Nigeria has led to comments and criticism from local and national levels. The provision of adequate health care services for citizens, especially those residing in rural areas left much to be desired. Despite the propaganda of the media and the current reforms of the health sector by the government, the public health care system in Nigeria is still inefficient in all ramifications. It is therefore argued that the problems faced by the public health care system in Nigeria could be attributed to poor implementation of the national health policy and other health-related policies and programs. In addition, the implementation of national health policy and the ongoing reforms in the health sector are called upon to solve the perennial problems inflicting the development of public health care in Nigeria. The study further argues that it is only when the government ensures that health is regarded as the right of all citizens of the country, irrespective of status that the public health care system is said to be developed in Nigeria. It is obvious that poor implementation of health care policies and programmes is the major constraint to the achievement of desired goals in public health care provision in Nigeria, particularly at the local government level. For better improvement, the research suggests the need for political commitment as well as elimination of bureaucratic bottlenecks in public health care provision in Nigeria.

1.3 Aims and objectives

The study aimed at assessing the problems and achievements of the Nigerian health care system Specifically the study sought to:

1. Assess Nigerian health care system versus SDGs
2. Investigate problems confronting Nigerian health care system.
3. Establish possible measures to improve the trend.

1.4 Research question

• Does Nigeria’s heath care system achieve or about achieving the SDGs?

• What are the problems confronting health care system in Nigeria?

• What have the system achieved in the last 15years?

• How are other measures going to be used to improve health care delivery in Nigeria?

1.5 Research hypothesis

For the purpose of testing, the null hypothesis is indicated by Ho, while the alternative hypothesis is represented by Hi:

Hi:       Nigeria’s heath care system has achieved the SDGs

Ho:      Nigeria’s heath care system has not achieve but about achieving the SDGs

Hi:       There are major problems confronting health care system in Nigeria

Ho:      There are no major problems confronting health care system in Nigeria

Hi:       The Nigeria’s health care system has achieved so much in the last 15years

Ho:      The Nigeria’s health care system does not achieve so much in the last 15years

1.6 Significance of the study

Health care systems are designed to meet the health care needs of target populations. There are a wide variety of health care systems worldwide. In some countries, the health care system evolved and was not expected, while in others, a concerted effort was made by governments, trade unions, charities, religious or other organizations coordinated provide planned health care services targeted to the populations they serve.  However, the result of this study will help the government reform health sector programme as well as passage of National Health Bill before the National Assembly to enable Nigeria to successfully revamp its primary health care system and implement the integrated Maternal, Newborn and Child Health (IMNCH) strategy and move closer to achieving SDgs 4 and 5 so to lead to sustainability. The result of this work will also help in illuminating the implication of poor health care system in Nigeria so that most decision makers will understand the good prospect of tackling the issue. It is held that the scheme from this research will help the government as well as the health care providers improve the Nigerian health care system.

1.7 Scope of the Study

The main focus of our concern is the question if Nigeria’s heath care system has achieved or about achieving the SDGs. To have this done efficaciously, a serious assessment of the previous successes in Nigeria’s heath care system will be done, indicating out their achievements and gains, not forget the challenges surrounding the gratification. Since this research is aimed at assessing the problems and achievements of the Nigerian health care system, consideration will be paid to the measures going to be used to improve health care delivery in Nigeria as to keep away the unrealistic deed.

1.8 Limitations of the study

Challenges that may threaten this study are as follows;

• Fund to be able to appraise online materials
• Financial constraints in terms of typing the work
• Collection and retrieval of documents from records, libraries and even those from documentation.
• Time constraints due to other academic pressure

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