Seye Abimbola on what Nigeria could learn from China’s healthcare system

seye_abimbolaThe look of surprise, bordering on cynical incredulity, was still there on the face of my fellow Nigerian “emerging voice” as our Chinese counterpart finished up his presentation introducing the Chinese health system during the 2012 emerging voices training programme in Beijing. He raised his hand to ask a question and I knew what it would be.

“How did China manage to increase skilled attendance at birth from 45% in 1990 to 95% by 2008? We’ve been trying to do that in Nigeria, but going by the last national survey in 2008, only 40% of our pregnant women are delivered by skilled attendants. Our strategies are not working because it is difficult to disengage women in rural areas from traditional birth attendants. How did China do it?”

The Chinese “emerging voice” then repeated what he had said during his presentation: that the increase in skilled attendance at birth was due to a change in policy and that once the central government made it policy for every delivery to be conducted by a skilled attendant in a health facility, the people complied. He hinted at the sometimes marked rural-urban differences, and explained that in the “most remote rural areas” skilled attendance at birth in 2008 was 60%, having increased from low level of less than 10% in 1990.

My Nigerian colleague and some others from East Africa were visibly dissatisfied with the answer, so I joined them on the way to lunch to offer another explanation, or indeed the same explanation, but differently. “It is different in China,” I said. “Here all the government needs to do is decide what it wants for the people, and make it into national policy. The central government directs, the subnational governments implement, and the people largely comply. There isn’t much of a choice.”

A few days later, I made a presentation at the emerging voices pre-conference on how the origin of health policies deserves to be a main focus of health systems research, if we are to really take seriously our knowledge translation ambitions. Just as Sancho Panza said in Cervantes’ Don Quixote, “in the matter of government everything depends upon the beginning.”

Unlike what I had started to think about China, my plan was to argue that once policies are made, it is difficult to change them. I was going to meditate on the question of how change happens to deeply entrenched institutional arrangements. Nigeria is an example of a well designed and deeply entrenched, but dysfunctional system. I started to wish we were like China, where changes in policy are not as complicated, and where once the change is made, the effect is far reaching.

I began to think that China and the United States of America were at two extremes: it took forever for the United States government to pass the Affordable Care Act, but I reckon that China would do that pretty much overnight, if the government wanted it. I thought the United Kingdom was somewhere in between, but closer to China; after all it wasn’t much trouble for the coalition government to approve a controversial restructuring of the National Health Service in England, through the Health and Social Care Act, in spite of little support from the public and professional groups.

What was distinct though about China is that in spite of their relatively lower level of development, the policy of a central government percolates through to the grassroots to restructure the institutional arrangements around health service uptake. I began to wonder how we could possibly achieve that in a country like Nigeria, where the decentralisation of essential services means that responsibility for primary healthcare is largely left to non-viable states and local governments, which depend on funds from the federal account, but are free to allocate their funds as they like, without accountability mechanisms between tiers of government.

The national government in Nigeria has little or no powers to compel the federating units to effect any policy direction, much like in the USA. But unlike the USA, the federating units of Nigeria generally lack the capacity to plan and manage primary healthcare. This fragmented system results in wide variations in health outcomes, the most striking of which is that maternal mortality is about ten times as high in parts of northern Nigeria compared to parts of southern Nigeria. Of course, this system would have worked quite well if two assumptions were true: 1) if communities are active in demand accountability and social services; and 2) if the commitment and technical capacity to understand and manage primary healthcare exists at every level of government.

Naturally, thinking about the Chinese health system, I wished that we could have a similar command structure of health system governance in Nigeria with effective top-down control and have a system where local health outcomes do not only depend on local realities, but can respond to central initiatives. Unfortunately, this is unlikely to happen except in a dictatorship, a high price to pay, I would wager; and who says the dictator will be benevolent? Whatever the case is, there is always a price to pay—to suffer the indignity of lack of choice or to enjoy freedom, with its attendant costs.

Nigeria’s ongoing experience also suggests that democracy may not hold the key to our redemption in the short or medium term. We can only hope that people and communities become active in the provision of their own public services, including primary healthcare. For the next few years, my focus will be to study how communities are able to restructure institutional arrangements for the uptake of health services in low income settings. I made my choice already; change must come from the bottom up, or not at all. China may yet have its own bottom up change coming.

Seye Abimbola was BMJ Clegg Scholar in 2007 and is currently a research fellow at the National Primary Health Care Development Agency, Abuja, Nigeria.

The author is part of the “Emerging Voices for Global Health” programme of the Institute of Tropical Medicine, Antwerp, Belgium. For more detail follow this link. The views of the author are solely his and not of any affiliated institution.

  • Benin is close to Nigeria and we share a number of realities. So some of these lessons are largely available for Benin also. Thanks Seye.

    The balance between the democratic thinking in Benin(counfonded sometimes to a “XXL” freedom) and the urge need to respect law, principles, governments decisions and values, this balance I said is a crucial question. Many researchers and policy makers try to avoid this complex and “taboo” issue. But we must start now to think about: what kind of democracy is suitable for a good health system in a Low income countries like Benin?

  • Olayinka Ayankogbe

    Interesting piece from Seye there on dreaming about Nigeria in Chinese. I urge him to dream more. His dream might just come to pass not only in his country but in the other countries he mentioned. And if he wants to dream strategically, let him collect the real bottom up evidence in his research that will inform his future dreams. Seye, welcome to the world of dreamers! Keep dreaming brother. Like Martin Luther King, your dream might just come to pass!

  • Joseph Ana

    Dear Seye, Thank you for your interesting contribution. I have the following to say about it:

    Nigeria, in many many socio-economic-political matters is an enigma, which is fed by the lower and detestable extremes of human attitude, behaviour, level of economic development and education (mind you I say education not literacy). Most of Nigeria is in denial of the status quo, which is fed by the tiny minority of parasitic gluttons. Like China, Nigeria had a dictatorship for almost 30 years of its 52 years of independence, but unlike China the dictators were so-self centred and destructive, that they never embarked on the market economy change that has seen China rise to the second largest economy in the world in less than two decades. Nigerian dictators created and entrenched the worst excesses that its citizens are suffering today – Nigerians are like the proverbial ‘man in the water, yet soap enters his eyes’.

    Nigeria operates no health care system in the real sense. It can’t even pass (or sign) a health bill because of all the fault lines in the country: ethnic religious, economic, and now professional!

    The distinction or description of tertiary, secondary, primary health care in Nigeria is on paper. In reality, there is hardly much difference if you attend any of these artificial tiers. Yes, there are specialists in tertiary and some secondary tier facilities, but that actually is where most of it ends. Every tier lacks the basics to deliver its mandate for sick Nigerians: the lack of water, light, cleanliness, effective infection control measures, rampant irrational drug and commodity use, lack of information resources centres (libraries), lack of equipment for emergency and non emergency care, and little or no enforcement of ethical practice, cuts across all three artificial tiers. That is the problem that we all should be addressing, if we want to make positive and measurable change happen in Nigeria’s health care outcome.. If we want to reduce / eliminate the outcome variation across the country.

    The new National Health Bill has just passed the second reading in both houses of the National Assembly. Next it goes to public hearing and then the third reading and passage! Hopefully this process will not become an exercise in futility like the last one, when Mr President Goodluck Jonathan refused to assent to a bill that took seven years to pass through the National Assembly. He allowed the discretionary assent time to evaporate, and then sent the unsigned bill to the Assembly. Yet Nigeria and DR Congo are alleged to be stalling the eradication of Malaria (WHO) and Nigeria, Pakistan and Afghanistan (at war) stall the eradication of Polio.

    First, Nigeria needs a Health Act to define a health system before we can begin to compare it with any country, be it China, UK or USA.

  • Oluyombo Awojobi

    “The persistence of Nigeria’s problems is not caused by lack of the knowledge of their solutions. It is often due to he DISSOCIATION OF THEORY FROM PRACTICE. This is the case in health.

    “The National Health Policy was launched in 1988. It adopted sound internationally accepted principles and adapted them to solve the health sector problems of Nigeria. It was acclaimed by the world as a good blueprint for delivery of first class health care in a developing nation, and requests for copies came from the four corners of the world. Attempts to implement it were seriously made in the first four years during the leadership of the late Olikoye Ransome-Kuti, the then Minister of Health. But, by the time he left office, it had not yet properly taken root. Despite the Primary Health Care Development Agency which he later returned to head, the Federal Executive Council had lost the missionary zeal he had earlier injected into its implementation, and his further efforts, he confided in me, met with several frustrations.

    “Nigeria’s health status is deplorable. The revised health policy document admits that preventable diseases account for 70 per cent of Nigeria’s disease burden and that poverty is a major cause of these problems. It admits that our maternal mortality of 1 per cent is “one of the highest in the world,” that some of our health indicators, such as the under-5 and adult mortality rates are higher than the average for sub-Saharan Africa.” – Prof S K Gyoh.

    When will Nigerians have the political will to adopt the health care delivery as enunciated and practised in Ibarapa since 1963?