Imagine a country without a health system; imagine the chaos, and inefficiency. In such a setting, the only form of health systems research necessary would be to generate evidence towards achieving universal coverage. Research will not only be about which interventions work, but where and how the interventions would be most optimal. Indeed, if we push our understanding of what constitutes a health system to include its ideals, it becomes clear that the thought experiment is not quite so far-fetched. Especially ideals which according to the WHO include improving population health, protecting people from the cost of ill-health, providing health care with fair treatment to all.
The world is at a watershed, on the brink of monumental change in what constitutes health care and life in general so much that the absence of health systems may even be desirable. To combat the challenge of non-communicable diseases (NCDs), we may even want to wish away current health systems altogether. Factors that are changing the way we perceive life and health include communication with internet and mobile connectivity, population ageing, the shift from acute and inpatient care to long-term care, and management of risk factors instead of disease states in themselves.
The new paradigm for service delivery, a shift from infectious disease of earlier centuries, will be self-management, risk factor management (hypertension, diet, inactivity, tobacco, alcohol), chronic disease and comorbidity. The question then arises as to how we may build a health system for the 21st century. This makes the thought experiment of a country without a health system necessary: it sets the mind free for uncluttered imagination and allows one to think as if one is building afresh.
The non-health components of society alongside how they might help support a health system are factors that come readily to mind when one thinks about a non-existent health system. In the case of Nigeria, two prescriptions presented themselves: the potential roles of mobile phones and patent medicine vendors in strengthening primary health care. In an email that challenged them to make suggestions as if Nigeria did not have a health system, I asked my old medical school classmates what to say about how we might improve the Nigerian health system. The suggestions were mostly about the need to strengthen primary care, and increase access to health care, especially for the poor.
There is a revolution sweeping through Nigeria with mobile phone use, which rose exponentially in both rural and urban settings following its introduction in 1999. Nigeria has one of the fastest growing mobile phone markets in the world. Mobile phones have had immense impact on economic and social life, but their potential benefits in health care delivery have not been investigated. The research challenge in Nigeria is to study how we may structure our health system to facilitate universal coverage based on remote consulting.
NCDs management struck me as particularly amenable to this technology. For example, the increasing prevalence of cardiovascular diseases in sub-Saharan Africa results in a large number of patients presenting as emergencies, owing to poor access to health care due to cost, distance and poor self-monitoring (1). It is important that we look at how to explore the use of mobile phones to collect population level data on NCDs risk factors and investigate the potential of remote consulting with mobile phones following self-diagnosis and monitoring (e.g. of blood pressure and blood glucose level). This may help provide cost-effective alternative strategies for managing risk factors and to prevent avoidable emergency presentation, improve care for remote patients, reduce patient load in primary care and in primary care nestled within tertiary centres.
Research into adapting trends in communication, information and health seeking behaviour, to maximise access is an imperative. Presently, about 70% of the health budget in Nigeria goes to hospital and tertiary care, but few hospitals serve a huge population of about 150 million. Hospitals are often overstretched from overcrowding by out-patients with NCDs and in-patients with fatal but avoidable emergencies. One way to address this is to harness the capacity of patent medicine vendors for primary care as highlighted in a Nigerian newspaper article: “Some of the pharmacies (read patent medicine vendors) have served their neighbourhood long enough that they are now trusted sometimes more than hospitals” and “their proximity makes them the doctors next door.”
There is at least one drug shop in every three streets in Nigeria, trusted outreach facilities where trained health workers could be made assessable to people at no extra cost. Many children die of malaria because of late presentation after three to four days’ consultation at the “Pharmacy” without improvement. If people have structures and systems to which they have grown to be loyal and accustomed, we must opt to build health systems around them.
It is safe to assume that every country has a health system, no matter how dysfunctional. But it is also true that when held to high standards, only few would measure up. The challenges of health are now global, and the theatre of research activity for building the 21st century health system should be the poorer countries of the world. For rich countries, ossified tradition is a major obstacle to research for change. The challenge is upon us to see with new eyes, and to think as if we were indeed blessed with a virginal, unpainted health care landscape with the task of building systems from scratch.
Really, if there wasn’t any health system in place, and we had to create something anew, in what ways do you think the new system would differ from the present? I look forward to your suggestions and ideas.
Seye Abimbola was BMJ Clegg Scholar in 2007 and is currently a research fellow at the National Primary Health Care Development Agency, Abuja, Nigeria.
This article is part of the “Emerging Voices for Global Health” programme at the Institute of Tropical Medicine, Antwerp, Belgium, and supported by the Belgian Development Cooperation (DGD). For more detail follow this link.
(1) Bertrand E, Muna W, Diouf S, Ekra A, Kane A, Kingue S, et al. Cardiovascular emergencies in sub-Saharan Africa. Archives des Maladies du Coeur et des Vaisseaux 2006;99(12):1159-65.