Health services include all services dealing with the diagnosis and treatment of disease, or the promotion, maintenance and restoration of health. They include personal and non-personal health services (WHO, 2010; Health Care Services) Health services are the most visible functions of any health system, both to users and the general public.
Service provision refers to the way inputs such as money, staff, equipment and drugs are combined to allow the delivery of health interventions.
Improving access, coverage and quality of services depends on these key resources being available; on the ways services are organized and managed, and on incentives influencing providers and users Health services are the most visible part of any health system, both to users and the general public. Health services, be they promotion, prevention, treatment or rehabilitation, may be delivered in the home, the community, the workplace, or in health facilities. Effective health service delivery depends on having some key resources: motivated staff, equipment, information and finance, and adequate drugs.
Improving access, coverage and quality of health services also depends on the ways services are organized and managed, and on the incentives influencing providers and users. A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction. And it needs to provide services that are responsive and financially fair, while treating people decently. (www. who. int/healthsystems/about/en/) SITUATIONAL ANALYSIS The poor state of health systems in many parts of the developing world is one of the greatest barriers to increasing access to essential health care.
However, problems with health systems are not confined to poor countries. Some rich countries have large populations without access to care because of inequitable arrangements for social protection. Others are struggling with escalating costs because of inefficient use of resources. Overall, there is a growing recognition that to maintain and improve the health of the world, governments must shape sound, efficient health systems that provide effective disease prevention and treatment to all women, men and children, no matter who they are or where they live.
WHO is committed to assisting its member states with that task. The current state of our health system in Nigeria is quite worrisome. Our Health indicators and statistics are abysmal. We are yet to make significant improvement in the area of maternal and child health; life expectancy at birth of our men and women falls below 50 years; doctor to population ratio is 3 per 10,000 compared to united States which stands at 26 per 10,000. Meeting the targets of MDGs in 2015 is still a mirage. The scourge of malaria, tuberculosis and HIV and AIDS is not abating.
Access to safe, emigration of health professionals, clean water in our cities and villages is to say the least, poor. The emigration of health professionals out of the shores of the land, regarded as brain drain is seen by many as a form of neo-colonialism by the west. Nigeria spends so much to train her professionals, especially medical doctors only to lose them soon after they complete their training programmes to UK, US and other European countries. Non-functional primary health care (PHC) system in the country which should cater for about 70% of health needs of the entire population has put good health care delivery to people in jeopardy.
In a country, where the quality of life is getting worse in the midst of rising national wealth, the national health statistics remain quite abysmal with life expectancy at birth at an all time low of 43 years. An examination of the three mortality rates shows the worsening of the situation following 1985, the year of Babangida Structural Adjustment Programme: maternal mortality, infant mortality and under-five mortality rates have worsened; life expectancy at birth fell from 56 in 1980 to 43. 4 in 2004. The Human Development Index rating is falling.
The latest Human Development Report on 9 November 2006 placed Nigeria 159th among 177 nations. In 2000, Nigeria was 151st from 136th in 1993. It is informative to digress very briefly to state that in 2003, when Nigeria rated at 158th position, the occupied territory of Palestine, not Israel but the occupied Palestine rated at 102nd position. Further, 33% of Nigerians that is 46 million Nigerians have no access at all to any form of organized modern healthcare service. Of the remaining 94 million, access to healthcare services is as follows, •1. million can readily access some limited care through the NHIS •16,560 political office holders can access healthcare services readily in Europe, India, Dubai, Israel and North America for which the taxpayer bears the heavy estacode, professional, travel, hotel costs as well as travel, hotel and estacode costs for family members accompanying the sick •18 million can access some form of care such as traditional, herbal, alternative or modern care service The remaining 76 million are at the mercy of relations and friends who are able to pool resources when the need arise.
The system appears to be uncoordinated in that the doctor, pharmacist, paraprofessional practitioners, public healthcare delivery institutions, private hospitals and clinics, pharmacies, laboratories and other paraprofessional institutions are operating with practically no peer assessment of the services being given to the sick. In terms of payment for health services, out of pocket payment has continued to be the mainstay of health care funding in Nigeria. The method is not only out of fashion, it is unreliable and inundated with a lot of stress and delay in the provision of optimum health care delivery.
The National Health Insurance Scheme’s (NHIS) coverage is yet to reach many states’ parastatals and the grassroots (Daily Independent, Lagos: Challenges Facing Nigerian Health System, 6th May 2010. Cross River State is one of the states in the Niger Delta area of Nigeria. The main towns are Akamkpa, Calabar, Ikom, Obubra, Odukpani, Ogoja, Okundi, Ugep, Obudu, Obanliku and Akpabuyo. Benue state is to the north, Enugu and Abia States to the west, to the east by Cameroon Republic and to the south by Akwa-Ibom and the Atlantic Ocean.
Also,there are 18 local government areas in the State, namely: Akpabuyo, Odukpani, Akamkpa, Biase, Abi, Ikom, Yakurr, Obubra, Boki, Ogoja, Yala, Obanliku, Obudu, Calabar South, Etung, Bekwara, Bakassi and Calabar Municipality. In Cross River State as it may be found in other states, delivery and management of health services is the responsibility of the Ministry of Health. The Ministry serves as the focal point, providing leadership and policy direction for all programmes in the Cross River State that have to do with health, in particular, the physical and mental wellbeing of the people of Cross River State.
The Ministry coordinates health care delivery to the public through 548 Primary Health Care-facilities, 17 Secondary Health facilities and 2 Tertiary Facilities. The Ministry also regulates health care practice by private providers in Cross River State and monitors programmes towards the attainment of national and international targets for health care provision. The Ministry has responsibility for securing funding for health initiatives in the state, many times working in partnership with donor agencies to facilitate programme implementation and ensuring transfer of relevant skills.
The primary mission of the Ministry is to provide and manage comprehensive and integrated quality health care services to the people of Cross River state, with emphasis on meeting the needs of the poor particularly those in rural communities (www. crossriverstate. org) THE JOURNEY SO FAR: ACCESS IN THE STATE Two landmark projects of this Administration, Free Health Care (Project Hope) and Conditional Cash Transfer (Project Comfort) are domiciled under the Ministry of Social Welfare and Community Development.
The objective of the Project Hope is essentially to reduce the high incidence of maternal and child mortality rates and to increase the utilization of health care services by the core poor in the society. Project Comfort enables core poor households invest in the human capital development of their children. Towards the attainment of these ideals, the Ministry of Social Welfare, through its Social Protection Department undertook the following: 1. Training/Retraining of Health Staff
To bridge the capacity gap of staff, the Ministry of Social Welfare organized a two-week capacity building Workshop for 282 health workers on Computer Application and Appreciation of the Health Benefit Administration and the CCT application. This is to enhance effective service delivery among staff in health facilities designated for the two projects, “Hope and Comfort. ” Also, 340 ad hoc staff are currently being trained in preparation for the proposed biometric registration of additional beneficiaries for Project Comfort as well as pregnant women and children for Project Hope. . Payment of Cash Transfer Beneficiaries The Conditional Cash Transfer (CCT) or Project Comfort to beneficiaries is paid bi-monthly and a total of 991 benefiting poor households have so far received their benefits. 3. Sensitization and Mobilization Exercise As part of efforts to create awareness of its key projects and programmes, regular State wide sensitization and mobilization exercise were carried out using the local electronic media, town announcers, community social mobilization officers, Churches, community traditional institutions and
Local government officials. 4. Focus Group Discussion/Recertification Exercise To encourage community ownership and participation in the CCT “Project Comfort”, Focus Group Discussion and recertification exercises were held simultaneously in the 196 Wards across the State. During the exercise, on-going beneficiaries, Ward Social Assistance Committee (WSAC) members were educated on their respective roles and responsibilities in the programme. The status of benefiting households was reassessed to ascertain the extent of compliance with the set conditions. . Biometric Registration of Displaced Persons in Bakassi LGA The enrolment and Biometric registration of displaced persons in Bakassi for Project Comfort is currently taking place at Ekpri Ikang, Bakassi LGA. The exercise was concluded on June, 2010. Other Milestones Apart from improvement of the physical infrastructures and medical equipment of the health centers and clinics, the concerns of medical staff are equally being addressed by the state government to ensure that all departments of the programmes are adequately catered for.
For instance, the government had renovated the School of Nursing and Midwifery as well as the College of Health Technology, which it strengthened with funds for training of medical personnel. Government had also ensured the training of at least 1,800 workers on ways of preventing and treating malaria. It also made available N105 million to the National Health Insurance Scheme (NHIS) as counterpart fund of 15 per cent of basic salary for enrollees. According to the Ministry of Health, government had distributed different types and sizes of insecticide treated nets (ITN) to children under five and pregnant women.
Still on the treatment of malaria, the government had distributed 455,000 doses of ACTs(anti malaria drugs) donated by Global Fund, and 5,660 doses from the Federal Ministry of Health to the 18 local councils for malaria case management. While most Nigerians were busy celebrating with fanfare May 29, 2007, on Democracy Day in Calabar, the Cross River State capital, Governor Liyel Imoke was looking beyond the symbolic celebration of that day. (Imoke’s 72-page economic blueprint for Cross River State : Gov Imoke’s Economic blueprint for Cross River State (by Bassey Inyang, Correspondent, Calabar ).
Gov Imoke unveiled his plans for the overall development of the state. The plan contained in a 72-page document entitled “The Economic Blueprint 2007-2011”, with a rider: “Towards Securing Our Future”. In the blueprint, the health sector is accorded top priority. To address the forbidden high maternal and infant mortality rate in the state, the Imoke-led administration in January this year introduced free medical services in public hospitals for pregnant women and children from five years and below.
The seriousness accorded to this sector is captured in the following words of the Governor: “It is clear that the current status of the health sector, with urgent, planned, and sustained intervention required for the people of the state to receive the type of service they deserve. Apart from the need to take care of the health requirements of the people of Cross River State, health services to the people need to be repositioned in order to meet the anticipated needs of the investor community being attracted here through projects such as Tinapa. CHALLENGES
The wide gap that exists between rural and urban areas in the available supply of medical and health facilities is a national problem. It has been accentuated in Cross River State because of the lack of good access roads, and basic facilities in the rural areas especially during the rainy season. This is why it is fortunate that the state has witnessed a remarkable increase in the contribution of voluntary agencies to health care delivery. Hospitals, maternity homes and other health centers built and run by missionaries, communities and individuals have helped to supplement government efforts in providing medical and health care services.
There are fifteen hospitals with 1,588 beds, two comprehensive health centers, nine primary health centers, seventy-nine health centers and twenty five dispensaries located all over the state. Other health establishments include two leprosy hospitals and seventeen maternal and child health centers. Calabar has a specialist hospital in addition to the University of Calabar Teaching Hospital (www. Onlinenigeria. com). These are still inadequate and cannot serve the ever growing population of Cross River State which is rowing by the day due to increased economic activities. According to data in the state’s Ministry of Health, maternal mortality in the state is the worst in Nigeria with a ratio of 2,000 deaths for every 100,000 births recorded, while death rate for children below the age of five years stands at 250 for every 1,000. This is as a result of poor access, inadequate facilities and low manpower in the state. On the 12th May 2010, Health Care workers went on strike and left health care services in disarray.
The striking workers said the strike will not be called off until the state government met their demands of improved pay and better condition of service as enjoyed by their counterparts in other states of the federation. Although they were challenged, the leaders insisted that the unions will not abandon their genuine demands which, he said, include an implementation of a new salary structure for workers; employment of more health workers in hospitals and health centers, and payment of a new uniform allowance to workers.
During this period, access to Health Care services became a challenge for the poor and only those who could afford it identified with the private health care service providers. (Modey Peters, www. 234next. com). Hence, workers satisfaction and pay package is still a challenge in the state. The above state of health care services have been recognized the government and Governor Imoke in his blue print launch stated that” All aspects and components of the state’s health care system currently requires improvement – infrastructure, equipment, power, water, and manpower development.
Weakness of the health care system in the state are demonstrated by the following, among others: “It has one of the highest maternal and infant mortality rates in the country, high rates of internal and external brain-drain of health workers, hospitals are ill-equipped and training policies are weak. Government’s Proposed Plans for Health Care in the State: The government of Cross River State approved formation of Primary Health Care Council (PHCC) to streamline its health intervention programmes in order to derive maximum benefit for its citizenry.
The PHCC is made up of chairmen of local government councils, Commissioner for Women Affairs, Commissioner for Social Welfare, Commissioner for Local Government Affairs, members of the House of Assembly Committee on Health, Representatives of Civil Liberty Organisations (CLO) and Faith Based Organisation (FBO). This council evolves policies and guidelines for implementation of the programme. In addition to this, the state government recently announced plans to procure an Identification Management System valued at N330 million to improve record keeping in the facilities.
To ensure the free medical care records success, government had approved formation of Primary Health Care Council (PHCC) to streamline its health intervention programmes in order to derive maximum benefit for its citizenry. Mrs. Edak Iwuchukwu, explained that the system was to enhance the use of biometric identity cards for beneficiaries of the free medical services and the conditional cash transfer programme designed to assist poor households of Cross River State origin.
Iwuchukwu said the identity management system was to ensure that the state’s social welfare programme was protected from abuse and infiltration so as not to frustrate the process. She added that facilities and equipment would be used for image capturing and data collection in the 18 local government areas of the state. According to her, the system will serve to fast track progress and stimulate positive impact on life expectancy of mothers and children. These proposed plans on paper will need to be backed up with specific actions and budgetary allocations before they can be actualized.
Strengthen PHCs to decentralize services and bring services closer to the people: To buttress his seriousness, Imoke’s focus is on primary health care, which is seen as a policy that could easily provide for the medical needs of millions of people in the state, who had been denied access to medical care. Besides, the Governor believes that primary health care would serve as shield against secondary diseases whose medical bills most people in the state cannot afford.
While delivering his address recently to commemorate the completion of 12,000 free eye surgeries undertaken by the Tulsi Chanrai Foundation (TCF), at the General Hospital, Calabar, Imoke announced that his government had earmarked N2. 4 billion for effective delivery of Primary Health Care Programme in the state. Implementation of Evidence Based Strategic Plan The Commissioner said for necessary impact to be made in the health sector, the administration had to evolve an intervention model to tackle the problems associated with delivering of quality health services to the vast majority of the people.
He said the state was currently implementing what he described as the Cross River State Health Plan for 2007-2011. The Commissioner added that the administration’s focus for now was geared towards Primary Heath Care Programme (PHCP) through the processes of renovation, equipping and data collection. Establishment and Equipment Of More Centers On many occasions, the state government had stated that it intends to provide at least one functional health centre in every ward, making a total of 196 in the state.
From the projection, the state intends to renovate 130 health centers in the first phase of the implementation of the PHCP, besides the 66 health centers already being renovated. In addition to the establishment of these service delivery points, up to date/standard equipments will need to be procured and personnel trained on how to use them before it can be used. Hiring of adequate personnel to improve manpower, Training and retraining of staff should be an integral component of the Health Care System to ensure that quality services are provided and manpower is increased.
These should not be limited to urban areas alone but spread across the rural centers and hard to reach areas of the state such as the northern part of the state that has suffered under development and public services are in a deplorable state. The Way Forward/Recommendations Increase public health funding- Government will require matching their commitment with adequate amount of funds to be able to improve the health care system thereby improving access to health care services in the state.
The core functions of public health are to prevent epidemics, to protect the environment, the workplace and to ensure safe housing, food and water. To further promote healthy behavior, to monitor the health of the states and the country, to help mobilize communities for action on health related issues, to respond to disasters, to target outreach communities for health services, to train employees for the investigation and prevention of disease, and to protect policies to protect the health of the environment and the people. All these require funding so there should be increased finding to agencies responsible for public health.
Environmental sanitation: Most of the causes of infant and maternal deaths are preventable infectious diseases that can be reduced by providing sanitary environments, such as provision of portable water, sewage, sewerage control and refuse management and reduction of overcrowding. Free prenatal and neonatal care: (The care of women when they are pregnant) every pregnant woman should have access to quality and free medical care throughout their term of pregnancy and delivery. Trained public health nurses and community health aides should visit mothers at home until when their children are three years old.
Although this has been pronounced in Cross River State, the health facilities will need to be monitored to ensure that they are free even in the rural communities and that hospital levies and other factors such as distance from the health facility are not threatening the process. Health education and behavioral change enlightenment programs for the people of Cross River State: This should involve area of diets, smoking, sanitation, exercise, sexual transmitted diseases and other behaviors that may impact the health of the country.
Proper education and empowerment of women in the country to take care of themselves: This singular action has been described as one of the most important factors responsible for the improvement of the health status of women and general health status indicators in Costa Rica and Cuba. Enforcement of Policies The regulatory bodies concerned will need to enforce the policies to ensure standard operating procedures are followed and systems are strengthened to ensure that quality services are provided at the health care centers. The bodies should be empowered to perform their roles.
Conclusion Overall access to health care services in Cross River State is still limited. The government has made significant progress identifying the gaps and developed a strategic plan which if implemented will improve access of service to health care services in the state. Although there are laudable plans in place which sometimes end up as mere political talk, there is an urgent need for the government to make available enough funds, implement proposed plans/recommendations, partner with development partners and ‘Walk the Talk’ of improving health care services in the State.