Contexto histórico de Calvario y Tabor: La lucha entre liberales y

The early diagnosis and treatment o f curable sexually transmitted disease plays an important role in reducing the continued spread o f infection. This section examines the Nigerian health service and the health care options open to Yoruba men and women who are suffering from, or suspect themselves to be infected by, a RTI.

The Nigerian health system

Following independence in 1960, the overall political and budgetary emphasis of Nigeria's health policy was on expansion o f teaching hospitals and* medical training.

National plans for the expansion o f health services were suspended with the beginning of the Civil War in 1967, and in the period following it, 1970-74, when emphasis was on the replacement o f infrastructure lost during the hostilities and on curative care. Under the Third Development Plan (1975-80) the the Basic Health Services Scheme (BHSS) was initiated. The objectives o f this scheme were to provide comprehensive curative care through the new expanded facilities, to promote appropriate health technologies for rural areas and to Introduce innovations in the classification and training o f health manpower (Nigerian Federal Ministry o f Health, 1978). However, financial problems and budgetary restrictions meant that the scheme was never fully realised. Between 1979 and 1983 the government encouraged the notion of free, comprehensive medical care. Free health care policies were pursued by many states during this period and in some areas government subsidies made up as much as 90 per cent o f the revenue of public health institutions (Ogunbekun, 1991). The 1981-1985 Fourth National Development Plan stated the government's commitment to provide adequate and effective primary health care to 80 per cent o f the population by 1985, this provision to be extended to the entire population by the year 2000. However, only since 1986-87 has primary health care been strongly supported financially and through formal policy by the federal government (Parker, 1991).

The stated objective o f Nigeria's national health policy is to 'achieve health for all Nigerians based on the national philosophy o f social justice and equity' (Ransome-Kuti et al., 1989). States are given the freedom to determine for themselves how to achieve this goal, and hence there is a wide diversity across states in the types and means of service provided. The organisation o f stationary government facilities is structured on a three-tier system. The primary tier operates on the local government level and generally provides maternal and child health (MCH) care, preventive care and basic curative care.

The second tier, at the state level, is made up largely o f district hospitals. These hospitals provide mainly curative care, although preventive services are also available.

The tertiary tier, which operates at the federal level, is made up o f teaching hospitals and other higher public health institutions. While policies and guidelines are set by the Federal Ministry o f Health (FMOH), policies for service provision are determined at the state level by the State Ministry o f Health (SMOH), and actual implementation and provision o f care is handled by the Local Government Health Department (LGHD). The FMOH formulates health policy for the whole country. In addition, it provides hospital services through teaching, specialist and federal government staff hospitals, access to the latter being restricted to staff o f the federal civil service and their dependents. The FMOH co-ordinates the activities o f the SMOHs and the LGHDs and provides them with technical and financial assistance.

Stock (1985) identifies the division of authority between the three levels of government as a major barrier to effective health care planning, leading to fragmented

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development and excessive duplication. It has also been argued (Ogupbekun, 1991) that the centralisation o f such activities as the purchase o f equipment and, hospital consumables and the recruitment and deployment o f personnel in the SMOHs, combined with the smaller authorities' minimal control over resource generation and distribution, has meant that public health institutions are slow to respond to changes in the pattern of demand for and consumption o f health services.

The health sector has suffered severely under the Structural Adjustment Program. Health expenditure as a percentage o f total federal government expenditure fell from 1.9 per cent in 1981 to 1.5 per cent in 1989 (Ogunbekun, 1991). Although total health spending decreased by only 9 per cent in real terms between 1981 and 1988, within the same period health expenditures per capita fell by 25 per cent (Ogunbekun,

1991).

A fall in real spending and the depreciation o f the Naira have resulted in persistent shortages o f drugs and medical supplies. Public health institutions have had to increase user charges and introduce fees. Registration and practice fees, paid to the state government by private hospitals, maternity homes and pharmacies, have been raised as a means o f boosting the revenue o f SMOHs.

The poor state o f health sector finances is also a reflection o f inefficiencies within the system, with resources being wasted through poor distribution and management. This has been coupled with a crisis in the distribution o f health personnel.

A trend towards specialisation, the concomitant decrease in the number o f general practitioners and the maldistribution o f health personnel have continued to create shortages o f health professionals (Ojo, 1990). The situation may have worsened in recent years , anecdotal evidence suggests that as a result of poor pay in the public sector and a rapidly decreasing level o f morale, an increasing number o f doctors and nurses are seeking more profitable employment in countries such as Saudi Arabia. The movement o f highly skilled personnel to the West and to the Gulf States has had serious effects on

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whole departments in medical schools and hospitals. An estimated 2,000 Nigerian doctors, most o f them consultants, emigrated between 1985 and 1990 (Alubo, 1990).

Despite efforts at decentralisation, the Nigerian health system suffers from a domination by urban based curative services. Hospital services consumed about three- quarters o f FMOH finances for most o f the 1980s (Ogunbekun, 1991), and health services continue to display a serious urban bias. Coverage by health services is low for the Nigerian population as a whole and is especially limited for the poor and for rural populations. In 1985 approximately 35 per cent o f the population nationwide was estimated to have access to modem health services (Nigerian Federal Ministry o f Health, 1988), the standard measure o f accessibility for rural areas being either a distance o f up to five miles or up to two hours o f travel time from the nearest health facility. There is a great deal o f regional variation in access to health services, with travel distances being

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greater in the north than in the south or east o f the country. The southwest o f Nigeria is relatively well served (Onokerhoraye, 1980; Akeredolu-Ale, 1985)/ , _

-A rough measure o f the availability o f modem health services isTprovided by physician-to-population ratios. In 1960 it was estimated that there was one physician for every 74,000 people in Nigeria; by 1980 this ratio had risen to one physician for every 13,000 people, well above the average o f 1:21,000 persons in all sub-Saharan Africa (World Bank, 1984). However, whilst the number o f health professionals increased substantially during ‘the 1970s, most o f the physicians continued to practice in urban areas and many were in private practice (Ojo, 1990).

Public health services in Nigeria have since independence been skewed in favour o f curative hospital care. This was reinforced during the 1970s and 1980s and it was only in the mid-'80s that primary health care became a priority. However, the economic recession and the adjustments to it have had serious detrimental effects on the health system and have stunted the growth o f primary health care.

Other sources of Western medicine

Apart from the government health services there are many different private- sector sources o f Western medicine. These include private clinics and hospitals, company-provided health care for employees, and services provided by non­

governmental organisations (NGOs) supported by overseas aid agencies, religious donor groups and revenues generated at the health facility. The demand for private medical care seems to be growing, judging by the 37 per cent increase in the number o f private medical establishments registered between 1983 and 1987 (Ogunbekun, 1991). In particular there has been a proliferation o f private maternity centres (Pearce, 1980).

While this could be construed as a result o f consumers' ability and willingness to pay, it must be emphasised that the increase is mainly in urban areas where in many cases the fees are paid by the employer. The use o f private health institutions is not restricted to the relatively affluent and subsidised employees; it may be chosen by indigents over

public health institutions because o f the more 'user-friendly' structure o f fee payment in operation.

Other important sources o f Western medicine are pharmacies and patent medicine stores, where not only pharmaceuticals but also diagnosis, advice and treatment such as injections are often given. Other sources, generally unregulated and illegal, include injection salesmen, itinerant hawkers o f drugs and health workers from the public sector who supplement their incomes through taking on private patients (Stock, 1985).

Church-based health care

Beginning in the 1980s there has been a huge upsurge in the Christian 'new churches'. These vital congregations demonstrate an openness to the Nigerian culture and cater to the emotional and physical needs o f the people. PhysicaJ healing is one o f the most important manifestations o f these churches and they constitute an important alternative source o f health care. Faith healing is carried out in the Aladura 'praying' churches, which are descendants o f African churches such as the United Native African Church which emerged in the 1890s in protest at some features o f the Christianity o f the missionary societies. Two o f the largest Aladura churches are the Christ Apostolic Church and the Church o f Cherubim and Seraphim. The main feature o f the Aladura movement is the u sej)f the power o f prayer to cure sickness. This is based on the theory that disease is a punishment for sins by God or His minsters and can only be cured by the moral repentance o f the sufferer (Peel, 1968). Using medicine is wrong because it shows lack o f faith, and foolish because it relies on man rather than on God. The Aladura's methods o f healing include visions, prayers with congregational responses and the use o f holy water, candles, holy oil or soaps. Aspects o f traditional religion including drumming, dancing and trance induction have been incorporated into the Christian services o f many o f these churches.

Traditional medicine

Traditional healers are widely used in both urban and rural settings. Oyebola (1980) has produced a comprehensive classification o f Yoruba traditional healers: the main categories are diviners (babalawo), herbalists (onisegun), shrine priests (olorisa), traditional 'pharmacists' (awon) and specialists, including those who treat conditions that afflict mother and child (elewe omo), birth attendants (iya abiye) and those responsible for ritual circumcision (olola). These are not rigid divisions and there may be some overlap o f function - for example, with diviners using herbs in treatments and herbalists on occasion using simple methods o f divination.

Symptoms and sicknesses which are short, self-limiting and familiar can be put down to dietary indiscretions, chills and minor traumata, but if a disease persists in spite o f simple counter-measures, suspicions will be aroused about the operation o f personal

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and spiritual forces whose nature must be properly defined and divined before the patient can hope for relief The onisegun deal with the commoner, more easily recognised disorders; for 'deeper' problems such as those arising from witchcraft, the afflicted person may consult a babalawo ('father o f secrets'). These priests o f the I f a cult specialise in divination and consult oracles for the diagnosis and cause o f a patient's illness. Many babalawo also offer treatment for those with mental illness.

Rituals, gestures and objects are an essential part o f the babalawo's therapy and represent in the material world what is taking place in the spiritual world. The babalawo's healing addresses the patient's place in the natural and supernatural world and seeks to restore balance and equilibrium in the social relations that are the ultimate cause o f their misfortune.

Health services in Nigeria and RTI

The health care options potentially open to men and women in.Southw est Nigeria are wide and include government and private hospitals and clinicsr pharmacies, church-based health care and traditional healers. However, whilst the southwest is, compared to the rest o f Nigeria, relatively well served by government health services (NDHS, 1990), it would appear that financially these services are becoming less accessible to certain sections o f the population.

Many RTIs are curable, and with timely, effective diagnosis and treatment the complications arising from them can be reduced and the spread o f STD diminished.

Both in the West and in Nigeria these services have been provided by specialised STD clinics. In countries such as Britain and Australia, the specialised services offer free diagnosis and treatment to any persons who suspect themselves to be suffering from an STD or to have been exposed to infection. In Nigeria, as in many resource-poor countries, STD clinics are few and are restricted to major cities. Ibadan, the largest city in Nigeria, has only one recognised STD clinic (Adekunle and Lapido, 1992:298). In the current economic climate and given the considerable strains being put upon government health services by the lack o f funds, declining morale and the loss o f higher level personnel, it is unlikely that whether there will be resources for the expansion o f these specialised clinics. The situation suggests that an alternative approach may be necessary.

Private hospitals and clinics, traditional and spiritual healers, pharmacies and other outlets are popular sources o f health care. Their potential, together with government services, for providing timely and effective diagnosis and treatment o f RTIs in a manner which is socially, culturally and financially accessible to all sections o f the population remains to be explored.