Within the State system services have developed in three tiers and can be related broadly to the financial structures described in the previous section:
PRIMARY HEALTH SERVICES are closest to the people and the responsibility of local government. Problems with the implementation of this scheme included the development of basic health units in each state. According to Ransome-Kuti et al (1989) after an expenditure of about N200 million at the end of 1983 (approximate exchange rate at th a t time N1 = £1 ) most of the facilities remained uncompleted all over the country. He fe lt that during the implementation of the scheme the principles of Primary Health Care (PHC) were not applied. The community did not in any way participate and at the end of the planned period and its extension till 1985, no PHC existed anywhere in the country.
SECONDARY HEALTH SERVICES are for those problems that cannot be solved at the Primary Health Care level and are delivered in general and district hospitals under supervision of the State government. They provide specialized services to patients referred from the primary health care level through outpatient and inpatient services of hospitals for general medical, surgical, paediatric patients and community health services. They also serve as administrative headquarters, supervising health care activities to the peripheral units. The Health Policy states that secondary health care should be available at the district, division and zonal levels of the state. Adequate support services such as laboratory, diagnostic, blood bank, rehabilitation and physiotherapy should be provided.
TERTIARY HEALTH SERVICES in teaching and specialist hospitals supervised by the Federal Ministry of Health. This type of care consists of highly specialized services provided by teaching hospitals and other specialized establishments. In the states of Oyo and Osun, there are two large training Hospitals, University College Hospital, Ibadan, and Obafemi Awolowo Teaching Hospital, Ife, which between them have a total of 1,000 beds. There
are also two large State Hospitals, one in Ife and one in Ibadan. All these four hospitals purport to having a full range of specialities, including ENT, Othopaedic, Psychiatric, Paediatric and Neurological. In practice however services in these areas are somewhat unpredictable, and may not exist for years at a time, while staff are away on training programmes or sabbatical leave, or when equipment is broken or medicines are in short supply. In 1993 there had not been any ENT operations for over a year due to the shortage of medicines and functioning equipment, (personal communication from the ENT Consultant. 1993)
Additionally the States in question, have two other quite large missionary Hospitals, Ololowo Catholic Hospital, in Ibadan, and the Baptist Mission Hospital in Ogbomoso. There is also the Wesley Guild Hospital in llesha which has recently become attached to the teaching hospital in Ife. With two of the longest established training establishments in the country located in the area, it might be that the medical services offered are more comprehensive than in any other area of Nigeria.
Only one of these centres. University College Hospital, offers free medical services and medicines, and interestingly these services are reported by its sta ff members to be underutilized. Attah (1986) comments on the under utilization of public sector health facilities in Imo State, Nigeria, and lists the following possible reasons:
- L im ite d A ccess. Many people simply live too far away and with no public transport and limited funds they are excluded from such services.
- P ro h ib itiv e c o sts in terms of time and money. Since 1985 registration deposits have been demanded before treatment and one night in the hospital is calculated to be the equivalent of a month's salary for an average worker.
- Lack o f supplies and e q u ip m e n t. It is common practice to send the patient’s family out to buy the drugs needed as they are not usually available in the hospital.
- Poor a ttitu d e s o f th e h e a ith care w o rk e rs . There is a wide spread per ception of an uncaring attitude and doctors caring more about “ purse than pulse"
Chapter 2. Situation Analysis of Service Provision
- N e p o tis m is often demonstrated by the need to ‘know someone’ before it is possible to obtain care.
- D ive rsion o f s e rv ic e s and su p p lie s o fte n to th e p riv a te s e c to r by referral to private clinics and the sale of drugs to market traders.
- U n o ffic ia l s u rc h a rg e s .
Attah (1986) feels th a t the high cost of health care drives people to the traditional health practitioners and people only contact a western trained doctor as a last resort Personal experience in Oyo State would corroborate these observations. The researcher has often observed empty wards and outpatient clinics, excessive charges made for services which should be provided free, the need to ‘know someone’ before cooperation or services are made available. The tremendous distances travelled by patients for treatm ent and a lack of drugs and supplies.
A speech therapy service exists at the tertiary level of service in Oyo State and by special request the therapist provided a breakdown of the type of clients seen. Although statis tics are requested each year, the directive is never enforced or made public. Her duties were clinical and predominantly audiological, yet she was specifically employed as a Speech Therapist. The Audiologist had left for Saudi Arabia the previous year and she had taken over most of his duties. He had not been replaced.
In a two month period in 1992 this speech therapist had seen a total of 50 patients, 38 for audiograms and the remainder diagnosed as following:
Stammer 1 Hearing Impairment 10 Aphasie 1 Language delay 2 Articulation disorder 2 Laryngectomy 2
Some of these cases had been seen several times but she had no record of how many times she had seen each patient. She felt her time was underutilized.
PRIVATE MEDICINE
Non government agencies, private practitioners and company provision, provide extensive services in all areas of care and help to meet the health needs of the more elite members of the Nation. In Oyo and Osun State there are numerous private clinics and hospitals. Although these establishments are supposed to be registered the researcher was unable to obtain any kind of list. Local knowledge of the clinic’s whereabouts, reputation and performance seemed to be communicated by word of mouth. There seemed to be no structure for accountability.
TRADITIONAL MEDICAL CARE.
Many people, particularly in the rural areas, use native medicine. Bone setters seem to have a good reputation and according to local Nigerians known to the researcher, herbalists would offer cures for the deaf and mentally handicapped or disturbed. (There seems to be a tendency not to distinguish between the latter two by the informants.)
COMMUNITY BASED REHABILITATION.
The only community based rehabilitation service that the researcher could find evidence of in Old Oyo State was the community based vocational rehabilitation project in Bodija, Ibadan. This is jointly funded by the Federal Ministry of Culture and Social Welfare, The International Labour Organization (ILO) and the United Nations Development Programme (UNDP). It is a new development and has only been in existence for ju st over a year. Details of this project have already been described in section 2.3.1. under article 56 No. 8 of the Special Education Policy.
Chapter 2. Situation Analysis of Service Provisior
2 .4 .5 . IMPLICATIONS FROM INFORMATION GATHERED ABOUT HEALTH CARE FOR THE DEVELOPMENT OF SERVICES FOR PEOPLE WITH COMMUNICATION DISABILITIES.
Poor coverage levels in nationally run health services. Services seem to be better developed in the private sector.
Implementation of a PHC system is poor with indications that funds have been diverted away from the original goals.
Poor levels of accountability and evaluation.
Lack of reliable information and statistics for use in planning decisions.
Financial commitment o f the government would seem small in relation to the overall budget and the health needs of the people.
A large proportion of the finances available seem to be directed towards curative care.
There is evidence of poor coordination and management with particular difficulty between the Federal, State and Local Governments.
GBR has only just started in Old Oyo State.
There would seem to be a very extensive traditional medical health care service about which a limited amount of information is available.
2 .5 .0 . NATIONAL POLICY ON SOCIAL SERVICES.
Unfortunately the researcher was unable to obtain a copy of the social development policy in Nigeria in spite of visits and letters to the Ministry of Social services and contact with Social workers in Ibadan, The Director of Social Service in Ibadan and the Director of the Rehabilitation Centre in Moniya. All those contacted did not have a copy o f the policy but said th a t they could obtain it for me. This was not forth coming. They reported th a t Oyo and Osun State did not have a separate policy, but followed the guidelines set out by the Federal Ministry of Social Development, Youth and Sports.
2 .5 .1 . IMPLEMENTATION OF THIS POLICY IN OYO AND OSUN STATE.
Without knowledge of the policy it is difficult to comment on its implementation. However it was decided th a t some value may be gained from a description of the local services supported by the Social Welfare Department.
The Ministry of Social Development, Youth and Sports in Oyo State, like its counterparts in other states, is divided into three departments. Each department has its own Director.
-The Social Welfare Department deals with disabled people, delinquents, marital disputes, abandonment, adult welfare and support of voluntary organizations. -The Community Development Department deals with all group work, self help work,
women’s groups etc.
-Youth Affairs deals with all the youth programmes and sports development.
STAFFING. The number of Staff employed in the whole Ministry in the Old Oyo State area is reported to be around 2,000. However the number employed in the Social Welfare Department is 540, about 400 of which are Social Workers.
THE SERVICES offered by these social workers fall into five categories. - Counselling people who are disabled and directing them to services. - Assisting disabled people to get employment.
Chapter 2. Situation Analysis of Service Provision
-A fter care service.
- Input, mainly at managerial level, into all the Associations and Voluntary bodies dealing with the disabled. All Voluntary bodies have to register with the Community Chest Council, Oyo State Government give the council a grant (N150,000 annually) and the Community Chest Council supervises its distribution.
Only one social service establishment is run totally by the State in Oyo and th a t is the Ibadan Remand Home. This has two sections to it, one th a t deals with young offenders, about 100 children at any given time and a child care unit for abandoned children, a number of whom are disabled in some way.
The Social Welfare Department also gives support by way of a state grant to five other establishments throughout the State.
1. There are 6 Rehabilitation Centres in the whole o f Nigeria which have been established by the Federal Government. There is one in Oyo State at Moniya, and, although it is federally funded, the State contributes by providing the salaries for the staff, and food for the Trainees.
2. Oluyole Cheshire Home School, Ibadan. Founded in 1959 cares for about 30 handicapped children, and attempts to make them useful citizens. They have children with polio, hearing impairment, visual impairment and cognitive impairment.
3. Ibadan School for the Deaf, Founded in 1963, has approximately 250 pupils and aims to educate the deaf academically and vocationally.
4. School for Handicapped Children, Ibadan, established in 1964, takes all categories of disability and has about 30 trainees. It aims to give educational and vocational training.
5. The Nigerian Training Centre for the Blind, Ogbomoso, established in 1958, gives educational and vocational training to about 50 trainees.
Each of the establishments receives a state grant with staff provision of social workers where appropriate. All of these establishments are within the boundary o f new Oyo State leaving Osun State totally without facilities o f this kind. In practice however the people of Osun state have access to these facilities as they have always done.
THE MEDICAL SOCIAL WORKERS work separately from the social workers within social services and 13 are to be found at University College Hospital. Their jobs are entirely Hospital based and the majority of their work involves assisting people with financial payment o f hospital fees. They also work with disabled people and their families, run a hostel for relatives of patients to stay in, offer marriage guidance counselling and spend quite a lot of time fund raising to do their work. Although their salaries are paid, offices cleaned and staffed, telephones and electricity supplied, they get no other running costs from the state.
2 .6 .0 . VOLUNTARY SECTOR.
The Voluntary sector has been responsible over the years for the establishment of a great many of the facilities for disabled people, and their present day contribution is still considerable. Philanthropists, missionaries and churches are often responsible for initiating and running services which are too numerous to mention. Associations of people with a common interest often develop , but when key figures move away or die, the activity of the association may cease. Some survive, in spite of the changes, and three such organizations are described below.