Power and privileges in medical care: An analysis of medical services in post-colonial Nigeria

.Soc. Sri. Med. Vol. 24, No. 5, pp. 453-462. Printed in Great Britain. All rights reserved

1987 Copyright

c

0277-9536187 S3.00 + 0.00 1987 Pergamon Journals Ltd

POWER AND PRIVILEGES IN MEDICAL CARE: AN ANALYSIS OF MEDICAL SERVICES IN POST-COLONIAL NIGERIA S. OGOH ALUBO Department of Sociology, University of Jos, Jos, Plateau State, Nigeria

Abstract-Subsequent Nigerian Governments since independence have been committed to a policy of health-for-all. The right to medical care is now constitutionally guaranteed. But it takes more than the

constitution to translate medical, and indeed all rights, to reality. In practice, as this study reveals, status, power and privileges determine whether or not one gets Western medical services and of what type in contemporary Nigeria. Further, medical services for the generality of the people have remained a second rate priority of post-colonial governments, very much like the situation in colonial days. The care for state employees and other elites continues to take precedence. Key words-power,

privilege, medical care, Nigeria

The various post-colonial governments of Nigeria have, theoretically at least, taken health care seriously; hence their declared commitment to a policy of health-for-all. This commitment is underscored by the huge financial allocations to the Ministry of Health at both Federal and State levels [l, p. 2841. Certainly, the right to health care is considered fundamental, inalienable, and enshrined in the 1979 constitution [2]. While the various military administrations have suspended several sections of the constitution, this right has been retained. But the more fundamental problem is the practical application of this right to care. Does it include equality of access and treatment for all? It is contended here that, in practice, there is an elite phenomenon at work that bestows special privileges on some, contrary to constitutional and other claims. The study reported here investigated the above and similar issues in the present operation of Nigeria’s Ministry of Health. Firstly, state elitism and reward structure are examined after which the methods employed in the study are laid out. Thereafter, the present structure and organisation of medical services are discussed. These will lay the ground work for an analysis of how power and privileges impinge on access to medical care in contemporary Nigeria, and how those so favoured maintained and justify their privileges. STATE ELITISM AND REWARD STRUCI’URE

One distinguishing mark of post-colonial states is the numerous legacies inherited from the colonial forebears; one of which is the skewed reward structure in favour of the elite. In present day Nigeria, this favoured share of rewards is particularly manifest in the medical services arena. It is argued here that elitism is crucial for understanding the present medical care system in Nigeria [3]. Strictly speaking, the state elites do not constitute

a class for they neither necessarily own the means of production nor are their positions, source of power, transferable to progeny. Though, as new class theorists argue [4, 51 it is possible to start their children ahead of others, through the use of official positions and relative economic privilege. Further, state elites are not a unitary group. They are in two major categories; less privileged (junior staff), i.e. those on government salary grade level (G.L.) 01-07; and the privileged (senior staff) salary (G.L.) 08 and above [6]; with the larger share going to the latter. While the junior staff receive little privileges they, unlike the generality of the population, have some entitlements like housing and transportation subsidies. The allocation of privileges applies essentially to the senior category, i.e. those who are in a position to determine public policy, distribute resources and oversee the implementation of policy, including health policy. While state elites might not directly control the means of production their privileged positions in the bureaucracy which includes some financial advantage objectively links them to their counterparts outside the public sector-officials of similar status in the multinational corporations for instance. Hence, the interests of this economically privileged social group, whether in public or private sector, is objectively linked. Indeed, not only do the elite have the same economic interests, there is an interweaving of family ties in both public and private sectors [7-91. The interests of this privileged group is realised through a social web deriving variously from social status, political and cultural power to the exclusion of other social groups in society. In more specific terms, they struggle to have more control of the state machinery, allocate bigger rewards to themselves and enhance their status relative to, and even to the detriment of others. They also have a stake in the maintenance of a disguised form of colonialism. By their historical formation, it is possible to isolate contemporary state elites into precolonial and

453

454

S. OGOH ALUBO

colonially nurtured elites. The latter comprise civil servants, technocrats, elected and appointed officers. and the officer corps in the armed forces and the police. In the former are ‘traditional rulers’-Chiefs, Emirs, Obis, Obas etc many of whom were incorporated into the administration of the colonial state, and have continued to serve subsequent administrations. In colonial days these state elites allotted several fringe benefits to themselves, such as paid house servants, children allowance, free housing and ‘bush’ allowance for rural postings [lo]. The overriding criteria of selection to this privileged group was attainment of prescribed Western education which determined access to the state apparatus. These fringe benefits, it is contended, have been retained by the post-colonial state. As in the colonial times, education continues to be an important determinant of recruitment, mobility and life changes. It determines whether one gets a job and what job and the rewards attached. This is not to deny the importance of other factors, such as relevant experience; the point is that educational certificates (popularly called National Meal Tickets) have become the passport to colonial-type jobs [ll, p. 66; 171. This is because “for generations, the Nigerian has associated social status, the exercise of responsibility security and the means of enjoying western material standard of comfort with government employment” [13, p. 691. This was precisely the situation as Nigerians stepped into the shoes of erstwhile colonialists; they lived in the latters’ exclusive residence, the European quarters, and renamed it Government Reservation (Residential) Areas (GRAS), and inherited the aforementioned benefits in various guises. As Nnoh explains, the transformation is total: They soon moved into the colonialists housing quarters. adapted the colonialists consumption habits particularly for imported consumer goods, and enjoyed the colonialists salary scale and innumerable fringe benefits. Even the colonialists’ habit of transferring and banking their savings abroad was emulated. Their life styles, pattern of income, social prestige, consumption habits, social and economic privileges and even power became closely linked to the continuation and reproduction of the colonial economy [ 12. p. 2671.

Our discussion has concentrated on civil servants, though the above privileges also apply to elected and appointed members of the elite and traditional rulers. Like civil servants, this category of state elites also carve a bigger share for themselves to the detriment of others. The elite in the private sector enjoy similar privileges. In fact, usually includes chauffeur driven staff cars, paid domestic servants, free lunch and entertainment allowances. It is stressed that because of the objective links between elites in the public and private sectors and the underdeveloped nature of the Nigerian economy, the private sector is heavily dependent on the public. All major public projects and purchases even for items like stationery are contracted to the private sector. Further, due to the underdeveloped level of our finance houses, the government has found it necessary to encourage private investments through such state programs as the Federal Mortgage Bank and the Bank for Commerce and

Industry [14]. There are also concessions like tax holidays, generous terms for profit repatriation and allocation of import licences. As a further illustration of this link between elites in the public and private sectors. bureaucratic and political power is frequently used as a stepping stone to economic and social privileges. Several Nigerian public elites are known to have established or bought controlling shares in private businesses through corrupt enrichment in public office which they subsequently use their positions in the state to patronise through legal and non-legal contracts [IO, 141. There is therefore a material basis for the elites in maintaining their privileges. In other-words “elites [whether in public or private sector] are in reality segments of a dominant class . and possess a high degree of cohesion and solidarity with common interests and common purposes. .” (15, pp. 189-1901. It is along this wider dimension that one can correctly comprehend the practical operations of the Ministry of Health. This then is the reward structure within which the elite live comparatively well at the expense of the majority inside and outside the public sector who are not similarly privileged. Nigeria has no welfare system or social security. The approximates are these fringe benefits which are, by definition, tied to jobs. A further significance of this reward structure is that those in favoured positions justify and perpetuate it. This elite phenomenon is central to the analysis and the present operations of the Ministry of Health. While the elite might have ‘good intentions’ in health policy formulation and implementation. there is little doubt that the underlying philosophy of liberalism falls short of these intentions but must follow the logic of accumulation which necessarily implies constructing privileges and exclusion, METHODOLOGY

The field work for this study was conducted in Benue State between August and December 1982 through observations and interviews. In these observations, particular attention was paid to how people passed through the various levels of medical care [ 16. p. 72f]. We were also attentive to such features of the treatment centres as available facilities, number of beds per room and spacing between them and crowding. Each of the four levels (details below) was observed for 8-14 days, size and complexity being the major determinants of length of observation. Observations were supplemented by interviews of staff members at the various levels. Respondents were purposively chosen, provided they fulfilled one or more of the following criteria. At each level the administrator, the chief therapist/physician and the head nurse/matron were interviewed; and so were the pharmacist/dispenser and the chief records clerk. Where there were in-patient facilities, the ward sister/head nurse was also interviewed. Using the focused interview format [17] the respondents were asked about services provided and who these were being provided for; how clientele was drawn; facilities available, staffing situation and kinds of services the level was best equipped to render; problems encountered.

Power and privileges in medical care In addition to these respondents at the various levels of care, policy makers/administrators in the Ministry of Health and Health Services Management Board (hereafter MOH, and HSMB), the two govemment organisations charged with policy matters and day to day health affairs of the state, were also interviewed. This group of respondents was asked about the state policy on health and the predominantly curative services. This set of interviews was conducted last providing an opportunity to raise some of the issues discovered in the different levels such as acute shortages of personnel and materials, differentiated facilities, and why some went abroad for medical care at government expense. In all 100 respondents were interviewed. The facilities researched were the hospitals at Makurdi and Otukpo and the Comprehensive Health Centre at Agasha; and the health centre and dispensary located at Makurdi North Bank and Ochobo respectively. While the field study for this paper was conducted during the civilian administration, the findings reported below remain valid. For one thing the military interventions (since December 1983) did not change the structure of society on which power and privileges rest. Secondly, the shortages discussed below have remained and in fact been exacerbated by the continuing economic crisis [18).

455

State MOH

The state MOH is the major policy making body at the state level charged with the regulation and running of all health facilities at the state level. The latter function, as elaborated below, was shed to HSMB in 1978. State M’sOH are located in the state capitals and were considered “. . . too remote from the day to day problems and requirements of modern hospitals and other health facilities for effective management and development of these institutions” [22, p. 2641. The colonial legacy was blamed for this development and a separate body, HSMB was set up in 1978 to oversee the day to day running of hospitals and similar facilities. The HSMB

HSMB was established to correct this weakness. Its main function, as the name suggests, is the management of health personnel and material. As one of the Benue State policy makers put it, HSMB is “responsible for the actual provision of health servicesdrugs, equipment purchase and distribution, and staff-it runs hospitals, health centres and health clinics”. Ironically they are very much like the MOH, located in the state capitals, though there were plans to decentralise at the time of our study. Four years later (1986) this decentralisation has yet to begin. Local government medical services

STRUCTURE

AND ORGANISATION

OF MEDICAL

CARE

As might be said of the entire system, the organisation of medical care has remained tied to the colonial format [19], reproducing the state structure. Thus the MOH is organised into federal, state and local government levels in descending hierarchy to reflect the three tier structure of the state. Our discussion of those various levels will be brief but because of the obvious manifestation of elite interests at the point of delivery, the procedure for obtaining care is described in some detail. While we focus mainly on public health care facility, it is noted that the state does not have a monopoly on medical services in Nigeria. Indeed, the private sector here is as old as the former [20], the basic distinction being sources of finance and the underlying logic. The one is for public welfare and the other is profit making. The federal

MOH

The federal MOH is an organisation of the central government and the highest policy making body in health affairs. This federal ministry is more concerned with supervision, education, research, and training than actual medical care delivery. The federal MOH is responsible for “maintenance of standards of practice in medical and allied professions, training of health personnel, health legislation, advisory, and inspectorate services, medical certification, laboratory and chemical production standards [and] communicable disease control” [21, p. 241 in addition to regulation of drug quality. Technically, the ministry owns the 12 medical schools and the country’s three orthopaedic hospitals.

The local government medical services are semiautonomous being neither part of MOH nor HSMB. Rather, they are part of State’s Ministry for Local Government. Local government medical services regulate medical and sanitary affairs within the administrative level and also operate health clinics and dispensaries. This is the lowest organisation level of medical care. At these different organisational levels, medical care is provided in hospitals (some are specialised), health centres, health clinics, and dispensaries, the last entry is limited to local government health services. In terms of resource allocation, the larger amounts go to hospitals, health centres, clinics and dispensaries in that order. These hospitals are staffed with an array of doctors, nurses, technicians and ancilliary and support staff. In addition to providing care, some of the hospitals have teaching facilities. In the health centre care is provided by health assistants, nurses and midwives, the doctor’s roie here is mostly supervisory. In health centres and dispensaries the iabour force consists of nurses, midwives, health assistants and a few administrative staff. The procedure for obtaining care is similar at each level, although there is a sharp dichotomy in hospitals between care for the general populace and for the elite. Care for the general populace

At all levels of care, except dispensaries, both out and in-patient services are available. The out-patient department (OPD) is open for normal services 6 days a week, although emergencies are received at all times. Appointments are not usually required as

456

S. OGOH ALUBO

patients are accepted on a walk-in-first-come-firstserved basis. Work is rationalised through the following three-step procedure. First, patients report to the records department where they are registered and a dossier opened. This process must be completed before a specific time (noon at Makurdi and 11 a.m. in Otukpo) after which patients are not accepted. This applies to both new and old patients. Because of problems of distance, transportation. and to be attended to early, some patients sleep over while others come in as early as 4 a.m., though works begins at 7 a.m. After registration, patients queue up for consultations in a crowded waiting room similar to the situation Webb and Webb [23, p. 1331described long ago: the crowding together of all sorts of sick personssometimes men, women and children of all ages-with sore and ulcers with cough and expectorations, not infrequently with a case of zymotic disease among them, kept waiting for hours cooped up in dirty and unsanitary waiting rooms. We cannot help regarding mammoth out patient departments as positive dangers to the public.

At Makurdi, consultations are conducted by medical officers (MOs, i.e. doctors) except during the afternoon and night shifts when this is done by nurses. In Otukpo, all consultations are conducted by nurses in the first instance and only special cases are referred to the MO. But as a consulting nurse explained “Some influential people go straight [to the MO] some [of whom] the MO will send back; some he won’t. Ideally, any patient should see the MO but nurses see patients because of shortage”. Because of staffing problems, MOs seen only the privileged (details below) and ‘special cases’. To consult an MO directly is indicative of one’s status and is prestigious in its own right. The final step is the filling of prescriptions from the pharmacy and/or treatments. Here at the pharmacy, tablets, pills, capsules and similar drugs are dispensed in old newspapers or plain sheets, and dosage marked in small circles or strokes to denote number of tablets of times per day. Patients for whom liquid medicines are prescribed provide their own containers. To be sure, the hawking of containers around hospital premises is a booming business in which empty beer, cosmetics, and coca-cola bottles are familiar merchandise. Regarding in-patient facilities. the wards are designated according to conditions. Thus, there is the TB/chest ward, eye ward, maternity, and gynaecology ward, children’s ward, and psychiatric ward. In each ward there is a small room in which there are four beds and a large open room in which beds are lined up on both sides. There is a lot of congestion, often necessitating beds on the verandas, corridors. and even sleeping on the floors. In one of the wards there were as many as 20 ‘floor beds’ at the time of research [24]. Food is provided free to patients provided they fulfill either or both of these conditions: that they have no family or significant other person around, or are too poor to afford their own meals. Food is served in aluminium plates and no cutlery is provided. A striking feature of in-patient care is the omni-

Table

I. Hospital

fees m Benue section*

general

Amount of fees (N)

Servrce Registration (card) Delivery Bed (‘hotel charge’) Minor surgery Intermediate surgery MaJory surgery Laboratory tests X-ray Drugs Food

lThoracic

State

m-patients

I IO

I SO 80 I20 5-5 IO Sold at cost pnce No longer provided recewe

all serwces

free of

charge.

presence of family/significant others. They are found sprawling on lawns, hallways, under the water tower. etc, where they also sleep and cook for themselves and their patients. This gives the hospital a semblance of a refugee camp. In some cases. e.g. psychiatric wards, the family or police are required to be present with the patients throughout hospitahsation. As is also true of out-patients, all in-patient services are free in genera1 wards. Situations have now changed with the continuing crisis. Hospital fees have been reintroduced by the military administration. The new charges are depicted in Table 1. Care for the elite

Provisions for the privileged are distinct from those for the general populace; the former receive medical care in ‘amenity’ (also called senior staff/service) and staff clinics. Some of these facilities for the elite are elaborate as in Makurdi amenity. The amenity facility is set aside for senior staff and other elites, separated socially and physically from the general OPD section. It was built in 1979 to cater for the VIPs who as one matron reminded us: “we cannot pretend do not exist”. Benue State was created out of the former Benue-Plateau State in early 1976. Prior to this time, Makurdi was only a local government headquarters, although it was a provincial capital during colonialism. The VIPs were then catered for in what was the SSB (Senior Service Block) which had only four beds. This small unit was sufficient for the handful of senior staff in town. With the creation of Benue State, Makurdi assumed a new status of a capital, and with this. an influx of VIPs. It therefore became necessary to expand the existing SSB to accommodate those new members of Makurdi VIPs who have been used to similar facilities; Plateau hospital, Jos, capital of the then Benue Plateau State was reserved exclusively for them. This explains why building an amenity facility received top priority and was completed soon after state creation even though some government offices are, to this day (1986) housed in rented accommodation. Unlike the general section. fees are charged (even before the economic programmes) in the amenity. At the time of research, there was 812.00 ($1.9) monthly subscription for out-patients. These fees, as we elaborate below, ensure that non-state elites are not denied access. The procedure for obtaining care is the same as the

Power and privileges in medical care

general section except that out-patients are accepted until 2 p.m. Further, the waiting time here is l-2 hr and consultations are only by MOs. In addition to the amenity OPD, staff (G.L. 01-07) of MOH/HSMB have their exclusive facilities. As if to under-score its purpose, the staff clinic as it is called, at Makurdi is located midway between the amenity and general facilities. In Otukpo the staff clinic which also caters for senior staff is similarly separated from the general section. In both clinics, consultations are only by MOs. There are no special OPD facilities at Agasha or the Health Clinic at Makurdi North Bank. At Makurdi in-patient care for the elite is available in the amenity ward, located on the first floor of the amenity building. This elevation, as we explain presently, is no mere architectural design; it is also of great symbolic significance. The ward is partitioned into 14 single rooms, and each has two doors, one opening to the hallway and the other to the balcony (sundeck). There are two beds in each room all fitted with mosquito nets. The nurses’ station is separated from the rooms and there is a bell in each room. Directly above the nurses’ station there is the bell monitor and nurses are advised in bold letters; “LISTEN TO THE BELL AND WATCH! FOR YOUR ATTENTION IS NEEDED IN ROOM.. .” (whichever is indicated by the monitor). Amenity patients who desire hospital food have a menu at each meal from which to choose. The meals are served in breakable plates and cutleries are furnished, unlike in the general wards. This is the ‘paying ward’; there is a daily ‘hotel charge’ of W 10.00 ($9) while Bi5.00 ($4.5) is for the meals. The new rates are shown in Table 2. There is no amenity ward in Otukpo but as the Chief MO intimated, there were plans to build one. However, this does not mean that the elite rub shoulders with general in-patients. Meanwhile, special beds are reserved for senior, indeed all categories of staff; this is in addition to an improvised amenity. A room in the maternity ward originally used for storage has been converted into a Senior Service Ward (SSW). We were informed that men and even children of senior staff have been on admissions in this maternity ward room. In-patient care in Agasha is similar to that in Otukpo. Here too there is no SSW but in order not to be out done, a room is set aside for staff admissions. The different levels are plagued with grave shortages of drugs and equipment which impede effective

Table

2. Hospital

fees in Benue

Se&X-

State

amenity

Amount

section*

of fees (N)

Registration

(card)

2 children

Bed (‘hotel

charge’)

5 children

Laboratory

tests

5.10 adult IO adult Food

(without

Food

(with

beef)/day

From

5

2.5 children 5.00 adult

beef)/day

7.50 child I5 adult

*Other charges such as delivery general section

and surgery

are the same as in the

457

medical care delivery. In the latter instance, expensive equipment sometimes lay idle due to lack of basic parts, fuel or technical expertise. The electricity generator in Agasha, for example, was out of use because of spare parts; and the ambulance in Otukpo lacked the fuel to run (in a big oil exporting country). Drugs are also in short supply. At Makurdi 60% of all prescriptions were unavailable in the general pharmacy, while the amenity pharmacy recorded 30%. The situation in Otukpo was similarly grim. In the words of a ward sister: “Forceps for dressing parge not available] and labour room is so small so we admit and deliver [pregnant women] in open wards. There is also a shortage of drugs and medications. Patients are often asked to furnish their own drugs. They buy them and keep them, and when it is time for medication they produce their drugs. We dispense and return [the remainder to them] though we are not supposed to leave drugs with patients.” “Linen and [bed] sheets and gowns are also lacking. We should change these every day but we can’t. Some beds are covered with the patients [own] linen .”

Agasha and Makurdi North Bank are not spared these exigencies either. These shortages constitute a major impediment to medical care. As noted earlier, shortages of drugs and other items have remained major problems in the medical care system. Regarding drugs, shortages have become more acute with the economic crisis and attendant foreign exchange problems. Policy statements (2 1, p. 321 notwithstanding, government hospitals have remained de facto ‘consulting clinics’. A preferential rationing mechanism is, however, enforced which shields some privileged sections and patients from the rigors of shortages, as at Makurdi. Here the amenity facility as indicated above has most prescriptions in stock, unlike the general section, This is possible through rationing and definition of priority areas. As a pharmacist put it, drugs are allocated as follows: 1. Privileged places like government house [governor’s residence] amenity and some drugs are kept for special needs and issued at doctor’s request. 2. Patients on admission. 3. Staff clinics [where supplies are augmented with free samples from drug detail men]. 4. Out-patients. It appears obvious that medical services are organised to suit certain interests-the elites’. As the foregoing depicts, in areas with large elite populations elaborate provisions are made for their care; in other areas like Otukpo and Agasha improvised facilities suffice. The organisation of medical care is then to the service and convenience of the elite hence their facilities are exclusive. That health care is organised to suit elite interests is not surprising, for as Kenneth Benson and others [26,27] have argued, organisations are reproductions of existing political economic structures as well as powerful tools at the service of dominant interests. These facts become even more obvious when the rural-urban distribution of medical care facilities are examined. We now proceed to do this along with the elite’s defence for separate but ‘equal’ facilities.

S. OG~H ALUBO

458 CLIENTELE

OF THE MEDICAL

SYSTEM

Access to medical care is contingent on several factors-economic, structural, and even political. Economic determinants of access revolve around finance and the monetary and related costs of seeking care. These factors become particularly important in fee-for-service, what Klein [28] calls the market model, type situations. In such, and indeed most, circumstances access of the financially indigent is restricted (29-331. Structural factors also influence access to medical care. How medical services are organised, distributed and other factors inherent in the broader system of which medicine is a part, are major determinants of access. Structural factors pertain to issues like regional imbalance, urban-rural differences, shortages, preferential treatment; and whether the process to care is complicated or bureaucratised. Where the above situations prevail, access tends to be restricted [I, 21,22,34,35]. Over and above purely economic and structural factors, access to medical care is also a political issue. In the first place. our classification of determinants is somewhat arbitrary for economic barriers are political as well and so are problems of maldistribution or privileged access [36, 371. Indeed, as Kelman [38. p. 301 has argued, developments in medical care are but mirror images of the wider society. Thus whether health-for-all should be a reality; whether the right to health is a fundamental human right g la UN; or whether health should be a commodity available only to those who have the ability to pay, are all political questions. In Nigeria, it is recalled, access to medical care is a constitutional right. But it takes more than the constitution to translate medical. and indeed all rights, into reality; enforcement is often necessary. Enforcement of this legal provision requires a political resolve whose philosophical underpining is the welfare of the generality of the people. However, in Nigeria. this people-oriented commitment is negated by the peculiar structural disarticulation between the state or public service and private interest. On the one hand, the same state bureaucracy-the elites who are entrusted with the detailed formulation and translation of this broad legal provision to reality-were given and continue to maintain such privileges, that on the other hand negate the very principle of public service. Hence objectively it is no longer service-ingeneral but services geared towards the interests both within and outside the State Sector. More fundamentally, this elitism corresponds with the wider motif operative in the overall post-colonial political economy in which privilege and socioeconomic advantages are intertwined. In the last analysis, therefore, it is the pattern and operational processes of this unequal socio-economic structure that must form the groundwork for understanding other forms of privilege to that in the health sector. In one vein, medical care is a constitutional right to be protected by the state; and in another, medical care is a benefit which objectively the same state provides for its economically and socially privileged members to the exclusion of the vast majority of the population. Hence the care for the rural majority and

non-elites has remained a subsidiary much as in colonial days.

priority,

very

Rural-urban differences The MOH, at both federal and state levels, seem to be fully aware that medical facilities are located in the urban areas, even though some 80% of the population are rural. This urban bias, prevalent in colonial times, has remained with us. According to the 1962 development plan: “clearly the present number of doctors is entirely inadequate particularly when it is realised that in many areas. vilages are situated as much as 100 miles [ 180 kilometers] from the nearest facilities” [39, p. 471. Indeed, each succeeding government document continued to pay lip service to rural-urban differences. The 1975 development plan was precise on this point; “The existing structure and nature of hospital services in the country still follow a pattern designed under the colonial administration. Apart from its total inadequacy. the distribution of these institutions between urban and rural areas reveals critical imbalances as regard access of the population to these facilities” [22, pp. 248 and 262; see also 1, p. 2761. The situation in Benue State is no different, as a top MOH policy maker/administrator admitted: “Major facilities are available in urban areas only. All hospitals are in urban areas. It is only the clinics that are in rural areas”. This schizoid distribution of facilities excludes the rural population in several ways. First. the sheer physical distance militates against access. As Murphy and Baba [40] have shown, rural sick people often have to wait several days until the local market day to catch public transportation to visit treatment centres. Secondly, even where facilities exist, these are, “undermanned and ill-equipped” [40, p. 2701, physical facility being of little use in itself. Finally, the neglect of rural areas in terms of other social amenities (paved roads, water. electricity) undercuts the government’s efforts to attract personnel to rural medical facilities. As the government is aware: “the relative neglect of these areas in the location of social and economic infrastructure has made it relativelv difficult to attract health personnel to work in them” [I. p. 2721. Apparently, we are trapped in a vicious circle. This discrimination against rural areas is a direct legacy from the colonial government when medical services catered for Europeans and ‘Nigerians of standing’, who lived in urban areas. Like their colonial precursors, the state and other elites are also concentrated in the urban areas. hence major medical facilities are located there, close to the target population. The same is true of other social services which remain concentrated in urban areas for the same reason. This urban centredness has been maintained by different post-colonial governments. On the government’s admission, “pipe-borne water. is. out of reach of a large segment of the population. This problem is even more serious in the rural areas [where] in many cases the quality of available water is also very poor” [I, p. 3231. In spite of paper commitments, the Nigerian rural population is virtually excluded, especially by the

Power and privileges in medical care

structural them.

factors which also discriminate

against

Structural barriers to access: on rights and privileges

Nigerians do not have equal access to medical care, neither is there equality of treatment. Civil servants for whom medical care is both a constitutional right and a fringe benefit have priority in medical facilities. This applies to access and to quality. The difference between senior and junior staff and the populace is illustrative of this differential access and treatment. Senior and junior civil servants, it is recalled, receive medical care in separate facilities from the general populace. In amenity facilities, a preserve of senior staff and other elites, fees are charged. The determinant of access would thus seem to be money, just as a respondent explained: “Amenity is for anybody who can afford it. But if you cannot afford it there is the other section for you”. The providers are also aware that the amenity facility is for a special class of people, a selected category “who don’t want to waste time, especially senior staff who want to go [return] to work quickly. We want this place to be different from the main place, by asking for money we keep the numbers down. It ensures that [the] type of people coming here are different from those at [the general] OPD”. In reality the situation is much more complicated. Even as money is the criterion for discrimination, amenity facilities are available to the ‘right’ people at no charge. For the senior members of staff HSMB, all amenity services are free and charges are underwritten by their conditions of employment. This free amenity service also applies indirectly to other senior civil servants. This latter group first pays from their packets and files for reimbursement with their various ministries; for a MOH policy maker this is because “if you are a civil servant you are entitled to free medical service. So if you pay, you get a refund. Even if you go to a private doctor on a government doctor’s recommendation the money is refunded. If not it [medical care] would not be free”. And for another respondent, this privilege of special medical care at government expense is for productivity reasons: “it is one of the conditions of service of government to take care of your health. You can produce more when you are healthy and therefore they [government] take maximum care of your health”. Our respondents intimated that amenity is for anybody who can pay and, as we have seen, the government pays for its staff; at least the senior staff. But can a non-government employee (unemployed, destitute. etc), invoke his/her constitutional right and receive free amenity care? And does not medical care as a constitutional right transcend a fringe benefit tied to jobs? MOH/HSMB administrators argue that medical care as a fringe benefit comes first. For this respondent amenity is a necessary privilege: If it is a privilege, then that privilege must have been given under a different circumstance than as a result of health policy. For instance, I am employed by the government. The condition of employment is that government is responsible for my medical [care]. So, automatically if I go to any place and get medical attention, it is part of my condition of service that I [re] claim that money. So you find that various civil servants who go to amenity pay and go to get reim-

459

bursement. They get it if that is part of their condition of service. . . Look at it this way. if these people are not civil servants, they can still use amenity services but nobody reimburses them, because nobody has that obligation to them, nobody has come into that contract with them to say. “well, if you work for me, when you’re sick, I’d be responsible for your bills”.

For another respondent the question of refunds or free amenity care for non-civil servants does not even arise. Service, he argued, is by definition government civil service: “that is not the condition of his service. He [the unemployed] is not serving anybody and therefore nobody is committed to him”. Even in the present period of economic emergency, declared in October 1985, civil servants can, theoretically at least, get refunds for medical expenses as part of their entitlement. Medical services administrators and policy makers deny that there is any difference between the quality of medical care delivered at the amenity and that in the general section. They argue that the differences are in social amenities only. In other words, what constitutes medical care? Even in its scientific Flexnerian terms there are some obvious differences between the two. In the amenity, consultations are done only by MOs; in the general, they are also done by nurses. In the amenity, the waiting time is l-2 hr as against 5-8 hr in the general section, and we add here that care delayed is care denied. Furthermore, in the amenity 70% of prescriptions are in stock; compared to the general section where only 40% are in stock. These obvious medical differences are in addition to the social: two bed, single rooms instead of an open dormitory ward; a balcony or sundeck vs none; beds fitted with mosquitoe nets as compared to none; and bell call compared to none. Most of our respondents were emphatic that the constitutional right to care does not transcend or supercede their conditions of service. Only a few (0.07%), like this respondent conceded some anomaly: The class system is a fact in Nigeria. If you begin from the top. you will see that the governor has his own doctor, just for himself and his family [at government expense]. Coming down, the deputy governor has a doctor. If you come down to the commissioners and so on, when they are sick, they call the doctor who will go to their house. As you move down [the social ladder] it becomes more and more difficult which means we recognise that there is a class system. But on the other hand, in addition to the fact that there is a class system, there is also the fact that the medical service is not enough. which makes it very difficult for the common people [as the inverse law of resource allocation sets in]. But our long term policy is that things will ease as we provide more

facilities. In other words, the majority of the working people who produce the wealth to sustain free medical care for the elite are excluded. Another respondent made the link (though as justification) between these medical care privileges and those outside medical circles. Invariably, both types accrue to the same ‘class’ of people, who might be ‘entitled to a double room, suite, or if they are travelling, they have to travel by a certain class. These are privileges attached to the office which also extends into the hospital’. He called them ‘social privileges’.

460

S. OG~H ALUBO

But these ‘social privileges’ do not extend equally to all senior civil servants. even in the amenity. There are some tiers of inequality within the amenity system. some senior staff are more equal than others: hence the contention that the state elite is not an egalitarian group. As a nurse there explained, there are permanent reservations for some top notchers: “Room 1 is reserved for the governor and his deputy and their families, in case anyone of them should be sick. Room 2 is kept for the members of the [state] house [of Assembly] and permanent secretaries, then Rooms 13 and 14 for senior, very senior medical officers and MOH and HSMB (staff]“. One of our respondents compared this allocation of medical facilities to housing which the government is committed to providing for all, but meanwhile some have several (government allocated) and others have none: O.K. if you come to the question of housing, the government wants to provide housing for everybody. But in the meantime, the [country’s] president has 19 guest houses [i.e. one in each state capital] which must not be occupied by anybody. He has one in Makurdi here also. But he cannot be in 19 places at the same time. So, it is a recognition of the fact that a class system really exists. But all the same, we are trying to cover everybody, which we hope will come through eventually.

The inequality among senior staff is multi-layered. Some senior civil servants seek treatment abroad and charge the cost to the government. Overseas treatment is one of the highest privileges in Nigeria and those in the right positions crave it. This desire is also true of Nigerian medical doctors some of whom in apparent disregard of their association’s call to ban medical treatment abroad, continue to fly out for medical attention [41, p. 51. As our respondents intimate, there are laid down guidelines for seeking medical treatment abroad, which stipulate inter ah that outside treatment should be as a last resort. In practice, the story has been different. This is because there are structural factors which enable some to by-pass stipulated procedures. Both the governor and the deputy governor have personal state furnished doctors who can refer them abroad even though they are not supposed to; only consultants can do so. Further, a respondent recounted a state governor going to the United States for a ‘medical check’ accompanied by an entourage of over 20 people. Perhaps a more unusual case of privileges was when Nigeria’s Chief Justice went to a London hospital accompanied by his family and “a consultant and matron of the Lagos University Teaching Hospital (LUTH) where he was treated for one week” [42, p. 171. While this consultant and matron were abroad with this patient (VIP), the hundreds who needed their services at home had to wait. The present economic crisis and its attendant hardships have not affected medical treatment abroad. The Nigerian Minister for Health, during the ousted civilian regime, Mr Daniel Ugwu, gave this assurance to “the House of Representatives Committee of Health that medical treatment of top government officials both in the executive and legislature will continue abroad at public expense in spite of the

austerity” [43, p. 5191. Moreover. since the military take over in December 1983. at least one military governor has been abroad for medical treatment. This privilege is also extended to traditional rulers. There is an apparent inconsistency. if not insincerity, on the part of some of Nigeria’s state elites who do not use the medical care system they plan and administer. We ascribe this inconsistency to a colonial mentality. the solution to his/her medical problems must be sought abroad and the need to distinguish themselves from others who lack similar privileges and must ‘patronize Nigeria’. This double standard undermines the people’s confidence in the government. Like those of senior staff. a staff clinic for junior civil servants is explained in terms of enhancing labour productivity and efficiency. It is important that they receive quick attention and return to work. Argued a respondent, “the idea of having a staff clinic is to make sure that staff who are sick get their services quickly and come back to work. We provide that service for them. It is no use having nurses queuing up until 12 o’clock when she [sic] probably has only a minor complaint. . . so we provide that service for them”. Policy makers insisted that this is neither discrimatory nor a special privilege. Said another respondent: Those are privileges they have regarding their job. Even in private hospitals where you’re employed, it is most unusual for anybody first [sic] not to give you some kind of preference for the following reasons: (1) nature of work exposes you to danger of infection; (2) it could be very demoralising for the patient to see the doctor or the nurse lying side by side with him sick. So when they are sick we have to treat them in a special area. It is a special privilege. I agree, but it is something that has to be done everywhere. I think it is justified in any medical institution if you want to keep the institution going.

This is the difference, some Nigerians claim their medical rights in crowded hospitals, others in staff clinics and amenity facilities and still others in hospitals in foreign lands. The ordinary Nigerian who has no special privileges who must wait 5-8 hr, buy his unavailable prescriptions and pick the medical crumbs that fall from amenity and staff clinics [44]. In sum, the colonial Europeans rationalised discrimination against the people and preservation of their privileges in like manner; they too were apparently interested in the health of the entire population. But while pursuing that, they set aside special facilities for themselves. Just as the colonialists made a distinction between themselves and “African personnel of standing” [45, p. lo] versus the general populace, their post-colonial successors distinguish themselves and those who have the ability to pay versus their ordinary compatriots. It exists in varying forms in other underdeveloped countries [35,46,47]. And because the state elites make the policy and allocate resources, it is able to serve the interests of the class they represent. This explains the presence of white elephant medical technologies in most underdeveloped countries (4%SO] in complete disregard to the prevailing causes of morbidity and mortality. Witness, for instance how the prime minister of India imported, despite general import restrictions, two linear accelerators. one of

Power

and privileges

which was to be used for the president; or “the import of a complete renal unit to Lusaka General Hospital . . to enable a Permanent Secretary to be flown back from England for continued treatment at home” [46, p. 1201. This study suggests that official proclamation of equality of treatment in the allocation of medical care is belied by reality. As we have seen, status, hence power and privileges, is the major determination of whether or not one gets Western medical services and what type. In other words, legislative and other declarations of equality are not translated into reality for all in a society whose very structure negates such declarations. In the final analysis, therefore, legislative and similar provisions yield to the basic ingredients of power, privileges, and hence domination, which sustain class societies like Nigeria. Until there is the political resolve to change the structure of society, a gulf would continue to exist between health policies and practice. Without such changes proposals such as community participation and involvement will be limited. As has been illustrated, in spite of health-for-all policy and pronouncements, health practice has been to provide, in the now popular cliche, ‘separate but equal’ medical services. The issue at stake here is true parity,

not

charity

nor

legislative

provisions.

Acknowled~emenrs--Comments on earlier drafts by Kofi Bonsi, Iyorchia D. Ayu, Femi Adelakun and anonymous Social Science and Medicine reviewers are acknowledged. While this essay has benefited immensely from their individual and collective suggestions, the author is solely responsible for its content. REFERENCES 1. Federal Republic of Nigeria. Fourth National Development Plan 1981-85. Federal Ministry of National Planning, Lagos, 198 I. of the Federal Republic of Nigeria, 2. The Constitution Section 17-3~. Daily Times Publishers, Lagos, 1978. Press, 3. Mills C. The Porczer Elite. Oxford University 1956. 4. Djilas M. The New’ Class. Praeger, New York, 1957. 5. Gouldner A. The Future of Intellectuals and the Rise of the New Class. Macmillan, London, 1979. 6. For a discussion of salary grade levels and the rewards that accrue to each level, see the Public Service Review Commission (Udoii Reoort). Federal Ministrv of Information, Lagos. 1974. . I. See Markovitz I. Power and Class in Africa, Chap. vi and passim. Prentice-Hall, Englewood Cliffs, N.J., 1977. 8. Williams G. State and Society in Nigeria. Afrografika, Idanre, 1980. 9. Shivji 1. Class Sfruggle in Tanzania. Monthly Review, New York, 1976. 10. Usman Y. For the Liberation of Nigeria. New Beacon, London, 1979. 11. Smythe H. M. The Neat Nigerian Elite. Stanford University Press, 1960. 0. A Short History of Nigerian Under12. Nnoli development, pp. 94-136. Path to Nigerian Development, Codsira, Darkar. 13. Damachi U. Nigerian Modernization: The Colonial Legacy. Third Press, New York, 1972. 14. Othman S. Classes, crises and the coup: the demise of Shagari regime. African Affuirs 83, 441-461, 1984. 15. Navarro V. Medicine Under Capitalism. Prodist, New York, 1976.

in medical

care

461

16. Alubo S. The political economy of health and medical care in Nigeria. Ph.D. dissertation, University of Missouri, Columbia, 1983. 17. Merton R. and Kendal P. The focussed interview. Am. J. Social. 51, 541-557, 1946. 18. Alubo S. Underdevelopment and health care crisis in Nigeria. Med. Anthrop. In press. 19. Information in Respect of Nigeria for the Year 1947. Federal Information Service, Lagos. 1949. 20. Schram R. A History of Health Sercices in Nigeria. Ibadan University Press, 1971. 21. Federal Republic of Nigeria. Second National Development P/un 1970-74. Federal Government Printer, Lagos, 1975. of Nigeria. Third Nntional Devel22. Federal Republic opmenf Plan 1975-80. Federal Ministry of Planning, Lagos, 1978. 23. Webb S. B. The State and the Doctor. Longman Green, London, 1910. 24. Situations are the same in the other public hospitals in Nigeria. In Plateau State for instance, three children have had to sleep in one hospital bed. See Ishaya S. Three children in one bed: congestion in hospitals. Daily Times 1, January 1, 1984. for the military overthrow of President 25. As a justification Shagari, General Abacha observed that public hospitals were mere “consulting clinics. without drugs”. For a text of the coup speech see Daily Times 32, January 2, 1984. a diatectical view. Admin. Sci. 26. Benson J. Organizations: Q. 22, I-21, 1971. D. Organization, Class and 27. Clegg S. and Dunkerly Control Routledge & Kegan Paul, London, 1980. 28. Klein R. The political economy of national health. Publ. Int. 26, 112-125, 1972. 29. Koos E. The Health of Region Ville. Columbia University Press, 1954. 30. Igun U. Stages of health seeking: a descriptive model. Sot. Sci. Med. 13A, 445-456. 1979. 31. Oculi 0. (Ed.) Health Problems in Rural and Urban Nigeria. Ahmadu Bello University, Zaria, 1981. 32. Aday A. Insurance courage and access. Hlth Serv. Res. 13-14, 369-277, 1978. H. and Waterman B. The Exploitation of 33. Waizkin Illness in Capitalist Society. Bobbs-Merrill, Indianapolis, 1974. 34. Inequalities in the Health Services. New Sot. 309, 812, 1971. 35. Lasker J. Choosing among therapies: illness behaviour in the Ivory Coast. Sot. Sci. Med. 15A, 157-168, 1981. 36. McKnight J. Politicizing health care. In Sociology of Health and Sickness (Edited by Conrad P. and Kern R.), pp. 551-563. St Martins, New York. 1981. 37. Townsend P. Toward equality in health through social policy. Int. J. Hith Sem. 7, 63-75, 1971. 38. Kelman S. Toward the political economy of medical care. Inquiry 8, 30-38, 1971. 39. Federal Government of Nigeria. Annual Report of the Federal Ministry of Health. Federal Information Service, Lagos, 1962. 40. Murphy M. and Baba T. Rural dwellers and health care in northern Nigeria. Sot. Sci. Med. ISA, 265-271, 1981. 41. Allah-De. Walking corpses, The Guardian 5, September 23, 1984. 42. Aderinola D. C. J. flown to U.K. hospital. The Guardian 1, 12, June 3, 1984. 43. Anonymous medical care. West Africa 34, 519, 1983. There are reports that Nigeria’s present Minister for Health, himself a Professor of Medicine, has been abroad at least once for medical attention since his appointment as Minister. 44. What we now have here is a situation where those

462

S. OCOH ALUBO

charged with the translatton of declarations of equality do not only fail to do so but justify their action. For a view from below, i.e. patients’ perception of the system the interested reader is referred to Ref. [30] above.

47. Aidoo T. Rural health under colonialism and neocolonialism. fnt. J. Hlfh Serr. 12, 637-657. 1983. 48. Piachaud D. The diffusion of medical technologies to less developed countries. Inr. J. Hlrh Serv. 9, 629-641.

45. Annual Report of the Departmenr of Health, 1951-1. Government Printer, Lagos, 1955. 46. Frankenberg R. Allopathic medicine, profession and capitalism. Ideology in India. Sot. Sci. Med. 15A, 115-125. 1981.

1979. 49. Gill D. and Twaddle A. Medical sociology: what’s in a name Inr. Sot. Sci. J. 29, 369-385. 1977. 50. Bader M. The international transfer of medical technology. Inl. J. H/th Serv. 7, 443458. 1971.