The look of surprise, bordering on cynical incredulity, was still there on the face of my fellow Nigerian “emerging voice” as our Chinese counterpart finished up his presentation introducing the Chinese health system during the 2012 emerging voices training programme in Beijing. He raised his hand to ask a question and I knew what it would be.

“How did China manage to increase skilled attendance at birth from 45% in 1990 to 95% by 2008? We’ve been trying to do that in Nigeria, but going by the last national survey in 2008, only 40% of our pregnant women are delivered by skilled attendants. Our strategies are not working because it is difficult to disengage women in rural areas from traditional birth attendants. How did China do it?”

The Chinese “emerging voice” then repeated what he had said during his presentation: that the increase in skilled attendance at birth was due to a change in policy and that once the central government made it policy for every delivery to be conducted by a skilled attendant in a health facility, the people complied. He hinted at the sometimes marked rural-urban differences, and explained that in the “most remote rural areas” skilled attendance at birthin 2008 was 60%, having increased from low level of less than 10% in 1990.

My Nigerian colleague and some others from East Africa were visibly dissatisfied with the answer, so I joined them on the way to lunch to offer another explanation, or indeed the same explanation, but differently. “It is different in China,” I said. “Here all the government needs to do is decide what it wants for the people, and make it into national policy. The central government directs, the subnational governments implement, and the people largely comply. There isn’t much of a choice.”

A few days later, I made a presentation at the emerging voices pre-conference on how the origin of health policies deserves to be a main focus of health systems research, if we are to really take seriously our knowledge translation ambitions. Just as Sancho Panza said in Cervantes’ Don Quixote, “in the matter of government everything depends upon the beginning.”

Unlike what I had started to think about China, my plan was to argue that once policies are made, it is difficult to change them. I was going to meditate on the question of how change happens to deeply entrenched institutional arrangements. Nigeria is an example of a well designed and deeply entrenched, but dysfunctional system. I started to wish we were like China, where changes in policy are not as complicated, and where once the change is made, the effect is far reaching.

I began to think that China and the United States of America were at two extremes: it took forever for the United States government to pass the Affordable Care Act, but I reckon that China would do that pretty much overnight, if the government wanted it. I thought the United Kingdom was somewhere in between, but closer to China; after all it wasn’t much trouble for the coalition government to approve a controversial restructuring of the National Health Service in England, through the Health and Social Care Act, in spite of little support from the public and professional groups.

What was distinct though about China is that in spite of their relatively lower level of development, the policy of a central government percolates through to the grassroots to restructure the institutional arrangements around health service uptake. I began to wonder how we could possibly achieve that in a country like Nigeria, where the decentralisation of essential services means that responsibility for primary healthcare is largely left to non-viable states and local governments, which depend on funds from the federal account, but are free to allocate their funds as they like, without accountability mechanisms between tiers of government.

The national government in Nigeria has little or no powers to compel the federating units to effect any policy direction, much like in the USA. But unlike the USA, the federating units of Nigeria generally lack the capacity to plan and manage primary healthcare. This fragmented system results in wide variations in health outcomes, the most striking of which is that maternal mortality is about ten times as high in parts of northern Nigeria compared to parts of southern Nigeria. Of course, this system would have worked quite well if two assumptions were true: 1) if communities are active in demand accountability and social services; and 2) if the commitment and technical capacity to understand and manage primary healthcare exists at every level of government.

Naturally, thinking about the Chinese health system, I wished that we could have a similar command structure of health system governance in Nigeria with effective top-down control and have a system where local health outcomes do not only depend on local realities, but can respond to central initiatives. Unfortunately, this is unlikely to happen except in a dictatorship, a high price to pay, I would wager; and who says the dictator will be benevolent? Whatever the case is, there is always a price to pay—to suffer the indignity of lack of choice or to enjoy freedom, with its attendant costs.

Nigeria’s ongoing experience also suggests that democracy may not hold the key to our redemption in the short or medium term. We can only hope that people and communities become active in the provision of their own public services, including primary healthcare. For the next few years, my focus will be to study how communities are able to restructure institutional arrangements for the uptake of health services in low income settings. I made my choice already; change must come from the bottom up, or not at all. China may yet have its own bottom up change coming.

Seye Abimbola was BMJ Clegg Scholar in 2007 and is currently a research fellow at the National Primary Health Care Development Agency, Abuja, Nigeria.

The author is part of the “Emerging Voices for Global Health” programme of the Institute of Tropical Medicine, Antwerp, Belgium. For more detail follow this link. The views of the author are solely his and not of any affiliated institution.

This post first appeared on the BMJ Group blogs and is crossposted from there.

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