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Being the third part of the text of a paper presented at the 19th Bassey Andah Memorial Lecture by Michael C. Asuzu, professor of Public Health &Community Medicine, College of Medicine, University of Ibadan; consultant, Clinical Epidemiologist, Community & Occupational Physician, UCH, Ibadan; director, Ibarapa Community & Primary Health Care Programme, UI/UCH, Ibadan; president, Society for Public Health Professionals of Nigeria (SPHPN
Organisation of the national health systems up till Alma-Ata
Human health care services started in individual nursing, midwifery and medical health care, based on the prevailing traditional understandings of disease causation in the various places. It did so right up till after Hippocrates brought the principles of objective science into it. However, as scientific medicine progressed, so also increased its cost. As such, many of the poor and underprivileged portions of the society had difficulty accessing it. Then came the group organisation of the medical and health care services around churches and other houses of religion for these poor people.
However, the birth of the present unbroken history of public health came about in 1374, with the birth of the port and international health care at the seaport of Venice; with the related quarantine laws against any suspected importation of infectious diseases by ships to that city state. This sanitary public health services soon spread beyond the seaports to embrace the environmental health and food hygiene of the food items; and the other ethics of trading (e.g., accuracy of weighing scales) in the markets and other commercial food houses. The growth of the humanitarian spirit and community organisation that was part of the industrial revolution saw to the demands that resulted in the governments beginning to provide clinical public health services to the people, as the religious bodies had tried to do before then. This resulted in the reportedly first public hospital, established for the clinical public health services at large, at the Pennsylvania Hospital in the USA in 1751. The introduction and expansion of these clinical, government-provided, health services occurred in Europe from the 1790s, along with the effects of the French Revolution.
The expansion of the understanding of health and disease prevention by James Lind (by preventive nutrition) and Edward Jenner (by immunisation) on the one hand, and of John Howard (in the prison reform and health services) and Bernardino Ramazzini (in occupational health) eventually resulted in aspects of what are today referred to generally as preventive medicine and social medicine, respectively. However, the pulling up together of sanitary public health, preventive medicine, social medicine and the most essential and basic clinical medical care for individuals, to be provided statutorily by the local governments to the people, was only to be achieved first in the United Kingdom in 1847/48. These followed in the same trend of the social reformation movements that earlier saw to the poor law reforms of Edwin Chadwick. The doctors and nurses (primarily; and health inspectors, also) had the social, professional and statutory responsibilities to see that the people in the local government areas get the services that they need in all these public health realms, and as optimally as possible.
It was fairly easy to provide these preventive, social and primary clinical services to those who would come for them at the centres provided for these. Same was the case in the homes and commercial facilities for the statutory (environmental) health inspections. These community medical and health services were also comprehensively possible in the captive communities of the schools, factories and prisons. However, those needing these services in their homes because of their physical disabilities were only to be reached when William Rathbone introduced the paradigm of community nursing to that public health practice in 185910. According to Rathbone, the community nurse should not be required to look after more than 2,000 populationsize communities at that time in 1859; as she was to act as that community’s “mother” in relation with all their health care and well-being. However, in the modern world and in the places where these best practices have been maintained, this population has varied from 2,000 to 7,000; depending on the population density of such communities, rural or urban. This oversight or full scale provision of the entire community medical and health care services of the local government area, preferably statutorily, has remained the basis of the best LGA/community and PHC services to date; with the types of community health indices as shown in Table 1 earlier here. In those places, it has produced as good or even better health service indices, even in the poorest of such countries, as compared with most of the richer and technically more advanced countries. Its full attainment in practice has however varied from one country to the other. It was, and still is, this introduction of the statutory community nursing (and later, nursing and midwifery by the same person, naturally) that achieved the total community health care of everybody in the statutory communities. It is able to keep the wellpersons maximally well, at home or visiting the clinic only for preventive health care; but with community rounds to ensure that this is and keeps being indeed the case. It is able to get the sick but ambulatory or meaningfully benefitted by hospitalisation to do so promptly. Above all, it is to get the chronically sick who may be at home but not needing to be admitted to a hospital to do so and to remain as maximally well as possible, have their drug given (and observedly taken) by a well prepared home member as the family’s auxiliary nurse. The community nurse-midwife on these community rounds is also able to get any needed health behavioural modifications at the personal and whole family level for their very illness as well as the chronically sick person’s health facility preventive care appointments kept – the basis of any true PHC and HFA.
With the evolution of countries as more than the city-states of old, came about the national health systems; that is, beyond the local government. These have also developed the secondary health services for the regional or state governments (as the federating units of those countries).Tertiary health care has also similarly developed for the national governments. The LGA/PHC services have revolved around the medical officers of health (the MOH, or howsoever else designated) as the statutory community physicians, with the district/zonal community nurse-midwives for the smaller divisions of those LGAs or community medical districts. The central doctor for the secondary health system (or primary medical services) only got the role of the specialist primary care or family physician recommended in 1920 by the Lord Dawson’s Committee for this central role. This eventually got enacted into law (in the 1946-1948 era) in the British National Health Act.
While part of the organ systems and human population group-based specialist medicine and nursing care still remain within the secondary health care in the generalist ranges of those (viz, general surgery, general obstetrics, etc), part of these as well as the rest of the single system or sophisticated aspects of the population group medical and nursing services properly now belong to the tertiary health care system. With time, some of these tertiary care specialties of medicine are referred to as super-specialist medical practices; and their greater refinements and sub-specialisations are still in progress. It has however been known that all these aspects of the health care system must fit honourably and mutually respectfully together; with emphasis for government provision for those of these services that relate to the largest portion of the underprivileged or marginalised polity as priority. Full scale tertiary health care at its exact financial value may only be provided by the private sector; or by a public-private partnership arrangements by the governments. Universal health insurance may be helpful in this regard; but it is not as easy as it may apparently seem.
