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\title{Effects of Globalization on National Healthcare Delivery Systems: The Nigerian Experience}
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             \author[1]{Dr. Ignatuius Uche  Nwankwo}

             \affil[1]{  Nnamdi Azikiwe University Awka, Anambra State, Nigeria.}

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\date{\small \em Received: 12 February 2015 Accepted: 5 March 2015 Published: 15 March 2015}

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\begin{abstract}
        


This paper has three related objectives. First is to chronicle the diverse dimensions to the conceptualization of the subject of globalization. The second is to put forward the argument that globalization as a contemporary social phenomenon has the characteristics and indeed constitutes an important social determinant of health. On this premise, this paper submits that as a social determinant of health, globalization has crucial effects on health status of individuals, small groups or communities, and nation states. The third objective is to briefly account for the exact effects of globalization on Nigeria?s health system. Anchored on modernization theoretical platform, this paper canvassed for a level playing field where developing countries are not subservient to their developed counterparts as globalization runs its course. Accordingly, there should be a fair balance in traffic of persons, goods, information and services between the West and less developed third world nations like Nigeria. This measure if adopted will evenly distribute the positive and negative effects of globalization across rich western nations and their poor third world counterparts. With particular reference to Nigeria?s health sector, the paper identified brain drain, easy spread of diseases and influx of health risks in forms of cigarettes, junk foods, and toxic wastes as some negative effects of globalization on health.

\end{abstract}


\keywords{globalization, health, health systems, social determinants of health, westernization.}

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\let\tabcellsep& 	 	 		 
\section[{I. Introduction}]{I. Introduction}\par
he world today is often regarded as a 'global village'. Although countries have well-defined geographical territories and their citizens live in separate apartments and neighbourhoods in their area, yet there has been an increased level of human proximity across national boundaries over the years. People are now living in each other's metaphorical pockets and issues that ordinarily may affect one group, now has supra-territorial dimensions and transcends the geopolitical boundaries of each nation.\par
The network of connections of organizations and people across national and cultural borders; the quick flow of information, human traffic, money, goods and services across the globe; and the situation where economic, political and cultural activities are not only interconnected but individuals and nations increasingly find themselves influenced from a distance, are developments that have far reaching implications for the political, socio-economic and health status of states.\par
The mission of Nigeria's Federal Ministry of Heath is to develop and implement appropriate policies and programmes and to undertake other necessary actions that will strengthen the national health system. All these are in its quest to deliver effective, quality and affordable health services to Nigerians. (Federal Ministry of Health,  {\ref FMOH, 2001} {\ref FMOH, , 2004))}.\par
Unfortunately despite Nigeria's well articulated health system missions, World Health Organization (2000) ranked the country a dismal 187th position among 191 United Nation member states in 2000. Furthermore, Nigeria has one of the lowest national health budgets in Africa. Above all, there are also differences in the capacity of Nigeria's 774 local governments to provide primary health care which ought to be the cornerstone of the healthcare delivery system. Thus under-funding of the health sector contributes to low quality of health services in the country. \hyperref[b17]{(Nwokeoma 2009}\hyperref[b2]{, Asuzu, 2002)}.\par
According to \hyperref[b4]{Chukwunwike (2005)}, many health facilities at primary, secondary and tertiary levels are dilapidated, totally dysfunctional or operating below average capacity. The health referral system, to say the least, is simply not efficiently operational. To compound the problems, poor remuneration and low motivation of health personnel prevail. All these translate to inefficient and ineffective health care delivery. Many health workers have also left the country to work elsewhere on account of poor remuneration.\par
The obvious victims of this state of healthcare services are the health consumers who have become disillusioned and dissatisfied with low quality of health care Such consumers also have to contend with problems of fake, sub-standard, adulterated and unregistered drugs as safe and affordable drugs and consumables are irregular \hyperref[b6]{(Ebigwei, 2005)}. Only about a quarter of health spending in Nigeria is through the public sector -so it is not surprising that the poor suffer the most from lack of access to health services. They cannot afford the costs of direct payments. Not only must people pay for health services in the private sector, but many public health services charge a fee as well. (see \hyperref[b19]{Ogunbekun, 2004}).\par
Nigeria's development efforts have over the years been characterized by lack of continuity, consistency and commitment (3Cs) to agreed policies, programmes and projects. There is also an absence of a long-term perspective. The overall effect has been growth and development of the Nigerian economy without a concomitant improvement in the overall welfare of Nigerian citizens. Disregard to 3Cs has resulted in rising unemployment, unequal access to health services and rising levels of poverty.\par
It is against the backdrop of above highlighted problems that the need to interrogate the effects of globalization processes on the health service delivery system in Nigeria was embarked upon. It was envisaged that globalization which facilitates easy movement of people, information, goods and services should have been taken to advantage to reposition the Nigerian public health sector to be responsive to the health needs of Nigerians and to ensure healthier, longer and more productive lives.\par
This paper with three related objectives, first seeks to chronicle the diverse dimensions to the conceptualization of the subject of globalization. The second is to present globalization as a contemporary social phenomenon with the characteristics of a social determinant of health which is often ignored by some scholars. The third objective is to briefly account for the exact effects of globalization on Nigeria's health system over the years and to make recommendations on how globalization should be harnessed to advantage to improve health care delivery in Nigeria. 
\section[{II. Conceptualizing Globalization}]{II. Conceptualizing Globalization}\par
Globalization is the flow of information, goods, capital and people across political and economic boundaries. \hyperref[b3]{Burbules and Torres (2000)}, argues that the process of globalization blurs national boundaries in such a way that local happenings are shaped by events occurring many miles away and vice versa. \hyperref[b13]{Lee (2000)} sees globalization as the process of closer interaction of human activity across a range of spheres, including the economic, social, political and cultural, experienced along three dimensions: spatial, temporal and cognitive. He \hyperref[b13]{(Lee, 2000)}  i. Ethnoscapes (tourists, immigrants, refugees).\par
ii. Mediascapes (lines between the 'real' and the fictional landscapes are blurred through the media). iii. Technoscapes (configuration of technology) iv. Financescapes (financial flows have decoupled themselves from other landscapes. v. Ideoscapes (ideas of freedom, welfare, rights and so on are spreading in the world). For Jary and Jary (2000), globalization is multifaceted and includes these aspects:\par
i. The transformation of the spatial arrangement and organization of social relations involving 'action at a distance' ii. The increasing extensity, intensity, velocity and impact of global social relation and transactions. iii. The creation of new networks 'network society' associated with new levels of dependence on information and expert systems (i.e. information or knowledge society) as well as new risks associated with this 'Risk society' iv. A dialect between the global and the local, in which the outcome is not a simple triumph of the centre over the periphery, but mere 'Americanization' or such like. 
\section[{Global Journal of Human Social Science}]{Global Journal of Human Social Science}© 2015 Global Journals Inc. (US) - Year 2015 ( H )\par
Globalization is therefore a step towards international integration in which people of the world are unified into a single society. In globalization, there is decoupling of space and time \hyperref[b10]{(Giddens, 2002)}; convergence of social preferences in matters of lifestyle and social values  {\ref (Kahn, 2003)}; and diminishing importance of geographical distance in cross border economic, political and socio-cultural relations. Indeed, globalization systematically restructures interactive phases among nations, breaking down barriers in the areas of culture, commerce, communication etc. As a capitalist economic ideology, it pushes for free-market economy, liberal democracy, good governance, gender equality and environmental sustainability among other values.\par
The concept of globalization cannot be easily divorced from "liberalization" since it seeks to remove all national barriers to free movement of capital and aims at homogenization of ideas, cultures, lifestyles, values as well as deterritorialization and villagization of the world (see \hyperref[b24]{Waters 1995} {\ref , Robinson 1991}\hyperref[b11]{, Jary and Jary 2000} {\ref , Scheafer 2005}).\par
It must be noted that globalization is not a value-free and self-determining process. Economic globalization is consciously engineered by capitalist ideology of the West and facilitated by supranational institutions (such as International Monetary Fund and World Bank), and transnational corporations whose decisions shape and constrain the policy options of nation states in similar direction \hyperref[b3]{(Burbules and Torres, 2000)}.\par
Although political and cultural dimensions of globalization are more self-propelling than the economic aspect, the former have also tilted heavily toward infiltration of Western cultural and political landmarks into the shores of developing nations. As in the economic sphere, there has been gross imbalance in the cross-border flow of cultural and political attributes which slants to the advantage of the West.\par
We can now summarise globalization as encompassing: ? Internationalization: cross -border relations between countries. ? Liberalization: removal of government imposed restrictions on movement. ? Universalization -spread of various objects and experiences. ? Westernization or modernization -dynamism ? Deterritoralisation -spread of supraterritoriality. 
\section[{III. Brief Overview of Historical Perspective on Globalization}]{III. Brief Overview of Historical Perspective on Globalization}\par
The concept of globalization is not new to the world. People have always carried goods, cultural traits, capital and information across countries. The earliest efforts at globalization could be traced to Europeans like the Portuguese, Spanish, Dutch, French and English who pioneered territorial and maritime expansion into habitable continents, including the discovery and colonization of the new world. \hyperref[b14]{Nadudere (2000)} supports the above viewpoint and dates the origin of globalization to 1492. He traced it to Western Europe as a cultural project whose roots are to be found in the attempt to make Christianity a universal religion.  {\ref Nemetinia (2007)} highlighted some earlier examples of globalization as follows:\par
? Fortunes from tea and cocoa trade in the 18 th  ). Globalization has intensified in the 1990s with the removal of barriers to international trade, foreign direct investment, privatization and crossborder acquisitions by multinational firms etc. 
\section[{IV. Conceptualizing Healthcare Delivery System}]{IV. Conceptualizing Healthcare Delivery System}\par
Health is broadly defined as a state of complete physical, social and mental well being and not merely an absence of disease or infirmity (World Health Organization, 1978). It is a state of optimum capacity for effective performance of valued tasks in which the individual is well and free from disease, defects and pains etc. Healthcare delivery system is defined as the totality of arrangements put in place by a social system for preventive, curative, rehabilitative and health promotion services in their environment. By social system, we mean different social collectives or groups, communities, nation states etc.\par
Health care system could also be conceptualized as a system of institutions, people, technologies and resources designed to improve health of the population. According to \hyperref[b2]{Asuzu (2002)} health system is an organizational framework for the distribution of health care needs of a given community. It is a fairly complex system of inter-related elements that contribute to the health of people -in their homes, educational institutions, in work places, the public (social or recreational) and the psychological environments as well as in health and health-related institutions. An effective and efficient health service is one that achieves set goals. Such health system is accessible, acceptable and affordable to majority of the population, particularly the poor.\par
Nigeria has two complementary systems of health care. These are the indigenous traditional medicine and the modern form of medicine introduced by European merchants, explorers, missionaries and colonialists. According to Nonyelu and Nwankwo (2014) patronage of the two services cut across class, but more of the poor patronise cheaper traditional medicine than their upper class counterparts who incline toward orthodox medicine. 
\section[{V. Globalization as a Social Determinant of Health}]{V. Globalization as a Social Determinant of Health}\par
Sociologists are very interested in social determinants of health (SDH), defined as conditions in which people live and work that affect their opportunities to lead healthy lives. Social determinants of health influence the health status of individuals and groups. They are grouped into three broad categories as social institutions, social surroundings and social relationships \hyperref[b16]{(Nwankwo 2007)}.\par
There are many social determinants of health. This is because health is a product of multiple levels of influence. The multidimensional nature of health is shaped by factors that are of physical, environmental, biological, socio-cultural, psychological, political, economic, and religious/spiritual backgrounds etc.\par
Globalization manifests economic, social and political ramifications. It constitutes one of the key social determinants that affect healthcare delivery systems in both developed and developing nations. Nonetheless, the magnitude and exact nature of influence of globalization on health system of different nations depends on specific circumstances of such nation states either as key player, passive participant or as mere major consumer of goods and services at the global market. Globalization also has implications for the state of health of individuals and social groups irrespective of their location as goods and services with diverse health implications criss-cross the face of the earth and is consumed in some places like Nigeria without adequate considerations to their side effects.\par
Unfortunately, although there are interventions that could address disparities in social determinants of health (SDH), including those arising from globalization, such interventions aimed at increasing the social resources of neighbourhoods, communities, or nations in other to attain a positive and measurable impact on health outcomes are yet to gain grounds in Nigeria.\par
Few examples of interventions that address the disparity of social determinants of health are training of health manpower, building and equipment of health facilities, adequate remuneration and incentives to health workforce, affordable housing program for the masses, increasing neighbourhood safety, promotion of community development to increase economic opportunities. Poverty, unemployment or low income negatively affects the level of health attainment of an individual. Furthermore, enhancement of literacy level of the people is a very important intervention. Education has positive correlation with level of health attainment. The absence or poor performance of above mentioned interventions in Nigeria compounds the negative effects of globalization in her area. 
\section[{a) Theoretical Framework}]{a) Theoretical Framework}\par
This paper is anchored on modernization theory.\par
Modernization theory portrays marked influences of classical theorists such as Durkaheim, Marx and Weber \hyperref[b20]{(Rex, 1961)}. However, many analysts of modernization follow the examples of Durkheim, Tonnies, Parsons and Merton. Both Durkheim and Merton were concerned with the moral breakdown and social disorganisation which followed the loss of traditional society \hyperref[b1]{(Ajiboye, 2007)}.\par
The basic approach of modernization theory is the tendency to dichotomise between traditional and modern society. It argues that there is a wide gap between developed and underdeveloped countries which could be closed by diffusing the characteristics of developed societies to underdeveloped ones. Also, the theory submits that underdeveloped nations must jettison their traditional characteristics which are considered as encumbrances to their development and embrace modern characteristics typified by western models.\par
Globalization, urbanization, industrialization, western education, advances in information technology etc are all by products and indicators of modernization. There is a relationship between globalization as an aspect of modernization, and the state of health of nations which could be positive or negative (or both) depending on a country's position as 'core' or 'peripheral' actor in the globalization chain. The relationship is also affected by a country's rules and policies towards globalization.\par
It is a fact that over dependence of underdeveloped countries on the integrated global economy dominated by the West has resulted in positive health/development outcomes to the centre (West), but stagnates socio-economic and health attributes of the periphery (underdeveloped nations). This is largely because of the fact that globalization as a socio-economic phenomenon is driven and manipulated to their advantage by the West. They dictate the tune and direction in their favour. Also, globalization is capitalist -driven rather than welfare or peopleoriented. 
\section[{Global Journal of Human Social Science}]{Global Journal of Human Social Science}\par
Adamu (2005:518-520) summarizes the relevance of modernization theory to the understanding of globalization when he noted that:\par
"One of the consequences of globalization is the end of cultural diversity, and the triumph of a homogenized culture serving the needs of Trans -National Cooperations (TNCs). Hence the world drinks Coca-cola, watches American movies and enjoys football, whilst traditional cultural values, traditions and practices decline in importance. The implication of this is not only in terms of its consequences on our economy but that such global commodities imply emergence of global culture. The issue here is not just the sale of goods globally, but also the ideas and statement that imply modernity, which is Westernization''. 
\section[{VI. Effects of Globalization on Nigeria's Healthcare Delivery System and Related Aspects}]{VI. Effects of Globalization on Nigeria's Healthcare Delivery System and Related Aspects}\par
There are enormous implications on health and welfare on Nigerian society arising from globalization. Such effects cut -across positive and negative dimensions. The magnitude of such impact depends on political, social, economic and stock of pre-existing endowment of a particular nation. 
\section[{a) Negative Effects of Globalization on Health in Nigeria}]{a) Negative Effects of Globalization on Health in Nigeria}\par
We earlier pointed out that spatial, temporal, and cognitive changes are three core changes occurring at unprecedented rates due to globalization. Spatial changes lead to increased migration of people around the world which facilitate fast spread of diseases across national borders. Nigeria encounters threat of epidemic infections such as Ebola virus disease, HIV/AIDS, tuberculosis, and severe acute respiratory syndrome (SARS), through immigrants from other countries, and particularly from poorer West African neighbours like Liberia, Niger, and Togo where such diseases are often prevalent. Such diseases could also flow in a reverse direction.\par
Migrants from other countries, particularly those from poor countries aforementioned above increase the financial burden borne by the Nigerian nation in responding to total number of unhealthy population in her territory. As a host nation in this instance,, Nigeria is burdened to carter for her teaming immigrants.\par
Globalization results in extensive import of health risks through tobacco, fast foods, ammunitions and hazardous waste etc. These harmful products are imported from high income countries to other parts of the world. Tobacco pandemic and tobacco -related deaths are consequently on the rise in Nigeria.\par
Furthermore, there is increased migration of insufficient Nigerian health professionals which disadvantage the capacity of the national health system to optimally respond to health needs of the populace. Nonetheless, such migration benefit understaffed health systems of high income countries.\par
To enhance free market mechanism in disbursement of health services in consonance with globalization philosophy, as well as to cut government spending on health services, user fees have remained a major form of health finance. These charges may aim at increasing financial returns to the health sector, but they also limit access of the poor to health services. The situation is worsened as national health insurance scheme is yet to consolidate and reach the masses, while privatization of health and hospital services is partly being encouraged.\par
Globalization emphasizes liberalization through trade agreements, structural adjustment programmes and lowering of tariffs on imported goods. Nigeria has since keyed into such philosophy. These measures cause reductions in Nigeria's national revenue, and alternative revenue yielding sources. The situation grossly affects ability of the country to provide public health, education, water and sanitation services essential for development.\par
Although globalization and open markets had provided wealth to some parts of the world, it has also increased the gap between developing and developed countries with adverse effects for their health indicators. This argument is also true for Nigeria.  {\ref Thompson (1995)} notes that globalization disregarded socio-economic development of poor countries while Berger  {\ref (1987)} writes that globalization had made more people prone to poverty. These situations compound the deplorable health standards among third world nations (Nigeria inclusive).\par
Cognitive changes brought about by advertising, and the glamorization of self -serving and unsustainable lifestyles through the media have had profound effect on social norms which directly influence health in Nigeria,. Consequently, globalizations have facilitated the spread of "lifestyle diseases" e.g. obesity, particularly in Nigeria and other developing countries who copy foreign advertorials.\par
The major vehicles through which globalization operate are imposed macroeconomic policies like Structural Adjustment Programme (SAP), Poverty Reduction Strategy Programme (PRSP) of the World Bank and IMF etc. These vehicles often have negative health effects by decreasing public sector capacity or resources and regulatory authority. In other words, the vehicles often weaken domestic policies that condition healthcare like universal access to education, restrictions to health damaging products like tobacco, hazardous waste and environmental degradation. 
\section[{b) Positive Effects of Globalization on Health in Nigeria}]{b) Positive Effects of Globalization on Health in Nigeria}\par
A major positive impact of globalization on health in Nigeria is that it has facilitated the spread of health sector reforms. This practice is a form of cognitive globalization in transferring policies about health service provision and financing across the world. The result is that national health systems only face the challenge of adapting these policies to their local contexts. The Millennium Development Goal (MDGs), and Health For All Strategies etc. are few examples of global pursuits at improving the health care systems adopted in Nigeria and other third world countries. In Nigeria, health reform initiatives aim to restructure and revamp the health system and, concomitantly, realize the goals of the recently revised National Health Policy and other health programmes, including health-related benchmarks of the Millennium Development Goals (MDGs).\par
The seven strategic thrusts of the current health reform in Nigeria are:\par
i. Improving the stewardship role of government ii. Development of the health system and its management iii. Reduction of disease burden iv. The availability of health resources and their management v. Improving access to quality health services vi. Improving consumers awareness/community involvement vii. Promoting effective partnership, collaboration and co-ordination Although the health reform project has been far from perfect, the development and implementation of related programmes represent a significant departure from the errors and deficiencies of the past, at least in terms of openness and greater public participation.\par
Globalization of communication has opened remarkable vistas for the exchange of information beneficial to health. Accordingly, doctors in Nigeria can now order vaccines or drugs via telephone and have them delivered through courier service at short notices. Modern technology has enhanced quicker response during emergencies in Nigeria.\par
Globalization has facilitated diffusion of benefits of economic growth and led to improvements in population health in Nigeria. Such improvements in population health will be further consolidated as the country works toward broader participation and leadership role in the integrated world economy.\par
Also globalization has aroused global consciousness and leads to increased sharing of principles, ethical values and standards that shape decision making about health. Nigeria has benefitted immensely from such sharing of principles, ethics and standards. Examples of such principles include the following:\par
? 1964 Helsinki Declaration on ethical principles for medical research involving human subjects. ? International code for marketing of breast milk substitutes adopted by WHO and UNICEF in 1981. ? Convention on Tobacco control adopted by World Health Organization in 2003. ? Therefore, with globalization, social, economic, environmental and health issues are becoming 'inherently global' rather than purely national or domestic.\par
Global life expectancy appreciated from 46years in 1948 when W.H.O was born to about 65 years presently. This huge increase has been attributed to global health revolution from which Nigeria has tremendously benefitted, while public health institutions have played an important role in the context of globalization of ideas, information etc. 
\section[{VII. The Way Forward}]{VII. The Way Forward}\par
The benefits of globalization in the areas of health could be maximised in Nigeria if the following recommendations are implemented: ? Improvements in health and well being should be central objectives of national economic policy in relation to the international economic system. ? Nigeria and other developing countries should work toward broader participation and integration into the world economy. They should move away from the 'periphery' to the 'centre' stage where decisions are made. ? Globalization should be people oriented and aim at improving health and welfare rather than being capitalist driven. ? Nigeria should drive or manage her roles and expectations from globalization. As a nation, she should be proactive towards globalization and avoid operating merely on terms and conditions set by western nations. She should operate with clearly defined agenda beneficial to her citizens in the face of her encounter with globalization process. ? Over liberalization should not be allowed in Nigeria. This is to ensure survival of local industries and employments. Social dislocations caused by overliberalization impact negatively on health standards. 
\section[{VIII. Conclusion}]{VIII. Conclusion}\par
Globalization has been part of human history for long. What may be new is the current nature and increased speed of globalizing activities over time and space.\par
Globalization has positive and negative effects on health. Nigeria and other third world nations are disadvantaged in the new socio-economic order associated with globalization. They are estranged from core decision-making positions thus compounding their poor health and economic indices.\par
Year 2015 ( H )\par
A genuine and balanced process of globalization is advocated where no nation is an underdog. This could be achieved by ensuring that Nigeria's interests and interests and those of other vulnerable populations are fully respected at all international decision making forum. To this end, marginalization and peripheral roles will be a thing of the past. This will give room for all nations, whether developed or developing to optimally benefit from globalization and take advantage of it to safeguard both their health system and health status of her citizen.\begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.7504878048780488\textwidth}P{0.008292682926829269\textwidth}P{0.033170731707317075\textwidth}P{0.008292682926829269\textwidth}P{0.037317073170731706\textwidth}P{0.012439024390243903\textwidth}}
combination\tabcellsep of\tabcellsep advances\tabcellsep in\tabcellsep transport\tabcellsep and\\
\multicolumn{6}{l}{communication technologies. Other stimulants were}\\
\multicolumn{6}{l}{large developing countries who sought foreign}\\
\multicolumn{6}{l}{investment by opening up to international trade (www.}\\
\multicolumn{3}{l}{globalizatiom.com, 2008}\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_1}}\end{figure}
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