BURNING POT BY DR. PRINCE CHARLES DICKSON
Nigeria's dead primary health system, and other deaths
I am shocked that the rising cases of Covid-19 in Lagos, Abuja and Plateau are becoming an issue of concern. Contemplating lockdown in such states and the FCT, shows something is fundamentally wrong with the government's response. The rising numbers in these states is a consequence of the government's effort in testing its citizens, which should be commended. Such concerns should be raised when the rising number is also translating into fatalities, which we are not recording. For the few fatalities recorded in Plateau recently, most of the persons had underlying conditions which must be taken into account. The focus of the federal, state and local governments should be on states with very low numbers. It’s either they are not testing, or they do not want to declare. Above all, the process of testing is cumbersome, except for the three aforementioned states where multiple testing centres exist.
The above was the reflection of my friend and brother Dr. Chris Kwaja, and I share in the truth that he nicked out in the reflection, and so I decided to stretch it. Professor Olikoye Ransome-Kuti was a leading figure in global health for several decades. A pioneer of primary health care, he was a proponent of an all-embracing system to provide health care in an integrated way, rather than through vertical disease-specific programmes. He pursued this goal relentlessly until his death. In his last public statement he made, on the day he died, he asserted that: “One of the challenges that countries [are] facing in tackling global health problems is that country health systems are dominated by vertical programmes—you can’t do global vertical programmes until you have health systems that work! Because many countries don’t have their own national health plan, they have multiple parallel mini systems reflecting the programmes they have been ‘offered’ by donors and accepted by heads of state, sometimes regardless of the actual health needs of the country. The priority must be national health system development.”
From 1986 to 1990, Olikoye Ransome-Kuti expanded PHC to all local governments, achieved universal child immunisation of over 80%, and devolved responsibility for PHC to local government areas. Olikoye Ransome-Kuti worked assiduously between 1985 and 1992 to implement PHC policy based on the Alma Ata Declaration for the benefit of the Nigerian population. He introduced a comprehensive national health policy with a focus on PHC, placed emphasis on preventive medicine and health-care services at the grass root, ensured exclusive breast feeding practice, introduced free immunisation to children, encouraged the use of oral rehydration therapy by nursing mothers, made compulsory the recording of maternal deaths, and encouraged continuous nationwide vaccination and pioneered effective HIV/AIDS campaign. In 1992, the National Primary Health Care Development Agency (NPHCDA) was established to ensure that the PHC agenda is continued and sustained. The military takeover of government that occurred in 1993 brought to an end the giant strides recorded under the leadership of Olikoye Ransome-Kuti from 1985 to 1992.
Ransome-Kuti was a professor of medicine, a World Health Organisation (WHO) executive and arguably the best cabinet minister Nigeria has ever had, a model of transparency and incorruptibility. Appointed health minister by Ibrahim Babangida's military regime, his passion was the rejuvenation of Nigeria's crumbling healthcare system.
It was while he was lecturing at the National Institute of Policy and Strategic Studies that he impressed Babangida. When IBB seized power in 1985, Ransome-Kuti got the health portfolio. He made qualitative healthcare available to every Nigerian, especially through his primary healthcare programme, which emphasised the grass roots.
Before I go too far, the basis of Primary Health Care has always been the debate that came to a head at the International Conference on Primary Health Care, held in Alma-Ata (USSR) in September 1978. The Declaration of Alma-Ata contains the best statement in defence of public health that has ever been adopted by the governments of the world. In addition to highlighting the importance of public health in general. It is worth revisiting point VII of the Declaration, which states that public primary health care:
Reflects and evolves from the economic conditions and sociocultural and political characteristics of the country and its communities and is based on the application of the relevant results of social, biomedical and health services research and public health experience;
Addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly;
Includes at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs;
Involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors;
Requires and promotes maximum community and individual self-reliance and participation in the planning, organization, operation and control of primary health care, making fullest use of local, national and other available resources; and to this end develops through appropriate education the ability of communities to participate;
Should be sustained by integrated, functional and mutually supportive referral systems, leading to the progressive improvement of comprehensive health care for all, and giving priority to those most in need;
Relies, at local and referral levels, on health workers, including physicians, nurses, midwives, auxiliaries and community workers as applicable, as well as traditional practitioners as needed, suitably trained socially and technically to work as a health team and to respond to the expressed health needs of the community.
Matter of factly Nigeria has failed in the last 30 years in adding any value to the declaration above, it has equally made no effort at putting any of the above back on the agenda. Infact it would seem like with the death of Ramsome-Kuti there was a deliberate effort at killing our health systems, through poor and almost zero-funding to waging an all-out battle on the wellbeing of the Nigerian populace.
Strong health systems help mitigate the disruption a health epidemic causes, limit the lives lost, and ensure local populations can resume normal functions sooner than later. Our is dead! Strong health systems also strengthen the overall social cohesion and economic productivity of communities in times of calm. We simply do not have any, we are accustomed to our auto-pilot methodology of governance.
We have a situation on hand, that will require more than lockdowns, isolations, quarantines, masks, medicines and executive orders. It will need infrastructure that cannot be created overnight, test centers to identify cases, means for communicating effectively with frightened communities, systems to reach even the poorest and most remote communities, trained health workers and facilities to care for the sick.
COVID19 and our dead PHC isn’t just about improving emergency management practices — such as rapid response when viruses emerge; but also ensuring that health systems can provide the most basic health services to people at any time. The strike ridden health sector, poorly motivated healthcare provider status cannot move this nation anywhere.
Resources are crucial. There’s no doubt that the costs of shoring up health systems are high, but costs of not doing so are higher. The Corona pandemic will come to an end eventually, but the challenge will not end there. If we fail to invest in 21st century health systems that meet everyone’s basic health needs, we will not only repeat today’s confused experience but when the real pandemic strike may we not all be victims as only time can tell.