22 C002D5556 Sunday 15 April 2018 Analysis OSARO EGHOBAMIEN Eghobamien, a senior advocate of Nigeria, is managing partner at Perchstone & Graeys. President Buhari’s declaration of his intention to seek re-election in 2019 comes against the backdrop of former President Olusegun Obasanjo’s contentious advice to join octogenarians and leave the field for “younger aspirants”. President Buhari’s boldness and stern conviction presents various permutations as well as stretches the limits of democracy in a fledgling economy. Often, the material necessary to make informed decisions is misunderstood, misinterpreted and sometimes ignored by the electorate. Consequently, the question as to who becomes Nigeria’s president assumes some complexities, and the role of the professional requires more penetrating focus. It would be recalled that in his characteristically colourful and anecdotal manner, Chief Obasanjo delivered a “balanced scorecard” of sorts, of the Buhari-led administration, in a Special Press Statement released to the media sometime earlier this year. Permit me to draw your attention to a passage in the statement, where the elder statesman remarked: “We have only one choice left to take us out of Egypt, to the Promised Land. And that is the coalition of the concerned and the willing – ready for positive and drastic change, progress and involvement… If leadership fails, citizens must not fail…” The former President appeared to have eloquently captured the nation’s insight in his analysis of the administration’s efforts at governance these past three odd years. Although it must be admitted that Alhaji Lai Mohamed (Nigeria’s Minister of Information & Culture) equally drew attention to some of the positive economic gains recorded by this administration. As often with reactionary posture or statements however, it carried little or no weight in the face of the ex-President’s volcanic criticisms. Chief Olusegun Obasanjo’s call for citizens to act in the face of failing leadership is worth introspection by all, particularly professionals and non-career politicians. Acting, in this context, implies supporting dynamic, and visionary professional leadership outside of the usual political circles, and strategically working to put such leadership into positions of power. To paraphrase a statement credited to one of Nigeria’s greatest political and cultural icons, Chief Obafemi Awolowo, at the turn of Nigeria’s independence: “…a nation cannot go on, when there are competent people around, to have incompetent people in charge”. The present administration is by no means utterly incompetent, but it has however been exceptionally slow in many respects; yet recording some successes along the way. It has slowly, but doggedly, pulled the nation out of recession. Again, it is not correct that whatever achievements it has recorded are attributable to increase in oil prices. Negotiating a fragile peace in A call to action: The role of the professional in Nigerian politics and national development the Niger-Delta, and the slow diversification of a monolithic economy from oil to agriculture, is worth extolling. These accomplishments must however be weighed against the herdsmen crises and general insecurity. Obasanjo’s advice in connection with these crises must be taken seriously. That said, a reflection on the 2015 general election and its outcome within the context of the present discussion, leaves one with some optimism, even though cautious. The ascendancy of non-career politicians (as we know it in Nigeria) in the person of Buhari (to a lesser extent) and Osinbajo has taught us that political victory is possible against all odds. Both men campaigned on the mantra of change, but more importantly, backed it with their personal integrity. Nigerians threw their weight behind the duo. While many will argue that all the goodwill may have since been frittered away, I sincerely believe it can be regained. For the first time, non-career politicians are at the helm of governance. To my mind, this sets the stage for other men and women of character, with the benefit of youth; experience and dynamism, to some-day soon, rule this nation. Perhaps not in 2019, but in 2023. I am speaking of a possible presidential candidacy of the likes of Peter Obi, Babatunde Fashola, Kingsley Moghalu, Godwin Obaseki, Ngozi Okonjo-Iweala and of course Professor Yemi Osinbajo, SAN. Even better still, a race between two or more of such candidates, would present a most desirable dilemma. Further down the line (eight years thereafter), the emergence of Northern candidates of similar extraction, such as Engineer Suleiman Adamu, the current Minister of Water Resources, is envisaged. The point being made here is that this present administration has set a platform for professionals with integrity, to get involved and define the pathway of the country. The operative word here is integrity, however, the perennial challenge has been the modality for the determination of integrity. As I proposed in a speech given at the Rotary Club, all aspirants to public office must have established worthy antecedents, verifiable by non-governmental organizations, such as the Convention on Business Integrity (CBI). Verification may be conducted by way of interviews with schoolmates, colleagues and members of the aspirant’s community. Having said that, there must be some level of intrusion into the person lives of the aspirants seeking public office. Lin Kuan Yew wrote that a man who has succeeded in leading or participating actively in a voluntary organization by mere persuasion and strength of character, invariably performs exceedingly well when backed up by state authority, in the event that he or she assumes public office. He was unapologetic in his intrusive nature in the lives of Singaporeans when he said: “I am often accused of interfering in the private lives of citizens. Yes, if I did not, had I not done that, we wouldn’t be here today. And I say without the slightest remorse, that we wouldn’t be here, we would not have made economic progress, if we had not intervened on very personal matters - who your neighbour is, how you live, the noise you make, how you spit, or what language you use. We decide what is right. Never mind what the people think.” CBI and organizations of that nature can perform that verification exercise effortlessly. They have a sophisticated formula of reaching conclusions about character and the behavioral pattern that is likely to emerge once a person is in a position of public trust, drawing from verifiable pedigrees. Regrettably, the Government institutions that should ordinarily perform this role are seriously compromised. In essence, an aspirant’s pedigree and character must be verifiable. Having declared his intention to contest the 2019 general elections, it is doubtful that there could be any viable opposition to President Buhari’s ticket. First, by the ‘gentlemen’s agreement’ that seems to hold an otherwise fractious nation together, the Northern region is expected to lay hold to the seat of power for another term, come 2019. Second, no other Northerner, whether within or outside the All Progressives Congress (“APC”), possesses the political clout, to unseat or even seriously rattle President Buhari’s bid for re-election. This is understandable. It took the sitting Lee Kuan Yew wrote that a man who has succeeded in leading or participating actively in a voluntary organization by mere persuasion and strength of character invariably performs exceedingly well when backed up by state authority President thirteen years to build his political base into its current monolithic proportions. It will be a very slim chance indeed to unseat him. This puts the premise of former President Obasanjo’s letter into sharper focus. It was essentially a roundabout plea to the President not to run, simply because it is unlikely that his candidacy can be defeated. Following the President’s decision to contest the next general election, it would make sense to pick as a running mate, his present Vice, who seems to have won the hearts and minds of many Nigerians. However, there is no guarantee that he would pick Professor Osinbajo SAN as his running mate once again. Nothing is certain in politics. Even though his Vice clearly demonstrated sterling qualities in strategizing and effectively implementing policies of government, he may be perceived as lacking a political base that could assist President Buhari in a keenly contested presidential race. If this happens, I see Professor Osinbajo as simply walking away, and that might be the end of his political career. The alternative, for the VP to challenge his boss, is unimaginable. The Vice-President, being a man of faith, character and loyalty, will never contemplate running against his boss. Insiders maintain that the relationship between both men is as cordial and trusting as can be. The logical next step for men like Professor Osinbajo, Kingsley Moghalu, and other professionals who would rule this nation, would be to put machinery in motion to contest the 2023 election. It is certainly not in the interest of most politicians to see candidates like these, elected to the office of President. But rather than a clarion call for non-specific political intervention to unseat the current President in 2019, I believe that a more attainable and worthy objective would be to work to ensure that an honourable professional, a non-career politician, is elected to the office of President in 2023. Nation-building is a marathon, not a sprint. In the absence of a strong political base, what are the chances of any professional having a successful outing at the 2019 general elections? Slim to none. Professor Osinbajo, currently the closest professional to the seat of power, has intentionally and systematically insulated himself from the politics of governance, concentrating instead on delivering a service. Any professional seeking at this stage to build the type of political base that can unseat a popular, if controversial, sitting President, this close to a general election, would have a tall order to fill indeed. Even with the support of the political elite (many of whom are themselves desirous of occupying the exalted office), it will be next to impossible to secure victory in the next elections without first being a household name, with massive support across all geo-political zones. Professionals with some decorum of integrity have mostly, albeit to varying degrees, performed exceptionally well in politics. They have certainly always been miles ahead of the average politician. The likes of Ambrose Alli, Alex Ekwueme, Babatunde Fashola and Donald Duke readily come to mind. What the professionals have however failed to realise when in power is that they have a silent base of likeminded professionals across the country, whom they can mobilize to begin to build political clout, when angling for leverage with politicians and the rest of the electorate. Therefore, rather than joining the bandwagon of criticising the failures of this administration, it is time for professionals to act, and throw their weight behind a candidate who represents the very best of us. As already alluded, a contest between two or more seasoned, respected and dynamic professionals, can only enrich and elevate the level of political engagement, from tribal and emotionally driven politics, to policy-based discourse on a national platform. While I may personally choose to support the professional who has been tested at the highest level, it will really be left to the individual to side with whomever he believes is poised to actualize the policies that will take the country out of the current doldrums, to the next level. The political elite have since realised that there seems to be no alternative to President Buhari in 2019. It would however be prudent to remedy the charges of nepotism, dereliction of duty in relation to the issue of Fulani herdsmen and the general state of insecurity. Rather than continue to simply criticize the administration and move on, our strategic role as professionals, must be to support and guide the present administration to achieve the mandate upon which it was originally elected. The support and guidance must be with a caveat; that when the time comes, President Buhari and the Northern elite will support one of our own to the presidency in 2023. It is unrealistic to expect such compromise without professionals offering something in return. That will come in the form of an organised critical mass of professionals (electoral votes) in return for the politicians “gesture.” If we do have the numbers, the partisan politicians will have no choice but to heed our request.
Sunday 15 April 2018 C002D5556 23 For the Records Challenges of health care delivery for all ages in Nigeria (4) Being the fourth part of 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). The lesson from these best practices for those who have not had a firsthand experience of them can be summarised as follows: 1. For each of the three levels of the national health system to properly and sustainable perform its function at a mutually challengeable way, each must be headed by medical doctors as the apex of the health professions. Some of the subdivisions or districts within these LGAs and their physical facilities would also be best to be run by medical or dental officers up to the senior medical officer cadre, as far as these can be found, for the best performance of these services. This must be the clear objective of the governments; the extent to which this is achievable depending on the prevailing circumstances. 2. For true community health care to be achieved at the LGA level, the LGAs need to be divided STATUTORILY into community nursing and midwifery districts and zones; as the principal producers of community health care. 3. Auxiliary community and general practice physicians as well as auxiliary community nurses (BUT NEVER OF MIDWIVES BUT ONLY COMPETENT BIRTH ATTENDANTS IN THAT REGARD)4 should be found and trained WITH THE FULL COM- MUNITY PARTICIPATION BUT FOR ONLY THOSE CLEARLY LIMITED AND KNOWABLE COMMUNITIES AND FACILI- TIES WHERE THESE PROFES- SIONAL COMMUNITY PHYSI- CIAS AND NURSES MAY NOT BE FOUND. 4. The starting point for any genuine community health work is with the de-jure census for the determination of the total denominator populations of all the sections of the communities for all the statutory community health services – the total population, total males and females, infants, pre-school aged children, school-aged children (in school and out of school), women of reproductive ages, the elderly and all the categories of the chronically ill and disabled. The determination of all the chronically ill and disabled members of such communities allows for the creation of the at-risk register for all these people, the prescription of their life-long health care plan by competent physicians and their home-based community rounds Michael Asuzu by the community nurse-midwife on 3 of the 5 working days of the week. These rounds are to ensure that the chronically ill subjects are living at the maximum level of their health possible at the given time. By this, they would be taking their medication, if so prescribed, keeping all the prescribed behavioural modifications by self and family and keeping to their health facility follow-up appointments as may be prescribed. A family member is usually trained to provide the auxiliary nursing services of such family member, including the custody of their drugs and ensured observed intake thereof. During these community rounds by the community nursemidwife, any other health behavioural inadequacies observed, by anybody and in any place in the community, are counseled on for those concerned. This will include pregnant women who had not registered in time for ante-natal care, any environmental health violations, forced feeding of children, etc. 5. It is only by this thorough professional community health care, especially the community nursing and midwifery care, that any persons, families, communities, local governments, states and nations are or will be able to attain health-for-all. It is not impossible for any country or state to set the policy, produce the strategic framework and implementation guidelines to do this – ONLY IF THEY WILL SIMPLY STOP PLAYING DIRTY POLITICS WITH THEIR PEO- PLE and so, provide the needed political will to do so. Virtually all the states in the southern and lower north-central states of this country can surely do this, if their citizens rise up and hold their governments to it. All the other states can do the same, only that they will make more use of the auxiliary medical and nursing officers than any of these other states to do so. Foreign partners are not the ones to teach them how to do this; nor will these be achievable by the vertical public (and some so-called community) health programmes (foreign and local) that has become the real shame of our national health services. The big efforts that had been made to improve our health systems, or even to establish PHC,will now be listed below and followed with what was their problems and limitations; based on the world’s best practices in these regards. We will then outline what we believe should be put in place at policy, legislation and their strategic frameworks and implementation guidelines, if we are going to meaningfully pursue the PHC and HFA agenda of the modern world’s health community. At the local government level The already established provisions: 1. Every LGA health service is to be called PHC (not “medicine and health”, as before);and run as the primary responsibility of the local government. 2. All the component services of PHC are to be provided there; with the assistance of some senior staff that may be posted to assist them by the state government to do so. 3. The principal officers meant to provide these services are the community health officers (CHOs) and the community health extension officers (CHEWs); who were initially to work as such auxiliaries, but later changed both in name and implementation to be otherwise. The persisting problems 1. The principal health professionals (the community medical and nursing-midwifery officers, specialist or otherwise) who run community health services in the best practices around the world, are not properly provided for nor even emphasized in these services; at least as the ideal to aspire to. Hence, PHC in Nigeria continues to be seen as well as run as the inferior health services for the unimportant people of the country: “free but not available”, “to be provided or actually posted there but absent”; for both health workers and services 2. The most functional unit of the provision of PHC – the community nurse-midwives and their nursing zones and districts – have never been acceptably discussed in the country; nor the staff and modalities of their practices. The closest to this is the “political ward-based PHC” but I do not know anywhere that it is working as in the practices whose results are shown in Tables 2 and 3 above. 3. The CHOs and CHEWs, who in the best world’s practices, their numbers are clearly determinable, and their candidates are identified and selected for training through full community involvement, trained as auxiliary community medical and nursing officers,respectively,and made to function as such, is otherwise in Nigeria. Thus, they would rather run the services largely as parallel health services to the normal world orthodox health services; with no responsibility to ANY communities that they serve, independent of any community medical and nursing services and with no avenues for their healthy up-grade training to the full community nurses (or eventually nurse-midwives) or medical officers as may be possible for some of them. 4. The selection of the CHOs and CHEWs (as the community health practice auxiliaries that they are) through community participation, and for the clearly noted communities only, that clearly need such personnel20, has never been the case in Nigeria. So, we neither know how many of such workers are needed, nor the communities that they are being trained for. Unlike in the best practices where these workers are selected, trained and posted only to the places where the needed community physicians or nurses MAY NOT BE FOUND, we train them at random and non-stop in the country. We also have developed no healthy avenues for those of them who understand what professional community health work is, and wishing to be properly absorbed into it have made up their erstwhile previously inadequate general education for it, to go ahead to do so. Thus, these avalanche of people are ending up either unemployed, unemployable, freely leaving these government services and/ or setting up their own private but unpredictable practices or organising very unprecedented training programmes for their already somehow obviously accepted alternative but yet unclear health systems in the country of their own. At the 1st National conference on human resources for health in 2011, the statistics provided from the Planning, Research and Statistics Division of the Federal Ministry of Health21 showed that over 47,000 CHEWs had been trained in the country, only some 11,000 of which are trace- able as to what they were doing in the public health services! As for the CHOs, the number was over 17,000 trained, only some 6,000 of which were traceable in any public health services in the country. Yet our health indices are not improving any significantly; and we are still producing these officers, even with greater speed and in greater numbers; when they are not retained in the public health services nor even traceable thereafter! 5. The other complementary health workers –laboratory technologists, radiographers or medical imaging technologists, environmental inspection officers, public health nutritionists, community pharmacists or pharmacy technicians, community dental officers or at least their appropriate auxiliaries, community rehabilitative assistants (CRAs), etc – are not properly identified nor trained and deployed to work as in those best world practices here. 6. In the few cases where such physicians or nurse/midwives are found, willing to work in the community/PHC services, there are no proper structural systems organizations, provisions for their proper training or at least orientation, nor the provision to them of even the minimum tools for these statutory community health work. These include, most especially, the proper organization of the LGA services for the community medical and nursing services (for example, the medical districts/ sub-districts and zones or of the nursing-midwifery ones),general conditions of service to be able to live and/or work in these difficult situations by these officers, good and well maintained transport systems for their supportive extension services to all the officers and physical health units of the LGA by the medical officers of health or their delegate. Others are ambulances (at least one per LGA) for the transportation of needful patients within and outside the LGA and promptly paid transport allowances for the community nurse/midwives for their community rounds and related services, the very basis of achieving HFA! 7. Because of the failure to provide for specialist or otherwise properly orientated community medical officers (or some reasonable extensions of it) for the PHC services, the practice of inter-sectoral cooperation and coordination with all the other health-related agencies for the attainment of HFA in the LGA remains an impossibility. These agencies include public works (especially with the sanitary/LG) engineer, agriculture, education, information, security (police), and the traditional, socio-cultural and civil leaderships; at the very least. *Countries with district or zonal community nursing and midwifery services