WEST AFRICAN COLLEGE OF SURGEONS.
20TH SIR SAMUEL MANUWA MEMORIAL LECTURE.
In pursuit of justice and equity:
ROOTING FOR THE HEALTH OF THE POOR.
Professor Emeritus, University of Port Harcourt, Nigeria.
Pro-chancellor and Chairman of Council, Federal University, Lokoja, Nigeria.
Banjul, the Gambia. Tuesday, 27 February 2018.
To be invited to deliver a Sir Samuel Manuwa Lecture is an honour of great distinction and recognition. This is more so when one considers the status, class and eminence of previous lecturers: an intimidating array of ten past college presidents and a galaxy of nine accomplished global technocrats and professionals, let alone the scholastic rigour and ardour with which they tackled their assignments. It is therefore with a deep sense of joy that I accept the invitation to deliver the 20th in the series of these seminal lectures in this historic city of Banjul, The Gambia as the first ordinary person, the first from the rank and file or the first hoi polloi, if you wish. Consequently, I express my profound appreciation to the president and council of the West African College of Surgeons for this magnanimous gesture and for allowing me to be counted among the giants1 who have had this wonderful privilege. Finally, Mr. president, in closing my brief preamble, please permit me to esteem, in a special way, the memory of the late Chief Dr. Moses Majekodunmi, Nigeria’s erstwhile Minister of Health not only for delivering the very first Sir Manuwa Lecture in 1980 at the 20th annual conference of the college, in the coal city of Enugu, Nigeria, but also for being the only obstetrician and gynaecologist to have so far, done so. Accordingly, it is with great delight, that I stand here, almost four decades after him, as the second in such a prestigious queue, to deliver the 20th Sir Samuel Manuwa Lecture at the 58th annual conference of our great college.
Sir Manuwa: The Man with a Heart.
The fact that the Sir Samuel Manuwa Lectures have now been delivered biennially for 38 years without interruption is due in part, to the vivacious spirit, striking personality and unparalleled compassion that characterized the life and times of this formidable man. For, if as an adaptation of the observation by Malvolio in Shakespeare’s Twelfth Night (Act 2, Scene 5) that “some are born great” …” “others have greatness thrust at them”, then indeed, Sir Manuwa “achieve(d) greatness” of immense proportion through an exceptional dedication to his duties and responsibilities, using his sharp intellect, extraordinary grit and unflinching tenacity of purpose. Today’s lecture is grounded on just one of his numerous luminous charms: his unbridled passion for fairness and equity.
That quality of Sir Samuel Manuwa of serving as a voice for the voiceless, being impartial and fair to all was manifest all through his working life; time will permit only the mention of a few instances here. At the third conference of directors of West African medical services, which was held in Ibadan, Nigeria in 1952, propelled by his fair-mindedness, Sir Samuel Manuwa succeeded in persuading the colonial government to admit non-British graduates for placement in the United Kingdom medical register. Thus, paving the way for the colossal contributions of many such persons to medical education and professional practice in the sub-region.2 Furthermore, as the first Chief Medical Adviser to the Government of Nigeria in the early 1950s he concentrated efforts on providing rural health care and grappling with wide spread tuberculosis, which was then, an African epidemic that did not receive sufficient attention from the colonial administration. In doing so, he was actually, living by his own dogma of carrying “the benefits of modern medicine …into the jungle, into the creeks, into the rural areas; to the peasants and the farmers in their hamlets and villages”3. No wonder it was said of him: “his judgment was always tempered by understanding, courtesy and solicitude…”4
It is in consequence of this outstanding attribute of the man, who went everywhere with all his heart, that today’s Sir Samuel Manuwa’s memorial lecture titled “In Pursuit of Justice and Equity: Rooting for the Health of the Poor” is predicated on issues of humanity, fairness and objectivity. Thus, two words – justice and equity – straddle the lecture. Justice is moral rightness, the fair treatment of people; equity, impartial judgment; one devoid of bias and in which everyone is treated equally. Accordingly, the purpose of the lecture is to survey the role injustice and inequity – the converse of justice and equity – have played in the lives of West Africans and to comment on that aspect of Sir Samuel Manawa’s life which enabled him to so richly serve the cause of the poor who are disadvantaged in most societies. At its core, the lecture advocates that in tandem with the charge of its first president, Sir Samuel Manuwa, the 21st century West African College of Surgeons should seek to use surgery, along with its related disciplines as an important resource to improve health equity and social justice5 and to prioritize the health needs of the poor, deprived and disadvantaged, who, most times, are unable to receive justice and equity in health care delivery.
Injustice and Inequity: Many Years Ago.
History tells us that over the years, the people of the part of Africa, now known as the West African sub region – the Mandingos, Hausas, Fulani, Yorubas, Ashanti, Ibos, Ijaws, Akan and many others – have suffered deprivation, neglect and many unfair and dehumanizing actions. Perhaps, chief among these was the trans- Atlantic slave trade with its associated injustice and inequity. For as a people, it was probably this institution which was built on the subjugation of humans that first caused significant global attention to be drawn to the sub-region where the Bights of Benin and Biafra of the current coastal areas of Nigeria that border on the Atlantic Ocean from where a sizable number of slaves were sold, are located. The coast was called “Slave Coast”, just as Ghana, “Gold Coast” and its francophone neighbour, “Ivory Coast”. Thus, Samba6, Badoe1 and some other previous Sir Samuel Manuwa Lecturers point to slavery and its associated factors as being partly responsible for the challenges the region faces, till this day, in its political, social and economic development. In today’s lecture, we highlight the extent of injustice that the institution of slavery represented as part of the humongous tribulations that West Africans suffered and the commitment that was required to rectify that level of unfairness.
And here, notwithstanding the many forms of servitude that exist in Africa, it is the bondage that was carried out through the trans-Atlantic slave trade that is held as being foremost in the scale of the dehumanization, subjugation and calamity it caused on humans and its profound contributions, albeit unwittingly, to the development of modern human societies. From 1526 when the Portuguese, as the first Europeans, completed the premier trans-Atlantic slave voyage from Africa to America, to 1859 when the last recorded slave ship landed on American soil (15th to the 19th century), over 15 million men, women, boys and girls, largely from West Africa, were compelled to suffer this fate of forceful deportation mainly to the American continents. They were sold to labour on plantations, to construction sites as beasts of burden and to homes as servants. The injustices, abuse, rape, brutality and barbarism which were the tools of the monstrous trade were probably only matched by the genocide of the indigenous inhabitants. So stark therefore were the contradictions that were inherent in that system of man’s inhuman action on man that challenging it until its ultimate abolition in 1865 was inevitable. The pursuit of justice and equity, in consequence, thereof, provided the platform for protests and resistance to injustice. The principled stand, fueled many subsequent actions that focused on the demand of justice and equity in the conduct of human affairs: civil rights, affirmative actions, and the commencement of America’s political and intellectual journey towards gender, social and racial equality and many more. Unfortunately, the spectrum of injustice by the European invaders did not end with the demise of slave trade.
With the abolition of the obnoxious trade in human cargo, the principal European dealers – among which were the Portuguese, French, Germans, Dutch and British directed their efforts at exploring the possibilities of legitimate commerce as a strategy for protecting their erstwhile interests. The Scramble for Africa (1880-1900) had begun during which the Partition of Africa was sealed in the inglorious Berlin Conference of 1884-1885, convened by Portugal, which divided Africa among Europeans as colonies. The indigenous peoples were not consulted and colonial flags fluttered over territories that ignored kinship, cultural heritage, ethnicity and religion. Thus, the “flag” which represented political and territorial domination, followed the “free trade” which the Europeans had touted as their interest in their long voyage to West Africa. Accordingly, the presence of the flag completed the real goals of the European adventurers: Power, Profit and Prestige.7-10
Those, of the African traditional leadership, who saw this injustice coming and resisted it in various ways, paid dearly for their supposed misdemeanor: Among the many were Jaja of Opobo, koko of Nembe, Ovonramwen of Benin, Olomu of Warri, Prempeh of Ashanti, Samori Toure of the Mandinka Empire. Many were captured and died in exile.
Injustice and inequity: Contemporary Times.
But then, are we as west Africans, even in contemporary times doing less to ourselves on fundamental issues of natural justice? A frank and honest answer to this question is in the negative.
The plunder and looting of our collective national wealth in complete contravention of natural justice by some of our political leaders; the abduction of hundreds of girls from their school and their incarceration under horrible conditions; the trafficking of women and children; the rape, maiming, beheading and double amputation of limbs, even of children in addition to the death and destruction from fratricidal wars, conflicts, political strife and electoral mayhems, that have been the lot of many in the West African Sub-region are all fresh in our minds. Let these few recapitulations suffice and let us leave history for now and draw from the more compassionate terrain of healthcare where humane considerations should apply. But sadly, the story here too, does not appear to be significantly different using obstructed labour and female genital mutilation(FGM) as templates.
Labour is obstructed when further descent of the fetus in the maternal birth canal becomes impossible due to mechanical factors. The commonest form of obstructed labour – cephalo-pelvic disproportion – is usually caused by a pelvis which is too small (contracted) to allow the passage of the head of a fully-grown fetus. Thus, with uterine contractions, the fetal head becomes impacted in the maternal pelvis applying immense pressure on adjacent soft tissues, especially the urinary bladder anteriorly, rectum posteriorly and sciatic nerves laterally against various parts of the surrounding hard maternal pelvic bone (girdle). The baby often dies in utero or shortly thereafter without appropriate intervention while the mother, in consequence of the prolonged obstructed labour, may suffer several adverse consequences including dehydration, keto-acidosis, vulval oedema, genital tract infection, fistulae formation, post-partum ambulatory difficulties, rupture of the uterus and possibly, death.11-13 Contracted pelvis is common among young teenage girls who commence childbearing before their pelves have had time to grow to good capacity to allow for the passage of full-term babies. Not infrequently, such girls are those who had been given out early in marriage and had commenced childbearing as young teenagers, as is common in many countries in West Africa including Niger, Mali, Nigeria, Ghana, The Gambia and Mauritania.
Female Genital Mutilation (FGM) on the other hand is a traditional procedure, akin to circumcision that is usually carried out by untrained older women on girls in their early years of life as a cultural rite of passage to womanhood. In Africa, it is practised by communities in 29 countries of which 18 are in the West African sub region. The process usually involves the cutting and removal of the clitoris with or without the surrounding tissues and is designed, among others, to curb a girl’s craving for sexual pleasures when she grows up, within or outside marriage. While the surgery may be minimally invasive with little or no physical damage or complications, often, the converse is the case. In such instances, the operation tends to be radical; the clitoris as well as large sections of the labia majora and minora, the vulva and even parts of the upper vagina are excised with severe outcomes. Haemorrhage is usually heavy and genital tract infection is expectedly frequent with the wound healing by secondary intention. The resultant cicatrization predisposes the girl to urinary difficulties, dyspareunia, apareunia and possibly, dystocia in the event of a subsequent pregnancy.13
These two apparently dissimilar conditions arise from violations of human rights. Young teenage girls are denied the right to make their own choices of life partners by the coercion of parents and relatives into marriage often, to much older men. Little wonder a number jump ship; a few take their own lives, and some see it through, get pregnant as children themselves and face up to the possible hazards of early teenage pregnancies with the risk of vesico-vaginal fistula (vvf) and the loss of life. In a study at Ahmadu Bello University Hospital, Zaria, Nigeria one in three of 1443 patients with vvf. were under 16 years of age.14 Furthermore, the Professor Kelsey Harrison led Zaria Maternity Survey in the late 1970s11 provides additional information on the dangers associated with early teenage pregnancies. In that study of 22,774 consecutive hospital births which took place at the Ahmadu Bello University Hospital, between 1976 and 1979, in primigravid singleton births, girls aged 15 years and under constituted 6% of the survey population with 30% of the maternal deaths. Besides, the caesarean section rates, embryotomies for babies that had died in utero, as well as the occurrence of severe anaemia, eclampsia, infection and haemorrhage were much more in the girls aged 15 years and under.15
Let me be clear, while no attempt is being made to disparage the virtues of early marriage as is often canvassed16, the fact remains that the practice exposes a teenage girl to pregnancy and its complications at a period in her life when she is not completely prepared, physically and mentally for motherhood. Sadly, of the 15 countries in the world where the rate of child marriage is over 30%, nine are in West and Central Africa with Mali at the summit position. There in Mali, a study by UNICEF in 2000 which covered six West African countries showed that 44% of 20-24 years old women, were married when they were under 15 years of age17, thus, encouraging the betrothal of teenagers, occasionally even before their menarche11. It is therefore not surprising to find a high incidence of the egregious and lasting consequences of early teenage pregnancies extend far into and beyond their adolescent life.18
In the case of genital mutilation, a defenseless young girl is forcefully assaulted ostensibly, to prevent her from being sexually promiscuous in the future. In a Thesis on the subject successfully defended for a higherj degree of the University of Glasgow in 1956, Dr. Mason Dokubo Braide observed, among other findings, in a study conducted in Eastern Nigeria, the “misery and unhappiness to many husbands and wives” with failed expectations and consequences unjustified by the “primitive and barbaric” custom. Unfortunately, the situation has hardly changed in communities that still cling on to the practice notwithstanding the strong advocacy for its elimination by many non-governmental organisations as well as major international development agencies.14,19,20 However, we are encouraged by the initiative taken by our host country in this conference, The Republic of The Gambia, in 2016 by endorsing strong punitive actions against child marriages and female genital mutilations.
As is so often the case, the poor and the weak, women and children are more likely victims of deprivation, neglect, discrimination, injustice and inequity. Many, in the trans-Atlantic slave trade, were prisoners of war captured in sponsored internal battles with the cooperation of local slave barons and marauding European slave merchants who had the superior fire power of naval bombardments.
Cultural practices in many societies, especially African, add to the travails of the female gender and to blatant acts of disrespect and institutionalized injustice: selective abortion of female fetuses together with gender selective killings; preferential education of boys; unfair inheritance laws for widows; smaller pay for women for the same jobs with men – because they are generally regarded as weak, poor, less important and less valuable.20,21 This partly explains the poor ratings of many African countries on the global Human Development Index (HDI).22 In the United Nations Development Programme HDI Report of 2015, the low ratings of West African countries for most of the development indices are regrettably unsatisfactory.
HUMAN DEVELOPMENT INDEX SURVEY OF 188 COUNTRIES
Rank All Countries WA Countries
- High Dev. 49 0(0)
High Dev. 59 0(0)
Medium Dev. 37 1(2.7) Ghana
Low 43 13(30.2) + Nigeria
Source: UNDP 2015 HDI Report.
It is essential to emphasize that the issues of inequity, injustice and discrimination are global albeit by varying degrees, under diverse shades and grades of morality. So pervasive are these issues that a female United States Presidential Candidate in 2016 claimed she was making history by becoming the first female to win the presidential ticket of a major political party while her male running mate at the conclusion of the electoral processes lamented “a nation that has made it uniquely difficult for a woman to become president” notwithstanding the constitutional creed that “all men are created equal”
Faced with the global realities of inequity and unfairness, several United Nations-sponsored conferences were convened between 1980 and 2000.
SOME IMPORTANT CONFERENCES AND SEMINARS THAT BORDERED ON ISSUES OF POVERTY, AVOIDABLE DEATHS AND BURDEN OF DISEASE.
|1.World Conference of the United Nations Decade for Women
||1980, July 14-30
|2. International Safe Motherhood Conference
||1987, Feb. 10- 13
|3. United Nation Summit for Children
||1990, Sep. 29-30
|4. Fourth World Conference on Women
||1995, Sep. 4-15
|5. International AIDS Conference
||2000, July 9-14
These meetings lead to the convergence of world leaders and international organisations at the United Nations Headquarters in New York, in September 2000 where they committed themselves to addressing eight development-related issues within 15 years. Known as the Millennium Development Goals (MDGs), the focus was on the reduction of extreme poverty (defined as a daily income of less than USD1.25) by 50% in 2015 and to eventually eradicate it. Attention was also paid to some other problems that were militating against human advancement in diverse ways. These included hunger, disease, gender inequality, lack of education, poor maternal and child health, and environmental degradation also within the time span of 15 years. Well-defined targets were specified for each goal, thus producing eight MDGs with 21 targets in addition to a series of measurable indicators.
The measure of achievements is best illustrated from the United Nations Millennium Development Goals Report of 2015 fore worded by the then Secretary-General, Ban Ki Moon. He stated inter alia that
“the global mobilization behind the Millennium Development Goals has produced the most successful anti-poverty movement in history… The MDGs helped to lift more than one billion people out of extreme poverty, to make inroads against hunger, to enable more girls to attend school than ever before and to protect our planet…”
Specifically, with respect to the issue of poverty, which was the main trigger for the emergence of the goals, extreme poverty declined significantly over the period. In 1990, nearly one half of the population in the developing world lived on less than USD 1.25 a day; that population dropped to 14% in 2015. Furthermore, globally, the number of people who lived in extreme poverty declined by more than half, falling from 1.9 billion in 1990 to 836 million in 2015.23
However, as thrilling as these observations may be, the Secretary- General, in the same Foreword, recognised the limitations of “the remarkable gains” in these words:
“I am keenly aware that inequalities persist and that progress has been uneven. The world’s poor remain overwhelmingly concentrated in some parts of the world…Too many women continue to die during pregnancy or from childbirth-related complications. Progress tends to bypass women and those who are lowest on the economic ladder or are disadvantaged because of their age, disability or ethnicity. Disparities between rural and urban areas remain pronounced”.
Buoyed by the successes attained, and in the recognition of the challenges to come, because “the poorest and most vulnerable people were still left behind”, the international community launched yet another set of development goals, this time, known as Sustainable Development Goals (SDGs) at the 71st Regular Session of the United Nations General Assembly in September 2016 guided by the past experience in ensuring “unswerving political will and collective long-term effort.” Unlike the 8 Millennium Goals with 21 targets, there are 17 Sustainable Goals with 169 targets.
Sustainable Development Goals strive to reflect on the lessons of the MDGs, build on the successes attained and are billed for achievement over a-15year period in 2030. They address issues as in the preceding millennium goals and also cover wider concerns like marine life, climate change and the ecosystem.
West Africa and the Development Goals
The expectation was that African countries would seek to maximise the opportunity offered by the MDGs as a coordinated global effort designed to address development issues that are most germane to them, as they were the centres where most of the concerns that led to the emergence of the development goals, festered.24 The outcome in the West African Sub-region was mixed. On one hand, there was accelerated growth. Some countries enacted policies that boosted education and tackled HIV and other diseases. Many also increased women’s presence in their Legislative Assemblies and other decision-making bodies as a way of fostering gender equality and parity. Death rates fell generally although demographic indices remained uncertain. The Republic of The Gambia, our host country in this year’s conference was reported to have reduced its poverty prevalence rate by 32% while Niger Republic successfully established schools for husbands to transform them into allies in the promotion of women’s reproductive health.25 The Niger Republic also posted impressive poverty reduction outcomes.
On the other hand, the growth in GDP in many countries did not translate to satisfactory job creation programmes thus, making unemployment, especially of the youths, a major problem. For more targeted comparison, this 20th Sir Samuel Manuwa Lecture will use Nigeria (on account of the size of its population), The Gambia (as a courtesy to its conference host status), and the Republic of Mali (to reflect the Francophone sectoral interest). It will do so on the outcomes of MDG 4,5 and 6, where health issues are emphasised as health is central to the global agenda of reducing poverty as well as an important measure of wellbeing.26
SOME OUTCOMES FROM 2015 MDG COUNTRY REPORTS
||Fell. 191 to 89
||Fell. 91 to 58
||Scaled up. Measles, Poliomyelitis.
||Dropped to 243
||Ploughed debt relief. Boko Haram.
||Fell. 131 to 54
||Fell. 93 to 34
||Scaled up. Measles.
||Dropped but not to target.
||Fell. 229 to 191
||Fell. 191 to 100
||Economic infrastructure. Serious political upheaval 2012
Sources: 2015 Terminal MDG Reports.27,28&29
In essence, the three countries reported improvements in their MDG 4,5 and 6; a few achieved predetermined targets.27,28 &29 The countries in their various terminal reports also discussed factors that militated against better outcomes.
The Current Realities
Despite the reported outcomes, poverty and its consequences remain the real problem of West African countries. The few gains made are frequently wiped off by political instability, recurrent fratricidal and internecine conflicts, persistent insurgency as well as general insecurity. In 2013, the ten countries with the highest proportion of residents living in extreme poverty were all in sub-Saharan Africa where about 1 in 3 persons are undernourished while 1 in 16 women will die from pregnancy related problems30,31. Sustained by several factors, including an economy in recession, wanton destruction of crude oil infrastructure, global collapse of commodity prices and the Boko Haram insurrection, extreme poverty is rising in Nigeria, the sub-region’s most populous country which probably is also the continent’s largest economy (US$ 509.9 billion in 2014) 32. In 2015, it was estimated that as many as 110 million out of the country’s estimated 150 million population were living on less than $1.25 per day.33
Although the attainment of some targets in the reports on the MDGs 4,5 and 6 from the sub region, such as Nigeria in HIV/AIDS, The Gambia in U5MR are welcome, these outcomes cannot be interpreted as emanating from robust national health sectors. Many public health institutions in the West African Sub-region are largely dysfunctional, badly administered and poorly funded. In addition, in a country like Nigeria, public health institutions are bogged down by incessant industrial actions from a multiplicity of Trade Unions that have effectively held the system to ransom for over several years.34 Confidence in public health institutions may therefore be low35 forcing some persons, including very highly placed government officials to seek medical attention in private medical establishments within and outside their countries at very high costs even for ailments that can quite easily be handled in public hospitals in their respective countries. The weak and the poor are left to grapple with the ill-equipped, badly functioning public health institutions even with conditions that are beyond the capacity of those institutions and quite often, at costs far more than what they can afford. It has been speculated that the annual capital flight from Nigeria alone arising from seeking medical treatment abroad may be enough to fix the frail public health institutions.
Between 2013 and 2016, an epidemic of Ebola virus disease (evd), the most widespread of the condition in history, occurred in the sub region. It turned out to be a major public health issue which exposed the weak underbelly of the health systems in the sub region with major consequences in Guinea, Liberia and Sierra Leone. It revealed the weaknesses of the health systems in the sub region as most countries were unprepared to cope with the public health issues raised by the epidemic due to lack of trained personnel, dearth of equipment and funds. Furthermore, ignorance and extreme poverty as was the case in impoverished rural areas as well as inequitable distribution of human and financial resources36 guaranteed that the disease ravaged the sub region and claimed thousands of lives before it was ultimately brought under control with the assistance of many international agencies. From the time the first case was discovered in Guinea in December 2013 to June 2016 when the WHO formally declared the end of the epidemic in the sub region, 28,621 persons were affected of whom 11, 311. died. Liberia, Sierra Leone and Guinea bore the brunt of the disease in addition to the devastations that some of those countries had earlier suffered from protracted wars and profound political instability. In Guinea, Liberia and Sierra Leone, 10,666, 14,122 and 3,804 persons contracted EVD and, 4,806, 3,955 and 2,536, died respectively.37 Nigeria, with its large population and propensity of its citizens to travel, escaped lightly in what was described by WHO as a spectacular success story.38 Of the 20 reported cases, 8 persons died; the rapid containment of the spread being due to an exceptional display of professionalism by the authorities of the First Consultants Hospital in Lagos where the index patient, Mr. Patrick Sawyer from Liberia was admitted as well as the commitment and dedication of the staff of the Federal Ministry of Health and those of the Lagos and Rivers State Governments.
Apart from the colossal death toll, economic and social effects of the disease, especially on the three most affected countries were severe. It was estimated that the countries lost $2.2 billion in their gross domestic product (GDP) as well as substantial loss in private sector growth and fall in agricultural production that led to food scarcity, let alone the unprecedented social dislocation that the epidemic caused. Furthermore, cross-border trade of goods and services declined with cumulative waning in investor and consumer confidence.39
Lassa fever is another zoonotic acute haemorrahgic fever that continually challenges the health system in the sub region where it is endemic but particularly so in Nigeria, Ghana, Liberia and Sierra Leone. The disease erupts into epidemics in those countries from time to time. In Nigeria alone, 4,883 cases of the disease were reported between 2012 to 2016; of these, 277 died.40
Then of course there is the perennial problem of poor maternal health as evidenced by high maternal death rates throughout the sub region. Here, without prejudice to the figures stated in the various MDG terminal reports, figures of MMRs arising from notable health institutions that were recently surveyed in the sub region continue to show that death rates are still quite high.41-49
DELIVERIES & MATERNAL DEATHS IN SOME HOSPITALS IN WEST AFRICA IN 2016.
||**Princess Christian Maternity Hospital, Freetown.41
||*John F Kennedy Medical Center,
||*Douala General Hospital.43a
|*Buea Regional Hospital.43b
|**UPTH, Port Harcourt.44a
Sources: ** Annual Reports
* Personal Communications.
Sources: Annual Reports; Personal Communications.
In 2015, Nigeria, along with India (in the Asian continent) were estimated to account for over one third of all maternal deaths worldwide with approximately 58,000 (19%) and 45,000 (15%) maternal deaths respectively.50 Globally, Sierra Leone was estimated to have the highest MMR of 1,360 per 100,000 live births, while Chad, Nigeria, Mauritania, Guinea Bissau, Liberia, Niger, Ivory Coast, Cameroon, The Gambia and Guinea, all countries in West Africa, had MMRs of between 549 (Guinea Bissau) and 856 (Chad) per 100,000 live births.50 Furthermore, in none of these countries was contraceptive practice prevalence rate more than 20% despite its proven benefits on maternal health and ability to cut pregnancy related deaths.50 It is this nexus between deaths from childbirth which affects only women, the causes of which are well known, preventable and could be satisfactorily treated on one hand and their high prevalence among the poor and deprived in countries with low development indices, on the other, that makes high maternal deaths a development issue12 and one that is iniquitous and a social injustice. Therefore, attending to issues of high maternal deaths is an exercise in pursuit of justice and equity.
The message from all this is clear. The pangs of a country with low development are felt more by those of its citizens who are poor, weak and marginalized, of which there are many in West Africa. Such persons are less likely to access healthcare when needed or pay for the treatment and services required to restore and keep them in good health. Therefore, for many of them, life is a grind, difficult and precarious as they die more from hunger, ignorance and disease. As mothers, they are more likely to suffer and die from pregnancy and childbirth and, more likely to lose their babies. As a group, they do not receive a fair deal from society in many respects because of their marginalization. Since health is a fundamental right, West African countries should take bold steps to secure the health of all their citizens especially the poor, weak and marginalized as a vital responsibility in an equitable process of development. For this reason, the balance of this lecture will critically address the challenges to be faced in meeting those fundamental responsibilities, the available opportunities on ground and the initiatives that are yet to be taken – all these within the ambit of the SDGs. They constitute the strategies for rooting for the health of the poor.
Rooting for the Health of the Poor.
Nigeria’s National Health Act 2014.
The enactment of a National Health Act 2014 for the regulation, development and management of a health system and sets standards for rendering health services in Nigeria51 is probably one of the most far reaching steps Nigeria has taken in recent times to fix its weak and dysfunctional health system and to make it more responsive to the needs of its citizens.
The Act delineates responsibilities in healthcare delivery, defines the rights and obligations of users and healthcare personnel, and includes several other miscellaneous provisions which benefit the poor more than they do the rich. Significantly, the Act provides for the creation of a Basic Health Care Fund (BHCF) which shall be financed from several sources but principally from a 1% allocation from the nation’s consolidated revenue. It also prescribes the manner of disbursement of the BHCF for the provision of basic minimum package of health services to all citizens through the National Health Insurance Scheme (NHIS) and other avenues. In effect, for the first time, the Act legislates inclusively for healthcare for the poor, rural dwellers and other vulnerable groups35 and is in consonance with a recent statement by Dr. Margaret Chan, immediate past Director General, WHO, that legislative and fiscal measures are among the most effective interventions that governments can take to promote the health of their citizens52
A New National Health Policy thus accommodates several actions that target the poor such as Universal Health Care and strengthening Primary Health Care to deliver effective, efficient, accessible, affordable and comprehensive healthcare to all Nigerians The Better Health for All Programme (BH4A) was launched in July 2016 to produce quick and visible impact and rebuild the citizens’ trust in the ability of the country’s health system to deliver and respond to their health needs.
But the main challenge affecting the regional health development is the poor implementation of approved policies. It is doubtful if the Health Act 2014 will be different, especially as the funding is predicated on an effective NHIS.
Universal Health Coverage (UHC)
It is common knowledge that healthcare is expensive, yet governments generally, especially in developing countries, are disinclined to charge for it as most of their citizens expect to receive it free of charge.53 This creates a dilemma of funding healthcare for all citizens while at the same time putting in place some cost recovery measures for sustainability. Payment for healthcare could be out-of-pocket at the point of service delivery or prepaid in various forms – taxes, levies, insurance. While out-of-pocket payments are often for curative purposes, they are difficult to estimate prior to the illness and are often stressful to bear, especially to the poor. It is estimated that about a billion people worldwide are unable to obtain modern healthcare and about 100 million are forced into poverty by out-of-pocket health costs – a burden that disproportionately affects the poor and could further deepen their poverty, especially those in low and middle level income countries, such as countries in West Africa.54 On the other hand, prepaid costs are often for preventive and unforeseen circumstances, the charges are predetermined and easier to absorb by most.55 It is these considerations for cost of healthcare and affordability as well as others that led to the emergence of UHC as the pathway to achieving health for all at reasonable cost.
Described as the single most powerful concept that public health has to offer,56 UHC aims to provide access to basic and functional health services in a sustainable manner to all people but without unbearable financial burden on them. It incorporates proactive and promotive activities, including education on lifestyle choices designed to enhance healthy living and so reduce the chances of ill health with their cost consequences.57 It offers everyone, especially the poor, the opportunity for a healthy life as a fundamental right as improvements in health contribute directly to human development and economic growth, just as those who are unable to work get pushed further into poverty.58 Furthermore, by aiming to deliver basic health services at affordable costs to all people, UHC can address most cases of preventable deaths and morbidities. The health system reforms that are contingent on UHC strengthen the system, enabling it to deliver services more equitably, efficiently and sustainably, thus reducing out-of-pocket health expenses.57
But setting up health systems that meet the goals of UHC is complex and difficult, necessitating different approaches.59,60 Helen Johnson Sirleaf, President of the Republic of Liberia in 2014, citing her country as an example noted that
‘the added challenge we need to overcome today is the declining contributions from international partners…this is a reality and it is clear that if our countries are to achieve Universal Health Coverage, we must go to work to build a sustainable health financing that is domestic based”.61
And as if in obedience to that command, countries in the sub region are funding various forms of health insurances – tax based or contribution based – that are helping to enhance UHC in the areas of financial protection, essential health services and equity in coverage. But progress has been slow. In Burkina Faso and other francophone West African countries, coverage has only ranged between 0.5 and 20%.62,63 Fragmented funding, making cross subsidization difficult has been mentioned as a militating factor.63 Serious problems exist in Nigeria with the National Health Insurance Scheme (NHIS), the avenue through which the country is pursuing UHC for its citizens. Despite committing itself in 2014 to 30% health insurance coverage by 2015 and expecting, within 5-10 years to have raised sufficient funds to enable it achieve UHC,64 the scheme is reported to be facing grave challenges. Only few Nigerians have access to good health services. Many families continue to face financial difficulties when illness strikes. Coverage by the NHIS is uncertain even though current figures are predicted to be as low as 10%. The system, it is observed, is badly planned, not mandatory and burdened with corrupt practices, among others.65 On the other hand, despite the occasional strident criticisms,66 Ghana appears to have made the greatest success towards achieving UHC in the sub region. The country established a National Health Insurance Scheme through which it has been able to reduce out-of-pocket expenditure to 28.7% of total expenditure on health and extend basic health cover to about 50%67 even though critics are of the view that the percentage is much less.66 What is clear is that going at this pace, it is unlikely that any country in West Africa would achieve the expectations of the WHO of coverage of all its citizens from health-related financial risks by 2030.68
Primary Health Care (PHC)
The WHO Alma Ata Declaration in 1978 provided the basic guidelines for the conceptualization of PHC as
“essential healthcare based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community…where they live and work.”69
Essential healthcare as defined, demands full participation of the community and is expected to serve as an integral part of the country’s health system, of which it should be the central function and main focus as well as the first level of contact of individuals, the family and community with the national health system.69 Thus, PHC is depicted as the foundation in a three-tier effective national healthcare delivery system of primary, secondary and tertiary70 and nations in West Africa have worked towards its establishment and fortification as the driver of the health engine in the sub region. This is a right approach as many persons in the sub region live in rural communities where access is poor and infectious and communicable diseases, are rife. Some progress has been made. Health districts and integrated community programmes have been created, some partnership established with non-public health providers, health institutions established for the training of different levels of healthcare providers, and essential drug lists drawn up.71 But sadly, the dream of using PHC to transform the health systems in the sub region has not materialised to any appreciable degree. Properly functioning PHCs are few; many lack basic utilities of power and water supply and they are poorly managed and financed. The result is that health outcomes remain poor and the secondary and tertiary health facilities are still over burdened with health conditions that could easily have been handled at the PHC level.
The advent of the SGDs, which seek to leave no one behind and to which countries in the sub region are committed, offers another opportunity to redress the injustice and inequity which the poor suffer particularly with respect to their health matters. As part of the SDGs, the world’s governments have set a target to achieve UHC by 2030 in the realisation that UHC is not only essential to achieving the health-related goals of the post 2015 agenda but will also contribute to achieving other goals such as poverty eradication everywhere, the provision of decent work and economic growth. Accordingly, it is central and fundamental to realising the SDGs72 and so, striving to achieve UHC based on a strong PHC foundation with complete coverage of basic health care, especially at community level, is the way to go for countries in the West African sub region if they wish to attain the concept of HEALTH FOR ALL with all its benefits.
While setting the SDG agenda, the global community realised the importance of surgical care as a key component of a functional and resilient health system required for the attainment of UHC. Thus, the need to provide such care at the first level hospital was identified as it is essential for the management of a diverse range of common conditions in many developing countries. The inclusion of such care, it was envisaged, would ensure that all persons have access to safe, high-quality surgical and anaesthesia care with financial protection when needed. Accordingly, a Lancet Commission on Global Surgery in which some fellows of our great college participated, was instituted to make such a vision a reality by embedding surgery within the global health agenda in the 2030 SDGs, catalysing the necessary political change and defining viable solutions for the provision of basic and quality surgical and anaesthesia care for all that would prevent permanent disabilities and life-threatening complications.73 Thus, the commitment is to integrate emergency and essential surgical, obstetrics, trauma and anaesthesia care, especially caesarean section, laparotomy and fracture repair as part of the primary package of health care.74 Expectedly, the number of surgical specialists to bring this about would be huge; sadly, Africa is particularly underserved by such specialists.75
Rooting for the good health of the poor is the core message of this 20th. Sir Samuel Manuwa Memorial Lecture. This is so because health is an important resource for daily living and a significant way of guaranteeing a life of dignity for all. Furthermore, ensuring good health for all and universal access to primary and secondary education are avenues for the eradication of poverty as well as fostering human and economic development and the promotion of social cohesion; lower levels of health and education go hand in hand with higher levels of poverty and unemployment.76 Thus, health is a sustainable development issue and a means for inclusive national growth and it is partly for these reasons that health and mortality indices – life expectancy at birth, under five mortalities, childhood immunization coverage and others – are some of the recognized gold standards for assessing quality of governance. As such, ensuring the health of all its citizens should stand out as a vital responsibility and ambition of all governments in West Africa as a way of addressing several issues concerning the injustice and inequalities suffered by the teaming population of the poor and deprived in the sub region. To do this, the weak health services in the sub region must leverage on the humongous contribution of technology and connectivity to healthcare. The current deficiencies of the system especially regarding equitable access to preventive and curative health services, funding and proper management must be robustly tackled in collaboration with other sectors. Nowhere are such effective and comprehensive services more obligatory than in the West African sub region where a country, Nigeria, is likely to be third most populous in the world by 2050(estimate 399M); another, Sierra Leone, currently has the highest maternal mortality ratio (1,365 per 100,000 live births)and the world’s lowest life expectancy for both sexes (50.8 years, women and 49.3, men) and with three of the five bottom countries in the world for life expectancy at birth: Chad, Ivory Coast and Sierra Leone.77
Speaking “with a full heart”, King George VI of the United Kingdom and the Dominions of the British Commonwealth at his coronation on 12 May 1937 stated that “the highest of distinction is the service of others”78. At that time, King George was 42 years old while Sir Samuel Manuwa was 34. King George was expecting to embark on a life of service to others but Sir Samuel Manuwa was already steeped in it.
Born in 1903 of a distinctive pedigree and with a foremost education as the second Nigerian to be admitted into the fellowship of the Royal College of Surgeons of Edinburgh, Sir Manuwa structured his astounding career of over four decades to be of service to the poor and disadvantaged despite the many lofty heights he attained. Acting ahead of his time, he pushed the need for public awareness on the issue of pulmonary tuberculosis that was of epidemic proportions at the time among the natives and ensured that relevant information about the disease was given in all cinema theatres before the commencement of the substantive films. His active involvement in the closure of the Yaba Medical School and the establishment of the University of Ibadan, the University College Hospital, Ibadan along with its associated Faculty of Medicine, were all to guarantee that tertiary education in Africa, especially medical education was up to the standard of what he had in Europe. His emphasis on rural medicine was intended to take healthcare to those who could least afford it and lived on the fringes of society. His design of a knife to excise tropical ulcers, was a vivid manifestation of his identification with the rural poor and hungry who commonly suffered from the disease.79 Consumed by such an intense career and altruistic passion to do good, Sir Manuwa would have wished, like the legendary Spanish artist and painter, Pablo Picasso (1881 – 1973), to work till his death. He died in 1976, after a long spell as the Pro-Chancellor and Chairman of the Governing Council of the University of Ibadan.
Mr. President, please permit me to draw our attention and to remind us once again of his focus and priorities. They were the poor, needy, disadvantaged and marginalized – those who, most often suffer discrimination, injustice and inequity; those on whose behalf this 20th Sir. Manuwa Lecture is being delivered because Sir Manuwa essentially passed his life in pursuit of justice and equity on their behalf. Sadly, poverty is still extensively rampant in the sub region, creating widely unequal societies that work in the interest of a few, limit opportunities for many and are riddled with crime and violence as well as other malfeasances. Besides, poverty is central to ill health and it is this inability to satisfactorily address the issue of extreme poverty and gross inequalities that has been partly responsible for the failure of many development projects in Africa, including the sub region.80, 81 Sir Samuel Manuwa, in his lifetime, used his God’s given compassion and acquired skills to bring health, hope and happiness to the poor whenever possible.
I thank you all for listening to me.
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