POLITICS OF TUBERCULOSIS CONTROL PROGRAMME IN RIVERS STATE, NIGERIA, 2001 - 2010
BY
KOMENE-ABANEE, PROMISE SARO
PG/PhD/06/41544
A THESIS PRESENTED TO THE DEPARTMENT OF POLITICAL SCIENCE, UNIVERSITY OF NIGERIA, NSUKKA, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DOCTOR OF PHILOSOPHY (PhD) IN POLITICAL SCIENCE (POLITICAL ECONOMY)
SUPERVISOR: PROFESSOR OBASI IGWE
MARCH, 2015.
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APPROVAL PAGE
This Thesis written by Komene-Abanee, Promise Saro (PG/Ph.D/06/41544), has been approved for the Department of Political Science, University of Nigeria, Nsukka
By
……………………. ………………………….. Professor Obasi Igwe Date Supervisor
……………………… ………………………….. Prof. Jonah Onuoha Date Ag. Head of Department
……………………………. ………………………….. External Examiner Date
……………………….. ………………………….. Professor C.O.T. Ugwu Date Dean, Faculty of The Social Sciences
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DEDICATION
This study is dedicated to the Almighty God, who’s infinite Mercy and Grace enabled me to complete this work.
And to all tuberculosis patients, especially in my immediate environment; whose circumstances remain a source of concern for me.
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ACKNOWLEDGEMENTS
Having successfully completed this study against all odds, I am eternally thankful to the Most High God, who gave me the strength, wisdom and the enablement for this adventure.
I am not only grateful, but highly indebted to the exceptional, unparallel ingenuity and profound display of understanding of my Supervisor, Professor Obasi Igwe for his attention given to me, that made this work to see the light of the day. He has a reputation for thoroughness and love for imparting knowledge in painstaking details and which he availed me. My Supervisor was not alone in this enterprise as Professors Jonah Onuoha (HoD), A.M.N. Okolie, Ken Ifesinachi, E.O. Ezeani, as well as Dr Gerald Ezirim played pivotal role in ensuring that I got the best.
I also owe a depth of gratitude and appreciation to Professor Ibaba S. Ibaba and Dr Lucky Legborsi Nwidu for their consistency in asking me “how far”. It was as if my completing this work will certainly give them satisfaction and fulfillment. And to Mr. Kialee Nyiayaana and Dr Kelechi Obi for their exhibition of comradeship towards me. For Happiness Deele, he remains a friend indeed.
My gratitude and appreciation also goes to my siblings: Messrs Ledum Komene Abanee, Barikpoa N. Komene Abanee, Monday Komene Abanee and Mrs. Zorkue Legbara.
My warmest regard and thanks to my immediate family Mrs. DumBari Joy Komene and my children Messrs. Barisua Hope Komene, GodisAble Legborsi Komene, Joshua LeBari Komene,and Miss Queen-Esther Barinuazor Komene for bearing the pain of this adventure.
Finally, to those who assisted in the distribution and retrieval of the questionnaire, Miss Ann Bannen for her assistance in typing the work; and to others that I cannot mention here, I remain grateful. God knows the best.
TABLE OF CONTENTS.
Title Page ………………………………………………………………………..i Approval Page……………………………………………………………………….ii Dedication…………………………………………………………………………...iii
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Acknowledgements………………………………………………………………….iv Table of Contents…………………………………………………………………...v-vi List of Tables………………………………………………………………………..vii List of Figures……………………………………………………………………….viii Abbreviations………………………………………………………………………..ix Abstract………………………………………………………………………………x
CHAPTER ONE: BACKGROUND TO THE STUDY.
1.1 Introduction……………………………………...... 1 1.2 Statement of the Problem…………………………………...... 7 1.3 Objectives of the study…………………………………………………...... 12 1.4 Significance of the study……………………………………………..………………13
CHAPTER TWO:
LITERATURE REVIEW 2.1 Theoretical Literature…...…………………………………………………………...16 2.2 Empirical Literature………………………………………………………………..18 2.3 Gaps in Literature……………………………………………………………………25
CHAPTER THREE: METHODOLOGY 3.1 Theoretical Framework………………………………………………………………27 3.2 Hypotheses………………………………………………………………………...... 33 3.3 Research Design ……………………………………..…………………………...…33 3.4 Methods of Data Collection……………………………………………………...... 36 3.5 Methods of Data Analysis………………………………………………………...... 41 3.6 Logical Data Framework..………………………………………………....…………43
CHAPTER FOUR: NATIONAL TUBERCULOSIS AND LEPROSY CONTROL PROGRAMME, AND IMPLEMENTATION IN RIVERS STATE. 4.1 The Geography and People of Rivers State……………………………….………45 4.2 Historical background of Rivers State……..……………………………………...51 4.3 The Economy and Resource Allocation to Health Services in Rivers State ...…..61 4.4 The Political Economy Context of Health Services in Rivers State………………92
CHAPTER FIVE: PROFILE OF THE NATIONAL TUBERCULOSIS CONTROL PROGRAMME. 5.1 Global Context of Tuberculosis Control and its Evolution……………………….96 5.2 Tuberculosis Control and the Nigerian Health Care System……………………..111 5.3 Rivers State Health Care System and Tuberculosis Control……………………. 118 5.4 Tuberculosis Control Programme Objectives and Targets………………………..121 5
CHAPTER SIX: PROGRAMME IMPLEMENTATION AND UTILISATION IN RIVERS STATE TUBERCULOSIS CONTROL SERVICES.
6.1 Government Health Care Facilities in Rivers State……………………………….124 6.2 Functional DOTs and Microscopy Centers by LGA during 2010 ……………….136 6.3 TB Situation in Rivers State LGAs, Nigeria (2001-2010)………………………...141
CHAPTER SEVEN: POLITICS AND HEALTH RELATED IMPLICATIONS FROM THE IMPLEMENTATION OF THE TUBERCULOSIS CONTROL PROGRAMME RIVERS STATE. 7.1 Politics (Political Commitment) and the implementation of the tuberculosis Control Programme in Rivers State………………………………………………..148 7.2 The Health Related implications from the implementation of the tuberculosis Control Programme in Rivers State…...... 176 7.3 Test of Hypotheses ………………………………………………………………..185
CHAPTER EIGHT: SUMMARY, CONCLUSION, AND RECOMMENDATIONS 8.1 Summary…………………………………………………………………………..188 8.2 Conclusion…………………………………………………………………………192 8.3 Recommendations…………………………………………………………………192 Bibliography………………………………………………………………………...193 Appendix A………………………………………………………………………….200 B………..…………………………………………………………………..203
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LIST OF TABLES PAGE Table 7.1 Number of questionnaires administered and retrieved…………149 7.1.1 On the respondents association with TB control………………..150 7.1.2 Number of years working in TB control…………………………151 7.1.3 Knowledge of set standards for TB control……………………...152 7.1.4 About the government policy (Law) for TB control……………..158 7.1.5 Has the control services been provided with the essential Requirements………………………………………………………159 7.1.6 On the percentage of requirements provided by the government..160 7.2.7 If any member of the executive arm has been involved in Advocacy for the tuberculosis control programme………………..161 7.1.8 On who provides the drugs consumables for the TB programme…161 7.1.9 If there has been drug stock-outs in the programme………………162 7.1.10 How frequent has been the drug stock-outs……………………….163 7.1.11 Did the government stepped in to the drug stock-outs……………164 7.1.12 If the State government allocates financial resources to TB………164 7.1.13 If the budgeted financial resources are released to TB programme165 7.1.14 How the released financial resources affects the programme…….166 7.1.15 On the Health Related implications from the implementation of the tuberculosis control services……………………………………166 7.1.16 If the Development Partners has been playing their role………….167
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LIST OF FIGURES PAGE
Figure 4.3.1 Budgetary provisions for health services 2004………….64 4.3.2 Budgetary provisions for health services 2005………….69 4.3.3 Budgetary provisions for health services 2006………… 72 4.3.4 Budgetary provisions for health services 2007………….76 4.3.5 Budgetary provisions for health services 2008………….81 4.3.6 Budgetary provisions for health services 2009………….84 4.3.7 Budgetary provisions for health services 2010………….87
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LIST OF ABBREVIATIONS
AU African Union CIDA Canadian International Development Agency DOTS Directly Observed Treatment Short Course D Ps Development Partners G D P Gross Domestic Product G L R A German Leprosy and TB Relief Association FMOH Federal Ministry of Health HBCs High Burden Countries HIV Human Immune Virus I L E P International Federation of Leprosy Partners I S T C International Standards for Tuberculosis Control IUATLD International Union Against Tuberculosis and Lung Disease MDGs Millennium Development Goals M D P Medium Term Development Plan M DR-TB Multi-Drug Resistance Tuberculosis MoU Memorandum of Understanding NEEDS National Economic Empowerment and Development Strategy NEPAD New Partnership for Africa’s Development N M A Nigerian Medical Association NTBLCP National Tuberculosis and Leprosy Control Programme N T P National Tuberculosis Programme PLWHA People Living With HIV/AIDs P H C Primary Health Care PPM Public Private Mix RSTBLCP Rivers State Tuberculosis and Leprosy Control Programme TB Tuberculosis U N D P United Nations Development Programme UN United Nations USAID United States Agency for International Development WHA World Health Assembly WHO World Health Organisation. XDR-TB Extensively Drug Resistance TB
ABSTRACT 9
This study interrogates the role of politics in tuberculosis (TB) control services in Rivers State, Nigeria. It raises questions about how the exercise of political power through the nature of the allocation and distribution of resources affects the effective implementation of the tuberculosis control programme in Rivers State, and its attendant implications for the populace. It draws on both qualitative and quantitative methods such as content analysis of documents and questionnaire for data collection; and a combination of qualitative and quantitative descriptive approach for data analysis. Adopting the Marxian Political Economy theory as a guide, the main finding is that there is very weak political commitment to the tuberculosis control programme, such that financial resources was allocated to the tuberculosis control services only once for the study period. The study equally uncovers that no legislative framework exists for the tuberculosis control services. The findings also indicate that the government has not embarked on any form of advocacy that will contribute to improve on the services of the programme, as well as that there are health implications from the implementation of the tuberculosis control services. Thus, it is recommended that government should improve on her political commitment to the programme, take proper ownership of the programme through the enactment of a legislative framework for it, provide adequate financial resources in her annual budget and release it for the programme; embark on advocacy for the programme to attract support for it, as well as forge partnerships (local and international) to enhance effective implementation of the programme, in order to change its fortune and mitigate the impacts on the society.
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CHAPTER ONE
INTRODUCTION
Politics is an inevitable activity confronting human existence from the smallest unit which is the family to the highest level-the State, and above all, between the States. To ensure not only effective but also sustained tuberculosis control services, the World Health Organization (WHO) recommended Directly Observed Treatment shortcourse (DOTS) broad policy strategy listed
“Political Committment with increased and sustained financing as the first element”. This policy strategy was adopted by Nigeria in 1993. This study examined how politics (political commitment) impacts on the implementation of the tuberculosis control programme in Rivers
State, Nigeria.
Tuberculosis (TB) is a highly infectious disease that is curable with modern efficacious drugs and appropriate treatment. The upsurge in the incidence of tuberculosis is certainly one of the greatest public health challenges that confront nation states of the world today. Despite increased attention and considerable progress toward containing it in recent years, tuberculosis continues to be of serious public health importance. Tuberculosis was perceived to have been eliminated before now such that it was described as the 17th century’s “Captain of all these men of death” and the 19th century’s “white plaque” (Fairchild, 1998:1105). However, according to
Kritski et al., (2007:1) “TB remains even in this millennium, the leading killer infectious disease in the world, with 1.6 million deaths in 2005”. Its incidence has thus waned and peaked overtime such that tuberculosis was decleared by the World Health Organisation (WHO) in 1993 as a
“global emergency” adding that the disease will claim over 30million lives in the next decade unless immediate action is taken to curb its spread”.
From the above, it is evidenced that it remains a major public health problem of inestimable magnitude. For example, the World Health Organisation (WHO) 2009 report on
Global TB Control indicates the following: Globally, there were an estimated 9.27 million incident of cases in 2007, 8.3million cases in 2000 and 6.6 million cases in 1990. Most of the
11 estimated numbers of cases in 2007 were in Asia (55%) and Africa (31%) with small proportion of cases in the Eastern Mediterranean Region (6%), the European Region (5%) and the Region of the America’s (3%). The five countries that rank first to fifth in terms of total numbers of cases were India (2.0million), China (1.3million), Indonesia (0.52million) Nigeria (0.46million) and
South Africa (0.46 million)” (WHO Global TB Control Report, 2009:11). It is pertinent to state here that these countries incidentally are in the forfront of those that fall within the category of
High Burden Countries (HBCs) as identified listed and categorized by the World Health
Organisation (WHO).
Given the magnitude and consequencies of TB on the society, the need for more proactive approach towards its containment becomes not only important but neccessay. “Although, there has been previous attempts and pockets of stop gap measures designed to respond to tuberculosis
(TB) disease” (Raviglione et al., 2002:775), the first internationally conceived, articulated and coordinated strategy to contain the menacing effect of tuberculosis by the World Health
Organisation (WHO) was the Directly Observed Treatment shortcourse chemotherapy (DOTs).
This heralded the platform for an integrated approach to the management of tuberculosis and provided “a framework for effective tuberculosis control” (WHO Global TB Programme framework for Effective TB control: 1994). The strategy comprised five essential elements,
“Two elements are technical: case finding through bacteriological examinations of patients with respiratory symptons attending primary health care units and administration of short course chemotherapy (SCC) mostly by direct observation for atleast the initial phase of treatment. The other three elements are managerial: generating greater political commitment to mobilize sufficient resources for TB control; securing a regular, uninterrupted supply of anti TB drugs; and establishing a reliable information system to provide data for mornitoring and assessing case finding and treatment activities” (Raviglione et al.,2002:778).
As a result of changes manifesting as growth, advancement and development which has led to a more bio–medical scientific breathrough coupled with globalization, there was need to
12 improve on the DOTS strategy. This imformed its review and orchestrated the emergence of the first global plan of 2001–2005, and the subsequent adoption of a second global strategy (plan) to contain the menace of tuberculosis by the World Health Organisation (WHO) in 2006. This was labeled “Global Plan to Stop TB (2006–2015)”, “Building on progress achieved, the present document the second Global Plan to stop TB is intended to guide partnership efforts in 2006–
2015 to achieve the TB target of the Millennium Development Goals (MDGs). The plan has been developed in the context of wider MDGs initiatives to reduce poverty” (WHO Global Plan to
Stop TB, 2006:24).
The Nigerian State by her membership of the international community–the United
Nations (UN), African Union (AU) and other regional and sub–regional organizations therefore subscribed to the international standards for the control of tuberculosis (TB). Beyond this, She went further to domesticate, as well as incorporating it into her National Health Policy
Framework and subsequently translating them into the relevant health programmes. The new
National Health Policy has been formulated within the context of “the Health Strategy of the
New Partnership for Africa’s Development (NEPAD), a pledge by African leaders based on a common vision and a firm conviction that they have a pressing duty to eradicate poverty and place their countries individually and collectively on a path of sustainable growth and development. The Millenium Development Goals (MDGs) to which Nigeria, like other countries, has committed to achieving the National Economic Empowerment and Development Strategy
(NEEDS) … and the development of a comprehensive health sector reform programme as an integral part of the NEEDS” (Federal Ministry of Health: Revised Policy Programme and
Strategic Plan of Action, 2007:2).
It is in keeping to this, that the Nigerian State formally lunched the National Tuberculosis and Leprosy Control Programme (NTBLCP) in 1991 and adopted the World Health Organisation
(WHO) recommended DOTS Strategy in 1993. The NTBLCP as conceptualized is designed to be a counterpart funding arrangement between the Nigerian State in the one hand and the
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Development Partners (DPs) on the other; with the role of each tier of government and that of the
Development Partners (DPs) clearly spelt out in the Memorandum of Understanding (MoU).
The necessity for a more pragmatic and sustainable approach and strategy for the control of tuberculosis was demonstrated in an event organized by the Stop TB Initiative. This conference was called the “Ministerial Conference on TB and Sustainable Development’ held in
Amsterdam, March 2000” (WHO, 2000). This resulted to the “Amsterdam Declaration to Stop
TB”. (WHO, 2000). The Ministers of Health and finance from 20 of the 22 high–burden countries were present in Amsterdam. It is worthy of note to state that the ‘Amsterdam
Declaration’ highlighted the magnitude and seriousness of the global epidemic and outlined the ways to curb these epidemic. It further called for accelerated expansion of control measures and for increased political commitment and financial resources to reach the targets for global TB control by 2005. In May 2000, a World Health Assemly resolution of the World Health
Organisation (WHO) also restated this call.
It is indeed apposite to state that the need for more sustainable strategies to contain tuberculosis is important because experiences in “TB control have shown that a laid–back approach regarding interventions could lead to a reversal of progress made, especially with the onset of the HIV epidemic” (Raviglione et al., 2002; Shrestha, 2005; cited by Amo–Adjei,
J,2014). Acknowledging this limitation, the need for the sustainability of efforts and political commitment (Politics) is very critical as highlighted in the DOTS strategy.
Commentators’ on Nigeria’s developmental trajectory confronting all sectors of the society including health, acknolwdges the fact that there is increased state intervention in all facets due to politics. However, it is their contention that “politics has become the primary source of capital accumulation by Nigerians” (Williams, cited by Kehinde, 2009:2) thus creating the class of the bourgeroise. Accordingly, “the dependent character of the bourgeoise restricts them to competing among themselves for the limited resources available within a neo–colonial political economy. This competition tends to take the form of a zero–sum game, modified by
14 cartel–type arrangements where the competitors (defining themselves in regional, ethnic, and state terms) all seek to protect their own area of activity” ( Williams, cited by Salami, 2009:2).
There is increasing interest in politics and public health, thus capturing scholarly attention on the necessity to integrate politics and public health. This is because, it is acknowledged that
“the politics of health has been underdeveloped and marginalized” (Bambra et al., 2005). For them, health is political because its social determinants are amenable to political interventions and thereby dependant on political actions (or more usually, inaction). Ultimately, “health is political because power is exercised over it as part of a wider economic social and political system. Changing this system requires political awareness and political struggle” (Bambra et al.,
2005). The interest in politics as power, where “politics is the process through which desired outcomes are achieved in the production, distribution and use of scarce resources in all areas of social existence (Bambra, et al, 2005), and public health is emerging from the recognition that direct and indirect political decisions on education, social security, housing and unemployment opportunities affect health either positively or negatively” (Mackenbach, 2013, cited by Amo–
Adjei, 2014).
Scholars writing on the politics of diseases control especially in Africa have identified a number of issues that are associated with the politics of public health. Consequently, Patterson examines how key aspects of African Politics–the state, democratic institutions, civil society and donors–affect AIDs policy making … She admits that the pandemic does not affect all people equally because of the character of African political institutions and the resource differences and inequities in policymaking in the politics of AIDs both within African Countries and between wealthy and poor countries (Patterson cited by Chimaraoke, 2007). Specifically four aspects of the African State–centralization, neopatrimonialism, state capacity and security are the grid upon which she interrogates the politics of AIDs (disease control) in Africa.
For Dickenson (2006)”greater analysis of the political dimensions of reponses to
HIV/AIDs (disease control) can and should be used to understand how and why governments
15 respond to HIV/AIDs interventions can be made more effective. If a country’s response is to be effective, it must reflect its political and institutional context…There is strong and growing interest in the international donor community in understanding the political factors that shapes development outcomes”.
Further, literature relating to the subject matter of politics of public health (Acheson,
1998; Marmot et al, 2001; cited by Bambra et al; 2005) contend that “it is profoundly paradoxical that, in a period when the importance of public policy as a determinant of health is routinely acknowledged, there remains a continuing absence of mainstream debate about the ways in which the politics, power and ideology which underpin it influence people’s health…Causes of and genetic predispositions to ill–health are becoming increasingly well understood… and that the major determinants of health or ill–health are inextricably linked to social and economic context”. Simillary, many of the major determinants of health inequalities lie outside the health sector and therefore require non–health sector policies to tackle them” (Towsend and Davidson,
1992; Acheson, 1998; Whitehead, et al, 2000; cited by Bambra et al; 2005).
Extant literature on the relationship between politics and public health (Brown, 1996) also agree that “to study public health politically is to inquire how public institutions and actors
(executives, legislatives, courts, bureaucracies, sub–national governments) and stakeholders shape the formulation and implementation of policies and programs the public health field proposes and pursues. Arguably, new challenges to and priorities within public health may encourage fresh political responses; conversely, new configurations of political power may condition the prospects and progress of public health”.
Since the adoption of the WHO policy strategy of DOTS by the Nigerian state that listed political commitment with increased and sustained financing as the first element, it is obvious that TB control programme still faces some challenges. In the contention of the Open Society
Institute (2006:49) “in principle, since 1993, the NTBLCP has embraced and adopted the WHO– recommended DOTS strategy to achieve its objective of reducing the prevalence of TB to a level
16 where it no longer constitute a public health problem. While the governemts commitment to TB control has increased since the program’s formal lunch in 1991, the realities on the ground reveal that the NTBLCP faces numerous obstacles in effectively addressing the five elements of DOTS
…” The challenges associated with political commitment (Politics) which is the first element of
DOTs strategy and it consequencies for the TB control programme is the problematique of this study. This study, therefore, examined how the exercise of governmental power (politics) in the allocation and distribution of resources impacts on the implementation of the TB control programme in Rivers State. The period covered by the study was 2001–2010. After the adoption of the DOTS policy strategy in 1993; the years 2001–2010 can be seen as a period of consolidation in the implementation of the strategy, and therefore, useful for an analysis. The documentation of the relationship between the exercise of power in the allocation and distribution of resources, and its impact on the implementation of the TB control services is not only timely, but necessary as it will provide an insight into the polical dynamics and its consequencies associated with TB control services in Rivers State, Nigeria.
1.2 STATEMENT OF THE PROBLEM
The resurgence of TB does not only have serious public health implications, it is as well an affront on the socio-economic milieu given the fact that “about 75 percent of TB cases are among the economically active 15-54 year–olds” (WHO, 2002), and the State is at the centre of the scourge. Perhaps this statement can better be appreciated if one realizes that:
As at the end of 2002, only 21 out of 36 States and Federal Capital Territory (FCT) were implementing the DOTS Strategy. However, with assistance from CIDA and USAID, DOTS expansion was put in place in all the 36 States and FCT at the end of 2004… The total number of newly detected TB cases increased from 29,465 in 2001 to 83,263 by end of 2008.There has been a remarkable increase in smear positive case detection rate from 15% in 2002 to 30.5% in 2008. However, this is considered low compared to the Global target...The dual epidemic of TB and HIV further threatens the gains so far made in TB control in the past few years. The prevalence of HIV among TB patients increased from 2.2% in 1991 to 27% in 2008.(FMOH, National Strategic Plan for TB and Leprosy:2010-2015, 2009:14).
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The graphic picture enumerated above suggests the contemporary status of our health care delivery system. This is complemented with the fact that “Recently, the World Health
Organisation (WHO) rated Nigeria as the fourth worst health system in the world” (Igboeli,
2009). This is in itself an indication of the devastating state of health care services in the country.
According to Igboeli, the country’s health system continued to fail mainly due to ineffective implementation of health care policies, mal-distribution of health workers, limited funding and poor infrastructure. It is this state of affairs in the health sector that has degenerated into the tuberculosis (TB) crisis with its attendant implications.
The fact is, there is an increasing incidence of tuberculosis (TB) in the world. The public health as well socio-economic implications of this prompted the World Health Organisation
(WHO) to identify, list and categorize twenty two (22) countries of the world as High Burden
Countries (HBCs) with Nigeria at the fourth position. In Nigeria, it is a scourge. According to
Awe, (2008:18) “in every four seconds, some one die of the disease”.
The debacle permeating the health sector is not a function of the lack of principles, values or objectives that are well articulated in a policy position by the state. It is precisely the opposite.
“Since health is an integral part of over all development, inter-sectorial cooperation and collaboration between the different healths related Ministries, development agencies and other relevant institutions shall be strengthened…and responsive national health system shall be achieved through the implementation of all health programmes” (FMOH), 2007:2). Beyond this,
She contended that the over all policy objectives are:
To strengthen the national health system such that it will be able to provide effective, efficient quality, accessible and affordable health services that will improve the health status of Nigerians through the achievement of the health related Millennium Development Goals (MDGs) (FMOH, 2007:3).
It is therefore obvious that the decaying state of health services in the country stems from the interest of the political leadership that abandon policies meant to address the needs of the people. According to Anya (2008:14), Nigeria is a “nation where executive privilege or
18 parliamentary immunity always successfully parades itself against the will of the people… The failure of Nigeria’s political leadership to work for social and economic transformation of the society in the immediate post-independence era is the most fundamental failure in our journey towards development:..” For him, ‘The bottom-line is that there is too high level of hypocrisy, insincerity and lack of integrity in the practice of our politics at the present time. Untill an acceptable code of values with sanctions and punishment clearly spelt out evolves as the guidepost to our politics neither the fruits of education nor that of economic development can become available to the mass of our people”. (Anya, 2008:16). The vices exhibited by the political leadership have unequivocally enveloped the society and has transformed into state actions.
The logical outcome is that there is a disconnect between policy documentation/adoption as well as pronouncements and its implementation. In the words of Gyoh (2008:25) “The National
Health Policy has all it takes to effect a credible fix in the health sector”. However his contention is that:
The persistence of Nigeria’s problems is not caused by lack of the knowledge of their solutions. It is often due to the dissociation of theory from practice. This is the case in health. The National Health Policy was lunched in 1988. It adopted sound internationally accepted principles and adopted them to solve the health sector problems of Nigeria. It was acclaimed by the world as a good blueprint for delivery of first class health care in a developing nation, and requests for copies came from the four corners of the world. Attempts to implement it were seriously made in the first four years during the leadership of the late Olikoye Ransome Kuti, the then Minister of Health, but by the time he left office, it had not yet properly taken root… The health services of the country have therefore continued to suffer from neglect by successive governments. The revised health policy document states “public expenditure on health is less than $8% capital, compared to the $34 recommended internationally:.
It is pertinent to acknowledge that the constitution of the state places health on the concurrent legislative list, meaning that each tier of government has the freedom to take action on health matters. Perhaps this is the principle underlying the drafting of the Memorandum of
Understanding (MoU) between the Nigerian State and the Development Partners (DPs), as each tier of government is clearly assigned her role in the agreement bordering on the provision of 19 infrastructure, logistics support and financing, etc. of tuberculosis (TB) control. This constitutional provision which gives outright autonomy to each tier of government to act on issues of health has been exploited by the various tiers to suit the desires of the political leadership.
The penetrating effect of the gross underfunding of the health sector and its implications for the provision of infrastructure, and programme implementation is more worrisome as it is a manifestation of the politics (political) commitment to the sector. In this case, political commitment to disease control is the
Decision of leaders to use their power, influence and personal involvement to ensure that… programs receive the visibility, leadership, resources, and ongoing political support that is required to support effective action to limit the spread… of and mitigate the impacts of an epidemic. Political commitment in the broadest sense means leadership commitment. Country leadership includes political and government leaders and managers, including the president or prime minister, ministers, permanent secretaries, parliamentarians, party leaders, program managers, district leaders, traditional leaders, and many others… (POLICY Project 2000:4).
This analytic perception is given credence to by the position of the Health Ministers of the 55th session of the World Health Organization’s (WHO) Regional committee for Africa held in 2005 at Mozambique, where ‘TB was declared an emergency’ “ Regional health ministers in
Africa declared tuberculosis an emergency on the continent. The measure underlines a new commitment to fight a disease that is killing more than 500 people a year on the world’s poorest continent”.
Politics as practiced in the current democratic dispensation since 1999 is seen more to have alienated the masses from the benefits associated with democracy in terms of the developmental needs of the people. This is corroborated by this contention:
In Rivers State, corruption and the gross mismanagement of government funds stand out as one of the most important reasons why many Local Governments (LGs) have continued to neglect their obligations to provide basic education and primary health care (Human Rights Watch, 2007:43).
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This is not unexpected as “in fact, governance at the state level in Rivers State is plaqued by many of the same problems that have crippled the states local governments. This is evidenced not only by the opaque and unaccountable manner in which the state dispenses with its revenues, but also by a host of other basic failures of government” (Human Rights Watch, 2007:75).
Scholarly writing on the challenges associated with the tuberculosis control services has evolved. Awofeso, et al (2008) found among others that “post basic training for TB control is inadequately funded by most developing country government and that human resources capacity for effective TB control in Nigeria remains weak at all levels”. A qualitative study by Harper, et al, (2003:506-10) “looked at factors which influence the outcomes of tuberculosis control programs in the Gambia factors identified include gender, urban/rural residence, knowledge about TB, migration, recourse to traditional leaders and socio-economic factors”. A review by
Noyes, et al (2007:227-43) synthesized the qualitative evidence in studies from 1990-2002 on factors affecting the success of DOTS programs. They found five themes in evidence : Socio- economic circumstances, materials resources and individual agency; explanatory models and knowledge systems in relation to TB and its treatment, experience of stigma and public discourses around TB; and sanctions, incentives and support, and the social organization and social relationships of care”.
Writing on the challenges and barriers ahead in 22 high endemic countries, Khan, et al
(2002:1) observed that “financial inabilities contribute greatly to the failure of respective national
TB control programs. High burden countries are usually in the economic recession or passing through severe socio-political turmoil that has further reduced spending on TB control. Majority depends on the international assistance and put little domestic efforts, coupled with the lack of political commitment”. Engel (2009:6) contends that “TB control efforts have been researched and analyzed from various disciplinary perspectives, Epidemiological studies estimate the changing burden of the diseases, clinical and biomedical research is trying to improve drug regimens, products and processes for diagnosis and treatment. Research from an anthropological 21 perspective analyses among others the factors influencing adherence to treatment, different understandings of TB within communities, gender aspects, reasons for delays in diagnosis or quality of services, importance of poverty and social justice, thus trying to improve program performance” (Narayan, et al, 2003). Literature on the politics of TB control (Watt, 1999; Watt, et al, 2003) “analyses the design of TB programs, the translation of WHO policies into national context of TB control pointing to the importance of power and processes of policy making for TB policy design”.
Generally, writers on challenges and issues bordering on the containment of TB appear to focus on epidemiological studies, clinical and biomedical issues, weak human resources, gender, inadequate knowledge about TB, recourse to traditional healers, migration, stigma, dependence on international donors, factors influencing adherence to treatment, poverty, and social justice; and politics bordering on the design of TB programs. However, politics (political commitment) explained in terms of commitment to resource allocation and its impact on TB control services in
Rivers State, as well as state intervention during drug stock-out, political authority’s involvement in advocacy, and adherence to her policy is yet to be given proper attention. This study seeks to contribute to our current understandings of the tuberculosis challenge in Rivers State, and investigated this gap in literature with the following questions:
1. Is there is relationship between the allocation and distribution of resources and the
implementation of the TB control programme?
2. Are there any health related implications from the implementation of the TB control
programme?
1.3 OBJECTIVES OF THE STUDY
On a worldwide scale, infectious and parasitic diseases disproportionately affect populations living in poverty. Social, political, and economic inequalities created by the state are central to the persistence and spread of these diseases, and the performance of health systems in 22 protecting vulnerable populations from the impact of these diseases often falls far short of what is needed. It is in this context that this study assessed how the exercise of power in the allocation and distribution of resources impacts on the effective implementation of interventionist programme for diseases that threaten human existence with a focus on tuberculosis (TB).
The main objective of this study is to examine the governance and implementation issues that have dogged tuberculosis control in Rivers State, Nigeria. Subtly, it is to examine how the exercise of governmental power in the allocation and distribution of resources impact on the control of tuberculosis in Rivers State. The sub-objectives are:
(1) To establish the relationship between the allocation and distribution of resources and the
implementation of the tuberculosis control programme.
(2) To determine any health related implications from the implementation of the tuberculosis
control programme.
1.4 SIGNIFICANCE OF THE STUDY
In our contemporary times, biomedical discoveries have greatly advanced our understanding of the biological and genetic foundations of a wide range of tropical diseases. Yet despite these gains, it has become increasingly clear that research in biology and medicine leading to the discovery of new health technologies alone will not automatically improve a public’s health as social, cultural, economic and political forces define who become ill, who seeks and has access to treatment, and who recovers.
The social sciences including-anthropology, economics, sociology, psychology, and political science and their respective sub-disciplines (medical anthropology, health sociology, health economics, social epidemiology, policy research, the political economy of health, health politics, and medical geography) are the fields of enquiry that aim to answer questions relating to human behavior and the social, political and economic, and cultural contexts in which people live.
23
Research in the social sciences is therefore an essential component of a global strategy for promoting health, preventing diseases, and improving the quality of treatment and services. Our accumulated body of knowledge succinctly demonstrates that awareness of social, economic and behavioral forces is essential for controlling tropical diseases for several reasons. First, social, economic and behavioural factors play an important role in establishing both individual and population wide vulnerability of disease. Secondly, the ineffectiveness of health promotion and intervention efforts and access to, availability of, and quality of services designed to prevent and treat diseases are all affected by social, economic and behavioral conditions. Therefore, understanding these areas is critical for formulating and implementing effective disease fighting strategies and policies.
Specifically, this study is important from both theoretical and social perspective. At the theoretical level, it is an innovative study in this part of the globe. An examination of the role of politics in the control of tuberculosis (TB) will enable us to have insights into understanding the political dynamics in effective tuberculosis control. It will also assist us to identify the challenges and needs, for an effective tuberculosis control in our changing world. It will thus enable us to place issues within the proper context and contribute to stimulating further studies on the subject matter.
Also the importance of studying the role of politics in the implementation of tuberculosis
(TB) control cannot be over emphasized. Research on assessing the role of politics is most needful, although it is difficult to locate one in this part of the globe, where the national control programmes faces multifaceted challenges in successful implementation. This is because
“science can identify solutions to pressing public health problems, but only politics can turn most of those solutions into reality” (Oliver, 2006).
Socially, in Nigeria, where there have been four attempts at democracy within her short span of fifty (50 years) of existence as a nation; it is inconceivable if any serious attention has been given to the relevance of politics in effective tuberculosis control services. This is because,
24 what we are witnessing is antithetical to the true spirit of democracy and by implication misplaced policy directives by the state. This study will highlight the relevance of politics in effective tuberculosis control services. It will equally contribute to the formulation and implementation of sound policies for the proper and effective control of tuberculosis since it has the potential of serving as a possible policy document for policy makers, who may use the recommendations that will be advanced to ameliorate the identified challenges.
According to Oliver (2006:195-6) “Politics for better or worse plays a critical role in health affairs. Politics is central in determining how citizens and policy makers recognize and define problems within existing social conditions and policies in facilitating certain kinds of public health intervention. It is important that public health professionals understand the political dimensions of problems and proposed solutions, whether they hold positions in government, advocacy groups, research organizations or the health care industry. This understanding can help leaders to better anticipate both short term constraints and long term opportunities for change”.
Finally, it is the contention of this study that its purpose is to examine the governance and implementation issues that have dogged proper tuberculosis (TB) control in Rivers State.
Hopefully, as this is achieved; the study would have been justified and thus very significant.
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CHAPTER TWO
LITERATURE REVIEW
2.1 THEORETICAL LITERATURE
In this review, an attempt is quintessentially made to operationalise the research variables.
Succinctly put, conscious effort is made to explore as much as possible, the various findings of scholars on the subject matter of politics, as well as the relationship of politics with policy implementation. We shall also examine how politics/policy affects the control of tuberculosis
(TB). To do this, we shall be guided by the thematic approach, basically not only because of its validity to address the questions raised, but also because of its concept clarity.
The Concept of Politics and its relationship with Policy Implementation.
Politics is an inevitable activity confronting humanity. This justifies Aristotle’s position that we are all political animals and political animals we seem to remain. Politics is a fundamental and complex human activity. Rightly, it is our capacity as human being, to be political- cooperate, bargain, disagree as well as compromise that helps to distinguish us from all other animals out there.
Among the actors in the political scene, politics enables them to determine without resource to ‘direct’ violence, who gets power and resources in a given society, and how they get them, as well as how they preside over the allocation and distribution of the resources. In this regard the resources may be jobs created in the public sector by government, laws that enable one to function optimally, the allocation and distribution of resources, as well as public policies that enhances the productive capacity of the citizenry.
For Sodaro (2001:27) “Politics is the process by which communities pursue collective goals and deal with conflicts authoritatively by means of government.” As a process “we mean that it is a continuing sequence of events and interactions among various sectors, such as individuals, organization and governments” (Sodaro, 2001:27). For him, the concept of process 26 also implies that these political interactions generally take peace within a structure of rules, procedures, and institutions rather than haphazardly. More than anything also, politics is about how people organize their communities for the purpose of collectively tackling the problems they face. The most important part of our definition refers to the manner in which communities pursue their goals and deal with their conflicts; they do so authoritatively by means of government.
Governments are “authoritative” to the extent they make laws and enforce them. “It is government that makes authoritative decisions on the community’s goals whatever those goals may be” (Sodaro; 2001:27).
In the view of Ake, 1990; cited by Nna, (2000:2), politics refers to the “system of behavior by which a society expresses its self determination by choosing its leader, holding them to account and evolving and pursuing collective goals” For Easton, politics is “the authoritative allocation of resources or values for the society” (cited by Nna (2000:4). In his assertion,
“Easton’s definition is important as it portrays the character of politics in society more vividly. In the first place, it reaffirms our view that politics emerges at that point in the development of human community when the things that are valued in the society are scarce and have become subject of conflict; such conflicts can only be resolved by the political system which has the capacity to authoritatively determine who gets what, when and how. This focus on the authoritative allocation of values has shifted emphasis to the realm of the state. “Thus, politics deals with the struggle for state power, the highest form of power, that is, the power to allocate resources including values within a given political community. Beyond that, it deals with the whole processes by which men select or order their priorities in terms of the allocation of resources or the implementation of public decision by means of the exercise of political authority and all relationships which follows that. It is at that level that politics become more meaningful”
(Nna; 2000:4-5).
In the contention of Ibaba (2010:3-4) generally, discussions on politics locate it at the macro level. In this sense, “politics is seen as rule, the exercise of power or authority, resource 27 allocation and the regulation of human conduct. A significant point to note here is that man’s nature makes politics necessary. Politics is thus a set of interacting activities which lead to binding decisions on the distribution of a society’s resources. It is noteworthy that the most manifest aspect of politics is the contest for power to direct society’s resources. This explains why in Nigeria for instance, many reduce politics to elections and the activities associated with it.
In all, politics is necessitated by the greed and selfishness of man, the incompatibility of human interest, the scarcity of socio-economic resources; the need to promote harmonious social existence; the need to regulate and control human conduct; the need to promote peace and security and the need for a single agent to direct the affairs of men for the common good”
(Ibaba, 2010). The common good of any society can only be promoted and actualized when there is political commitment to the implementation of programmes that will enhance this ‘common good’.
How Politics/Policy Affects the Control of Tuberculosis
Public policies refers to “all those authoritative public decisions that governments make…and are seen as the ‘outputs’ of the political system”(Almond, et al, 2006:129).The outputs of any political system is a function of the way politics is practiced in that society.This is because “Politics has to do with human decisions and …it is authoritative. Authority means that formal power that is vested in the individuals or groups with the expectation that their decisions will be carried out and respected. That is to say, those choices in which we are interested are designed to be binding (compulsory) for those individuals or groups to whom they apply. Those who have political authority typically have access to force and to monetary resources so that they can enforce their decisions” (Almond, et al, 2006:1-2).
Public policies are therefore driven by the nature of politics. According to Almond, et al,
(2006:2) “politics refer to the activities associated with the control of public decisions among a given people and in a given territory, where this control may be backed up by authoritative and coercive means. Politics refers to the use of these authoritative and coercive means–who gets to
28 employ them and for what purposes”. In this perspective, “Public policies are designed to strengthen national identity and community by reinforcing the status of a common language or culture, or by promoting allegiance to a shared political heritage. A host of economic policies aims to promote economic and social development and to distribute its benefits more or less broadly” (Almond, et al, 2006:130). In the opinion of Almond, et al, (2006:133) “Distributive policies include the allocation by governmental agencies of various kinds of money, goods, services, honors, and opportunities to individuals and groups in the society. They can be measured and compared according to the quantity of what ever is distributed, the areas of human life touched by these benefits, the sections of the population receiving these benefits, and the effectiveness of the distributive program”.
Public policy therefore influences focus on the implications that public policies have on the behaviours of individuals, groups, communities, and organizations, with emphasis on issues relating to government, funding, etc.
Politics defined classically as who gets what, when and how by Lasswell (1936) as cited by Glassman, et al, (2008:163) affects the origins, formulation, and implementation of public policy in the health sector. Politics dictates, for example, who is entitled to services, which are the priority areas, who will provide services, who will be subsidized, and how the budget ought to be allocated and spent (Gonzalez-Rosseti, et al, 2003, cited by Glasman,2008:163).
It follows that government entity, from federal to local, play a critical role in tuberculosis related services. From federal level research funding to service delivery at local departments, tuberculosis (TB) control is affected greatly by policy decisions. Given these arrangements, the development of a better understanding of the policy process and greater of decision-makers by those working in tuberculosis control may lead to improvement in tuberculosis services.
For Jack (2001:79-96) using public policy to address the tuberculosis (TB) menace is imperative for a number of reasons. “There are strong reasons to favour public intervention due to the specific characteristics of tuberculosis. First, there are clear contemporaneous externalities
29 associated with detection and treatment because of its contagious nature. Second, especially early on in the disease individuals may not be very well informed about the need for diagnosis because the symptoms mirror those of other less serious health problems. Third, because full treatment requires extended drug therapy over 6-8 months, incomplete treatment is common and contributes to drug resistance. This is a form of dynamic externality. Finally, and perhaps most importantly, tuberculosis (TB) is a disease of the poor, and public intervention in its detection and treatment could represent an effective part of an anti-poverty approach to development”
Perhaps, this may have informed the mobilization of efforts worldwide, manifesting in the form of political commitments by nation-states of the world towards tuberculosis (TB) control. In recognition of the enormity of the tuberculosis (TB) menace, it was declared as a ‘global emergency’ thus giving impetus on the need for serious attention by all. Contemporary political commitments towards tuberculosis control led to the evolution of the ‘Global Plan to Stop TB
2006-2015’. “The Global Plan to Stop TB sets out the most effective approaches based on the best estimates and projections of the tuberculosis (TB) epidemic, as well as the resources needed to support comprehensive TB control and priority research”(WHO,2007:85).
According to Raviglione (2008:327) “The Global Plan addresses each major challenge, providing the rationale for interventions, estimation of their potential impact and costs and financial gaps. It also describes what needs to be done to reach the MDGs in different epidemiological regions. Full implementation of the Global Plan will result in major gains worldwide and the MDG 6 may be achieved globally and in most regions. By 2015, global TB incidence could be reversed and its prevalence and mortality reduced by half compared to 1990”.
In Africa, “African Heads of State and Government demonstrated their commitment in the Abuja Declaration and Plan of Action on HIV/AIDs, TB and Other Related Diseases (ORID) of April 2001, which recognized the challenges of developing feasible policies, strategies, structures, and processes to ensure adequate prevention and control of HIV/AIDs, TB and ORID.
By 2001, TB had been declared as a global emergency by WHO and the DOTs strategy
30
(government commitment, diagnosis through microscopy, standardized and supervised treatment, uninterrupted drug supply, and regular monitoring) adopted as the main framework to combat TB globally”(African Summit,2006:7).
As a follow-up to the Abuja Declaration of 2001 on HIV/AIDs, TB and Other Related
Diseases, “The Maputo Declaration on Malaria, HIV/AIDs, TB and Other Related Infectious
Diseases of July 2003, reaffirmed the Abuja Declaration, as did the AU/NEPAD report on
HIV/AIDs, TB, Malaria and Polio of January 2005. The New Partnership for African
Development (NEPAD) Health Strategy of 2003 and the African Union (AU) Assembly Decision
55(IV) on the interim Health Strategy seeks to reduce the burden of disease through six priority areas, including the scaling up of disease control. For TB control, the NEPAD Health strategy advocates increased access to quality DOTs, collaborative TB/HIV/AIDs activities and public– private partnerships and the development of regional strategies to mobilize human and financial resources for TB control activities”(African Summit, 2006:7).
In May 2005, the African Union and the Stop TB Partnership endorsed a “Blueprint to accelerate TB control activities and achieve the millennium development goals (MDGs) TB targets in Africa. The Global Plan to Stop TB (2006-2015) provides the ten-year framework for
TB control, and within that context the “Blueprint” sets out the priority activities for Africa in the near term. The “Blueprint” describes activities and financial needs as part of efforts to reach the
MDGs, and has key recommendations for all key stake holders” (African Summit, 2006:7).
The implication of ineffective tuberculosis (TB) control on the economy at the individual level and the society at large justifies the need for political commitment to TB control programme. In the contention of Kim, et al, (2009:1) “TB halts work in the formal and informal economies, as well as within households. Country studies document between three and four months work time lost annually to the disease, and lost earnings of 20 to 30% of household income. Families of persons who die from the disease lose about 15years of income. As economic difficulties put pressure on state budgets, the social cost of this lost of productivity is
31 compounded”. Further, “TB and poverty are closely linked. Malnutrition, overcrowding, poor air circulation and sanitation–factors associated with poverty-increase both the probability of developing clinical disease. Together, poverty and the tubercle bacillus form a vicious cycle: poor people go hungry and live in close, unhygienic quarters where TB flourishes. TB decreases peoples’s capacity to work, and adds treatment expenses, exacerbating their poverty…” ( Kim, et al, 2009:2).
For Kim, et al, (2009:2) the global burden of TB may be summed up in economic terms through a few brief computations. “Given 8.4 million sick, according to the most recent WHO estimates, the bulk of them potential wage-earners, and assuming a 30% decline in average productivity, the toll amounts to approximately $1 billion yearly. Two million annual deaths, with an average loss of 15 years’ income, add an additional deficit of $11 billion. Every twelve months, then the TB causes somewhere near $12 billion to disappear from the global economy”.
Furthermore, Laxminarayan, et al, (2007:1), observes that “Adult mortality has a significant effect on national economies, both through the direct loss of productivity among those of working age and altering fertility, incentives for risk-taking behavior, and investment in human and physical capital. TB places an extra ordinary burden on those afflicted by the disease, their families, and communities and on government budgets. The greatest burden of TB falls on productive adults who, once infected, are weakened and often unable to work. The burden of taking care of sick individuals usually falls to other family members and, in addition to putting them at greater risk of infection, and can lower their productivity.Adult deaths place an especially high economic burden on societies. The loss of working age adults represents a loss of human capital and has a profound effect on household economic well being”.
In spite of the grave consequences of TB burden on the economy, it is gratifying to note that there are economic benefits of TB control. According to World Bank research report, countries with world’s highest numbers of tuberculosis (TB) cases could earn significantly more than they spend on tuberculosis diagnosis and treatment if they signed on to a global plan to
32 sharply reduce the numbers of TB related deaths. “Highly affected African Countries could gain up to nine times their investments in TB control” (Who/Stop TB Partnership/World Bank, 2007).
Specifically, for Africa, “The study says that the economic cost of TB related deaths
(including HIV co-infection) in Sub-Saharan Africa from 2006 to 2015 is US$519 billion when there is no effective TB treatment as prescribed by WHO’s Stop TB strategy. However, if these same countries in Sub-Saharan Africa were to offer such treatment to TB patients, in keeping with a global plan to halve the prevalence and death rates by 2015 relative to 1990 figures, countries could see their economic benefits exceed their costs by about nine times over. “There were already compelling reasons to fight TB, which causes massive human suffering. Now, as a further incentive, there are strong indications that investment in meeting the Millennium
Development Goal (MDGs) related to TB carries important economic benefits” (World/Stop TB
Partnership/World Bank, 2007).
According to the study, stepping up TB treatment also makes economic sense outside
Africa. The study finds that “the economic return would be even higher in countries such as
China and India, where income growth projections over the next 10 years are higher and the burden of HIV co-infection lower”. This important new study shows us why TB control is a smart investment in lasting development for low-and middle-countries. This economic justification for TB control strengthens the case for governments and donors to sharply reduce
TB prevalence and deaths in the name of better health and higher incomes for people living at grave risk of TB illness and death”(WHO/Stop TB Partnership/World Bank, 2007).
Although, the current state of health in Nigeria is intricately linked with its history of political governance, Nigeria recognizes the right to health and has committed herself to its protection by assuming obligations under international treaties and domestic legislations, mandating specific conduct with respect to the health of individuals within its jurisdiction.
There are legal commitments to the right to health. The international treaties which recognize the right to health are legionary. And Nigeria is a party to most of them. “The most
33 important of these treaties are the International Covenant on Economic, Social and Cultural
Rights (ICESCR), Convention on the Elimination of all Forms of Discrimination (CERD), the
Convention on the Elimination of all Forms of Discrimination against Women (CEDAW) and the
Convention on the Rights of the Child (CRC). Nigeria is also a party to two health-related treaties on Civil and Political, namely the International Covenant on Civil and Political Rights
(ICCPR) and the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. In addition, the Country is a party to several Conventions of the International
Labour Organization, some of which contain provisions on health of workers. Nigeria is also a party to the Geneva Conventions and Additional Protocols that prescribe rules for conduct of warfare, including health-related obligations”( Nnamuchi, 2007:1).
Beyond all these international treaties and their domestication, the interest of the Nigerian
State in health care delivery was further demonstrated in the formulation of her health policy.
The current health policy of Nigeria is contained in the National Health Policy and Strategy to
Achieve Health for All Nigerians. This was first introduced in 1988 and subsequently revised in
2004 (FMOH, 2004). It is founded on egalitarian principles, the policy seeks to improve the health of all Nigerians by devising a sustainable health system based on primary health care
(PHC), that is promotive, protective, preventive, restorative and rehabilitative and which will ensure a socially and economic productive and fulfilling life to every individual. The Policy adopts World Health Organisation’s strategy for realizing PHC as elaborated in the declaration of
Alma Ata. It has its focus to be on National Health System and its Management; National Health
Care Resources; National Health Interventions and Services Delivery; National Health
Information Systems; Partnership for Health Development; and Health Research and Health Care
Laws.
However, it is imperative to state as Erinosho (2006:84) has observed that “health care delivery systems are not amorphous entities but shaped by the dominant ideologies, which underlie social systems”.In spite of the various ideologies, the nature, character and interest of
34 the ruling class determines the interest of the state in health care delivery. In Nigeria, the interest of the state in health care delivery cannot be isolated from her interest in other sectors of the society as there has been lack of commitment on the part of the state. According to Ufot
(2010:50) “The lack of commitment on the part of government towards reviving the health sector is the reason why government officials go abroad for medical treatment”. “The absence of modern facilities in many public hospitals across the country is linked to corruption and failure of successive governments to pay adequate attention to the health sector”. It is not news that our hospitals are ‘still, at best, mere consulting clinics’.
The dwindling fortunes of financial provisions for the health sector explain the interest of the Nigerian state in health care delivery. According to the UNDP, (2006:303), government expenditure on health as a percentage of GDP was 1.3% in 2003, a decline from 2.2% in 2000.
For government expenditure as a percentage of total expenditure on health ,WHO (2006:182),
“the Nigerian government share declined from 29.1% in 1999 to 25.5% in 2003, lagging behind many other African countries, even those similarly classified by the World Bank as low income economies”.
GAPS IN LITERATURE
Given the reviewed literature, it is quite evident that a lot of efforts have been made to explain the concept of politics and its relationship with public policy, as well as how politics affects public policy implementation especially tuberculosis (TB) control. Succinctly put, the relationship between politics and public health has to some extent been examined but not with reference to the focus of this study. Also flowing from the existing literature that was reviewed is the fact that there appears to be a general consensus that the philosophy guiding the implementation of public policies in Nigeria can be located in the origin, nature and character of the State as exhibited by the political gladiators. It is this nature that has driven policies affecting tuberculosis control services. However, there still exists a yawning gap or lacuna in the literature.
Indeed, none of them specifically investigated the relationship between the two variables in 35
Rivers State. It is therefore, not only important, but necessary to to examine how the exercise of power in the allocation and distribution of resources impacts on the implementation of the TB control services in Rivers State. The fact that Rivers State is one of the major source of income to the Nigerian nation by virtue of being a major oil producing State; and therefore not likely to be cash-trapped, makes the investigation of the relationship between politics and its impact on
Tuberculosis (TB) Control services imperative in the State.
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CHAPTER THREE
METHODOLOGY
3.1 THEORETICAL FRAMEWORK
Igwe (2005:442-3) contends that a theoretical framework is a theoretical guide, example or school of thought, expressing some level or form of existing relevant knowledge, and adopted by the student or researcher as the foundation of his work; chosen, normally from an array of political theories revealed after a thorough literature review and incorporated, depending on the type of activity, into the initial papers. The theoretical framework provides a guide to an enquiry; it not only contextualizes it, it also permits a degree of prediction of outcomes on the basis of the analyses engendered by the framework. A good theoretical framework while not automatically jettisoning a theory can, in the process of its thorough re-evaluation and utilization, disclose the internal contradictions of the theory and, in so doing, improve upon the process of classification, abstraction and conceptualization embodied in it.
Although, a number of theoretical perspectives exist which can be used to explain the issues that are of concern in this study, this study adopted the Marxist political economy theory approach. The approach is a Marxist methodological and theoretical framework of analysis based on dialectical materialism. It is a philosophical and sociological science concerned with the most general laws and motive forces of the development of society. It has been used for social research from the days of Karl Marx in social, political and economic analysis.
Also Igwe (2005:333) posits that Political economy “is both an approach in social research and a theory seeking to explain the system of economically influenced political relations at the domestic and international levels…express an obvious reality, namely, the economic basis of the political behaviour of states and the people’’. This brings to the fore that political economy is the name given to an important division of the science of government, the physical wellbeing of man, so far as it can be produced by his government, is the object of political economy. The end of government is not to accumulate wealth in the state, but to make every citizen participate 37 in those enjoyments of physical life which wealth represents” (Simonde; www.socew2.socsci.mcmaster.ca).
Karl Marx first employed political economy as an approach for analyzing and justifying the root causes of conflicts and contradictions in human societies. Marx expressed the belief that the root cause of tension or conflicts in every human society should be found in the relationship between the haves (Bourgeoise) and the have-nots (Proletariat) Karl Marx (1915) as cited by
(Aja, 1998:12).
Ihonvbere (2009: viii-ix) is of the opinion that “in simple terms, political economy encompasses a critical, holistic and rational understanding of the essential forces and factors that link and shape politiccs and economy. Politcal economy directs us to consider the places of history, the balance of social forces, the nature of contestation for power and hegemony, the solidity and hegemony of the state and its constituent units, nature of production and accumulation, class struggles, the circulation of consciousness among class positions, location and role of the formation in the global divisions of labour and power in trying to understand our societies”.
For Ekekwe (2009:15-16), what we call political economy or historical materialism evolved mainly out of the views and findings of Karl Marx and Friedrich Engels. They, “working from the materialistic basis of knowledge and existence already developed in natural science and philosophy, adopted historical materialism as (a) a means through which we can derive an objective and theoretical knowledge of the world. That is through it we begin to understand the forces that form and transform economic, political and social life. Since it was not enough to simply have knowledge of the world they condemned knowledge for its own sake; knowledge without a social purpose-Marx and Engels saw historical materialism as (b) providing the scientific basis for action in which the world can be changed for the greater benefit of mankind.
Their eventual vision was that the science of social change (historical materialism) would be
38 instrumental in creating global societies in which exploitation of man by his fellow man did not exist.”
Dialectical materialism operates on the assumption that a society’s social and political institutions grow out of its economic infrastructure or power base, and it is from the conflict between social classes with opposed economic interests that social change takes place (Brown,
1981:1).
Given the above, it is obvious that a major thrust of this theoretical framework is that it is the nature of the economic base that to a large extent shapes the superstructure, though the latter, in turn, affects the former. According to Ake (1981:23) this suggests that:
once we understand what national assets and constraints of society are, how the society produces goods to meet its national need, how the goods are distributed and what type of social relations arise from the organization of production, we have come a long way to understanding the culture of that society, its laws, its religious system, its political and even its mode of thought.
The statement above clearly demonstrates that the approach underscores the inevitability of understanding the nature and character of the mode of production, its forces of production and relations binding them. This means that for one to understand anything in the economy, it is necessary to understand politics. This is because actions of politicians and their appointees significantly determine economic policy. It is imperative to observe that since economic power determines politics, those with higher economic status are those who govern. The state power is therefore used for the interest of the custodians of power.
Within our context, attention was given to unequal economic relations that exist between the bourgeoisie (political class) and others (proletariat). The reproduction of this economic inequality, how politics is used to determine the economic policies that should have significantly affected the proletariats positively. In this regard, we are not unmindful of the neo-colonial status of African States.
According to Fanon, cited by Salami (2009:13-42):
39
Many of the rulers we have in Africa, never concerned themselves with what exactly to be done to move the nation forward when they acquire power. Rather you have them thinking of how they will play the roles of the colonial masters when they acquire the power of governance. Based on this, you hardly expect any tangible or time enduring development. Although, Okolie (2008:70-85) opines that the State form in human society is a natural necessity. Nevertheless, he observes that “States in post colonial societies are generally caged and hijacked by a few political notables who blatantly dictate the course of political events”.
Such elements are generally regarded as political gladiators (Godfathers) whose economic, social and political networks are overwhelming and place them in positions to influence state actions.
Inherent in this observation is that given the interest of the political gladiators, they are not likely to implement policies that will positively affect the down trodden masses of the society.
Given the neo-colonial status of the Nigerian state, it is a ‘privatized one’ and political power is used for private interest. In the words of Ake (1996:7) much of what is uniquely negative about politics in Africa arises from the character of the state, particularly its lack of autonomy, the immensity of its power, its proneness to abuse and the lack of immunity against it.
The character of the state rules out a politics of moderation and mandates a politics of lawlessness…what emerges from this is politics which does not know legitimacy or legality, only expediency.
The import from the above analysis is that the gladiators in the Nigeria political scene may not have seen it as an instrument for development and therefore emancipation of the proletariats. Rather, “politics has become the primary source of capital accumulation by
Nigerians” ( William, cited by Salami; (2008:131-42) This explains why our politics has moved us from medium income country in the 1980’s to low income presently as categorized by the
United Nations Development Programme (UNDP).
In the contention of Toyor (2011:35) “Marxists are the scholars who honestly see the importance of economic power in determining the constitutions, the character of decision taking, the performance, and the status of justice in a society…there is no case in human society where a
40 servant can dictate to a master. If one man has the power to exploit another, then he can dictate to the exploited man”
Another major thrust of our theoretical framework is its emphasis on class. In this regard, we are unavoidably made to predicate social analysis on the fundamental understanding of the structure of property relations and the processes of the distribution of power and other scarce resources and opportunities in a given mode of production (Eteng, 1996, cited by Barikor,
2001:20).
In choosing class analysis as a component of the theoretical framework, the focus is to show how the intense class struggle to win access to the state and thus preside over the allocation of public funds is at the root of our ‘politics of expediency’.
Broadly, the defining index in Marxist Political Economy is the determination of who benefits from the control and exercise of political power. Marxists argue that the exercise of power benefits those who control the state, a fact attributable to the partisan nature of the State.
In adopting this, it has exposed the nature of our politics which apparently alienates the people in democratization and development. In the contention of Ake (1994:1) “The democratization occurring in Africa does not appear to be in the least emancipatory. On the contrary, it is legitimizing the disempowerment of ordinary people who seem to be worse than they use to be because their political oppression is no longer perceived as a problem inviting solution but a solution endowed with moral and political legitimacy”. It brings to the fore that State power is used for the interest of the custodians of power to the neglect of others. In this perspective since tuberculosis is a disease that mostly affects the lower class and the upper class are the custodians of power, their actions has always negated the interest of the lower class. “Tuberculosis the age– old disease is found to be prevalent highly in the developing and underdeveloped parts of the world. TB is associated with poverty and deprivation. The association between poverty and health is well documented…” (Thapaliya, et al, 2009:1-9).
41
Furthermore, scholars of the Marxist leaning subscribe to the view that the post–colonial state is an instrument in the hands of the ruling class to serve a particular class interest (Onuoha,
2000:203). This suggests that the State pursues the interest of the capitalist class simply because the state is controlled by them. Consequently, State Policies are formulated not only to serve the interest of the ruling elites but also to perpetuate structures of alienation and deprivation of the poor/lower class by the ruling elites of the State. The theory therefore elucidates on the fact that since members of the ruling class are directly involved in both the state machineries and economic process, the State in its adoption and implementation of public polices and programmes pursues the interest of the ruling class and not the interest of the entire citizenry.
In using it to explain politics and its relationship with policy implementation, it becomes very clear that the politicians in adopting policies merely create room for the accumulation of surplus by the capitalist class. That is, the financial resources voted for the implementation of public policies and programmes are in turn diverted and used by the elites for their selfish interest.
By utilizing this theoretical framework as our guide for this study, the study demonstrates that it is not in the interest of the Nigerian State to sincerely provide an enabling environment
(Legislation) as well as commit resources towards the eradication of TB since this would have helped to reduce poverty in the society. In our clime, the capitalist class thrives on the misery of the people. It also indicates that the design and adoption of the policies and programmes are basically aimed at advancing the interest of the ruling class and not necessarily to solve the problem for which it was meant. The issue is, as long as the interests of the ruling class are concerned, the utmost need of eradicating tuberculosis in line with the Millennium Development
Goals (MDGs) remains inconsequential.
It is within this context that the role of politics in the effective control of Tuberculosis, given the rising incidence of the disease will be analyzed. Specifically, implied in our theoretical framework is the suggestion that it is perhaps impossible to discuss the resurgence of tuberculosis
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(TB) and the politics of its control without locating such discussion within the historical experiences of the social formation called Nigeria, the nature of the State and the class forces existing within it.
3.2 HYPOTHESES
The following hypotheses served as our guide in this study. That:
1. There is a relationship between the allocation and distribution of resources and the
implementation of the tuberculosis control programme.
2. There are health related implications from the implementation of the tuberculosis control
programme.
3.3 RESEARCH DESIGN
Attaining the goal of a study of this nature which can be described as ambitious is
certainly a challenging one. As a retrospective study, the study was based on survey and single
case study research design. In the contention of Anikpo (1986:37) “Survey studies are applied
mainly in the examination of current condtions or practices relating to any aspect of the social
system in order to make more effective plans for improvement” Surveys are conducted in case
of descriptive research studies studies…surveys are concerned with describing, recording,
analyzing and interpreting conditions that either exist or existed. The researcher does not
manipulate the variable or arrange for events to happen. Surveys are concerned with conditions
or relationships that exist, opinions that are held, processes that are going on, effects that are
evident or trends that are developing … Surveys are usually appropriate in case of social and
behavioural sciences (because many types of behaviour that interest the researcher cannot be
arranged in a realistic setting… surveys are concerned with hypothesis formulation and testing
the analysis of the relationship between non-manipulated variables” (Cothari, 2012:120-121).
For Harrison, cited by Nwaorgu (2002:25) Social surveys is a “comparative undertaking which
applies scientific method to the study and treatment of current related social problems and
43 conditions having definite geographic limit and bearing, plus such a spreading of facts, conclusions and recommendations as will make them as far as possible the common knowledge of the community and a force for intelligent coordinated action”. The social survey method as a technique enables the researcher to have a view of something from some higher or advantage position.
The Case Study is a method “in which the researcher focuses on a particular social institution or a community and attempts to relate any particular attribute of that unit to other variables. The aim is to find out as much detail as possible about a particular problem. It involves collecting information about the pressing problems, past experiences and any environmental factors that affect the behaviour or functioning of the social unit. In this way, it also connotes a survey. Case studies tend to maximize details about specific social units”
(Anikpo, 1986: 39). For Kumar (2008:113) the case study method is an approach to studying a social phenomenon through a thorough analysis of an individual case. The case may be a person, group, episode, process, community, society or any other unit of social life. All data relevant to the case are gathered and organized in terms of the case. It provides an opportunity for the intensive analysis of many specific details often overlooked by other methods. This approach rests on the assumption that the case being studied is typical of cases of a certain type so that, through intensive analysis; generalizations may be made that will be applicable to other cases of the same type. According to Hilway, cited by Anikpo (1986:39) “In sociological and psychological research in general, the survey and case study are used as complimentary to one another for there is close relationship between them. The case study especially, seems to be more effective when used in conjunction with the survey method. Further, “being an exhaustive study of a social unit, the case study method enables us to understand fully the behaviour pattern of the concerned unit. In the words of Cooley, “case study deepens our perception and gives us a clearer insight into life. It gets at behaviour directly and not by an indirect and abstract approach”. The method makes possible the study of social changes. On account of the minute
44 study of the different facets of a social unit, the researcher can well understand the social change then and now. This also facilitates the drawing of inferences and helps in maintaining the continuity of the research process. Infact, it may be considered the gateway to and at the same time the final destination of abstract knowledge” (Cothari; 2012:115). The study is thus a deductive and descriptive one. For this reason, we shall employ both the qualitative and quantitative data collection methods to obtain information.
The qualitative research techniques involve the identification and exploration of a number of often related variables that give insight into the nature and causes of certain problems and into the consequences of the problems for those affected. According to Obono (2009:2)
“qualitative methods are means of collecting and analyzing interpretive and subjective social reality in which the researcher is typically immersed. They are particularly good at answering the “why” and “what” question”.
In contrast to quantitative methods, however, “qualitative research methods are flexible, fluid lively, in-depth, assessment methods for exploratory pilot research into an unfamiliar, uncharted research terrain” (Khasiani, 1991; Nigeria, 1991 cited by Sunday; 2005:34).
Qualitative methods are more-or-less free from what has been described as “the strait- jacket of prior design decisions “(Smith et al, 1991 cited by Sunday; 2005:34). They are so flexible that they can be applied even when these design decisions are severely challenged in the open field.
They facilitate the need to follow new research leads, reconnoiter previously unanticipated developments and integrate the outcomes with the special character of the present investigation.
The quantitative research techniques are used to quantify the size, distribution, and association of certain variables in a study population. This combination of several (qualitative and quantitative) methods of data collection is expected to provide data on both infrastructural, financial and other resources as well as the socio-political contexts in which they occur.
In addition, contemporary thinking in social research considers reality to be so complex and multidimensional that a single instrument or perspective may prove incapable of traversing all of
45 it. It is contended that the use of both methods enhances our ability to understand issues under investigation more holistically or from a comprehensive point of view. The process underlies much research activities in the modern period and it is hinged on the position that the use of multiple methods would compensate for the individual weakness that may be associated with each one of them.
3.4 METHODS OF DATA COLLECTIONS
This study was based on empirical methodology. The study therefore, used extensively, both primary and secondary data. Primary data was sourced through self administered questionnaire method of data collection. The secondary sources of data include books, journals, magazines, newspapers, Government publications and World Health Organization, (WHO)
Publications.
PUPULATION OF STUDY
This study was conducted in Rivers State. The population for this study stood at 193 persons. These comprised of 105 DOTS focal persons, 25 State programme officers, 23 LGA programme officers; 23 LGA Assistant Programme Officers; 7 WHO/ Development partners personnel; and 5 collaborating NGOs personnel, as well as 5 public-private mix personnel.
These are the stakeholders directly involved in the tuberculosis control services
SAMPLE SIZE
For the self administered questionnaire, we administered a total of 140 copies of questionnaires to the 105 DOTS sites and the State Control Programme Office as well as representatives of World Health Organisation, NGOs and other Collaborating agencies. It is indicated in the table below:
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LOCATION NUMBER OF QUESTIONNAIRE ADMINISTERED DOTS Centres 105 State Programme Office 25 LGA Programme Officers 23 WHO/Development Partners 7 NGOs 5 Public/Private Mix Centres 5 Total 170
SAMPLING PROCEDURE
For the purpose of generating data that was used to evaluate the research hypotheses, with a view to achieving the objectives of the study, we sampled all the 3 senatorial districts that are located within the 23 Local Government Areas (LGAs) of the state. The sample design was based on both random/probability and non-random/non-probability sampling designs. To this end the
Simple random sample (SRS) and the judgmental or purpose sample methods were employed.
The Simple random sample (SRS) permits or creates the chance for the representation of all sectors or elements within a group. In essence, each element in the population is given an equal and independent chance of selection. The judgmental or purpose sample was adopted to reach out to persons or organizations that are involved in the tuberculosis control services in the state. According to Kumar (2008:179) “the primary consideration in purposive sampling is the judgment of the researcher as to who can provide the best information to achieve the objectives of the study. The researcher only goes to those who in his/her opinion are likely to have the required information and be willing to share it. It is useful to describe a phenomenon or develop something about which only a little is known”.
Within the 3 senatorial districts of the 23 LGAs of the state, we limited the sample sites to
the 105 Directly Observed Treatment (DOTs) centres and other individuals as well as
organizations involved in the tuberculosis (TB) control services. The state TB control personnel,
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all the focal persons (anchor men) at the DOTs centres and individuals/representative of
organizations involved in tuberculosis (TB) control services in the state formed the core of the
sample size. The justification is that they are the major stakeholders in the execution of the
tuberculosis control services of the state.
The following is the list of the 23 LGAs of the state and the number of DOTs centres.
S/N Local Government Area Number of DOT Centers 1. Abua/Odual 4 2. Ahoada East 7 3. Ahoada West 6 4. Akuku Toru 2 5. Andoni 5 6. Asari Toru 4 7. Bonny 4 8. Degema 6 9. Eleme 3 10. Emohua 5 11. Etche 3 12. Gokana 2 13. Ikwerre 7 14. Khana 5 15. Obio/Akpor 7 16. Ogba/Egbema/Ndoni 15 17. Ogu/Bolo 2 18. Okrika 1 19. Omuma 7 20. Opobo/Nkoro 2 21. Oyigbo 2 22. Portharcourt City 8 23. Tai 4 Total 109
Source: TB and Leprosy Control Programme, Rivers State Ministry of Health.
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Although, it is obvious that the time and financial implications of collecting data from all the DOTs centers listed above is much, we endeavored to do it in order to generate comprehensive data and information.
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INSTRUMENTS FOR DATA COLLECTION
Primary Data for this study were collected through questionnaire method of data collection.
A) DOCUMENT REVIEWS
Documentary sources constitute such information that are documented and kept by organizations as well as individuals. Some of this information is kept in archives, while some are found in the offices as reference materials for both members of the organization and visitors.
In this case, the researcher visited and interacted with the state tuberculosis (TB) control officer and other key officials of the tuberculosis control programme. The essence of the visits and interaction were to solicit for information with regards to Government support such as the allocation and release of financial resources to the programme, the presence of appropriate legislative framework; a national plan for TB control and international corporation. We also examined their documents for the number of registered cases for the period, the percentage cure rate and other statistics/records that are in their custody. Document review permits examination of past trends.
B) THE QUESTIONNAIRE
The questionnaire is a written list of questions, the answers to which are recorded by respondents. In a questionnaire “respondents read the questions, interpret what is expected and then write down the answers” (Kumar, 2008:126).The questionnaire was designed to collect data from the stakeholders involved in the tuberculosis (TB) control services of the State. A total of sixteen (16) questions are contained in the questionnaire .And they were designed to address issues such as the enactment of appropriate legislative and regulatory frameworks; involvement of top government officials in advocacy for the TB control programme, a plan for TB control;
50 the allocation and use of sufficient resources and the involvement of Development Partners as well as the health-related impact from the improper implementation of the tuberculosis control services. A total of 140 copies of questionnaires were administered specifically to all the focal persons at the DOTS centers and other persons that are involved in the provision of the services.
The structure of the questionnaire adopted both the closed and open-ended types. This enhanced the collection of a wide range of data on the research objectives. The questionnaire permits anonymity and may result in more honest responses.
3.5 METHODS OF DATA ANALYSIS
The obvious fact is that social analysis is known to parade an array of techniques for data analysis. The choice of any technique is entirely dependent on the needs of the research focus/problem.
In order to effectively do this, we used the qualitative and quantitative descriptive analysis and were also guided by the World Health Organisation’s toolkit/ framework used for the analysis of the health system which focuses on the organizational structure, financing, allocation of resources and service delivery. It is a systematic rapid assessment and monitoring toolkit developed for concurrent analysis of health systems and tuberculosis programme was used to guide the analysis. According to Atun, et al (2005:218) “this toolkit comprises two elements: The horizontal assessment that investigates the health system within which the infectious disease programme is embedded from a variety of perspectives. The vertical assessment investigates the specific infectious disease programme. This toolkit has the advantages of other rapid assessment approaches as well as providing an opportunity to make a more in-depth longitudinal assessment of specific areas, such as the political economy, financing of the health system, service delivery and societal attitudes, in order to provide a better understanding of these contextual issues”. The chi-square test was equally adopted to determine the relationship between some of the variables.
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Generally, the logical data framework provided below served as the guide for our data analysis
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3.6 LOGICAL DATA FRAMEWORK
RESEARCH HYPOTHESIS MAJOR VARIABLES OF THE EMPERICAL INDICATORS SOURCES OF DATA METHOD OF DATA METHOD OF DATA
QUESTION HYPOTHESIS: OF VARIABLES COLLECTION ANALYSIS
INDEPENDENT (X)
DEPENDENT (Y)
(X)
(Y)
Is there a There is a ( X ) The lunching of the NTBLCP WHO documents and Primary and secondary Qualitative and relationship relationship The adoption and lunching of the in 1991 and adoption of the publications, Books, data such as self quantitative descriptive between the between the TB control programme policy WHO recommended DOTS Government administered questionnaire, analysis of institutional allocation allocation and strategy of DOTS that listed broad policy strategy in 1993. documents and official reports and and official and distribution of political commitment with publications. publications, publications, summit distribution resources and increased and sustained conference/summit declarations, internet of resources the financing as the first element. declarations, newspapers, sources, newspapers and the implementatio Implementation according to Annual reports, magazines, Internet and magazines. Chi- implementat n of the TB ( Y ) the NTBLCP DOTS policy documents/records of materials. square test was equally ion of the control The implementation of the TB strategy, first global plan, the State TB control used to determine the
TB control programme. control programme according to second global plan and the programme, NGOs, as relationship between programme? the DOTS broad policy strategy. TB related targets of the well as WHO reports, some of the variables.
MDGs. Government annual
budgets etc.
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LOGICAL DATA FRAMEWORK
RESEARCH HYPOTHESIS MAJOR VARIABLES OF THE EMPERICAL INDICATORS SOURCES OF DATA METHOD OF DATA METHOD OF DATA
QUESTION HYPOTHESIS: OF VARIABLES COLLECTION ANALYSIS
INDEPENDENT (X)
DEPENDENT (Y)
(X)
(Y)
Are there There are ( X ) The lunching of the NTBLCP WHO documents and Primary and secondary Qualitative and any health health related The adoption and lunching of in 1991 amnd the adoption of publications, books data such as self quantitative descriptive related implications the TB control programme the WHO recommended government administered questionnaire analysis of institutional implications from the strategy of DOTS that listed DOTS broad policy strategy documents and Official reportsand and official from the implementatio political commitment with in 1993. publications. publications, conference/ publications, summit implementat n of the TB increased and sustained summit declarations, declarations, internet ion of the control financing as the first element. Implementation according to Annual reports, newspapers, magazines, sources, newspapers
TB control programme. ( Y ) the NTBLCP DOTS policy documents/ records of books, internet materials. and magazines. Chi- programme? The implementation of the TB strategy, first global plan, the state TB control square test was equally
control programme according to second global plan, and TB programme, NGOs, used to determine the
the DOTS broad policy strategy. goals and targets related to Governments budgets, relationship between
the MDGs. WHO reports etc some of the variables.
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CHAPTER FOUR
RIVERS STATE OF NIGERIA
4.1 THE GEOGRAPHY AND PEOPLE OF RIVERS STATE
Rivers State is presently located in what is being described in the political parlance as the
South–South geo-political zone of the country. It is situated in the Eastern heartland of the Niger
Delta.
Okonny (2002:10) explains that the word delta, a Greek alphabet “describes the triangular landmass observed from the trunk of the Niger River and the twenty odd rivers that radiate in a lobate manner as these rivers and their distributaries meander across the swamp created by deposition, in order to debouch into the relatively modern Atlantic ocean’’. While the
Benue trough sediments are cretaceous in age, the Niger Delta sediments are Tertiary in age, confirming the sequence, in the stratigraphy, of the southern part of Nigeria. While ammonites are the index fossils for the Benue trough, foraminifera are the index fossils for the Niger
Delta. These index marker fossils are accepted internationally and confirm the geology of the
Niger Delta (Kogbe, 1972 cited by Okonny, 2002).
For Okonny (2002:10) “the amount of published works from the prospecting oil companies in the Niger Delta attests to the veracity of the Niger Delta geology sequencing. The top of the Tertiary sequence is overlain by modern deposition of alluvium and sands, which are dated quaternary to Recent in age”.
Given her location in the Niger Delta, “the state is bounded on the south by the Atlantic
Ocean, on the North by Imo and Abia States, on the East by Akwa Ibom State and on the West by Bayelsa and Delta States. As one of the Niger Delta States, it has topography of flat plains with a network of rivers and tributaries. These include new Calabar, Orashi, Bonny, Sombreiro and Batholomew rivers’’. (Rivers State Diary, 2010). With a tropical climate, numerous rivers
55 and vast areas of arable land, the people have lived up to their traditional occupation of agriculture, especially fishing and farming. They also engage in commerce and industry.
Characteristically, rainfall is heavy throughout the state. However, it decreases from 430 centimeters to an average of 342 centimeters at the Northern periphery. Presumably, the dry season lasts from November to March but interrupted occasionally by sporadic down pours.
Expectedly, there are some major and important towns in Rivers State. These include: Port
Harcourt (the current state capital), Ahoada, Bonny, Bori, Buguma, Degema, Isiokpo, Nchia,
Opobo etc. Rivers State occupies an area of about 50, 000 square kilometers (Rivers State Diary
2010).
Rivers State as currently constituted and peopled are “composed of communities which identify themselves by language, but also by history. The language dialect spoken by members of the community clearly distinguishes them from members of other communities, but may also relate them to some communities, and may also relate to some other groups. In some cases, however, there may be pockets of people within a community whose speech may be different, in the process of being absorbed, or diverging, because of historical antecedents. In the majority of cases, similarity of language is accepted by the communities themselves as indication of common historical origins” (Alagoa, et al., 2002:173).
According to linguistic classification, two families of the Niger–Congo phylum of
African languages are present in Rivers State, “which prefigures a historical divide into two major ancestral grouping: The Benue–Congo family and the Ijoid family”. (Alagoa, et al.,
2002:173).
Alagoa, et al., (2002: 174) contends that “The Benue–Congo family of Rivers State is itself quite complex, comprising four branches, with the following list of groups”.
1. Igboid Branch, comprising the following groups:
i. Ikwere (Ikwerre)
ii. Ekpeye
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iii. Echie
iv. Ogba (ogbah)
v. Egbema
vi. Ndoni
2. The Delta–Cross Branch comprising the following groups:
i Ogoni
ii Lower cross: Obolo (Andoni)
3. The Central Delta Branch, comprising the following groups
i Abua
ii Odual
iii Ogbronuagum (Bukuma)
iv Obulom (Abuloma)
v Ochichi (an enclave in Echie)
4. The Delta Edoid Branch, comprising the following groups
I Degema
ii Egene (Engeni)
Accordingly, the Ijoid family in Riivers State is limited to two branches with the following listing of the component groups:
1. The Defaka Branch, comprising
i. Only the small Defaka group, being itself no more than a minority part of the
Nkoro group of the Ijo Branch.
ii The Ijo Branch, comprising the following groups:
i. Kalabari
ii. Bile (Bille)
iii. Ibani (Bonny and Opobo)
iv. Kirike (Okrika)
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v. Nkoro
Interestingly, Alagoa, et al., (2002:175) observes that “The linguistic classification reveals certain external affiliations: The Igboid communities to the north and north–east major
Nigerian Igbo communities outside the Niger Delta region; the Delta–Cross indicates affiliation to groups in the Cross-River Valley to the east of the Niger Delta groups; and the Delta Edoid, to the Edo north-west of Rivers State across the Western Niger Delta. Thus each of the families and individual communities would display complex historical relationships in their traditions. In addition, historical relationships transcend these comparatively simple linguistic categories, and tend to integrate communities across linguistic boundaries. Thus, the Bukuma of the Central
Delta Branch as well as the Degema of the Delta Edoid Branch have very close historical relationships with the Kalabari of the Ijo Branch of the Ijoid family. The Abuloma of the Central
Delta Branch of the Benue–Congo family also have close historical links to the Okirika, and the
Ochichi to Echie of the Igboid Branch”.
In what follows are brief descriptions of traditions of origin of communities along the delineations indicated by the linguistic relationships as suggested by the above listing of linguistic branches and groups.
THE IGBOID BRANCH
This branch comprises the Ikwere, Ekpeye, Echie, Ogba, Egbema and Ndoni of Rivers
State and they speak languages close to Igbos, thus suggesting a generic relationship with the
Igbo of the North of them. “Early oral traditions in each of these groups often, indeed, recount traditions of Igbo origin but recent accounts have tended to give priority to traditions of Benin origin and historical contacts with Ijo and other neighbours in the Niger Delta to the south”
(Alagoa, et al., 2002:175). Igbo scholars locate the Igbo homeland in the central plateau area of
Anambra State, from which movements radiated outwards, including the movement of the
Igboid groups of Rivers State south wards into the northern fringes of the Niger Delta. However, some recent linguistic studies also suggest movements south down the River Niger, and from the 58 lower Niger, east into the region now occupied by the Igboid groups of Rivers State.
Accordingly, some of the traditions of Benin origin could refer to such movements from Igbo– speaking areas of the present Delta State then under Benin influence (Alagoa, et al., 2002:176).
As earlier mentioned, the major groups in this Igboid Branch are the Ikwerre with her main communities, the Ekpeye and Ogba and Ndoni.
THE DELTA–CROSS BRANCH
The Ogoni and Obolo (Andoni) are the main groups of this branch. Interestingly, they
“speak languages which relate them ultimately to peoples of the Cross River Valley, the
Cameroons, and beyond, despite traditions of origin among them suggesting other affiliations”
(Alagoa, et al., 2002:177).
The Ogoni comprise the communities of Kana (Khana, Eleme, and Gokhana), Baan and
Tai. There are several traditions of origin among these communities, including: claims to autochthony, migration from an eastern location; and migration from “Ghana (Alagoa, et al.,
2002:178).
Jeffreys (1931 cited by Alagoa, et al., 2002: 178) had recorded a tradition of autochthony deriving the Ogoni from Gbenebeka, great mother, who had “come down from the sky”.
However, Kpone–Tonwe, (1990) had paid great attention to the traditions of eastern or Ibibio origin, and migration from Ghana. Interestingly, Alagoa, et al., (2002:179) contends that “The most promising line of investigation of Ogoni history seems to lie in the direction of larger scale archeological excavations at Nama, and the professional analysis of the artifacts already recovered, because the radiocarbon dating of the Nama site still remains to be carried out”.
For the Obolo (Andoni) clearly, Obolo traditions of origin take account of their linguistic roots in the Cross River valley and eastwards. The traditions also take account of Obolo relations with Bonny, Okrika and the Kalabari Ijo to the west of them (Alagoa, et al., 2002:179).
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THE CENTRAL DELTA BRANCH
The Central Delta Branch is of the Benue–Congo family. The member groups are: Abua,
Odual, Bukuma, Abuloma and Ochichi. They are found on the northern fringe of the Eastern
Niger Delta, between the Ijo groups to the south and the Igboid and Delta cross groups to the north. Alagoa, et al., (2002:180) observes that “Their membership in the Benue–Congo suggests relationships to the east of their present locations. However, the relative age of their settlement is attested by traditions of origin which rarely cite places of origin to the east as suggested by their linguistic affiliations”.
THE DELTA–EDOID BRANCH
The two groups in the Delta Edoid Branch in Rivers State are Degema and Engeni. They are credited with recorded traditions of origin which include references to Benin, in line with the linguistic classification. But their history within memory of oral traditions, however, must refer principally to the local environment of the Sombreiro and Orashi Rivers.
THE IJOID FAMILY
The Ijoid are noted to represent an old family in the Niger–Congo phylum. The majority of its branches are expectedly to be found in Bayelsa and Delta States. “The geographical distribution of the family suggests the heartland to lie in the Central Niger Delta in Bayelsa
State. They are thought to have moved into the Niger Delta down the River Niger. But the position of the old Defaka branch in the Eastern Delta fringe suggests complex historical developments yet to be resolved. The traditions of origin within the family, branches and groups tend generally to suggest migrations from the Central Niger Delta, with a few cases of movements into the region from the neighbouring mainland, and out of the region westwards”
(Alagoa, et al., 2002:182)
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The Defaka Branch and Ijo Branch are the main groups in this family. The Defaka live in the Afakani ward of Nkoro town, among the Nkoro Ijo group.
The Ijo branch of Rivers State comprising the Kalabari, Bille, Ibani, Okirika and Nkoro, tell traditions of migration from the Central Niger Delta, which conform with the linguistic relationships with the other branches of the Ijoid family to the west of them.
4.2 THE HISTORICAL BACKGROUND OF RIVERS STATE
Tamuno (2012:20) avers that “Nation States are accidents of history. They are not natural political phenomena. They are not as old as the age of man…Nation states, as instruments of organized societies, demonstrate systems as complex as human beings themselves before and after the age of Aristotle… Nation states, as human organizations, are dynamic institutions which respond to the differential sensitive factors of time, circumstance, leadership/ followership, chance/accident or pot–luck”. For Naanen (2011:3–4) “Rivers State is not a natural entity in the sense of an ethnic community that formed naturally. It is rather a heterogeneous political entity that was brought into existence through certain means and for some purpose, which is the common good of the diverse community of people that makes up the state”.
The emergence of Rivers State as an organized political unit within the Nigerian nation state was an outcome of a long chequered struggle that predates even Nigeria’s Independence. It was a product of a major political attempt towards redesigning Nigeria structurally in 1967 by the Head of State, General Yakubu Gowon; which among other measures decreed a twelve state structure for the country. “In 1967, a major political restructuring of Nigeria was effected.
Twelve states were created out of the existing four regions which make up the federal republic of Nigeria. Rivers State was one of these states. However, the birth of Rivers State was not an act of benevolence. Rather it was a product of a combination of more than two decades of political and constitutional struggle and the Nigerian political crisis of the 1960s. The struggle
61 was not undertaken by a single group having a single conception of what the proposed state should be. On the contrary, it was a convergence of several movements having varied conceptions of the composition of the state”. (Naanen, 2011:4).
ORIGIN OF STATE AGITATIONS: RIVERS STATE
The issues which provided the platform for agitation for a state to be called Rivers State in the Niger Delta may be difficult to understand in isolation from the broader social problems which afflicted the Nigerian Nation. The most outstanding of these has been the unflinching struggle for dominance by the major ethnic groups and also underdevelopment. The perceived rights of the smaller ethnic or minority groups were not given the recognition they deserve in this struggle. “Considering Nigeria’s multiethnic composition, the primacy of ethnic identity is by no means strange. But this ethnicity is sustained and reinforced, among other factors, by poverty and the resilience of primordial social relations which emphasize ethnic affiliation as the primary form of identity and by the elite who manipulate ethnic sentiment to its economic and political advantage. This briefly, is the social basis of ethnicity in Nigeria” ( Naanen, 2002:340).
For Naanen (2002:340 “It is against this background of domination and the perceived neglect of the smaller ethnic groups in the allocation of political and scarce economic resources that we must relate the demand for states especially before the civil war. Other factors such as historical and cultural differences definitely played their roles, but these were clearly minor factors. The essence of state demands, then, was the creation of political units to ensure a degree of ethnic and regional balance in the allocation of resources. In later years, states creation was to be seen primarily as a means of transferring oil wealth produced mainly in the Niger Delta to other less endowed parts of the country, which controlled political power”.
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THE EMERGENCE OF ETHNIC NATIONALISM
The struggle for ethnic dominance in Nigeria, which is often times referred to as ethnic nationalism, has been justifiably linked to the formation of pan–ethnic unions from the 1920s.
Evidently, these movements were founded as cultural and welfare associations of a sort, they were rapidly transformed and eventually assumed a political character when party politics emerged in Nigeria. Characteristically, the Jam’iyyar Mutanen Arewa founded in 1949 transformed into the Northern People’s Congress (NPC) in 1951, and the Egbe Omo Oduduwa or Descendants of Oduduwa, formed in 1945, undoubtedly constituted the nucleus of the Action
Group (AG). Following this pattern, when the National Council of Nigeria and the Cameroons
(NCNC) was inaugurated in 1944, the Igbo Union in Lagos became the party’s main source of support. Remarkably each of these parties had national colouration and objectives in varying degrees, it was obvious that the interest of the major or dominant ethnic groups remained inherent and paramount.
This scenario of the growth of ethnic politics expectedly became a source of anxiety to the minority groups. As if this was not enough, “the 1954 constitution which established regionalism in Nigeria and gave residual powers to the regions intensified this anxiety and suspicion. For, under the new structure, the minorities were virtually left at the mercy of the regional governments, which were dominated by the major ethnic groups in each region”
(Naanen, 2011:6).
In line with the prevailing atmosphere and driven by the passion for ethnic nationalism in the Niger Delta, there emerged the formation of an Ijo Rivers Peoples’ League in Port
Harcourt in 1941. The cardinal objective of this group was the removal of Ijaw territory from
Owerri province as a response to the emerging pattern of domination. Pressure for the creation of a Rivers Province was mounted by the League and also by the Ijaw State Union formed within the same period in Lagos through the Rt. Rev. E. T. Dimiari, a member of the Legislative
63 council in Lagos from 1944-1946. Eventually, in 1947 the League sent a delegation to the Chief
Secretary to the Colonial Government in Lagos to press for the creation of Rivers Province.
Given this scenario, during the same time similar agitations were also going on among the non–Ijaw Rivers People such as the Ogoni, the Ekpeye, the Etche and the Abua. These agitations climaxed in a petition addressed to the Governor-in-Council of Owerri and Calabar provinces and signed by the representatives of the ethnic communities in the proposed Rivers
Province. Harold Dappa Biriye (1995) cited by Ogali (2005:150) asserts that:
As a result of these pressures, the Governor of Nigeria, Sir Arthur Richards, toured the old Owerri Province visiting some of the places proposed for the Rivers Province in 1947. Subsequently, the Rivers Province was constituted with Headquarters at Port Harcourt with effect from April 1947, sending the headquarters of Owerri Province to Umuahia. The first residence of the Province was Mr. Chubb who could from then make his representation to the Legislative Council in Lagos for attention of the maritime and amphibious problems of the new Province. This was the first capital success achieved by the League and its assessors. It is imperative to note that the Rivers Province comprised of Ahoada, Brass, Degema and Ogoni and Headquarters in Port Harcourt. This ethnic nationalism in the Niger Delta culminating in the creating of a Rivers Province undoubtably could be seen as the fore-runner to the subsequent state movements in the Niger Delta. As with most human endeavours, the victory and the accompanying euphoria of the creation of a Rivers Province were only momentary. This was a function of the fact that “The grievances of Rivers People did not end with the creation of Rivers Province, for effective power still lay with regional governments.
The idea of a separate state for Rivers State then began to crystallize” ( Naanen 2011:7).
ISSUES IN THE QUEST FOR STATE DEMANDS
The minorities’ sense of neglect and insecurity was intensified with the establishment of regional governments and their exercise of control by political parties which ipso facto identified themselves closely with the aspirations of the dominant ethnic groups in each region.
Thus, it was felt by Rivers People that they were subordinated in the existing political and
64 constitutional order which ultimately translated into their economic and social neglect of the
Rivers territory. It was their position that neither the federal nor Eastern Regional Government controlled by the NCNC could adequately recognize the development needs of the Niger Delta.
Instances of discrimination against Rivers people in political appointments, awards of scholarships, provision of amenities, and the siting of development projects, were enumerated.
Further, Rivers people complained of the indignities and prejudices to which they were subjected by their more numerically higher neighbours. The dominant ethnic group was accused of practicing internal colonialism through migration and domination of their host communities.
The situation, rightly or wrong was blamed on the existing political and constitutional structure.
In spite of the pervasive feeling of the need to agitate for a state, the agitation for a separate state was undertaken by more than one group or movement. The movements did not spring up simultaneously nor did they all start as separate movements. Some were off shoots of the central movement. These movements can be grouped into three. The first was the central movement led by Harold J. R. Wilcox, later Chief Harold Dappa–Birinye. The second was led by agitators for a COR (Cross River, Ogoja and Rivers) State. These two movements adopted a peaceful constitutional approach featuring petitions, memoranda, lobbying and rallies. The third movement, which was led by Isaac Boro, adopted revolutionary approach”. ( Naanen 2011:8).
Within the Rivers Province, the idea of a separate state was given impetus with the formation of the Council of Rivers Chiefs in 1953. Given this, the chairman of the council, who did attended the 1953 constitutional conference in London on behalf of Rivers people, was mandated to formally present the demand to British Colonial Secretary in the same year.
Subsequently, the congress was renamed Rivers Chiefs and Peoples Conference with Chief
Francis O. Alagoa, Mingi X of Nembe as Chairman. The compositions were recognized Chiefs, members of House or Representatives and House of Assembly, County council members and officials of recognized ethnic unions. In a characteristic candour, the conference voted for a separate state at a mass meeting on 4 July 1956. It was anticipated that the proposed Rivers State 65 would comprise the Rivers province with Opobo town, Andoni and Ndoki in the Eastern Region as well as Western Ijaw in the Western Region. Characteristics of human beings the inclusion of
Western Ijaw was opposed by some parties to the conference on the ground that it would make the Ijaw dominant, and this will defeat the essence of the state struggle. This gained prominence among the non–Ijaw groups such that the prevention of an Ijaw majority in the proposed state became as important to them as the struggle for the state itself. “It should be emphasized that the
Rivers State which the conference advocated was supposed to be an autonomous one reflecting the spirit of self–determination that inspired the state movement. It was not supposed to be a mere administrative entity in a more or less centralized polity which successive military regimes tended to make Nigeria and still survives in certain important respects to this day” ( Naanen,
2011:9).
The conference at this point took two major decisions. These include asking for a commission of inquiry by the British Government into the fears of the minorities and how to allay those fears and the formation of a political party. This eventually gave birth to the Willink
Commission and the Niger Delta Congress. In the 1959 general elections, the party won a lone seat–the Brass Federal Constituency and was represented by the late Chief Melford Okilo. An important achievement by the party was the prevention of the abrogation of the Niger Delta
Development Board (NDDB) and Special Status at the 1963 Republican constitutional conference.
As will be expected, resistance to the creation of Rivers State was enormous. And one of
“the greatest obstacle to the creation of Rivers State was the Eastern regional Government. The government took exception to its perception that the state like the other state proposal in the
East–the COR state–were based on the anti–Igbo sentiment” (Naanen, 2001:9). However, in
1966 the Rivers State agitation took another turn when a Rivers State memorandum was presented to the Head of state, Lt Colonel Yakubu Gowon by the Rivers State Leaders of thought urging the creation of Rivers State by decree. This document was signed by the
66 following. Barrister S.N. Dikibo (Chairman), E.N. Kobani representing Ogoni Division, Dr.
TJM Fiberesima (Degema Division), Barrister RPG Okara (Brass Division) Mr. GBC Otoko
(Opobo Division) and Barrister N. Nwanodi (Ahoada and Port Harcourt Division)
THE RADICAL APPROACH
This was led by Isaac Boro. The vision of Boro consisted of a Niger Delta State comprising mainly the Ijaw. His conviction for this approach was based on the perceived daunting difficulties associated with the constitutional approach and for him revolutionary violence was therefore the most potent weapon for achieving his objectives. Following Nigeria’s first military coup of January 1966, Boro shortly afterwards recruited some youths totaling about 150, trained and called them Niger Delta Volunteer Service (DVS). And under his command, the Delta Volunteer Force (DVS) lunched a guerrilla campaign from its base on
River Nun in Yenagoa province. He followed this with the declaration of a Niger Delta
Republic. It should be noted that this revolution lasted for about 12 days before it was crushed by the Nigerian Army. Subsequently, Boro and two of his lieutenants- Sam Owonaro and
Nothingham Dick– were tried and convicted of treason and sentenced to death. But they were pardoned and released by Gowon. Boro there after joined the Nigerian army and died in action near Bodo in Ogoni Division in 1969. His radical approach underlined the passion of Rivers
People for a separate and distinct state of their own.
THE CREATION AND BIRTH OF RIVERS STATE
Following persistent agitations from a broad segment of the society, Lt Colonel Yakubu
Gowon, the Head of State in an important nation–wide broadcast on 27 May 1967 through
Decree No. 19 of 1967, decreed a twelve state structure for the country out of the existing four regions. This was a milestone in the restructuring of the Nigerian federation. Rivers State was one of the twelve states decreed into existence from then. Others included: North–West, North–
Central, South East, Kano, Benue, Kwara, Mid-Western, East-Central, South-Eastern, Lagos
67 and Plateau States. Rivers State upon creation comprised of the former Ahoada, Brass, Degema,
Ogoni and Port Harcourt Divisions.
It is noteworthy to observe that state creation as undertaken by Gowon at the time was done primarily to solve two national challenges. First, to allay the fear of domination by any group or region and the political crisis which was as a result of the 1966 coup? Second, to discourage the secession of Eastern Nigeria by way of Republic of Biafra under the leadership of Lt Col Chukwuemeka Odumegwu Ojukwu. Several decades after this major restructuring of the Nigerian Federation through the instrumentality of States creation, the demand for more states in the country remain unabated. It is in fact gaining more popularity as it is seen more now as an instrument to share oil revenues and transfer of oil wealth from the Niger Delta, to other less endowed part of the country.
Currently, Rivers State is located in the South-South geo-political zone of the country.
Using the 2006 National Housing and Population Census, her population was 5,185,400; although it is projected to be 5,666,226 by 2010. Administratively, it is divided into twenty three
(23) administrative units called Local Government Areas (LGAs).
These are highlighted below:
68
S/NO NAME OF LGA CENSUS 2006 ADMINISTRATIVE . POPULATION CAPITAL
1 Abua/Odual 282,988 Abua
2. Ahoada East 166,747 Ahoada
3. Ahoada West 249,425 Akinima
4. Akuku Toru 156.006 Abonnema
5. Andoni 211,009 Ngo
6. Asari Toru 220.100 Buguma
7. Bonny 215.358 Bonny
8. Degema 249.773 Degema
9. Eleme 190,884 Ogale,
10. Emohua 201.901 Emohua
11. Etche 249,454 Okehi
12. Gokana 228,828 Kpor
13. Ikwerre 189,726 Isiokpo
14. Khana 294,217 Bori
15. Obio/Akpor 464,789 Rumuodomaya
16. Ogba/Egbema/Ndoni 284,010 Omoku
17 Ogu/Bulo 74,683 Ogu
18 Okrika 222,026 Okrika
19 Omuma 100,366 Eberi
20 Opobo/Nkoro 151,511 Opobo Town 21 Oyigbo 122,687 Afam
22 Port Harcourt City 541,115 PortHarcourt
23 Tai 117,797 Saakpenwa
Since its creation in May 1967, there has been a turn over of Administrators and Governors. The lists of the Administrators as well as the Governors are itemized below:
69
NAME TITTLE ASSUMPTION END OF TENURE PARTY
Alfred Diete Spiff Governor 28 May 1967 July 1975 Military
Zamani Lekwot Governor July 1975 July 1978 Military
Suleiman Saidu Governor July 1978 October 1979 Military
Melford Obiene Okilo Governor October 1979 December 1983 NPN
Fidelis Oyhakilome Governor January 1984 26 August 1986 Military
Anthony Ukpo Governor 28 August 1986 July 1988 Military
Ernest O. Adeleye Governor July 1988 July 1990 Military
Godwin Osagie Abbe Governor August 1990 January 1992 Military
Rufus Ada-George Governor January 1992 November 1993 NRC
Dauda Musa Komo Administrator 9 December 1993 22 August 1996 Military
Musa Shehu Administrator 22 August 1996 22 August 1998 Military
Sam Ewang Administrator August 1998 May 1999 Military
Peter Odili Governor 29 May 1999 29 May 2007 PDP
Celestine Omehia Governor 29 May 2007 26 October 2007 PDP
Rotimi Amaechi Governor 26 October 2007 29 May 2015 PDP/APC
70
4.3 THE ECONOMY AND BUDGETARY ALLOCATIONS TO HEALTH SERVICES IN
RIVERS STATE.
Igwe (2007:130) contends that an economy is “the system of production and production
relations peculiar to a society, characterized in each epoch by identifiable means and modes of
production, the basis or foundation upon which rests the superstructure/organized life”.
Accordingly, Wikipedia (The free Encyclopedia) opines that “a given economy is the result of a
process that involves its technological evolution, history and social organization, as well as its
geography, natural resource endowment, and ecology, as main factors. These factors give
context, content and set the conditions and parameters in which an economy functions”. What is
deducible is that an economy conceptualizes activities related to the production and distribution
of goods and services and its utilization in a particular geographic region.
However, our main concern in the use of the concept in this study is to briefly describe
the nature of the economy of Rivers State and to highlight the resource/budgetary allocations to
health services for the period, as much as possible. This will be done against the back drop of
the standard recommended by the World Health Organization (WHO).
Farming and fishing are the dominant economic activities that are engaged by the people
of Rivers State. Okowa (2002:417) asserts that “the majority of Rivers people are farmers and
fishermen. Those who live in the upland part of the state are predominantly farmers while those
who live in the riverine are mostly fishermen. Those in the central part of the state combine
farming and fishing. Other traditional occupations of Rivers people are canoe-carving,
carpentry, palm-cutting as well as various other craftworks. Trading is another important
occupation of the people. Indeed, the exchange of fish for food items between the farming and
fishing communities through trade has been a key link between the various Rivers people,
resulting in a measure of harmony among their diverse cultures”
71
However, it must be noted that with the emergence of industries and the introduction of modern day manufacturing and commercial businesses that are mainly located in the capital city of Port Harcourt, some of the people have found employment opportunities in these current form of production. “ In summary, the production structure of the economy of Rivers State is about the same as that of the rest of the country, with agriculture, industry and services being the main employers of labour” (Okowa, 2002: 417). The oil industry that is largely located in the state has had both negative and positive impacts on the economy of Rivers State and by implication the economy of the people. The main reason for this is that although, the oil industry is located in the territory of the state, it is ultimately controlled by the Federal Government. The income generated by it, as well as the revenues accruing from the industry largely go to the Federal
Government.
The nature of the income distribution pattern is similar to that which is obtainable in the rest of the country. There is rural-urban income divide that appears to be widening over time, with the associated urban-biased resource allocation pattern of succeeding governments. There is also the obviously widening intra-urban income divide perhaps most pronounced in the city of
Port Harcourt as between the Government Residential Area (GRA) residents and the waterside dwellers. Indeed, the two aspects of the matter are inter-related. The rural-urban income gap drives rural inhabitants into the urban centre (i.e. Port Harcourt) as government tries to improve socio-economic infrastructure in Port Harcourt to cope with the deluge of rural-urban immigrants, it increasingly drives the rural-urban problem thereby encouraging more rural dwellers to move into Port Harcourt. As it is the youths that mostly migrate from the rural areas to the urban, the process of such migration increasingly depletes the rural agricultural labour force and exacerbates the resulting economic dislocation. Agriculture continues to suffer, piling inflationary pressures on the economy”.
For Semenitari (2011:2) “Rivers State, created on the 27 of May 1967, is easily the second largest economy in Nigeria. With a total GDP in US dollars in excess of $21.1bn, it is 72 believed to be larger than most national GDP’s in the African continent. The state has two major refineries, two major seaports, airports and industrial estate in the state capital”. Rivers state has a huge economy; bigger indeed than those of many African countries. Rivers state economy, ranking among the best two performing state economies in the Federation, has the potential to grow even bigger. In terms of population, Rivers state is 6th in Nigeria and higher than 131 countries in the world but there is a paradox which has continued to remain a challenge, the high level of contribution to the country’s GDP and foreign earnings is not reflected in the domestic economy”.
The implication of this gap in the high level of contribution to the country’s GDP and foreign earnings that is not reflected in the domestic economy is that the state seems to be operating two parallel economies as the oil and gas sector is yet to be linked to the domestic economy. It is obvious that this will not augur well for the economy of the state as it may not enhance that optimal development of the local (domestic) economy.
73
BUDGETARY ALLOCATION TO HEALTH SERVICES IN RIVERS
STATE, 2004 - 2010.
EXPENDITURE
HEAD: 419: MINISTRY OF HEALTH 2004
Sub head Actual Detail of PROVISION expenditure expenditure Up to June 2003 PERSONNEL OVERHEAD TOTAL COSTS COST 2004 2003 2004 2003 2004 2003 Ministry of N N N N N N health 584,965,357 477,656,678 58,037,122 51,404,577 643,002,479 529,061,255 TOTAL 584,965,357 477,656,678 58,037,122 51,404,577 643,002,479 529,061,255
Source: Rivers State Ministry of Budget and Economic Planning
Appropriation Law.
74
EXPENDITURE
HEAD: 419: MINISTRY OF HEALTH 2004
PROVISION Actual expenditure Up to June, 2003 CLASSIFICATION, CODE AND TYPE Grade No of 2004 No of 2003 level Staff Staff N N STAFF AND PERSONNEL COSTS 1 - - 2 106,912 SUMMARY 2 -1 - 4 432,576 3 - - 29 2,246,340 4 42 3,580,416 70 5,967,360 5 50 4,893,000 55 5,382,300 6 77 9,231,684 20 2,397,840 Total for 01-06 169 17,705,100 180 16,520,328 7 39 5,933,772 61 9,281,828 8 64 12,426,240 38 7,378,080 9 34 7,805,856 96 22,040,064 10 109 28,828,756 63 16,662,992 11 - - - - 12 70 22,005,480 80 25,149,120 Total for 07-12 316 77,000,104 338 80,512,084 13 74 25,575,288 86 29,722,632 14 158 59,923,080 55 20,859,300 15 44 18,476,304 73 30,653,868 16 20 9,515,760 31 14,749,428 17 9 4,799,944 10 5,333,160 Total for 13-17 309 11,490,432 255 101,318,388 Total 01-17 790 212,995,580 929 252,735,250 Commissioner/Permanent Secretary 3 1,601,522 3 1,655,011 Sub total 793 214,597,102 939 200,028,511 Less 15% due to Probable Over estimation 32,189,565 30,004,277 Allowance I 363,904,984 278,191,884 Sub Total 182,407,537 170,024,234 Allowances II (House Officer, S/ST Nurse) 36,652,836 29,440,560 Grand Total (Staff and Personnel Costs) 793 584,965,357 932 477,656,678
Source: Rivers State Appropriation law, 2004
75
Expenditure
Head: 419: Ministry of Health 2004
Sub Detail of Expenditure PROVISION Actual expenditure Head Up to June, 2003
2004 2003
Overhead costs N N N
2 Staff Leave Bonus 18,240,753 17,002,423 -
2a Travel and Transport 5,929,579 4,500,000 443,500
3 Utility Services 1,000,000 350,000 30,000
4 Telephone Services 1,000,000 600,000 191,500
5 Stationery 800,000 1,500,000 3,374,100
6 Maintenance of furniture and equipment 1,912,790 200,000 1,304,341
7 Maintenance of Vehicles & Capital 3,854,000 5,000,000 1,307,404 Assets 8 5,000,000 - - Consultancy Services 9 - 1,600,000 - Grants, Contributions and Subventions 10 2,000,000 2,000,000 171,000 Training and Staff Development 11 2,000,000 152,154 359,400 Entertainment and Hospitality 12 250,000 16,350,000 4,920,034 Miscellaneous Expenses 12A - - 2,126,900 Miscellaneous Expenses 13 - - - Contributions to International Organization
TOTAL 58,037,122 51,404,577 2,614,415,68
Source: Rivers State Appropriation Law, 2004.
76
2004 BREAKDOWN OF SUB-HEAD 12 (MISCEL. EXPENSES)
A Public Health Service 1,200,000 B PRIMARY HEALTH CARE B Primary Health 4,500,000 13 Planned Parenthood Federation 500,000 of Nigeria (PPFN) C Nursing Services 2,220,000 14 Day of the African child 200,000 D Planning, Research and statistics 2,400,000 15 No Tobacco Day 200,000 E Medical Services 5,200,000 16 Electronic Media Health 300,000 F Pharmaceutical Services 700 17 Interpersonal Channels 500,000 programme Activities G Financial and supplies 100,000 18 Safe Motherhood 300,000 Total 16, 350,000 19 World population day 500,000 Celebration 21 Breast feeding week celebration 100,000 22 Health Education in all LGAs 300,000 22 No. 1 Activities 100,000 23 Advocacy and Social 500,00 mobilization A PUBLIC HEALTH SERVICES TOTAL 3,500,000 1 Rivers State Committee on cancer 50,000 C NURSING SERVICES Activities 2 Aids Campaign 100,000 24 School of Nursing Games 250,000 3 Industrial Health programme 50,000 25 Graduation Ceremony for 500,000 School of Nursing 4 Environmental Health and Pest 100,000 26 Nursing and midwifery council 300,000 Control Activities Committee 5 Malarial and Vector Control 100,000 27 Postgraduate Nurse Training 1,000,000 Activities 6 Public Health Activities 200,000 28 Seminars, workshops and conferences 7 Sexually Transmitted Disease 50,000 TOTAL 2,250,000 Suurvellance 8 Non – Communicable disease 50,000 Surveillance 9 Inspection of private Hospitals / 100,000 Clinics 10 Maintenance of Medical Boats 200,000 programme 11 Prevention of Blindness Programme 100,000 12 Epidemic Disease Control / 100,000 Epidemiology TOTAL 1,200,000 Source: Rivers State Appropriation law, 2004.
77
BREAKDOWN OF SUB – HEAD 12 (MISCELLANEOUS EXPENSES) 2004
D PLANNING, RESEARCH E MEDICAL SERVICES
AND STATICTICS
29 Hosting of State council on 500,000 37 Health insurance Scheme 100,000
Health
30 Participation in National council 600,000 38 Refund of staff medical (MOH) 5,000,000
of Health
31 Purchase of Library Furniture 200,000 39 Conferences / Workshops / 100,000
Seminars
32 Health Management Information 100,000 TOTAL 5,200,000
System
33 Quartely Epidemiological 200,000
Reports
34 Seminars / Workshops 300,000 F PHARMACEUTICAL
SERVICES
35 Annual Health Data Providers 300,000 40 Observation of 2003 Anti – drug 100,000
and users Meeting week
36 Reports of the ministry 200,000 41 Drug Campaign in the LGAs 100,000
36A Monitoring / Evaluation of the 200,000 42 Drug manufacturing Laboratory 300,000
Ministry’s Programmes
TOTAL 16,350,000 43 Drug Information Services 100,000
44 Drug Outlet Inspection 100,000
TOTAL 700,000
G FINANCIAL AND SUPPLIES
45 Budget Preparation 100,000
TOTAL 100,000
Source: Rivers State Appropriation Law, 2004.
78
2005
CLASSIFICATION GRADE PROVISION ACTUAL CODE & TYPE LEVEL EXPENDITUR NO. OF 2005 NO. OF 2004 E UPTO JUNE STAFF STAFF 2004 Staff & Personnel Cost N N Summary 1 nil nil nil nil nil 2 nil nil nil nil nil 3 8 669,248 42 3,580,416 nil 4 33 3,038,211 50 4,893,000 nil 5 28 2,959,208 77 9,231,684 nil 6 28 3,625,524 nil Nil nil TOTAL FOR 01 – 06 97 10,292,191 169 17,705,100 Nil 7 65 10,680,735 7 5,933,772 Nil 8 42 8,725,542 64 12,426,240 nil 9 46 11,300,084 34 7,805,856 nil 10 99 28,037,889 109 28,828,756 nil 11 nil nil nil nil nil 12 90 29,707,380 70 22,005,480 nil TOTAL FOR 07 – 12 342 88,451,630 284 77,00,104 nil 13 81 29,394,522 74 25,575,288 Nil 14 117 46,592,091 158 59,923,080 nil 15 55 24,019,160 44 18,476,304 nil 16 31 15,339,389 20 9,515,706 nil 17 30 16,639,440 9 4,799,944 nil TOTAL FOR 13 – 17 314 131,984,332 305 188,290,376 nil TOTAL For 01 – 17 753 230,728,153 758 212,995,580 nil Commissioner / 3 1,663,944 3 1,601,522 Nil Permanent Secretary TOTAL 756 232,392,097 761 214,597,102 nil Less 15% due to probable 34,758,427 32,189,,565 Nil over estimation Sub – Total 197,633,670 182,407,537 nil Allowance I 330,914,879 365,904,984 Nil Allowance II (House 71,898,702 36,652,836 nil Offrs. / S. Nurses) Grand Total (Staff & 756 600,447,251 761 584,965,357 nil Personnel Costs) Source: Rivers State Appropriation Law, 2005.
79
2005
SUB DETAILS OF EXPENDITURE PROVISION ACTUAL HEAD EXPENDITURE 2005 2004 UP TO JUNE 2004 OVERHEAD COSTS N N 2 Staff leave Bonus 19,696,442 18,240,753 nil 2A rie 6,734,950 5,629579 nil 3 Travel and Transport 200,000 1,000,000 nil 4 Utility Services 200,000 1,000,000 nil 5 rie 1,300,000 800,000 nil 6 Telephone Services 1,400,000 1,912,790 nil 7 rie 3,000,000 3,854,000 nil 8 Stationery 2,000,000 5,000,000 nil 9 Maintenance of Furniture and Equipment nil nil nil 10 Maintenance of Vehicle and Capital Assets 2,000,000 2,000,000 nil 11 Consultancy Services 2,300,000 2,000,000 nil 12 Grants, Contribution and Subventions 9,000,000 16,350,000 nil 12A rie 8,000,000 250,000 nil 13 Training and staff Development Nil Nil nil rie Entertainment and Hospitality Miscellaneous Expenses rie Miscellaneous Expenses rie Contributions to international Organization TOTAL 55,831,392 58,037,122 4,249,561
Source: Rivers State Appropriation Law, 2005.
80
BREAKDOWN OF SUB – HEAD 12 (MISCELLANEOUS EXPENSES) 2005
S/NO. DETAILS OF EXPENDITURE 2005
A Public Health Services 450,000
b Primary Health Care Services 450,000
c Nursing Services 450,000
d Planning, Research and Statistics 450,000
e Medical Services 1,000,000
f Pharmaceutical Services 200,000
g Finance and Supplies Nil
TOTAL 3,000,000
PLANNING, RESEARCH AND STATISTICS
1 Hosting of State Council Health 200,000
2 Participation in Nigeria Council Health 200,000
3 Purchase of Library Furniture 200,000
4 Health Management Information Systems 100,000
5 Quarterly Epidemiological Reports 200,000
6 Seminars / Workshops 400,000
7 Annual Health Data Providers and users Meetings 300,000
8 Annual reports of the Ministry 200,000
9 Monitoring / Evaluation of the Ministry’s Programme 200,000
TOTAL 2,000,000
Source: Rivers State Appropriation Law, 2005.
81
2005
DETAILS OF PROVISION AVUAL
EXPENDITU N EXPENDITU RE RE UP TO
JUNE 2004
2005 2004 2005 2004 2005 2004 N
N N N N N N
SUMMARY
Ministry of 600,447,251 584,965,375 55,831,392 58,037,122 656,278,643 643,002,479 Nil
Health
TOTAL 600,447,251 584,965,375 55,831,392 58,037,122 656,278,643 643,002,479 nil
Source: Rivers State Approprition Law, 2005.
2006
DETAILS OF PROVISION ACTUAL
EXPENDITURE EXPENDITURE PERSONNEL COST OVERHEAD TOTAL UP TO JUNE 2006 2005 2006 2005 2006 2005 2005 N N N N N N N
SUMMARY
Ministry of Health
717,416,461 600,447,251 65,279,096 55,831,392 782,695,557 656,278,643 Nil
TOTAL 717,416,461 600,447,251 65,279,096 55,831,392 782,695,557 656,278,643 Nil
Source: Rivers State Appropriation Law, 2006.
82
2006
Classification code & type Grade Provision Actual Expenditure Level No. of 2006 No. of 2005 up to 2005 Staff staff Staff & Personnel cost Summary 1 nil nil nil nil 2 nil nil nil nil 3 10 1,020,610 8 669,248 4 20 2,246,440 33 3,038,211 5 32 4,126,080 28 2,959,208 6 60 9,478,140 28 3,625,524 TOTAL FOR 01 – 06 122 16,871,270 97 10,292,191 7 22 4,410,340 65 10,680,735 8 50 12,672,800 42 8,725,542 9 36 10,789,128 46 11,300,084 10 83 28,677,994 99 28,037,889 11 nil nil nil nil 12 74 29,799,800 90 29,707,380 TOTAL FOR 07 – 12 265 86,350,062 342 88,451,630 13 72 31,876,416 81 29,394,522 14 93 45,182,376 117 46,592,091 15 144 76,721,616 55 24,019,160 16 45 27,165,553 31 15,339,389 17 30 20,300,130 30 16,636,440 TOTAL FOR 13 – 17 384 201,246,093 314 131,984,602 TOTAL FOR 01 – 17 771 304,467,014 756 1,663,944 Commissioner / Permanent 3 2,030,014 3 232,392,367 Secretary TOTAL 774 306,497,439 756 232.392,367 Less 15% due to probable Nil 45,974,616 nil 34,758,427 over estimate SUB – TOTAL 774 260,522,823 756 197,633,940 ALLOWANCES Nil 378,194,932 nil 330,914,609 Allowances (House Offrs. / Nil 78,698,706 nil 71,898,702 S. Nurses) Grand Total (Staff & 774 717,416,461 756 600,447,251 Personnel Costs) Source: Rivers state Appropriation Law, 2006.
83
2006
SUB DETAILS OF EXPENDITURE PROVISION ACTUAL
HEAD EXPENDITU
2006 2005 RE UP TO
N N JUNE 2005
N
OVER HEAD COSTS
2 Staff Leave Bonus 26,052,282 19,686,442
2A rie 8,526,814 6,734,950
3 Travel and Transport 200,000 200,000
4 Utility Services 200,000 200,000
5 rie 1,500,000 1,300,000
6 Telephone Services 1,500,000 1,400,000
7 rie 3,500,000 3,000,000
8 Stationery 2,000,000 2,000,000
9 Maintenance of Furniture and Equipment Nil Nil
10 Maintenance of Vehicle & Capital Assets 2,500,000 2,000,000
11 Consultancy Services 2,300,000 2,300,000
12 rie 9,000,000 9,000,000
12A Grants, Contributions and Subvention 8,000,000 8,000,000
13 rie Nil Nil
Staff Training and Development
Entertainment and Hospitality
Miscellaneous Expenses
rie
Miscellaneous Expenses
Contribution to International Organization
TOTAL: 65,279,096 55,831,392
84
BREAKING – DOWN OF SUB – HEAD 12A 2006 2005
(MISCELLANEOUS EXPENSES) N N
DETAILS OF EXPENDITURE
1 Public Health Services 1,000,000 450,000
2 Primary Health Care Services 2,000,000 450,000
3 Nursery Services 500,000 450,000
4 Planning, Research and Statistics 2,000,000 450,000
5 Medical Services 2,000,000 6,000,000
6 Pharmaceutical Services 500,000 200,000
7 Finance and Supplies NIL NIL
TOTAL: 8,000,000 8,000,000
Source: Rivers State Appropriation Law, 2006.
85
2006
BREAK – DOWN OF SUB – HEAD 12A 2006 2005 (MISCELLANEOUS EXPENSES) N N DETAILS OF EXPENDITURE PLANNING, RESEARCH AND STATISTICS
1 Hosting of State Council Health 1,000,000 1,200,000 2 Participation in National Council Health 1,000,000 1,200,000 3 Purchase of Library Furniture 1,000,000 1,200,000 4 Health Management Information Systems 1,000,000 1,100,000 5 Quarterly Epidemiological Reports 1,000,000 1,200,000 6 Seminars / Workshops Nil 1,400,000 7 Annual Health Data Providers and users Meetings 1,000,000 1,300,000 8 Annual Reports and the Ministry 2,000,000 200,000 9 Monitoring / Evaluation of the Ministry’s Programme 1,000,000 200,000 TOTAL: 9,000,000 9,000,000
2007
DETAILS OF PROVISION ACTUAL EXPENDITURE EXPENDITURE PERSONNEL COSTS OVERHEAD COSTS TOTAL UP TO JUNE, 2007 2006 2007 2006 2007 2006 2006 SUMMARY N N N N N N N Ministry of 653,770,768 717,416,461 70,776,007 65,279,095 724,546,775 782,695,557 Health Total 653,770,768 717,416,461 70,776,007 65,279,095 724,546,775 782,695,557 526,250,893.81
Source: Rivers State Approprition Law, 2007.
86
2007
CLASSIFICATION CODE GRAD PROVISION ACTUAL
AND TYPE E NO. 2007 NO. 2006 EXPENDITU LEVE OF OF RE UP TO L STAF STAF JUNE 2006 F F STAFF AND PERSONNEL COSTS N N N SUMMARY 1 - - - - - 2 - - - - - 3 4 408,245 10 1,020,610 4 27 2,853,598 20 2,246,440 5 43 5,567,784 32 4,126,080 6 37 5,844,879 60 9,478,140 TOTAL FOR 01 – 06 111 14,674,506 122 16,871,270 7 30 6,167,317 22 4,410,340 8 31 8,045,567 50 12,672,800 9 46 14,119,060 36 10,789,128 10 60 21,208,533 83 28,677,994 11 - - - - 12 64 25,772,818 74 29,799,800 TOTAL FOR 07 – 12 231 75,313,295 265 86,350,062 13 59 26,121,009 72 31,876,416 14 78 37,894,901 93 45,182,376 15 183 97,500,463 144 76,721,616 16 41 24,750,880 45 27,165,553 17 26 17,593,455 30 20,300,130 TOTAL FOR 13 – 17 387 203,860,708 384 201,246,093 TOTAL FOR 01 – 17 729 293,848,509 771 304,467,425 HON COMMISSIONER / 3 2,030,014 3 2,030,014 PERMANENT SECRETARY TOTAL 732 295,878,523 774 306,497,439 LESS 15% DUE TO PROBABLE 44,381,779 45,974,616 OVER ESTIMATION SUB TOTAL 732 251,496,744 774 260,522,823 ALLOWANCE 1 339,866,539 378,194,932 ALLOWANCE 2 (House Offrs. / S. 62,407,485 78,69,706 Nurses) TOTAL STAFF AND PERSONNE 732 653,770,768 774 717,416,461 COSTS Source: Rivers State Appropriation Law, 2007. 87
2007
SUB DETAILS OF EXPENDITURE PROVISION ACTUAL
HEAD 2007 2006 EXPENDITU
RE UP TO
JUNE, 2006
OVERHEAD COSTS N N N
2 Staff Leave Bonus Rie 25,149,674 26,052,282
2A Travel and Transport 10,000,000 8,526,814
3 Utility Services Rie 50,000 200,000
4 Telephone Services Rie 50,000 200,000
5 Stationery 3,000,000 1,500,000
6 Maintenance of Furniture and 2,500,000 1,500,000
Equipment
7 Maintenance of Vehicle and 3,438,178 3,500,00
Capital Assets
8 Consultancy Services Rie 50,000 2,000,000
9 Grants, Contribution and Rie - -
Subventions
10 Training and Staff Development 3,500,000 2,500,000
11 Entertainment and Hospitality 3,000,000 2,300,000
12 Miscellaneous Expenses Rie 9,000,000 9,000,000
12A Miscellaneous Expenses 11,038,155 8,000,000
13 Contributions to International - -
Organizations
TOTAL: 70,776,007 65,279,096
88
S/N DETAILS OF EXPENDITURE AMOUN AMOUNT
O. T 2006
2007
1 Public Health Services 2,000,000 1,000,000
2 Primary Health Care Services 2,000,000 2,000,000
3 Nursery Services 1,000,000 500,000
4 Planning, Research and Statistics 2,000,000 2,000,000
5 Medical Services 1,000,000 2,000,000
6 Pharmaceutical Services 1,000,000 500,000
7 Administration / Finance - -
TOTAL 9,000,000 8,000,000
Source: Rivers State Appropriation Law, 2007.
89
2007
S/NO DETAILS OF EXPENDITURE AMOUNT AMOUNT
2007 2006
BREAKDOWN OF SUB – HEAD 12A (MISCELL. N N
EXPENDITURE
1 Training / Workshop (Primary Health Care) 2,250,000 1,000,000
2 Training / Workshop (Public Health Care) 2,150,000 1,000,000
3 Training /Working / Conferences (Medical) 1,000,000 1,000,000
4 Training / Workshop (Administration) 1,000,000 1,000,000
5 Post Graduate Nurse training 2,000,000 1,000,000
6 Seminars / Workshop (PRS) 1,268,155 -
7 Death Benefits 200,000 -
8 Uniforms 200,000 1,000,000
9 Budget preparation 230,000 2,000,000
10 Upkeep of Library and Purchase of Book / Journals (PRS) 240,000 1,000,000
11 Postal Services 50,000 -
12 Department Section Board 250,000 -
13 IT Allowances 50,000 -
14 Toiletries 150,000 -
TOTAL: 11,038,155 9,000,000
Source: Rivers State Appropriation Law, 2007.
90
2008
Sub Detalised of Expenditure Cost / Plan Appropriatio Appropriation Head Allocation n 2009 2008 – 2010 2008 N N N 1 Construction / Upgrading / Renovation of new / Existing Hospitals a) Braithwaite Memorial Hospital Preventive 300,000,000 100,000,000 240,000,000 Maintenance and cleaning b) Construction / provision of Equipment for 2 7,500,000,000 2,500,000,000 new General Hospital at N1,25b each c) upgrading and Conversion of Okirika 1,500,000,000 500,000,000 - General Hospital to a Burns Specialist Hospital d) Upgrading of General Hospital Isokpo to a 900,000,000 300,000,000 - Traumu Centre e) Construction of Mega Hospital 3,000,000,000 - - f) Reconstruction / Equipment of Rivers State 900,000,000 300,000,000 - Pharmaceutical Manufacturing Laboratory g) Mini Lab Rehabilitation for public Health 1,500,000 500,000 - h) Central Medical Stores 150,000,000 50,000,000 - i) Hospitals / Equipment 2,100,000,000 700,000,000 - j) Construction / Equipment of new Public 900,000,000 300,000,000 - Health Laboratory 2 Medical Equipment (Other Hospitals/ Health Centres) 750,000,000 250,000,000 - 3 College of Health Science and Technology 150,000,000 50,000,000 - a) School of Health Technology Library 150,000,000 50,000,000 50,000,000 b) School of Health Technology, Hospital 1,800,000,000 600,000,000 50,000,000 Building c) School of Nursing 75,000,000 25,000,000 25,000,000 d) School of Midwifery 120,000,000 40,000,000 - e) School of Public Health 60,000,000 20,000,000 - 4 State of HIV/AIDS 240,000,000 80,000,000 80,000,000 5 Free Medical Care Programme 1,5000,000,000 500,000,000 500,000,000 6 Tuberculosis / Leprosy Control Activities 60,000,000 20,000,000 20,000,000 Sub Total 19,156,500,000 6,385,500,000 725,000,000
Source: Rivers State Appropriation Law, 2008. 91
2008
Sub Detailed of Expenditure Cost / Plan Appropriatio Appropriatio
Head Allocation n 2008 n 2007
2008 – 2010
N N N
19,156,500,000 6,385,500,000 725,000,000
7 Roll Black Malaria (Free Malaria Treatment) 1,500,000,000 500,000,000
8 National Programme on Immunization (NPI) 300,000,000 100,000,000 75,000,000
9 Disease Survellance and Control 150,000,000 50,000,000 -
10 Avian Influenza Control (Human Component) 45,000,000 15,000,000 -
11 Counterpart Contribution for Assisted Programme
(a) UNICEF 60,000,000 20,000,000 20,000,000
(b) HSDP – II 360,000,000 120,000,000 20,000,000
(c) UNFPA 60,000,000 20,000,000 20,000,000
(d) GLRA 60,000,000 20,000,000 20,000,000
12 Task Force on Health Establishment regulation 30,000,000 10,000,000 10,000,000
Rivers State Primary Health Care Managementy
13 Agency 90,000,000 30,000,000 30,000,000
14 Emergency Medical Services (EMS) Air / Marine / Road
Ambulances 600,000,000 200,000,000 200,000,000
15 In – Services Training (Medical / Dental Doctors and
other Health Personnel) 300,000,000 100,000,000 50,000,000
16 Post Graduate Training Programme (BMH 150,000,000 50,000,000 50,000,000
17 Task Force on Fake Drug / Food 30,000,000 10,000,000 10,000,000
18 Construction of Staff Quarters in 10 General Hospitals at
N100,000,000 each 3,000,000,000 1,000,000,000 -
19 Construction of 4 – Storey Building (BMH) 1,500,000,000 500,000,000 -
20 State Health Insurance Scheme 2,951,250,000 983,750,000 800,000,000
21 Grants to Health Partners e.g. Red Cross PPFN 30,000,000 10,000,000 10,000,000
22 Emergency relief and Natural Disasters 90,000,000 30,000,000 -
23 Strengthening of Rural Hospitals - - -
24 Accreditation of Hospitals for Intensive Trainings - - -
92
25 Public Enlightenment / Press Activities of the Ministry 30,000,000 10,000,000 -
26 Allowances for Committees (TACH), etc. 150,000,000 50,000,000 -
27 Seminars / Conference / National Council on Health /
State Council on Health 150,000,000 50,000,000 -
28 Rebuilding of 4 Primary Health Care Centers at
250,000,000 1,500,000,000 500,000,000 -
29 Convention of Dental Hospital, PH to inpatient Facility 900,000,000 300,000,000 -
WCFHS – Women and Children Friendly Health
30 Services / Initiatives and Others 60,000,000 20,000,000 -
Overseas Medical Assistance (Grants) 1,800,000,000 600,000,000 -
31 Inspection and Standardization of Government and
32 Private Health Institution 15,000,000 5,000,000 -
Onchology Unit 1st Phase 2,700,000,000 900,000,000 -
33 Construction Niger Hospital 2,100,000,000 700,000,000 -
34 Specialist Manpower Development Programme 1,800,000,000 600,000,000 -
35 Specialist Heart Centre 1,500,000,000 500,000,000 -
36 Building 20Bed cottage Hospital with Doctors quarters
37 in Obu – ama (Constituency Project with Generator Set
and House)
300,000,000 100,000,000
Total 43,467,750,000 2,040,000,000
Source: Rivers State Appropriation Law, 2008.
93
2009
DETAILS OF PROVISION ACTUAL
EXPENDITUR EXPENDITU E RE UP TO
JUNE 2008
PERSONNEL COSTS OVERHEAD COSTS TOTAL
2009 2008 2009 2008 2009 2008 2008
SUMMARY N N N N N N N
Ministry of 1,838,883,725 917,752,313 45,373,828 76,929,183 1,884,257,553 994,681,496
Health
TOTAL 1,838,883,725 917,752,313 45,373,828 76,929,183 1,884,257,553 994,681,496
CLASSIFICATION GRADE PROVISION ACTUAL
CODE AND TYPE LEVEL NO. 2009 NO. 2008 EXPENDITU RE UP TO OF OF JUNE 2008 STAFF STAFF STAFF AND N - N N PERSONNE COSTS 01 - - - - 02 - - - - 03 2 251,059 - - SUMMARY 04 9 1,243,337 7 904,197 05 58 9,198,068 68 10,083,108 06 48 9,325,960 85 15,441,525 TOTAL FOR 01 – 06 117 20,018,424 160 26,428,830 07 32 8,091,022 34 7,838,360 08 19 6,064,950 19 17,197,025 09 61 23,027,997 61 22,402,510 10 57 24,780,708 57 18,675,262 11 - - - - 12 50 24,764,560 50 29,175,615 TOTAL FOR 07 – 12 219 86,729,237 268 95,288,772 13 57 31,037,835 57 29,020,866 14 63 37,644,827 43 24,024,358 15 185 121,228,84 166 101,709,528 16 77 57,171,034 104 72,200,128
94
17 48 39,948,240 26 20,232,472 TOTAL FOR 13 – 17 430 287,030,776 396 247,187,352 TOTAL FOR 01 – 17 766 393,778,437 824 368,904,954 LESS 15% DUE TO PROB. OVER 59,066,765 55,335,743 ESTIMAT. SUB TOTAL 766 334,711,672 3 313,569,211 HON. COMMISSIONER / PERM 2 12,585,095 3,832,965 SECRETARY TOTAL 768 347,296,767 827 317,402,175 ALLOWANCES I 1,274,629,451 486,637,404 ALLOWANCES II (HOUSE OFFRS. / S. NURSES) 216,957,507 113,712,733 TOTAL STAFF AND PERSONNEL 768 1,838,883,725 827 917,752,313 COSTS
Source: Rivers State Appropriation Law, 2009.
2009
SUB DETAILS OF EXPENDITURE PROVISION ACTUAL HEAD EXPENDIT 2009 2008 URE UP TO JUNE, 2008 OVERHEAD COSTS N N N 2 Staff Leaves Bonus rie 31,555,355 2A Travel and Transport 11,000,000 11,000,000 3 Utility Services 50,000 50,000, 4 Telephone Services rie 50,000 50,000 5 Stationary 3,500,000 3,500,000 6 Maintenance of Furniture and 2,523,828 2,523,828 7 Equipment 3,500,000 3,500,000 8 Maintenance of vehicle and capital rie 50,000 50,000 9 Assets - - 10 Consultancy Services rie 4,2000,000 4,200,000 11 Grants, Contribution, Subventions 3,500,000 3,500,000 12 Staff Training and Development rie 5,000,000 5,000,000 12A Entertainment and Hospitality 12,000,000 12,000,000
95
13 Miscellaneous Expenses rie - - Miscellaneous Expenses Contribution to International Organist
TOTAL: 45,373828 76,929,183
Source: Rivers State Appropriation Law, 2009.
96
2010
DETAILS OF PROVISION ACTUAL EXPENDITURE EXPENDITURE PERSONNEL COSTS OVERHEAD TOTAL UP TO JUNE, COSTS 2009
2010 2009 2010 2009 2010 2009 2009
N N N N N N N
SUMMARY
Ministry of 1,976,000,710 1,838,883,725 45,373,828 45,373,828 2,021,374,538 1,884,257,553
Health
Total 1,976,000,710 1,838,883,725 45,373,828 45,373,828 2,021,374,538 1,884,257,553
CLASSIFICATION GRADE PROVISION ACTUAL CODE AND TYPE LEVEL EXPENDITU NO. OF 2010 NO. OF 2009 RE UP TO STAFF STAFF JUNE, 2009
STAFF AND N - N N
PERSONNEL COSTS
01 - - - -
02 - - - -
03 - - 2 251,059
04 26 3,591,863 9 1,243,337
05 21 3,330,334 58 9,198,068
06 35 6,800,179 48 9,325,960
TOTAL FOR 01 – 06 82 13,722,276 117 20,018,424
07 30 7,585,333 32 8,091,022
08 307 231,706,456 19 6,064,950
09 132 96,842,122 61 23,027,997
10 120 89,543,676 57 24,780,708
97
11 - - - -
12 74 36,651,548 50 24,764,560
TOTAL FOR 07 – 12 663 462,329,135 219 86,729,237
13 237 417,527,102 57 31,037,835
14 34 20,316,255 63 37,644,827
15 209 136,955,825 185 121,228,840
16 74 118,074,104 77 57,171,034
17 50 41,612,749 48 39,948,840
TOTAL FOR 13 – 17 604 734,486,035 430 287,030,776
TOTAL FOR 01 – 07 1349 1,210,537,546 766 393,778,437
LESS 15% DUE TO 181,580,632 59,066,765
PROB. OVER
ESTIMATE
SUB – TOTAL 1349 1,028,956,914 766 334,711,672
HON. 2 12,585,095 2 12,585,095
COMMISSIONER/PERM
SECRETARY
TOTAL 1351 1,041,542,009 768 347,296,767
ALLOWANCES I 715,501,194 1,274,,629,451
ALLOWANCES II 218,957,507 216,957,507
(HOUSE
OFFRS./NURSES)
TOTAL STAFF AND 1351 1,976,000,710 768 1,838,883,725
PERSONNNEL COSTS
98
2010
SUB – DETAILS OF EXPENDITURE PROVISION ACTUAL
HEAD EXPENDITURE
UP TO JUNE,
2009
OVERHEAD COSTS N N N
2 Staff Leave Bonus rie
2A Travel and Transport 11,000,000 11,000,000 5,500,000.00
3 Utility Services 50,000 50,000 -
4 Telephone Services Rie 50,000 50,000 -
5 Stationery 3,500,000 3,500,000 1,750,000.00
6 Maintenance of Furniture and 2,523,828 2,523,828 1,261,914.00
Equipment
7 Maintenance of Vehicle and Capital 3,500,000 3,500,000 1,750,000,000
Assets
8 Consultancy Services rie 50,000 50,000 -
9 Grants, Contributions, Subventions - - -
10 Staff Training and Development rie 4,200,000 4,200,000 2,100,000.00
11 Entertainment and Hopitality 3,500,000 3,500,000 1,750,000.00
12 Miscellaneous Expenses rie 5,000,000 5,000,000 -
12A Miscellaneous Expenses 12,000,000 12,000,000 4,200,000.00
13 Contributions to International rie - - -
Organization
TOTAL: 45,373,828 45,373,828 18,311,914.00
Source: Rivers State Appropriation Law, 2010.
99
2010
S/NO DETAILS OF EXPENDITURE AMOUNT AMOUNT
2010 2009
BREAKDOWN OF SUBHEAD 12 (MISCEL. N
EXPENSES)
1 Public Health Service 1,000,000 1,000,000
2 Primary Health Care Services 1,000,000 1,000,000
3 Nursery Services 500,000 500,000
4 Planning, Research and Statistics 1,000,000 1,000,000
5 Medical Services 500,000 500,000
6 Pharmaceutical Services 500,000 500,000
7 Administration / Finance 500,000 500,000
TOTAL: 5,000,000 5,000,000
S/NO DETAILS OF EXPENDITURE AMOUNT AMOUNT
BREAKDOWN OF SUBHEAD 12A N
(MISCEL EXPENSES)
1 Training / Workshop / Conferences 2,300,000 2,300,000
(Primary Health Care)
2 Training / Workshop / Conferences 1,300,000 1,300,000
(Public Health Care)
3 Training / Workshop / Conferences 1,000,000 1,000,000
(Pharmacy)
4 Training / Workshop / Conferences 1,300,000 1,300,000
(Medical Services)
5 Training / Workshop / Conferences 1,050,00 1,050,000
100
(Nursing Services)
6 Training / Workshop / Conferences 1,100,000 1,100,000
(Admin / Finance)
7 Post Graduate Nurse Training 600,000 600,000
(Doctors, Nurses & Other Health
Care Personnels)
8 Seminars / Workshop (PRS) 1,000,000 1,000,000
9 Budget Preparation 400,000 400,000
10 Uniforms (Nurses / Drivers) 400,000 400,000
11 Budget Preparation 277,000 277,000
12 Upkeep of Library and Purchase of 350,000 350,000
Books / Journals
13 Postal Services 73,000 73,000
14 Departmental Selection Board 500,000 500,000
15 IT Allowance 100,000 100,000
16 Toiletries 250,000 250,000
TOTAL: 12,000,000 12,000,000
Source: Rivers State Appropriation Law, 2010.
The appropriation acts of Rivers State as highlighted for the period above, evidently shows that the percentage allocated to the health services has remained very low compared to the 15% pledge by the African Heads of State in their various summits and the recommendation by World Health Organisation (WHO). Specifically, for the tuberculosis control programme, it was only in the years 2008-2010 that financial allocation was made to it. However, the issue of its release could not even be ascertained. This is an expression of the dynamics of politics, and an indication of the degree of political commitment to the programme.
101
4.4 THE POLITICAL ECONOMY CONTEXT OF HEALTH SERVICES IN RIVERS
STATE
For a long time, politics and economics were divorced from health care delivery until Navarro (1976) and other workers began to provide insight into the interplay between them. The application of the Marxian theoretical paradigm to the analysis of health care delivery, most especially in North and South America opened new vistas… Health care delivery may be analysed within the framework of a continuum that is characterized by two polar ends. At one end of the continuum is a system, which is grafted to laissez faire, and at the other is one, that is shaped by a socialist/communist ideology. In between are different stands, which may be closer to either of the two polar ends. (Erinosho, 2006:84) Political Economy as a concept has various interpretations, some situating it as a discipline while others see it as a method. Basically, it is concerned about the way a society produces, manages and distributes its wealth, among the various social groups or segments in the society. Furthermore, it focuses attention on the relationship among people in the process of production and distribution. Fundamentally, Political Economy emphasizes the relationship between politics and economic forces in the development of the society. Beyond this, Political
Economy is a combination of politics and economics in the study of the society. It provides a window to understanding the laws which govern the economic life of the society. And provide man with a scientific compass to navigate the vast and dynamic material world. This is achieved through the investigation of the economic relations existing among people, and the laws of production and distribution of material benefits.
The political economy of health services in Nigeria has its roots in the fact that Nigeria, in principle operates Federalism which delineates three tiers of governance. Succinctly put,
Nigeria, in principle practices federalism and is composed of thirty six (36) states and Federal
Capital Territory (FCT) in Abuja. The health care system in Nigeria is unequivocally structured along three levels, namely primary, secondary and tertiary corresponding to the level of government that provides oversight and is responsible for health care services, the Federal, State
102 and Local government. The public and private sectors are equally partners in the delivery of health care throughout the country.
What is discernible therefore is that health care provision in Nigeria is a concurrent responsibility of the three tiers of government in the country. However, because Nigeria operates a mixed economy, private providers of health care have a visible role to play in health care delivery. For Erinosho (2006:84)
“Health care delivery systems are not amorphous entities but shaped by the dominant ideologies, which underlie social systems. The character of a health care delivery system is to an extent determined or shaped by the ideology underlying the society. Thus health care delivery systems in their different contexts are more or less reflections of distinct ideologies, which are variously labeled as capitalism, welfarism socialism or communism”. Although, health care delivery in Nigeria is a concurrent responsibility of the three tiers of government, the autonomous status of states puts a constraint on the exercise of control by the Federal Government over States and Local Governments in term of resource allocation to the various sectors, including health services, as well as states control over local government areas.
This is the point of departure for the political economy of health services in Rivers State.
“Overall, health care delivery in Nigeria is a product of the socio-historical antecedents underlying colonialism. The colonial model is still basically intact, and the practice of medicine in the public sector remains largely bureaucratized. The bureaucratization of the practice of medicine has continued to undermine professional ethos, job satisfaction and quality care.
Furthermore, the burgeoning cosmopolitan private sector remains un-integrated into the national health care delivery” (Erinosho, 2006:94-95)
Given the autonomous status of the Federal, States and Local Government Areas in the country, in terms of exercising control over each other, the allocation of resources to the various sectors of the economy has remained at the whims and caprices of the political gladiators. This
103 has often affected the allocation of resources to the critical sectors of the economy. In this perspective, adequate financial resources are sometimes never allocated to health services and even those allocated are never released for the services or even utilized for it when released.
This is a function of the independent status of the states and local government areas and, this has manifested as corruption and mismanagement in Rivers State. “Corruption has a disastrously debilitating impact on the Nigerian Government’s ability to deliver on its legal obligations to support the progressive realization of the rights to health and education. This report focuses mainly on five local governments in Rivers State, one of Nigeria’s oil-producing states in the Niger Delta, which in recent years have experienced a financial bonanza as a result of rising oil prices. This has not been translated into investment in health or education. Instead, as this report documents, funds have been embezzled and squandered. Governance at the state level in Rivers State is plagued by many of the same problems that have crippled local governments. Corruption, however, is not a localized issue…Human Rights Watch believes that the patterns of corruption and mis–management revealed by our own field research–along with the human rights impacts of those issues–reflect a problem that exists in many other local governments in Rivers State and elsewhere in the oil–rich Niger Delta” (Human Rights Watch,
2007:10).
Suffice it to say that the lack of control or proper monitoring of the use of financial resources over states, as well as the Local government areas, as a result of their perceived autonomy has led to unbridled corruption and gross mis–management of funds. Human Rights
Watch (2007:42) contends that:
In Rivers State, corruption and gross mismanagement of government funds stand out as one of the most important reasons why many local governments have continued to neglect their obligations to provide basic education and primary health care. Corruption first leads many local governments to allocate insufficient funds to health and education, and in some cases leads even to the theft of those that are allocated.
104
The corruption and gross mis–management of funds that have shaped the political economy context of health services in Rivers State have continued unabated. National Network
(2011:7) asserts that “Governor Amaechi in his 2010 budget speech said: “In terms of population, Rivers State is 6th in the Federation and higher than 131 countries in the world. The state is by population as big as Denmark, Norway, Singapore and Ireland and bigger than
Botswana, Namibia and Liberia just to mention a few”. However National Network (2011) further contended that:
When the Governor was making this speech, he was set to launch N429b, four Hundred and Twenty nine billion Naira (almost three billion dollars) into the domestic economy. Instead of directing his budget to achieve an impact on the people and the domestic economy, he votes 7.5billion naira to security vote which is a dash to himself because he does not have to account for it. Security vote was 8 billion naira in the 2009 budget and 12 billion naira in the 2008 budget. This adds up to 27.5 billion naira pocket money for Amaechi in the three years. This money is more than the 18 billion naira budgeted for the much touted health centers in the 2010 budget. In this same 2010 budget, general Administration was 16.3 billion naira! Government house alone is responsible for 11billion of this amount, but as high as the budget for General Administration is, it pains when you consider that the Governor’s 27.5billion naira pocket money in three years is almost twice the cost of running the government in one year. What is discernable here is that more funds and resources are allocated to the political gladiators than for the social services sector which includes health. As it has been argued, a defining index in Marxist Political Economy is the determination of who benefits from the control and exercise of political power. Marxists contends that the exercise of power benefits those who control the State, a fact that is rightly attributed to the partisan nature of the State.
105
CHAPTER FIVE PROFILE OF THE NATIONAL TUBERCULOSIS CONTROL PROGRAMME
5.1 Global Context of Tuberculosis Control and its evolution
Although the isolation of tubercle bacillus, the causative bacteria of tuberculosis was made public on March 24, 1882 by Robert Koch, a Prussian Physician on the occasion of a meeting of the Physiological Society of Berlin; it was not until 1944 that effective chemotherapy
(Streptomycin) was discovered and made available in 1946 for wide use. Remarkably, it is for this reason of the first public presentation of a major breakthrough about tuberculosis that 24th
March of every year is set aside by the World Health Organization (WHO) as World
Tuberculosis (TB) day. The discovery and use of anti-tuberculosis drug activated the hope that the development of an effective weapon for the control of tuberculosis is feasible. Tuberculosis control thus became a worldwide priority.
“In 1947, the prioritization by WHO of tuberculosis control was driven by the high prevalence and wide distribution of the problem throughout the world…the first Expert
Committee of WHO met in Paris in August 1947. The tuberculosis section was then established within the World Health Organisation (WHO) Secretariat to assist governments in developing effective control programmes based on BCG vaccination and case management. Since then, case management has persisted as the central technical strategy for tuberculosis control” (Raviglione et al; 2002:775). Subsequently, there has been improvemens in the case management strategy and this is an outcome from the introduction of isoniazid in the early 1950s, which was followed by pyrazinamide as well as that of rifampicin some years later. The discovery and use of rifampicin ushered the development and introduction of short–course chemotherapy (SCC) regimens in the control of tuberculosis which drastically reduced the duration of treatment.
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As it will be expected, the managerial strategies/policies for tuberculosis control also had some structural changes along the lines of the emergence of new drugs and or developments; due to the successive doctrines that informed the management and organization of health services in the later 20th century. The evolution of WHO managerial policies for tuberculosis control and the issues involved are highlighted below. This is done with a view to establish a link between them and the emergence of national control programmes of the various nation states such as Nigeria.
THE VERTICAL PROGRAMME (1948–63)
The end of the Second World War ushered in the discovery of effective drugs against communicable diseases emerging then as being of public health importance. “After the second
World War, the discovery of effective chemotherapeutic agents against communicable diseases of public health importance (e.g Tuberculosis, Leprosy, Syphilis, Yaws) and insecticides against vectors transmitting infectious diseases (Malaria, Yellow fever, Plaque) prompted the building of vertical control programmes, also known as categorical or specialized programmes. Each of these programs established its own structure staffed with specialized personnel from a central level through to the local level in which the technical control services were delivered”.
(Raviglione., et al; 2002). This specialized machinery, that stood alone of both the general health infrastructure and the structure of other vertical programmes, was desirable because it dealt with experimental treatment methods that required, from the onset specialized services for delivery. Thus, tuberculosis (TB) programmes were developed and managed in most high income countries in line with such a vertical structure. The direct line of command originated from the central tuberculosis division or unit down to the designated hospitals, tuberculosis clinics, etc. the central authority operated through its own officers for training, supervision, logistics and health education etc.
This approach, enhanced by socio-economic development succeeded in the industrial countries through the “acceleration of the decline in the annual risk of infection from 5% yearly 107 in 1910–39 to 13% following the introduction of chemotherapy in the 1940s until 1970” (Stybjo,
1980:1–63). This approach was proposed subsequently by World Health Organisation (WHO) expert committees to less developed countries. It was introduced and reinforced through the establishment of training and demonstration centers in less–developed countries, satellite tuberculosis clinics etc.
Comparably, by the late 1950s, it was clear that, unlike in the more developed countries, in most less–developed countries, there was decline in tuberculosis. It was obvious that the mass case finding and specialized case management used in the more–developed countries could not be transferred effectively to other parts of the world, as the cost was far beyond the resources of less–developed countries. This situation therefore called for a new managerial direction and led to the foundation for radical move towards the integration of tuberculosis programmes into the general health services.
THE INTEGRATION OF SERVICE DELIVERY (1964–76)
The earliest attempt at integration was the handwork of tuberculosis (TB) experts whose antecedents were located in a long scientific and programmatic experience in less–developed countries. “Madras Chemotherapy Centre indicated the efficacy of home treatment and suggested that tuberculosis hospital beds were no longer necessary to cure the disease. The team also highlighted the efficacy of intermittent regimens, which facilitated the full supervision of isoniazid intake as the companion drug of streptomycin injection, given twice weekly at the health centers. Importantly, Wallace Fox’s concept of “entirely supervised administration of medicines” today called “directly observed therapy” (DOT), began to emerge as a result of the work of the Madras Chemotherapy Centre” (Raviglione et al., 2002:776)
Agreed that this concept was not original in the tuberculosis field, it was inspired by the existing experience of supervised administration of sulphones in Leprosy, hetrazan in filariasis, and prophylactic anti-malaria, mostly in African programmes.
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Following this, “The National tuberculosis institute at Bangalore showed that most sources of tuberculosis infection could be diagnosed through bacteriological examination of patients with respiratory symptoms attending general health services. The tuberculosis specialized centre of a district could barely deal with 200–300 cases annually. By contrast, it was possible to diagnose and treat 1630 sputum–positive tuberculosis patients in a pilot implementation of the integrated programme involving the district general health infrastructure in which 22 microscopy centers were established and 60 health units participated in supervising home treatment” (Raviglione et al., 2002: 776)
From these demonstrations emerge the launching pad and a rational basis to promote in less developed countries the idea of a national programme that covers the entire country, stable, and based upon simplified technology delivered through the general health services. “The integration of case finding and treatment activities into the general out patient’s services resulted in the dismantling of the mobile tuberculosis clinics and hospitals into health centers and general hospitals. The World Health Organisation (WHO) expert committee met in 1964 and spelt out these policies in her eight reports” (Raviglione et al., 2002:776). It must be noted however, that despite this, the specialized approach was kept intact for the managerial functions and support to the health facilities. The reason was, now that tuberculosis (TB) treatment had been simplified and standardized, that multipurpose health personnel could be trained to prevent, diagnose and treat the disease. The tuberculosis (TB) control experts met again in 1973 under the aegis of
World Health Organisation (WHO) expert committee refined the earlier version of their report and reaffirmed it in what was called the ninth report. This session that was chaired by Wallace
Fox established the principles of the current World Health Organisation (WHO) strategy of tuberculosis control.
It is imperative to note that during this period “the delivery of case management activities through the general health infrastructure became the national policy for tuberculosis control in almost all less–developed countries. However, implementation was far from
109 satisfactory. Whereas in a few, the countries transfer of responsibilities of general services was backed by increased resources, in most, dismantling of specialized services and delegation to general services was not accompanied by any extra resources” (Raviglione et al., 2002:776) thus, no significant impact was attained in tuberculosis control in less developed countries creating room for a wider epidemiological gap.
This created room for strong objections in the 1970s against the specialized management of the tuberculosis programme. The contention by public–health experts was that integration of services delivery could not be efficient without the integration of all the managerial functions.
The primary health care movement, with its universal appeal and declaration of Alma Ata, propelled a second strand of integration.
THE INTEGRATION OF MANAGERIAL FUNCTIONS (1977–88)
As a second wave of integration, it was driven by general public–health experts and primary health care promoters. Setting aside managers that were reluctant to give up their traditional functions in training, supervision, logistics and communication; tuberculosis specialists were confined to providing technical guidance to general health managers. The idea behind these changes was that, since all programmes operated through the same types of managerial and support activities, integration would make a more efficient use of human and financial resources, eliminate duplication of tasks; and provide more effective support to the units responsible for tuberculosis.
Successes were recorded and the examples include integration of immunization services
(Expanded programme on immunization) as well as the integration of drug logistics into a single
Essential Drugs Programme, and that of Laboratory services. However, in some countries, specialized laboratories such as those of tuberculosis were integrated into general public– health laboratories.
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The issue however, was that the benefits that could be brought by the integration of immunization, logistics, and laboratory services were overshadowed by the failures in key areas of tuberculosis (TB) control in many less–developed countries. This was made worse by the economic crisis that caused a weakening of the public–health infrastructure at that time; in general, managerial integration meant determination of quality of services in tuberculosis (TB) control. General health experts (workers) without proper training were unable to provide adequate supervision and training for tuberculosis (TB) control services. The integration and simplification of the data collection system did not provide basic data enough to monitor and evaluate case finding and treatment results, and essential tuberculosis (TB) drug shortages were frequent”. During this period, WHO, many international agencies, most ministries of health and the academic institutions were perceived to have lost interest in TB control” (Raviglione, et al:
2002).
The individual nature of tuberculosis programmes was further eroded by a WHO
Executive Board decision in 1977. This decision made the WHO secretariat to expand control activities to the control of communicable and chronic diseases of the respiratory system. In
1978, the WHO TB Unit was transformed into a TB and Respiratory infections unit with the responsibility of developing a programme for the control of acute respiratory infections but without an increase in human and financial resource.
During the late 1980s, managerial integration was further accelerated with the
‘globalization of the health sector reform’ process. Although set up to increase equity, efficiency and quality, this process had three focuses: documentation of authority (Local empowerment), managerial integration of programs, and public consultation. “This excessive speed in implementing health-sector reforms with too little participation of tuberculosis (TB) managers was particularly destructive for the tuberculosis control programmes in the many countries”
(Berman., 1995:13-29). The integration policies although correct in theory, did result in a loss of
111 visibility of TB control and a gradual loss of expertise in organizing effective case management strategies.
SPECIALISED MANAGERIAL APPROACH REVISITED 1989-98
The outcome of the philosophical changes in the guiding principles of the management of health services and programmes had a profound effect on tuberculosis control during the
1980s. This, among others led to the drastic reduction in the number of specialized staff for TB control services such that “In 1989, the WHO Headquarters staff devoted to TB had shrunk to two professionals managing a tiny budget for operations. In most WHO Regional offices, TB activities were one of the many responsibilities of a general epidemiologist, and no permanent consultants were posted at country level. The contributions provided by outside agencies like the
British Medical Research Council TB Units had ceased to exist, and with it, the stimulus of research that drives policy changes” (Raviglione et al., 2002:776). This created a substantial gap between the international resources for TB control and the major public–health concerns that the disease represented globally.
The situation was becoming compounded with the HIV pandemic that was fuelling and producing sharp increases in TB notifications especially in Africa, the dissolution of the former
USSR that resulted in the collapse of health services thus increasing significantly tuberculosis notifications in that part of the globe; and the reverse in the declining trend in incidence in large towns of the developed countries which started to increase year after year. Beyond these, the deterioration of socio-economic conditions in many countries resulted in increased poverty, overcrowding and malnutrition. These are favourable conditions to the transmission of tuberculosis infection and eventual progression of infection to disease. “In 1990, it was estimated that the global incidence of TB was 8million new cases and resulted in around
3million deaths. With only a handful of exceptions, countries did not have sound TB control
112 programmes to be able to achieve high cure rates and monitor progress of control efforts”
(Raviglione et al., 2002:777).
Expectedly, the rapidly increasing global TB challenge could no longer be ignored. This was based on the experience of a few national programmes promoted and assisted by the international union against TB and Lung Disease (IUATLD) in the 1980s and this prompted the bases of a revised managerial approach to control programme. According to Raviglione et al.,
(2002:777) “This focused primarily on improvement of cure rates through effective short-course chemotherapy regimens, a regular supply of drugs, full supervision of drug intake (at least during the initial phase of treatment) and rigorous cohort analysis of the treatment outcomes.
Expansion of case finding should be pursued only after improving substantially the cure rates.
Through this approach, Karel Styblo of the IUATLD showed that it was possible to achieve
80% cure rates in field conditions. In essence, this experience proved that effective case management of TB could be achieved in any situation”.
Pragmatically, WHO in her response conceptualized the fundamentals of a new strategic approach to tuberculosis control, with emphasis on specialized managerial functions at central, regional and district levels? This marked a clear departure from the managerial integration concepts. However, the principles of integration of case management delivery into the primary health care infrastructure were maintained. For Raviglione et al., (2002:778) “Such moves were a return to the managerial policies of the 1960s with the technical innovations of the 1990s.
Standard 12months treatment regimens were abandoned; short–course chemotherapy with rifampicin (finally affordable in all countries) become the standard treatment for every new patient; direct observation of drug intake was no longer an option carrying the same weight as self administered treatment, but the highly preferred way of administering drugs during the initial phase to both hospitalized patients and outpatients”. As a way to concretize this, in 1991, the World Health Assembly (WHA) in her 44th session, through resolution WHA 44.8 adopted the new strategy and formulated the two global targets for the year 2000 of curing 85% of 113 infectious cases detected; and detecting 70% of cases. This provided a stimulus for tuberculosis control in many countries.
It is necessary to state that this new strategy, which was subsequently labeled DOTS, provided a framework for effective tuberculosis control. The strategy comprised five essential elements. As a way of complementing this “the World Development Report of 1993 emphasized that a sound strategy of tuberculosis control is one of the cost–effective health interventions available today” (World Bank: 1993:63). This new strategy of DOTS was keyed into worldwide such that whereas in 1990 less than ten countries had a proper TB control system, by 1999 at least 127 countries had adopted it.
Progress or otherwise of tuberculosis control was again reviewed with the covening in
March 1998, a WHO ad-hoc committee in London to discuss the global constraints to widening
TB control and to identify potential solutions. “The report was visionary, and recommended that political will and commitment must be strengthened through increased social mobilization and that technical consensus could be achieve via a global partnership with non- governmental organizations (NGOs)” (Ravilione et al., 2002:778). Such issues as encouraging the donor community to do better in addressing the financial constraints as well as establishing a proper balance between integration and specificity, and between decentralization and centralized functions were also canvassed.
THE RESURGENCE OF THE INTEGRATED APPROACHES (1999–2000)
Following the London WHO ad–hoc committee meeting, WHO was reorganized later in the year with a closure of the Global TB programme at WHO headquarters. The main reason for this was to integrate the managerial functions of World Health Organisation’s separate control programmes. The tuberculosis control staffs were incorporated into various new teams organized to address surveillance, prevention and control, and research and development.
Concurrently, a small stop TB initiative secretariat was created to establish, expand and nurture
114 a new international partnership of agencies, institutions, organizations and groups involved in tuberculosis control.
However, the wave of integration at WHO headquarters was short–lived. This was anchored on the fact that the integrated structure could lead to a gradual loss of focus and specific expertise within World Health Organisation. By the beginning of 2001, the sections dealing with TB activities at WHO headquarters were re-organized under a renewed stop TB department. In fact, it was recognized that the best way to achieve a wider implementation of
DOTs was through a clearly defined managerial approach and a more visible structure. Within this period of reorganization, two constraints were addressed: the tuberculosis and HIV co- epidemic and the spread of multi drug–resistant tuberculosis (MDR–TB). For TB and HIV, it is clear that without functional integration of tuberculosis and HIV/AIDS prevention and control, little can be achieved, especially in Africa; as the prevention of HIV transmissions results in TB control. In the case of Multidrug resisstance–tuberculosis (MDR-TB), its threat is today better quantified than a few years ago “Surveys in 72 countries have shown that MDR–TB is a major constraint to tuberculosis control” (Raviglione et al., 2002:779). It was during this period that saw the establishment of a WHO–hosted Green Light Committee (GLC) by some partners who intervened in the cost of treatment by providing a possible solution through negotiating lower prices with drug industry, posting procurement, and assessing the quality of programmes and projects that intend to manage MDR–TB.
THE CONTEMPORARY TUBERCULOSIS CONTROL
The realization that attaining the goal of a successful and proper tuberculosis control will be possible through the development, engagement and use of partnerships characterized the post-modern era. “The post–modern era began with the creation of a partnership aimed at promoting tuberculosis control as an element for health–system development, a basic human rights and an integral part of poverty alleviation strategies. Thus, the stop TB partnership is
115 working in such a way that governments of endemic countries receive, where needed, the adequate support to fulfill their commitments to tuberculosis control” (Raviglione et al.,
2002:776).
The post–modern tuberculosis control era is specifically characterized and dominated by global coordinated efforts by partners as well as between nation–states. One unique and outstanding feature of this era is the publication of an annual report by WHO on the state of tuberculosis control in the world. This is usually made public on 24 March each year to commemorate ‘World TB Day’. It began in 1997 such that since then there has been a global, regional and national statistical figure on tuberculosis. “The main aim of the report is to provide a comprehensive and up–to–date assessment of the TB epidemic and progress made in prevention, care and control of the disease at global, regional and country levels, in the context of global targets set for 2015 and WHO’s recommended strategy for achieving these targets”
(WHO TB Report; 2011:3)
For the year 2010 which was published in 2011 as the 16th Global Report on tuberculosis by World Health Organization (WHO):
It provides a comprehensive and up–to–date assessment of tuberculosis epidemic and progress in implementing and financing tuberculosis prevention, care and control at global, regional and country levels using data reported by 198 countries that account for over 99% of the World’s tuberculosis cases (WHO TB Report; 2011:1). Accordingly, on the burden of disease caused by TB, (WHO TB Report 2011:9) the following were the highlights (key messages):
- There were an estimated 8.8 million incident cases of TB (range 8.5 million– 9.2million)
globally in 2010, 1.1million deaths (range, 0.32million–0.39million) among people who
were HIV–Positive.
- In 2009, there were an estimated 9.7million (range, 8.5–11million) children who were
orphans as a result of parental deaths caused by TB.
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- Globally, the absolute number of incident TB cases per year has been falling since 2006
and the incidence rate (per 100,000 populations) has been falling by 1.3% per year since
2002. If these trends are sustained, the MDG target that TB incidence should be falling
by 2015 will be achieved.
- TB mortality is falling globally and the stop TB Partnership target of a 50% reduction by
2015 compared with 1990 will be met if the current trend is sustained. The target could
also be achieved in all WHO regions with the exception of the African Region.
- Although TB prevalence is falling globally and in all regions, it is unlikely that the stop
TB partnership target of a 50% reduction by 2012 compared with 1990 will be reached.
However, the target has already been achieved in the Region of the Americas and the
Western Pacific Region is very close to reaching the target.
- Dramatic reductions in TB cases and deaths have been achieved in China. Between 1990
and 2010, prevalence rates were halved, mortality rates were cut by almost 80% and
incidence rates fell by 3.4% per year. In addition, a method for measuring trends in
disease burden in China provides a model for many other countries.
- Between 2009 and 2011, consultations with 96 countries have led to a major updating of
estimates of TB incidence, mortality and prevalence, particularly for countries in the
African Region.
- Estimates of TB mortality have substantially improved in the past three years, following
increased availability and use of direct measurements from vital registration systems and
mortality surveys.
- In this report, direct measurements of mortality are used for 91 countries (including
China and India for the first time).
- For World Health Organisation (WHO), “The burden of disease caused by TB can be
measured in terms of incidence (defined as the number of new and relapse cases of TB
arising in a given time period, usually one year), prevalence (defined as the number of
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cases of TB at a given point in time) and mortality (defined as the number of deaths
caused by TB in a given time period, usually one year). It can also be expressed in terms
of the years of life lost or, to account for illness as well as mortality, the disability–
adjusted life years (DALYs) lost. WHO publishes estimates of the burden of disease by
major causes and risk factor using all of these metrics” (WHO TB Report 2011:9).
As a result of the globally coordinated efforts, all countries are made to report their TB figures which are then compiled and used to produce estimated TB statistics for each country, region and globally as highlighted above. WHO TB Report (20011:12) contends that “Globally it is thought that only about 65% of TB cases are notified”. The figures for the estimated incidence, prevalence and number of deaths from TB in each WHO region for the year 2010 are given below:
Region Incidence Prevalence Deaths Population
Africa 2,300,000 2,800,000 250,000 836,970,000
Americas 270,000 330,000 20,000 933,447,000
Eastern Mediterranean 650,000 1,000,000 95,000 596,747,000
South – East Asia 3,500,000 5,000,00 500,000 1,807,594,000
Western Pacific 1,700,000 2,500,000 130,000 1,798,335,000
Grand Total 8,840,000 12,190,000 1,0506,000 6,869,573,000
Source: WHO Global TB Report, 2010.
Tuberculosis statistics for “high burden” countries were also highlighted. High burden countries have been identified and prioritized at a global level since the year 2000. They are currently 22 of these countries and between them they accounted for 82% of all estimated cases of tuberculosis worldwide in 2010 (WHO TB Report 2011:12).
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Region Incidence Prevalence Deaths Population Afghanistan 59,000 110,000 12,000 31,412,000 Bangladesh 330,000 610,000 64,000 148,692,000 Brazil 85,000 92,000 5,000 194,946,000 CAMBODIA 62,000 93,000 8,600 14,138,000 China 1,000,000 1,500,000 54,000 1,341,335,000 D R Congo 220,000 350,000 36,000 65,966,000 Ethiopia 220,000 330,00 29,000 82,950,000 India 2,300,000 3,110,000 320,000 1,224,614,000 Indonesia 450,000 690,000 64,000 239,871 Kenya 120,000 110,000 6,900 40,513 Mozambique 130,000 110,000 11,000 47,963,000 Myanmar 130,000 110,000 54,000 23,391,000 Nigeria 210,000 320,000 33,000 158,423,000 Pakistan 400,000 630,000 58,000 173,593,000 Philippines 260,000 470,000 31,000 93,261,000 Russian Federation 150,000 190,000 26,000 142,958,000 South Africa 490,000 400,000 25,000 50,133,000 Thailand 94,000 130,000 11,000 69,122,000 Uganda 70,000 64,000 5,000 33,425,000 UR Tanzania 79,000 82,000 5,800 44,841,000 Viet Nam 180,000 290,000 29,000 87,848,000 Zimbabwe 80,000 51,000 3,400 12,571,000 Total for High Burden 7,200,00 10,000,000 860,000 4,321,967,000 Countries Source: WHO Global TB Report, 2010.
Further as a mark of the globally coordinated effort, the statistics for multi drug resistant
TB (MDR–TB) was highlighted. Multi drug resistant TB is the name given to TB when the bacteria causing it are resistant to at least isoniazid and rifampicin, the most effective TB drugs.
In 2010 the World Health Organization (WHO) “estimated that there were globally 290,000 cases of MDR–TB among those cases of pulmonary TB that were reported to them” (WHO
Global Tuberculosis 2011:38). It was also estimated that in total there were 650,000 cases of 119
MDR–TB among the World’s 12million prevalent cases of TB” (WHO Global TB Report
2011:20).
It must be noted that there are 27 “high burden” countries for MDR–TB. According to
WHO, these are countries where there are at least 4,000 cases of MDR–TB each year, and for at least 10% of newly registered TB cases are of MDR–TB. The table below indicates the estimated number of cases for each “high burden” country. It also shows figures for each of the
WHO regions. “It should however be noted, that these are only the estimates for the number of cases of MDR–TB amongst those cases of pulmonary TB notified to WHO. There will in addition have been many cases of MDR amongst those cases of TB which were either not detected and/or not notified” (WHO Global Tuberculosis 2011:38).
Country/Region Estimated cases of Notified Cases Enrolled on MDR – TB cases of Treatment for MDR – MDR – TB TB Armenia 260 177 154 Azerbaijan 1,700 63 286 Bangladesh 5,900 184 339 Belarus 1,700 1,576 200 Bulgaria 94 56 56 China 63,000 2,792 1,222 D R Congo 2,700 87 191 Estonia 76 63 80 Ethiopia 2,100 140 120 Georgia 68 359 618 India 64,000 2,967 2,967 Indonesia 6,100 182 142 Kazakhstan 6,400 7,387 5,705 Kyrgzstan 1,00 566 566 Latvia 100 87 87 Lithuania - - - Myanmar 5,100 192 192 Nigeria 2,400 21 23
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Pakistan 9,700 444 44 Philippines 8,800 522 548 Republic of Moldova 1,700 1,015 791 Russian Federation 31,000 13,692 13,692 South Africa 9,100 7,386 5,402 Tajikistan 1,400 333 245 Ukraine 6,600 5,333 3,870 Uzbekistan 3,100 1,023 628 Viet Nam 3,600 101 101 Total for MDR–TB High 250,000 46,748 38,652 Burden Countries Africa 32,000 9,504 7,406 Americas 6,200 2,158 3,186 Eastern Mediterranean 14,000 829 1,000 Europe 53,000 32,616 27,844 South – East Asia 88,000 3,779 3,901 Western Pacific 77,000 4,222 2,210 Global Total for MDR–TB 290,000 53,108 45,553
Source: WHO Global TB Report, 2010.
5.2 TUBERCULOSIS CONTROL AND THE NIGERIAN HEALTH CARE
SYSTEM.
Nigeria as a member state of the United Nations (UN) participated in the World Health
Organizations (WHO), sponsored meetings/activities of the World Health Assembly (WHA) targeted towards the control of tuberculosis (TB). She was thus privy to the evolving global concerns on the control of tuberculosis. At the regional level, she also actively participated in the African Union (AU) meetings concerning the control of Tuberculosis. Infact, She hosted the
African Summit on HIV/AIDS, Tuberculosis and other Related Infectious Diseases at Abuja on
24–27 April 2001, which led to the Abuja Declaration on HIV/AIDs, Tuberculosis and Other related Infectious Diseases, as well as the special ‘summit of African’ union on HIV/AIDs,
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Tuberculosis and Malaria (ATM) on 2–4 May, 2006. This special summit was tagged ‘Update on Tuberculosis Control in Africa’ with the Theme: Universal Access to HIV/AIDs,
Tuberculosis and Malaria Services by a United Africa by 2010.
THE CONTROL OF TUBERCULOSIS IN NIGERIA 1980–1990
Given the global context of the control of Tuberculosis, Idigbe (2010:6) observed that
“By 1981, adequate diagnostic tools had become available globally for the detection of active cases of the disease. Effective drugs for the cure of the disease were also available. Using these tools several countries across the world were able to articulate and implement well organized
Tuberculosis control programmes which helped to improve the situation in their communities.
The strategic thrust of most countries was to detect active cases and provide effective treatment, most countries implemented active case finding initially but subsequently resorted to passive case finding and organized chemotherapy. By the late 1970s and early 1980s after effective drugs were in place, most countries were able to establish coordinated National TB Programmes for the control of the disease in their countries”.
Idigbe (2010:6) further asserted that “however at this time in Nigeria, there were no formal or organized national strategies for tuberculosis (TB) control in the country and TB care was essentially the responsibility of the State Government. A few of the infectious Disease
Hospitals (IDH), which were inherited from our colonial masters across the country and some missionary hospitals served as chest clinics where new suspected tuberculosis (TB) cases were referred to and, for diagnosis and treatment. Diagnosis of a case of TB was essentially based on clinical symptoms and chest X-ray findings because capacities for sputum microscopy and culture were very minimal. When cases were diagnosed, patients had to pay for their TB drugs.
Several short and long term regimens were implemented often not in accord with the standard recommended regimens and with minimal supervision or follow–up. Affordability of treatment was a great issue, as it was greatly enhanced by the patient’s financial capacity. Also because the stock of drugs in the health facilities was often minimal or not often available, a significant
122 number of patients bought their drugs from pharmacies or road side chemists. A good number of patients also patronized the traditional healers”.
Given the challenges of the un-coordinated nature of tuberculosis control in the country within this period, the situation was not only bound to be chaotic but also disastrous especially for the patients and for the country at large. The manifestations were: haphazard diagnostic and treatment practices, encouragement of under detection of active cases in the communities, mis- diagnosis of cases, faulty prescriptions, and inadequate drug intake resulting from poor finances of the patients, drug stock outs, treatment failure, relapse and resistance to drugs. The end-result of all these was the un-interrupted transmission of the infection across and in all the communities and the country at large.
Despite all these, efforts were still been made towards the coordination of tuberculosis control and by the close of the decade, “precisely in 1988, it resulted in the establishment of the nationally coordinated activity named National Tuberculosis and Leprosy Control Programme
(NTBLCP) in the Department of Public Health at Federal Ministry of Health and by extension in all the states of the Federation”. (NTBLCP Workers Manual 2008:9).
THE CONTROL OF TUBERCULOSIS IN NIGERIA: 1991–PRESENT (2010)
It is imperative to observe that although, the national tuberculosis control programme was established in 1988, it was “officially launched in February 1991 with a mandate to coordinate tuberculosis (TB) control activities in all states of Nigeria in order to significantly reduce the public health burden of the disease on the Nigerian population. The National programme employs the Directly Observed Therapy Short-course (DOTS), as well as other initiatives of the STOP TB Partnerships and the Multi–Drug Therapy (MDT) both recommended by the World Health Organization (WHO), as the strategic interventions for the control of the disease in Nigeria” (Federal Ministry of Health 2009:9)
The National TB and Leprosy Control Programme (NTBLCP) are headed by the
National Coordinator with his retinue of other support staff, each with a focal area. Also, the 123 state programme is located within the Department of Public Health in the various State
Ministries of Health and led by a State Control Officer who coordinates all the activities of the programme. And at the last tier of Government, it is headed by a Local Government TB &
Leprosy Control Officer/Supervisor (LGTBLS). Significantly, coordination is top down by the national coordinator while the State coordinator in turn superintends and oversees the activities of the State as well as that of the Local Government Supervisor. The Local Government
Supervisor oversees the DOTs focal persons as well as overseeing the entire programme in the
Local Government Area. However, reporting is bottom-up, where the Local Government
Supervisor reports to the State Coordinator and the State Coordinator inturn reports to the
National Coordinator and other Development Partners involved in tuberculosis control. It is instructive to state here that this was the beginning of a nationally coordinated tuberculosis (TB) control programme in the country.
By the assertion of the Federal Ministry of Health, as contained in the annual report
FMOH (2009:9) “since February 1991, remarkable landmarks have been achieved in the joint fight to reduce the burdens of TB and Leprosy to levels where they no longer constitute public health problems in Nigeria”. These include:
1991: MDT started nation-wide with the support of ILEP organizations for treating
Leprosy patients.
1993: DOTs started in 14 GLRA Supported States.
1995: MDT coverage of Leprosy patients reached 100% country wide
1998: WHO elimination target of less than 1 leprosy case per 100,000 populations by
2000 attained.
2001: Commenced first TB strategic plan for 2001 to 2005
2002: Expansion of DOTs to 17 Northern States commenced with assistance from
CIDA and USAID
2004: DOTs implementation expanded to all states of Nigeria
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2005: DOTs coverage of 65% of all 774 LGAs
2006: Case Detection Rate (CDR) of New smear positive TB cases improved to 13%
from 4% (1994) 15% (2002)
2006: TB treatment success rate reached 75% from 71% in 1996
2007: Launched the first strategic plan for Leprosy control 2007-2011
2007: Enhancement of TB control activities with gaps filling grant of first phase of
Global Fund Round 5
2008: Inauguration of the STOP TB partnership, Adoption of the ISTC by the NMA
End of first phase of the gap filling grants (GFATM R5).
STRUCTURE AND ORGANIZATION OF THE NTBLCP
Given that Nigeria is a federation with three tiers of government, “NTBLCP is structured along the three tiers of government i.e. Federal, States and Local Government Areas (LGAs).
The National level at the Department of Public Health of the Federal Ministry of Health is responsible for policy development, tertiary care, mobilization and development of human and material resources and provision of technical support to state programmes. The state
Tuberculosis and Leprosy (TBL) programmes coordinate tuberculosis activities, provide secondary care and provide technical management to programme implementation at the LGA
Level. The LGA is the operational level of the programme based on the primary Health Care
(PHC) principle. In the last few years, there has been also a supervisory zonal level from where
WHO National Professional Officers provide technical assistance to an insufficient–capacity national level in routine monitoring of activities at the state level in the six geo–political zones”
(FMOH, Annual Report 2008:11)
Supportive of the Federal Government in the fight against this disease are the development partners (DPs) which also operate at all levels. Prominent among them are World
Health Organization (WHO), members of the International Federation of Anti–Leprosy
Associations (ILEP), International Union Against TB and Lung Disease (IUATLD), Canadian 125
International Development Agency (CIDA); Department for International Development (DFID),
Global fund to fight AIDs, Tuberculosis and Malaria (GFATM), United States Agency for
International Development (USAID) and other voluntary organizations. As a result of the organized coordination of the activities of the Tuberculosis control programme, the World
Health Organization (WHO) estimates for the Country for the year 2010 as highlighted are reproduced below:
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Source: WHO Country Profiles of 22 High Burden Countries (HBCs) 2010.
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5.3 RIVERS STATE HEALTH CARE SYSTEM AND THE CONTROL OF
TUBERCULOSIS
A health care system depicts the organization of people, institutions, and resources in order to deliver ‘health care’ services to meet the health needs of a designated population such as Rivers State. There are varieties of health care systems around the world, with as many origins and organizational structures as there are nation states. For some countries, health care system planning is distributed, while in others, there is some effort by governments, trade unions, religious organizations, charities or other organized bodies to deliver planned health care services meant to the populations they serve. To this extent, health care planning appears to have been evolutionary instead of revolutionary.
The Rivers State health care system has evolved as a manifestation of the adoption of the health policies of the Nigerian Nation State.
THE ADVENT OF LEPROSY/TUBERCULOSIS CONTROL SERVICES IN THE
STATE
“Leprosy control services was brought into this state, when it was under Eastern Region in 1928 by one Dr. Geoffrey, a missionary, who had come to Port Harcourt from England for the purpose of carrying out some research work on Leprosy” (Agborubere, 2001:2). According to him, there was no organized tuberculosis and Leprosy control services in the state rather there were segregation villages for the leprosy patients at Degema, Kira, Wiiyaakara and Igbogene
(now in Bayelsa state). The TB patients received services at Choba and later chest clinic Diobu”.
However, in 1985, events changed with the leadership of Rivers State government and that of the Catholic mission of Daughters of Charity of Saint Vincent De Paul with Sister
Elizabeth Fallon as their team leader having an understanding on care for leprosy patients. With this, several dapsone monotherapy clinics were established in some local government Areas. It is also interesting and noteworthy to state that nominations and sponsorship for trainings at the
National Tuberculosis and Leprosy Training Centre (NTBLTC), Zaria in the early years of these 128 services in the state came from Sister Elizabeth Fallon of the Daughters of Charity, Ogale,
Nchia-Eleme.
As events evolved, in March 1990, the German Government represented by the German
Bank for Reconstruction and Development, (KFW) indicated its willingness to provide funds as grant for support of the Leprosy control services initially in thirteen (13) States in the Country supported by the German Leprosy Relief Association (GLRA). Rivers State was among these
States although; it later became fourteen (14) States with the inclusion of Akwa Ibom.
Sustainability meetings were held between the Federal Government and the German
Government represented by the German Leprosy Relief Association (GLRA) and in the process, the Federal Government sought assistance for the inclusion of Tuberculosis component. The sustainability meetings finally led to the signing of Memorandum of Understanding (MoU) in
1993 between the parties. The main objectives of the Bilateral Agreement was to enable the initial take off of the project and then to hand over to the country.
The nature of the bilateral agreement was such that the German Bank for Reconstruction and Development (KFW) will fund the provision of tuberculosis and Leprosy drugs, provision of means of transportation, provision of Laboratory equipments/materials/reagents while
German Leprosy Relief Association (GLRA) the execution agent will fund training (Local and
International), provide field allowance for Tuberculosis and Leprosy (TBL) field workers, provide logistics and technical support as well as programme preparation expenses. On the other hand, the Nigerian Government will fund infrastructural development (renovation of buildings mainly), running costs through fuelling and maintenance of project vehicles and motorcycles, as well as payment of staff salaries.
Specifically, the Nigerian State was also to bear all taxes and other public charges and
Port duties. The period for implementation was from 1991–1995, although, it was later extended up to 2004 before they finally pulled out in 2005. “In 2005, the German Bank for Development and Reconstruction (KFW) the main financiers of the German Leprosy Relief Association
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(GLRA) exhausted its budget and withdrew its support to the programme in the country which further increased the existing gap in funding” (Agborubere, 2011).
“Rivers State officially adopted the combined Tuberculosis and Leprosy Control
Programme in 1994. Following this, she signed the first memorandum of Understanding (MoU) with the German Leprosy and TB Relief Association in 1994. Due to the trend of events, this first Memorandum of Understanding (MoU) elapsed and a revised MoU was signed on 10th
December, 2002” (Agborubere, 2011). The fulcrum of this agreement was that the GLRA provided drugs, Laboratory reagents and materials, Microscopes, Vehicles (boats, motor
Vehicle, motor cycles and bicycles), allowance for field staff (supervisors) in the various LGAs and regular trainings in TBL control activities. On the other hand, the State/Local Governments provides manpower and pays staff salaries and allowances, infrastructure and their maintenance.
“Government is also expected among other things to: provide transport means, fueling and maintaining the programme vehicles, make provisions for public enlightenment/health education, provide for running cost of the programme, provide for the training of staff in the programme and provide laboratory and logistics support to the programme” (Abgorubere, 2011).
THE CONTEMPORARY TUBERCULOSIS CONTROL IN RIVERS STATE
Given the evolving scenarios from the international scene to the national, since the State
Government signed the first memorandum of Understanding (MoU) with the GLRA in 1994, the combined and structured TB/Leprosy Control Programme became established in Rivers State.
“Currently, the State TB and Leprosy Control Programme is a sub-sub Recipient of the Global funds for AIDs, TB and Malaria (GFATM) grant consolidated rounds 5 and 9). However, funding gaps still exist and the various state Governments are requested to take ownership of the programme and improve their counterpart funding to bridge the gaps” (Agborubere., 2011).
Succinctly put, it is obvious that although it operates with obvious deformities and challenges, it remains organized along the lines of the ‘International Standards’ and structures set for the
130 control of the diseases. Thus, it is structured to conform to the standards set by the World Health
Organisation and operates within this framework.
5.4 TUBERCULOSIS CONTROL PROGRAMME OBJECTIVES, TARGETS AND STRATEGIES.
Given the global concerns as expressed in the various World Health Assembly (WHA) resolutions which are a function of the public health importance of the disease, international standards were set for its control. And these standards were adopted by the various nation states.
These standards were synthesized and expressed in the form of goals and objectives, targets, as well as strategies for the proper control of tuberculosis.
They are stated expressly in the two strategic plans (TB 2006–2010 and Leprosy 2007–
2011). “The long–term goals and objectives of the National Tuberculosis and Leprosy Control
Programme include: To reduce significantly the burden, Socio–economic impact and transmission of tuberculosis and Leprosy” (FMOH, 2009:11). The general objectives include:
1. To reduce the prevalence of tuberculosis and Leprosy to a level at which they no longer
constitute public health problems in the country.
2. To prevent and reduce the impairment associated with Leprosy.
3. To provide appropriate rehabilitation for persons affected by Leprosy.
Specifically, the goal of the National tuberculosis program is to reduce, significantly, the burden of tuberculosis by 2015 in line with the millennium development goals (MDGs) targets.
The targets for tuberculosis control are:
- To detect at least 70% of the estimated infectious (smear–positive) cases.
- To achieve a cure rate of at least 85% of the detected smear–positive cases.
- By 2015 reduce TB prevalence and death rates by 50% relative to 1990 level.
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- By 2050 eliminate TB as a public health problem (<= 1/1,000,000 population) (FMOH,
Workers Manual, 2009:19)
Furthermore, the stop TB strategy components and the implementation approaches are stated as follows:
1. Pursue high – quality DOTs expansion and enhancement.
- Political commitment with increased and sustained financing.
- Case detection through quality–assured bacteriology.
- Standardized treatment with supervision and patient support.
An effective drug supply, and management system.
- Monitoring and evaluation system and impact measurement.
2. Address TB/HIV, MDR–TB and other challenges.
- Implement collaborative TB/HiV activities.
- Prevent and control multi–drug resistant TB
- Address prisoners, refugees, other high risk groups and special situations.
3. Contribute to health system strengthening
- Actively participate in efforts to improve system–wide policy, human resources,
financing, management, and service delivery and information systems.
- Share innovations that strengthen systems including the Practical Approach to Lung
Health (PAL).
- Adopt innovations from other fields.
4. Engage all care providers.
- Public–public, public–private mix (PPM) approaches
- International standards for Tuberculosis care (ISTC)
5. Empower people with TB and Communities
- Advocacy, communication and social mobilization.
- Community participation in TB care.
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- Patients charter for Tuberculosis care.
6. Enable and promote research
- Programme–based operational research.
- Research to develop new diagnostics, drugs and vaccines.
Based on the above international stop TB strategy, the specific targets for tuberculosis control in
Nigeria for the year 2010 were stated as follows:
1. To detect 70% of the estimate infectious (smear positive) tuberculosis in Nigeria.
2. To treat at least 85% of all TB patients detected successfully.
3. To strengthen the technical and managerial capacity of the NTBLCP at all tiers to ensure
achievement of at least 80% implementation rate of programme activities.
4. To promote behavioral change in the community about TB such that 70% of adult
populations know about TB, its prevention, free treatment and TB services and the
attendant risk groups are motivated to seek prompt care.
5. To reduce by 25% the incidence of TB among people living with HIV/AIDs (PLWA)
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CHAPTER SIX
PROGRAMME IMPLEMENTATION AND UTILIZATION IN RIVERS STATE
TUBERCULOSIS CONTROL SERVICES
6.1 Government Health Care Facilities in Rivers State.
LGA NAME S/NO NAME OF HEALTH FACILITY LOCATION
ABUA/ODUAL 1 Abua General Hospital Ayama town 2 Ayama Health Centre Ogbema town 3 Adada Health Post Adada town 4 Agada 1 Model Health Centre Agada 1 town 5 Aminiowere Health Centre Aminiowere town 6 Anyu Model Health Centre Anyu town 7 Arukwo Health Centre Arukwo town 8 Akani Health Centre Akani town 9 Amuruto Health Centre Amuruto town 10 Aminigboko Cottage Hospital Aminigboko town 11 Egbolom Health Centre Egbolom town 12 Elok Health Post Elok town 13 Emago Health Post Emago town 14 Emelego Health Post Emelego town 15 Emesu Health Post Emesu town 16 Emoh Health Post Emoh town 17 Emirikpoko Health Post Emirikpoko town 18 Iyak Health Centre Iyak town 19 Obarany Health Centre Obarany town 20 Ogboloma Health Post Ogboloma town 21 Ogonokom Health Post Ogonokom town 22 Okoboh Health Post Okoboh town 23 Okolomade Health Post Okolomade town 24 Otapha Health Centre Digiriga town AHOADA EAST 1 Comprehensive Health Centre Ahoada
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2 Model Primary Health Care Ahoada 3 Ogbo Health Centre Ogbo 4 Abarikpo Health Centre Abarikpo 5 Ula-Ehuda Health Centre Ula-Ehuda 6 Ula-Upata Health Centre Ula-Upata 7 Ihuowo Health Centre Ihuowo 8 Odiabidi Health Centre Odiabidi 9 Edeoha Health Centre Edeoha 10 Okporimini Health centre Okpromini 11 Odiemuchie Health Centre Odiemuchie 12 Okporowo Health Centre Okporowo 13 Ogbele Health centre Ogbele 14 Ihugbogo Health Centre Ihugbogo 15 Ochigba Health Centre Ochigba 16 General Hospital Ahoada AHOADA WEST 1 Akinima Comprehensive H/Centre Akinima 2 Edagberi Cottage hospital Edagberi 3 Odawu Health Centre Odawu 4 Mbiama Health Centre Mbiama 5 Okarki Primary Health Centre Okarki 6 Ikodu Primary Health Centre Ikodu 7 Igova Health Centre Igova 8 Ododa Health Post Ododa 9 Akiogbulogo Health Centre Akiogbulogo 10 Okogbe Health Centre Okogbe 11 Ogbologbolo Health Centre Ogbologbolo 12 Idu Health Centre Idu 13 Ukpeliede Health centre Ukpeliede 14 Oyigba Health centre Uyigba 15 Ula-ubie Health Centre Ula-Ubie 16 Ebrass Health Centre Ebrass 17 Ubio Health Centre Ubio 18 Odiokwu Health Centre Odiokwu 19 Ubeta Health Centre Ubeta
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20 Odiereke Health Centre Odiereke 21 General Hospital Ususu 22 Ubarama Health Post Ubarama 23 Oshie Health Centre Oshie 24 Anwunugbokor Health Post Anwunugbokor AKUKU – TORU 1 General Hospital Abonnema 2 Comprehensive Health Centre Abonnema 3 Model Health Centre Obonoma 4 Cottage Hospital Soku 5 Elem-Sangama Health Elem-Sangama 6 Model Health Centre Idama 7 Kula Health Centre Kula 8 Abissa Health Centre Abissa ANDONI 1 Asarama Health Centre Asarama 2 Asukama Health centre Asukama 3 Asaramaija Health Centre Asaramaija 4 Agbalama Health Centre Agbalama 5 Ataba Health Centre Ataba 6 Akaradi Health Centre Akaradi 7 Ajakajak Health Centre Ajakajak 8 Egbomung Health Centre Egbomung 9 Egendem Health Centre Egendem 10 Ebukuma Health Centre Ebukuma 11 Egwede Health Centre Egwede 12 Ekede Health Centre Ekede 13 Agwut-Obolo Health Centre Agwut-Obolo 14 Ibot-Irem Health Centre Ibot-irem 15 Ikuru Health Centre Ikuru 16 Inyong-orong Health Centre Inyong-Orong 17 Itombi Health Centre Itombi 18 Isiodum Health Centre Isiodum 19 Iwoma Health Centre Iwoma 20 Otuafu/Otunria Health Centre Otuafu/Otunria 21 Oronija Health Centre Oronija
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22 Orjorokoto Health Centre Orjorokoto 23 Unyeada Health Centre Unyeada 24 Unyengala Health Centre Unyengala 25 Ngo Health Centre Ngo 26 General Hospital Ngo Ngo 27 Okoroboile Health Centre Okoroboile ASARI-TORU 1 General Hospital Buguma Buguma 2 Buguma Model Health Centre Buguma City 3 Ido Health Centre Ido town 4 Abalama Model Health Centre Abalama Town 5 Tema Health Centre Tema town 6 Sama Model Health Centre Sama town 7 Oprama Health Centre Oprama town 8 Krakrama Health Centre Krakrama town 9 Ifoko Health Centre Ifoko town 10 Minama Health Centre Minama town 11 Ilelema Health Centre Ilelema 12 Angulama Health Centre Angulama 13 Omekwe-Ama Health Centre Omekwe-Ama town BONNY 1 Comprehensive Health Centre Bonny 2 Abalamabie Health Centre Abalamabie 3 Finima Health Centre Finima 4 Peterside Health Centre Peterside 5 Olama Health Centre Olama 6 Halliday Health Centre Halliday 7 Dema-Abbey Health Centre Dema-Abbey 8 Banigo Health Centre Banigo 9 Greens Health Centre Green 10 Burikiri health Centre Burikiri 11 General Hospital Bonny Bonny town DEGEMA 1 Comprehensive Health Centre Degema 2 Bakana Health Centre Bakana 3 Bille Health Centre Bille 4 Tombia Health Centre Tombia
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5 Ogruama Health Centre Ogruama 6 Bukuma Health Centre Bukuma 7 Usokun Health Centre Usokun 8 Obuama Health Centre Harry’s town 9 Ke Health Centre Ke 10 General Hospital Degema Degema ELEME 1 General Hospital Nchia Ogale 2 Modern Health Centre Akpajo 3 Modern Health Centre Agbonchia 4 Modern Health Centre Onne 5 Modern Health Centre Ebubu 6 Modern Health Centre Eteo 7 Modern Health Centre Ekporo 8 Primary Health Centre Ogale EMOHUA 1 Primary Health Centre Oduaha 2 Primary Health Centre Ogbakiri 3 Comprehensive Health Centre Isiodu 4 Comprehensive Health Centre Elibrada 5 Primary Health Centre Ndele 6 Comprehensive Health Centre Rumuji 7 Comprehensive Health Centre Ovogo 8 Comprehensive Health Centre Rumuewhor 9 Primary Health Centre Akpabu 10 Primary Health Centre Ibaa 11 Comprehensive Health Centre Egbeda 12 Comprehensive Health Centre Umudioga 13 Primary Health Centre Ubimini 14 Comprehensive Health Centre Ekwutche 15 Comprehensive Health centre Ovelle-Oduaha ETCHE 1 Abara Health Centre Abara 2 Afara Health Centre Afara 3 Akpoku Health centre Akpoku 4 Akwa Model Health Centre Akwa 5 Chokota-Igbo Health Centre Chokota-Igbo
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6 Egbeke Health Centre Egbeke 7 Egwi Health Centre Egwi 8 Elele Health Centre Elele 9 Grass Root Health Centre Okehi 10 Igbo-Imeh health Centre Igbo-Imeh 11 I.W.C Health Centre Okpodim 12 Ndashi Health Centre Ndashi 13 Nihi Health Centre Nihi 14 Obite Health Centre Obite 15 Odufor Model Health Centre Odufor 16 Okoroagu Health Centre Okoroagu 17 Opiro Health Centre Opiro 18 Orwu/Ogida Health Centre Orwu/Ogida 19 Ozuzu Health Centre Ozuzu 20 Umuakuru Health Centre Umuakuru 21 Umuaturu Health Centre Umuaturu 22 Umudele/Ndashi Health Centre Umudele/Ndashi 23 Umuede-Mba Health Centre Umuede-Mba 24 Umuechem Health Centre Umuechem 25 Umuogerem-Obibi Health Centre Umuogerem-Obibi 26 Umuala Health Centre Umuala 27 Umuohie Igbodo Health Centre Umuohie Igbodo 28 Umuoye Health Centre Umuoye 29 Ulakwo Health Centre Ulakwo 30 Umuebulu Cottage Hospital Umuebulu 31 Ihie Cottage Hospital Ihie 32 OKomoko General Hospital Okomoko 33 Okehi General Hospital Okehi GOKANA 1 Model Primary Health centre Kpor 2 Model primary health Centre Bomu 3 Model primary health centre Yeghe 4 Model Primary Health Centre Barako 5 Model Primary health Centre B.Dere 6 Primary Health Centre K. Dere
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7 Primary Health Centre Bera 8 Primary Health Care Unit General H Terabor 9 Primary Health Centre Mogho 10 Primary Health Centre Gbe 11 Primary Health Care Centre Deeyor 12 Primary Health Care Centre NweBiara 13 Primary Health Care Centre Biara 14 Primary Health Care Centre Denken 15 Primary Health Care Centre Lewe 16 Primary Health Care Centre Bodo Gen Hospital 17 Primary Health Care Centre Nwe-ol 18 General Hospital Bodo Bodo City 19 General Hospital Terabor Terabor IKWERRE 1 Comprehensive Health Centre Igwuruta 2 Comprehensive Health Centre Aluu 3 Comprehensive Health Centre Omagwa 4 Comprehensive Health Centre Adanta,Isiokpo 5 Comprehensive Health Centre Elele 6 Comprehensive Health Centre Omerelu 7 Comprehensive Health Centre Apani 8 Comprehensive Health Centre Ubima 9 Comprehensive Health Centre Omuanwa 10 Comprehensive Health Centre Ipo 11 Comprehensive Health Centre Omademe 12 Comprehensive Health Centre Ozuaha 13 Zonal Hospital Isiokpo 14 Nucleus Estate Clinic Ubima 15 Zonal Hospital Ubima 16 Madona University Teaching Elele Hospital KHANA 1 General Hospital ,Bori Bori 2 General Hospital,Taabaa Taabaa 3 Comprehensive Health Centre Bori 4 Health Centre Taabaa
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5 Model Health Centre Beeri 6 Model Health Centre Luawii 7 Model Health Centre Bane 8 Health Centre Uegwere 9 Health Centre Gwara 10 Health Centre Opuoko 11 Model Health Centre Wiiyaakara 12 Health Centre Okwali 13 Health Centre Kwawa 14 Health Centre Kaa 15 Health Centre Luebe 16 Health Centre Kaani 17 Health Centre Sogho 18 Health Centre Bori 19 Model Health Centre Kpean 20 Health Centre Loore 21 Health Centre Taabaa 22 Health Centre Lueku OBIO/AKPOR 1 Eliozu Model Health Centre Eliozu 2 Rumuokrurusi Model Health Centre Rumuokwurusi 3 RumuodomayaModel Health Centre Rumuodomaya 4 F.S.P. Elelenwo Elelenwo 5 Woji Model Health Centre Woji town 6 2 BD Medical Centre Bori Camp 7 Obio Cottage Hospital Obio town 8 Airforce Medical Centre Airforce Base PH 9 Rumuepirikom model Health Centre Rumuepirikom 10 College of Health Technology Rumueme Demonstration Clinic 11 Rumuigbo Model Health Centre Rumuigbo 12 Eneka Model Health Centre Eneka 13 Rukpoku Health Centre Rukpoku 14 Rumuekini Health Centre Rumuekini 15 UNIPORT Teaching Hospital Alakahia
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16 Akpor Health Centre Akpor 17 Rumuolumeni Model Health Centre Rumuolumeni 18 Rumueme Model Health Centre Rumueme 19 Naval Base Medical Centre Borokiri 20 UOE Medical Centre Rumuolumeni 21 Iriebe Model Health Centre Iriebe 22 Choba Health Post Choba 23 Rumuodara Health Post Rumuodara 24 Rumuokparaeli Health Post Rumuokparaeli 25 ST.Jude C.A.C Rumuokoro Rumuokoro OGBA/EGBEMA/ 1 Model Primary Health Centre Omoku NDONI 2 Model Primary Health Centre Ndoni 3 Model Primary Health Centre Okwuzi 4 Model Primary Health Centre Mgbede 5 Model Primary Health Centre Ibocha 6 Model Primary Health Centre Ase-Aziga 7 Primary Health Centre Eneme 8 Primary Health Centre Akabuka 9 Primary Health Centre Oboburu 10 Primary Health Centre Akabuta 11 Primary Health Centre Iju-Ogba 12 Primary Health Centre Obagi 13 Primary Health Centre Kreigari 14 Primary Health Centre Obor 15 Primary Health Centre Ohiaugu 16 Primary Health Centre Elieta 17 Primary Health Centre Egbeda 18 Primary Health Centre Ikiri 19 Primary Health Centre Okposi 20 Primary Health Centre Obigwe 21 Primary Health Centre Obite 22 Primary Health Centre Ogbogu 23 Primary Health Centre Obrikom 24 Primary Health Centre Aggah
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25 Primary Health Centre Amah 26 Primary Health Centre Ndoni 27 General Hospital,Erema Erema 28 General Hospital,Omoku Omoku 30 General Hospital,Okwuzi Okwuzi OGU/BULO 1 General Hospital,Ogu Ogu 2 Model Primary Health Centre Ogu 3 Chuku Health Centre Ogu 4 Basic Health Centre Bolo 5 Owuogono Health Centre Owuogono 6 Ele Health Centre Ele 7 Opuama Health Centre Opupuama 8 Ikpoama Health Centre Ikpoama 9 Wakama Health Centre Wakama OKRIKA 1 Model Primary Health Centre Ibaka 2 Model Primary Health Centre Ogoloma 3 Model Primary Health Centre Okochiri 4 Model Primary Health Centre Ogan-Ama 5 Model Primary Health Centre Anyungu-Biri 6 Primary Health Centre Ogbogbo 7 Primary Health Centre Isaka 8 Primary Health Centre Okujagu 9 Primary Health Centre Oba-Ama 10 Primary Health Centre Kalio-Ama 11 Primary Health Centre George-Ama 12 Island Maternity Home Okrika 13 General Hospital,Okrika Okrika OMUMA 1 Eberi Health Centre Umualika Eberi 2 Obiohia Model Health Centre Okpolor-Obiohia 3 Chim-Oyiro Health Centre Umuobuo-Ohimgho 4 Oyiro-Model Health Centre Umuoko town 5 Ofeh Health Centre Umunwaka-Ofeh 6 Umunju Health Centre Umunju-Umuogba 7 Umuogba Health Centre Umukamanu
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8 Umueze Health Centre Umuegwu-Umueze 9 Umuokwa Health Centre UmuokwaUmuogba 10 Umuoke Health Centre EgbeluUmujulaka 11 Comprehensive Health Centre UmudikeUmujulor 12 Owuahiake Health Centre UmuakaliUmuajulok 13 General Hospital Eberi Umuobasi-Eberis OPOBO/NKORO 1 Comprehensive Health Centre Opobo town 2 Queen’s Town Health Centre Queen’s town 3 Comprehensive Health Centre Nkoro Town 4 Health Centre,Kalaibiama Kalaibiama 5 Health Centre Epellema 6 Health Centre Minima 7 General Hospital,Opobo Opobo Town OYIGBO 1 Comprehensive Health Centre Afam Road,Oyigbo 2 Umusaya Health Centre Umusaya 3 Egberu Health Centre Egberu 4 Obeakpu Health Centre Obeakpu 5 Umuagbai Health Centre Umuagbai 6 Imirinwanyi Health Centre Imirinwanyi PORTHARCOURT 1 Elakahia Health Centre Elakahia Community CITY 2 Orogbum Health Centre Ogbum-nuabali 3 Civil Servant Clinic State Secretariat 4 Every Woman Clinic Marine Base 5 Naval Medical Centre New Rd Borokiri 6 Churchill Health Centre Churchill Rd Borokiri 7 Mini Health Centre Mile3,Diobu PH 8 Abuloma Health Centre Abuloma town 9 Azuabie Health Centre Azuabie Community 10 RSUST Clinic RSUST Campus 11 Ozuboko Health Centre Ozuboko town 12 Amadi-Ama Health Centre Amadi-Ama town 13 2nd Amphibious Brigade Clinic Rainbow T/Amadi 14 Mgbundukwu Health Centre Okija Street,Diobu
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15 Bundu Health Centre Gbundu Community 16 Custom Clinic NPA Portharcourt 17 Ports Johnson Clinic PortsJohnson Street 18 Police Clinic Moscow Road,PH 19 B M S H Hospital Old GRA,PH 20 Military Hospital Aba Road TAI 1 Kpite primary Health Care Centre Kpite 2 Nonwa Primary Health Care Centre Nonwa 3 Bunu Primary Health Care Centre Bunu 4 Koroma Primary Health Care Centre Koroma 5 Bara-Ale Primary Health Care Bara-Ale Centre 6 Botem Primary Health Care Centre Botem 7 Ban-Ogoi Health Centre Ban-Ogoi 8 Koro-Koro Health Centre Koro-Koro
Total number of Government Health Facilities is 377.
Source: Rivers State TBL Annual Report, 2010.
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6.2 FUNCTIONAL DOTS AND MICROSCOPY CENTRES BY LGA DURING 2010
S/NO NAME OF LGA NAMES OF HEALTH NAME OF FACILITIES MICROSCOPY CENTRE 1 1. Ayama Health Centre Ayama Health Centre ABUA/ODUAL 2. Aminiboko Cottage Hospital Lab. 3. Egbolom Health Centre 2 1. Comprehensive Health Comp. Health AHOADA –EAST Centr,e Ahoada Centre Ahoada Lab. 2. Edeoha Health Centre 3. Ula-Upata Health Centre 4. Ihuowo Health Centre 5, Ochigba Health Centre 6. Odiabidi Health Centre 7. Ahoada Prison DOTS Clinic 3 1. Akinima Health Centre AHOADA-WEST 2. Edagberi Cottage Hospital 4 1. Abonnema Health Centre Comp. H/Centre Lab AKUKU-TORU Abonnema 2. Kula Health Centre 5 1. Ngo Health Centre ANDONI 2. Otuafu/ofunria Health Centre 3. Unyeada Health Centre
6 1. Maternal and Child Health Maternal and Child ASARI-TORU Health Centre Lab, Centre, Buguma Buguma
7 1. Comprehensive Health Comprehensive Health BONNY Centre, Bonny Centre Bonny 2. Finima Health Centre 8 1. Comp. Health Centre Degema DEGEMA 2. Bille Health Centre
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3. Obuama Health Centre 4. Bakana Health Centre? 5. Degema Prison 9 1. Nchie Health Centre GeneralHospital ELEME Nicha Laboratory: 2. Daughters of Charity Ebubu 3. Sonabel Medical Centre Annex Onne
10 1. TB- Intake Centre. Emohua TBL Lab TB Intake EMOHUA Centre, Emohua 2. Comp. Health Centre Ndele 3. Comp. Health Centre Rumuji 4. Comp. Health Centre Ibaa 5. Comp. Health Centre Omudioga 11 1. Ulakwo II Health Centre Okehi Health Centre ETCHE 2. Nihi Health Centre Lab 3. Umuede-Mba Health Centre 4. Okehi Grassroot/Maternity 12 1. Kpor Health Centre GOKANA 2. Yeghe Health Centre 3. Bomu Health Centre 13 1. General Hospital Isiokpo GeneralHospital IKWERRE Isiokpo Laboratory: 2.Omagwa Health Centre 3. Igwuruta Health Centre 4. Apani Health Centre 5. Elele Health Centre 6. Omerelu Health Centre 7. Ubima Health Centre 14 1. Bori Health Centre GeneralHospital KHANA Bori Laboratory: 2. Uegwere Health Centre
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3. Eeken Health Centre (Pope Eeken Health Centre John Paul PHC Centre) Lab
15 1. Rumuokwurusi Health Centre OBIO/AKPOR 2. Rumuigbo Health Centre 3. Ozuoba-Akpor Health Centre 4. Army Medical Centre Bori Camp Portharcourt 5. Air Force Medical Centre, off Aba Air Force Medical Rd. Centre Lab,
6. UPTH, Port Harcourt DOTS Centre 7. Immanuel Clinic, Rumuokwuta Immanuel Clinic Lab. 8. Rumueme Health Centre 9. Woji Cottage Hospital 10. Iriebe Model Health Centre 11. Immanuel Hospital 16 1. Comprehensive Health Centre TBL Lab Comp Health OGBA/EGBEMA/ Omoku Centre, Omoku: NDONI
2. Obriokon Health Centre 3. Mgbede Health Centre 4. Ohiauga Health Centre 5. Kreigani Health Centre 6. Obite Health Centre 7. Ogbogu Health Centre 8. Akabuka Health Centre 9. Erema Health Centre 10. Oboburu Health Centre 11. Gbeye Clinic, Omoku Gbeye Clinic Lab. 12. Idu Health Centre Omoku 17. 1. Comprehensive Health Centre, Comp Health Centre OGU/BOLO OguTown Lab Ogu: 2. Bolo Health Centre, Bolo Town
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3. Ikpo Health Centre
18 1. Anyungu Biri Health Centre General Hospital OKRIKA 2. Ogoloma Health Centre Laboratory, Okrika 3. Ibaka Health Centre 19 1. Eberi Health Centre Eberi Health Centre OMUMA Laboratory: 2. Umuokwa Health Centre 3. Umuajuloke Health Centre 4. Obiohia Health Centre 5. Umuoke Health Centre 6. Umuogba Health Centre 7. Umunju Health Centre 8. Ofeh Health Centre 9. Oyoro Model Health Centre 20 1. Comprehensive Health Centre, OPOBO/NKORO Opobo 2. Queen’s Town Health Centre 21 1. Umuagbai Health Centre TBL Lab, Umuagbai OYIGBO Health Centre: 2. Comp. H/Centre, OyigboTown Oyigbo H/C Lab
22 PORT 1. MorningStarHospital, P.H. Morning Star Hospital HARCOURT Lab, P.H 2. St. Patrick’s Hospital P.H. St. Patrick’s Hospital Lab, P.H 3. Churchill Health Centre P.H. 4. Orogbum Health Centre P.H. 5. Abuloma Health Centre 6. Potts Johnson Health Centre, P.H. 7. Prisons Port Harcourt.
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23 1. Kpite Health Centre TAI 2. Sime Health Centre 3. Ban-Ogoi Health Centre 4. Bunu Health Centre 5. Koroma Health Centre
105 DOTS CENTRES 23 MICROSCOPY Total CENTRES
Total number of DOTs facilities = 105
Total number of Government health facilities = 377
The percentage coverage of DOTs centres in the state is: 105 x 100
377 1 = 28%
What is discernable from the percentage coverage of DOTs facilities among the government health facilities in the State is, that patients affected by tuberculosis may have to travel long distances before they can access treatment. Given their financial status and the demanding nature of the treatment due to the duration of treatment, this may definitely not be in the interest of either parties- the care-giver and the patients. Above all, it is also not in the interest of the programme as some of them will default in the treatment schedule.
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6.3 TABLE 1: TUBERCULOSIS SITUATION IN RIVERS STATE LOCAL
GOVERNMENT AREAS (LGAs), NIGERIA (2001-2004)
LGA POPULATION CASE FINDING TUBERCULOSIS 2005 CENSUS 2001 2002 2003 2004 Ahoada East 166747 41 83 204 222 AHOADA WEST 249425 34 43 82 87 Abua / Odua 282988 37 58 127 139 Emohua 201901 21 84 166 230 Ikwerre 189726 15 70 104 132 Etche 249454 7 43 71 79 Omuma 100366 7 22 43 49 Obio / Akpor 464789 30 85 277 345 Port Harcourt 541115 115 314 826 1087 Eleme 190884 16 50 145 173 Oyigbo 122687 5 16 48 64 Khana 294217 20 65 271 313 Gokana 228828 15 37 108 129 Tai 117797 5 74 108 129 Akuku – Toru 156006 6 10 25 35 Asari – Toru 220100 5 12 27 29 Andoni 211009 2 610 38 47 Bonny 215358 7 10 38 47 Degema 249773 6 8 36 39 Ogba/ Egbema / Ndoni 284010 24 61 156 197 Ogu / Bolo 74683 4 7 29 39 Opobo / Nkoro 151511 1 4 12 16 Okirika 222026 4 4 50 61 Total 5,185,400 427 1,166 2997 3685
Source: Nwidu Lucky et al., 2008
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QUARTERLY STATISTICAL REPORT ON TUBERCULOSIS CASE–FINDING BY
LGA ALL QUARTERS 2007
NO NAME OF LGA 1ST 2ND 3RD 4TH ALL QTER QTER QTER QTER TOTAL 1 Abua / Odual 13 11 11 14 49 2 Ahoada – East 17 8 29 27 81 3 Ahoada – West 5 10 13 3 31 4 Akuku – toru 5 3 2 0 10 5 Andoni 8 8 4 4 24 6 Asari – Toru 0 3 2 1 6 7 Bonny 11 6 15 5 37 8 Degema 4 5 0 0 9 9 Eleme 16 21 26 18 81 10 Emohua 50 40 41 34 165 11 Etche 8 14 10 10 42 12 Gokana 10 13 24 25 72 13 Ikwerre 14 19 19 16 68 14 Khana 34 35 32 31 132 15 Obio / Akpor 63 95 149 88 395 16 Onelga 11 34 25 34 104 17 Ogu / Bolo 0 3 3 2 8 18 Okirika 7 6 7 10 30 19 Omuma 5 3 4 3 15 20 Opobo / Nkoro 1 3 7 4 15 21 Oyigbo 4 11 9 13 37 22 Port Harcourt 154 154 141 95 544 23 Tai 5 7 7 8 27 Total 445 512 580 445 1982
Source: Rivers State Annual TBL Programme Report, 2007.
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QUARTERLY STATISTICAL REPORT ON TUBERCULOSIS CASE–FINDING BY
LGA ALL QUARTER 2008
NO NAME OF LGA 1ST 2ND 3RD 4TH ALL QTER QTER QTER QTER TOTAL 1 Abua / Odual 21 13 7 11 52 2 Ahoada – East 36 25 30 32 123 3 Ahoada – West 4 3 3 4 14 4 Akuku – toru 5 2 3 5 15 5 Andoni 2 6 4 5 17 6 Asari – Toru 6 4 4 2 16 7 Bonny 14 8 10 13 45 8 Degema 6 2 2 2 12 9 Eleme 22 17 17 19 75 10 Emohua 50 34 48 43 175 11 Etche 10 19 24 16 69 12 Gokana 21 9 22 19 71 13 Ikwerre 10 19 24 16 69 14 Khana 40 17 52 41 150 15 Obio / Akpor 157 80 155 140 532 16 Onelga 22 23 21 31 97 17 Ogu / Bolo 0 1 1 3 5 18 Okirika 7 9 6 11 33 19 Omuma 6 4 2 4 15 20 Opobo / Nkoro 5 4 2 4 15 21 Oyigbo 18 22 12 16 68 22 Port Harcourt 153 144 130 147 574 23 Tai 5 3 11 9 28 Total 620 457 574 590 2241
Source: Rivers State TBL Programme Report, 2008.
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QUARTERLY STATISTICAL REPORT ON TUBERCULOSIS CASE – FINDING BY
LGA ALL QUARTER 2009
NO NAME OF LGA 1ST 2ND 3RD 4TH ALL QTER QTER QTER QTER TOTAL All Cases All All Cases All All Cases Cases Cases 1 Abua / Odual 11 5 2 7 25 2 Ahoada – East 38 26 12 26 102 3 Ahoada – West 5 1 3 3 12 4 Akuku – toru 4 2 1 5 12 5 Andoni 3 1 3 5 12 6 Asari – Toru 6 4 3 3 16 7 Bonny 12 14 5 7 38 8 Degema 2 2 2 6 12 9 Eleme 13 21 26 11 71 10 Emohua 57 45 52 43 197 11 Etche 15 6 10 13 44 12 Gokana 14 18 15 23 70 13 Ikwerre 50 42 52 23 167 14 Khana 50 42 52 23 167 15 Obio / Akpor 159 160 170 121 610 16 Onelga 25 31 22 30 108 17 Ogu / Bolo 4 3 0 0 7 18 Okirika 9 10 6 15 40 19 Omuma 1 4 5 7 17 20 Opobo / Nkoro 1 1 2 2 6 21 Oyigbo 12 10 10 18 50 22 Port Harcourt 145 144 148 114 551 23 Tai 6 4 3 4 17 Total 601 567 558 499 2225
Source: Rivers State Annual TBL Programme Report, 2009.
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QUARTERLY STATISTICAL REPORT ON TUBERCULOSIS CASE – FINDING BY
LGA ALL quarter 2010
NO NAME OF LGA 1ST 2ND 3RD 4TH ALL QTER QTER QTER QTER TOTAL All Cases All All Cases All All Cases Cases Cases 1 Abua / Odual 12 11 15 7 45 2 Ahoada – East 47 55 21 28 151 3 Ahoada – West 8 0 3 3 14 4 Akuku – toru 2 2 6 2 12 5 Andoni 5 0 1 1 7 6 Asari – Toru 4 4 3 4 15 7 Bonny 14 20 8 13 55 8 Degema 2 2 1 3 8 9 Eleme 23 19 24 27 93 10 Emohua 55 45 45 54 199 11 Etche 8 6 19 12 45 12 Gokana 27 21 22 14 84 13 Ikwerre 16 14 20 16 66 14 Khana 31 52 43 39 165 15 Obio / Akpor 145 113 145 172 575 16 Onelga 29 21 23 22 95 17 Ogu / Bolo 3 7 1 2 13 18 Okirika 12 4 9 9 34 19 Omuma 4 1 3 4 12 20 Opobo / Nkoro 1 3 2 2 8 21 Oyigbo 14 8 13 25 60 22 Port Harcourt 120 130 79 93 422 23 Tai 6 5 5 4 20 Total 588 543 511 556 2198
Source: Rivers State Annual TBL Programme Report, 2010.
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RIVERS STATE TUBERCULOSIS CASES NOTIFICATION (6 YEARS TREND)
YEARS NO. OF CASES YR 2005 1676 YR 2006 1643 YR 2007 1982 YR 2008 2241 YR 2009 2225 YR 2010 2198
CASES OF TUBERCULOSIS
2500
2000
1500
1000
500
0
YR 2005 YR 2006 YR 2007 YR 2008 YR 2009 YR 2010
Source: Rivers State TBL Programme Report 2010
The figures as indicated in the tables presented above are the number of patients for each
specific period. This begins from the year 2001 to 2004, and then 2007 to 2010. For the years
2005 and 2006; absolute numbers were indicated.
An overview of the documented numbers of tuberculosis patients clearly indicates that
there has been a marked and steady increase in the number of patients for the stated period.
However, despite this steady increase in the number of patients, it is worthy to note that from the
156 annual report of the programme for the year 2010, the case detection rate is still abysmally low, at an average of about 40%. If we are to reconcile this with one of the cardinal target of the programme; which is to detect at least 70% of the estimated sputum smear positive cases, it implies that the programme is far from attaining this target. This has had a multiplier effect on the entire goal of the programme.
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CHAPTER SEVEN
POLITICAL AND HEALTH RELATED IMPLICATIONS FROM THE
IMPLEMENTATION OF THE TUBERCULOSIS CONTROL PROGRAMME
IN RIVERS STATE.
7.1 POLITICS (POLITICAL COMMITMENT) AND THE IMPLEMENTATION OF
TUBERCULOSIS CONTROL PROGRAMME IN RIVERS STATE.
The focus of this chapter is to present and analyse data that was generated from our field work in relation to the stated hypotheses advanced for this study. The data is the outcome of both the primary and secondary sources. In this section, the basic question answered is: (1) Is there a relationship between the allocation and distribution of resources and the implementation of the tuberculosis control programme?
What is measured through the data that will be presented and analyzed are the governance and implementation issues that have impacted on tuberculosis (TB) control in
Rivers State. Succinctly put, we shall examine the current health sector, financial and economic policies and practices that has impacted on Tuberculosis control in the State. It is anticipated that: how the use of government power in the distribution and allocation of resources impacts on the implementation of tuberculosis (TB) control programme in Rivers State will become illumined. Hopefully, as this is achieved, the purpose will then have been fulfilled.
It is necessary to state that a total of one hundred and forty (140) copies of close and open–ended questionnaires were administered amongst stakeholders and focal persons of the tuberculosis (TB) control services in Rivers State. The simple random sampling and judgmental or purpose sample methods were employed in the distribution of the questionnaires. This enabled all LGA programme officers, DOTS focal persons and other actors in the control programme to receive the questionnaire. Out of a total of one hundred and forty (140) copies of questionnaires that were distributed, 117 or 84% were retrieved from the respondents. This is graphically shown below (see table). 158
Table 7.1.
NUMBER OF QUESTIONNAIRES ADMINISTERED AND SUBSEQUENTLY RETRIEVED FROM THE LGA PROGRAMME OFFICERS, DOTS FOCAL PERSONS AND OTHER STAKEHOLDERS IN TUBERCULOSIS CONTROL SERVICES IN RIVERS STATE
S/NO LOCAL GOVERNEMENT NUMBER NUMBER AREA ADMINISTERED RETRIEVED 1 Abual / Odual 5 4 2 Ahoada East 7 7 3 Ahoada West 6 5 4 Akuku Toru 3 2 5 Andoni 6 5 6 Asari Toru 5 4 7 Bonny 5 5 8 Degema 7 5 9 Eleme 4 4 10 Emuoha 6 5 11 Etche 4 4 12 Gokana 3 3 13 Ikwerre 8 7 14 Khana 6 5 15 Obio/Akpor 8 6 16 Ogba/Egbema/Ndoni 16 12 17 Ogu/Bulo 3 3 18 Okrika 2 2 19 Omuma 8 5 20 Opobo/Nkoro 3 3 21 Oyigbo 3 2 22 Port Harcourt City 9 7 23 Tai 5 5 24 State Programme Officers / Others 8 7 Total 140 117 Source: Field survey data, 2010.
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In the course of the analysis of the questionnaire, the gender response indicates that of the 117 retrieved questionnaires which form the basis of the analysis 50 or 42.7% were females while 67 or 57.2% are males. The lesson that unfolds here is that it is consistent with the nature of public service in our society, where men still dominates the affairs; although health care services by nature is perceived to be a female dominated system
To accomplish the task of our analysis, the responses from the questionnaire survey were tabulated, coded and expressed in terms of simple percentages. Following these, they were interpreted and used in the evaluation of the research hypotheses. Additionally, information from the secondary sources that are relevant was used in supporting the analysis of the data. The chi-square test was equally used to determine the relationship between some of the variables.
We started with the aim of establishing how the respondents are associated with the tuberculosis control services in the state. The intention here is to identify and categorize their level of involvement and knowledge of the tuberculosis control programme.
TABLE 7.1.1 ON THE RESPONDENTS ASSOCIATION WITH THE TUBERCULOSIS CONTROL SERVICES.
RESPONSE ALTERNATIVE NUMBER OF PERCENTAGE RESPONDENTS OF TOTAL WHO Representative/staff 1 0.85% Development partner/Donor Agency 7 5.9% State control programme officers 24 20.5% LGA Programme Staff 26 22.2% NGOs in TB Control 0 0% DOTs Centre Staff/Focal Person 59 50.4% Total 117 100% Source: Field survey data, 2010.
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What manifests from the table above is that 59 or 50.4% of those who responded to the questionnaire were Directly Observed Treatment (DOTS) Centre personnel, 26 (22.2%) were
Local Government Areas (LGA) Programme personnel while 24(20.5%) were state control programme Officers. The Development Partners/Donor Agency personnel were 7 (5.9%) and the World Health Organisation (WHO) staff was just 1(0.85%). Although, the programme has a structure cutting across the Federal, State and Local Government Levels, it is basically implemented at the Local Government Area (LGA) with supervisory role carried out by the
State Programme Officers. Suffice it to say that from the respondents’ background, a greater number of them are those who are actually involved at the level of the implementation of the tuberculosis control services. Ordinarily, it should be taken that they have a better knowledge of the programme implementation issues, as well as its challenges and are better placed to answer the questions fairly and objectively.
TABLE 7.1.2
ON THE NUMBER OF YEARS WORKING IN THE TUBERCULOSIS (TB) CONTROL SERVICES.
RESPONSE NUMBER OF PERCENTAGE OF ALTERNATIVE RESPONDENTS TOTAL 1-10Years 83 70.9 11-20years 25 21.4 21years and above 9 7.7 Total 117 100 Source: Field survey data, 2010.
An analysis of the table above rightly indicates that 83(70.9%) of the personnel involved in the delivery of the tuberculosis control services in the state have worked for less than ten(10) years in the programme; while 25(21.4%) have been working in the programme for between 11-
20 years and 9(7.7%) for 21years and above.
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With more than 50% having worked in the Tuberculosis control services for less than ten years and less than 25% being involved for between 11-20 years, and 9(7.7%) for 21years and above, it shows that the programme has suffered from incessant staff movement and this can be likened to a ‘war of attrition’ in the programme. The implication is that the tuberculosis control service is short–changed in terms of personnel who have the knowledge, skills and experience to effectively carry out the services. This may be a reflection of response from the staff towards government attitude to the programme considering the risk of attending to a tuberculosis patient due to its infectious nature and source of transmission. It is obvious that retaining a crop of dedicated personnel with the requisite experience requires a measure of incentives which are not forthcoming. The only option is for people to continuously move in order to satisfy their desire.
This is not, in the least, in the best interest of the programme.
TABLE 7.1.3
ON THE KNOWLEDGE OF ANY SET STANDARDS FOR THE PROPER IMPLEMENTATION OF THE TB CONTROL SERVICES LOCALLY AND INTERNATIONALLY.
RESPONSE NUMBER OF PERCENTAGES OF OPTIONS RESPONDENT TOTAL Yes 110 94 No 5 4.3 Not Aware 2 1.7 Total 117 100 Source: Field survey data, 2010.
An overview of the table above shows that 110(94%) responded in the affirmative,
5(4.3%) were contrary while 2(1.7%) exhibited ignorance of the issue at stake. Those who work in the programme and are knowledgeable about the set standards for the proper implementation of the tuberculosis control services are overwhelmingly in the majority with a whopping 94%
162 while those who do not know are a mere 4.3%, too insignificant; and people not aware just
1.7%.
What can be deduced from this is that given the right environment and necessary requirements, a greater number of personnel involved in the prosecution of activities of the tuberculosis control services are highly informed and have better knowledge of set standards for the proper implementation of the programme. This is a positive development for the programme and requires complementary support from the government through the provision of the consumables for the services and the granting of incentives to them in order to enhance their productivity.
There exists an International Standards for Tuberculosis Care (ISTC) as provided by the
World Health Organization (WHO; 2006). In all, there are seventeen (17) standards that are delineated into three sub–headings: Standards for Diagnosis, Standards for Treatment and
Standards for Public Health Responsibilities. They are highlighted below:
The International Standards for Tuberculosis Care(ISTC) describes a widely accepted level of care that all practitioners, public and private, should follow in dealing with people who have, or are suspected of having, tuberculosis. The Standards are intended to facilitate the effective engagement of all care providers in delivering high-quality care for patients of all ages, including those with sputum smear-positive, sputum smear-negative, and extra pulmonary tuberculosis; tuberculosis caused by drug resistant mycobacterium tuberculosis complex (M. tuberculosis) organisms; and tuberculosis combined with human immunodeficiency virus (HIV) infection.Developed by the Tuberculosis Coalition for Technical Assistance, Funded by the US
Agency for International Development. Endorsed by the World Health Organization, Stop TB
Partnership, American Thoracic Society, International Union Against Tuberculosis & Lung
Disease, U.S. Centers for Disease Control & Prevention, Dutch Tuberculosis Foundation
(KNCV), Indian Medical Association, Philippine Coalition Against Tuberculosis, Philippine
College of Chest Physicians, Sociedade Brasileira de Infectologia (SBI), International Council 163 of Nurses, American College of Chest Physicians, Advisory Council for the Elimination of
Tuberculosis (U.S.), Indonesian Association of Pulmonologists, Infectious Diseases Society of
America, and World Care Council.
INTERNATIONAL STANDARDS FOR TUBERCULOSIS CARE
Standards for Diagnosis
STANDARD 1.All persons with otherwise unexplained productive cough lasting two–three weeks or more should be evaluated for tuberculosis.
STANDARD 2.All patients (adults, adolescents, and children who are capable of producing sputum) suspected of having pulmonary tuberculosis should have at least two, and preferably three, sputum specimens obtained for microscopic examination. When possible, at least one early morning specimen should be obtained.
STANDARD 3.For all patients (adults, adolescents, and children) suspected of having extra pulmonary Tuberculosis, appropriate specimens from the suspected sites of involvement should be obtained for microscopy and, where facilities and resources are available, for culture and histopathological examination.
STANDARD 4.All persons with chest radiographic findings suggestive of tuberculosis should have sputum specimens submitted for microbiological examination.
STANDARD 5.The diagnosis of sputum smear-negative pulmonary tuberculosis should be based on the following criteria: at least three negative sputum smears (including at least one early morning specimen); chest radiography findings consistent with tuberculosis; and lack of response to a trial of broad-spectrum antimicrobial agents. (NOTE: Because the fl uoroquinolones are active against M. tuberculosis complex and, thus, may cause transient improvement in persons with tuberculosis, they should be avoided.) For such patients, if facilities for culture are available, sputum cultures should be obtained. In persons with known or suspected HIV infection, the diagnostic evaluation should be expedited.
164
STANDARD 6.The diagnosis of intrathoracic (i.e., pulmonary, pleural, and mediastinal or hilarlymphnode) tuberculosis in symptomatic children with negative sputum smears should be based on the finding of chest radiographic abnormalities consistent with tuberculosis and either a history of exposure to an infectious case or evidence of tuberculosis infection (positive tuberculin skin test or interferon gamma release assay). For such patients, if facilities for culture are available, sputum specimens should be obtained (by expectoration, gastric washings, or induced sputum) for culture.
Standards for Treatment
STANDARD 7.Any practitioner treating a patient for tuberculosis is assuming an important public health responsibility. To fulfill this responsibility the practitioner must not only prescribe an appropriate regimen but, also, be capable of assessing the adherence of the patient to the regimen and addressing poor adherence when it occurs. By so doing, the provider will be able to ensure adherence to the regimen until treatment is completed.
STANDARD 8.All patients (including those with HIV infection) who have not been treated previously should receive an internationally accepted first-line treatment regimen using drugs of known bioavailability. The initial phase should consist of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol. The preferred continuation phase consists of isoniazid and rifampicin given for four months. Isoniazid and ethambutol given for six months is an alternative continuation phase regimen that may be used when adherence cannot be assessed, but it is associated with a higher rate of failure and relapse, especially in patients with HIV infection. The doses of anti–tuberculosis drugs used should conform to international recommendations. Fixed-dose combinations of two (isoniazid and rifampicin), three (isoniazid, rifampicin, and pyrazinamide) and four (isoniazid, rifampicin, pyrazinamide, and ethambutol) drugs are highly recommended, especially when medication ingestion is not observed.
STANDARD 9.To foster and assess adherence, a patient-centered approach to administration of drug treatment, based on the patient’s needs and mutual respect between the patient and the
165 provider, should be developed for all patients. Supervision and support should be gender- sensitive and age-specific and should draw on the full range of recommended interventions and available support services, including patient counseling and education. A central element of the patient-centered strategy is the use of measures to assess and promote adherence to the treatment regimen and to address poor adherence when it occurs. These measures should be tailored to the individual patient’s circumstances and be mutually acceptable to the patient and the provider.
Such measures may include direct observation of medication ingestion (directly observed therapy—DOT) by a treatment supporter who is acceptable and accountable to the patient and to the health system.
STANDARD 10.All patients should be monitored for response to therapy, best judged in patients with pulmonary tuberculosis by follow-up sputum smear microscopy (two specimens) at least at the time of completion of the initial phase of treatment (two months), at five months, and at the end of treatment. Patients who have positive smears during the fifth month of treatment should be considered as treatment failures and have therapy modified appropriately.
(See Standards 14 and 15.) In patients with extra-pulmonary tuberculosis and in children, the response to treatment is best assessed clinically. Follow- up radiographic examinations are usually unnecessary and may be misleading.
STANDARD 11.A written record of all medications given, bacteriologic response, and adverse reactions should be maintained for all patients.
STANDARD 12.In areas with a high prevalence of HIV infection in the general population and where tuberculosis and HIV infection are likely to co-exist, HIV counseling and testing is indicated for all tuberculosis patients as part of their routine management. In areas with lower prevalence rates of HIV, HIV counseling and testing is indicated for tuberculosis patients with symptoms and/or signs of HIV-related conditions and in tuberculosis patients having a history suggestive of high risk of HIV exposure.
166
STANDARD 13.All patients with tuberculosis and HIV infection should be evaluated to determine if antiretroviral therapy is indicated during the course of treatment for tuberculosis.
Appropriate arrangements for access to antiretroviral drugs should be made for patients who meet indications for treatment. Given the complexity of co-administration of anti-tuberculosis treatment and antiretroviral therapy, consultation with a physician who is expert in this area is recommended before initiation of concurrent treatment for tuberculosis and HIV infection, regardless of which disease appeared first. However, initiation of treatment for tuberculosis should not be delayed. Patients with tuberculosis and HIV infection should also receive co- trimoxazole as prophylaxis for other infections.
STANDARD 14.An assessment of the likelihood of drug resistance, based on history of prior treatment, exposure to a possible source case having drug-resistant organisms, and the community prevalence of drug resistance, should be obtained for all patients. Patients who fail treatment and chronic cases should always be assessed for possible drug resistance. For patients in whom drug resistance is considered to be likely, culture and drug susceptibility testing for isoniazid, rifampicin, and ethambutol should be performed promptly.
STANDARD 15.Patients with tuberculosis caused by drug-resistant (especially multiple-drug resistant [MDR]) organisms should be treated with specialized regimens containing second-line anti-tuberculosis drugs. At least four drugs to which the organisms are known or presumed to be susceptible should be used, and treatment should be given for at least 18 months. Patient- centered measures are required to ensure adherence. Consultation with a provider experienced in treatment of patients with MDR tuberculosis should be obtained.
Standards for Public Health Responsibilities
STANDARD 16.All providers of care for patients with tuberculosis should ensure that persons
(especially children under 5 years of age and persons with HIV infection) who are in close contact with patients who have infectious tuberculosis are evaluated and managed in line with international recommendations. Children under 5 years of age and persons with HIV infection
167 who have been in contact with an infectious case should be evaluated for both latent infection with M. tuberculosis and for active tuberculosis.
STANDARD 17.All providers must report both new and retreatment tuberculosis cases and their treatment out comes to local public health authorities, in conformance with applicable legal requirements and policies.
TABLE 7.1.4
HAS THE GOVERNMENT ENACTED ANY LAW THAT SUPPORTS THE IMPLEMENTATION OF TB CONTROL SERVICES?
RESPONSE OPTIONS NUMBER OF PERCENTAGE OF RESPONDENTS TOTAL Yes 40 35 No 74 65 Not Aware 0 0 Total 114 100 Source: Field survey data, 2010.
The table above is the respondents’ response to the issue of whether the government, who are the policy makers, has any one in place in support of the proper implementation of the tuberculosis control services. As it can be observed, those who respond in the affirmative
40(35%), while 74(65%) are those whose views are in the contrary, indicating that they do not have any knowledge of the enactment of any legislation by the government in support of the control of tuberculosis. This response coming from people who are directly involved in the delivery of the services shows that the government may not have any policy in place, in which through its implementation will enhance the delivery of the tuberculosis control services.
Indeed, the World Health Organization (WHO) provides a set of indicators called ‘a
Compendium of indicators for monitoring and Evaluating National TB program’. In it, (WHO,
2004:83), a national tuberculosis policy is listed as an indicator. The National TB Policy is defined as when “the government formally adopts, through legislative or administrative
168 measures, complete national tuberculosis control policy that supports the internationally recommended DOTS strategy and guidelines for tuberculosis control. According to this indicator for monitoring and evaluating TB programs “the adoption of a formal policy demonstrates political commitment to action at the central level and facilitates more effective, strategic implementation of TB control activities. The policy should reflect the internationally accepted DOTS strategy and specify its position in the health system as a key element of health services. The policy should also refer to the role played by management units and facilities at all levels of the health system in DOTS implementation, with a goal of nationwide coverage. This indicator may be helpful for stimulating policy development and for identifying strengths and weaknesses of national TB control policy” (WHO, 2004:83).
It is worthy to note that policy is a set of principles guiding decision making. It provides a framework against which proposals or activities can be tested and progress measured. Ideally, a policy contains a definition of the problem being addressed, a statement of goals (the desired state of affairs), and at least the broad outline of the instruments (approaches and activities) by which the goals are to be achieved. The fact is, at the national level, there exist policy framework that has been captured in the 2005–2010 and 2010–2015 national strategic plans for the control of tuberculosis and leprosy. It is expected that states should adopt and domesticate them. However, this does not exist in Rivers State. In the absence of policy framework for the implementation of tuberculosis control services, the implication can better be imagined.
TABLE 7.1.5 HAS THE CONTROL TEAM BEEN PROVIDED WITH THE ESSENTIAL REQUIREMENTS NEEDED FOR THEIR WORK BY THE GOVERNMENT? RESPONSE NUMMBER OF PERCENTAGE OF OPTION RESPONDENTS TOTAL Yes 28 29.2 No 32 33.3 Not Aware 36 38 Total 96 100 169
Source: Field survey data, 2010.
As indicated above, the response to the question if the government has provided the essential requirements needed for the work shows that 28(29.2%) are affirmative, 32(33.3%) are on the contrary while 36(38%) says they are not aware. It justifies the fact that, the government may not have been provding the essential requirements needed to enhance their work.
TABLE 7.1.6
PERCENTAGE OF THE ESSENTIAL REQUIREMENTS PROVIDED BY
GOVERNMENT FOR THE TUBERCULOSIS CONTROL SERVICES.
RESPONSE OPTIONS NUMBER OF PERCENTAGE OF TOAL RESPONDENTS Below 20% 21 22.4 Between 21-40% 43 44.3 Between 41-60% 26 26.8 Between 61-80% 4 4.1 Above 80% 3 3.0 Total 97 100 Source: Field Survey data, 2010
This is also a follow–up question that sought to know or determine the percentage of the essential requirements provided by government for the delivery of TB control services if any. As can be seen above 21(22.4%) said it is below 20%, 43(22.3%) stated that it is between 21-40%;
26(26.8%) contends that it is between 61-80% while 3(3.0%) says that it is above 80%. A significant point about this question is that it is among those that received the least number of respondents. The response to this question certainly indicates a kind of mixed fillings among the respondents.
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TABLE 7.1.7
HAS ANY MEMBER OF THE EXECUTIVE ARM OF GOVERNMENT BEEN INVOLVED IN ANY ADVOCACY ACTIVITY (IES) FOR THE TUBERCULOSIS CONTROL PROGRAMME?
RESPONSE OPTIONS NUMBER OF PERCENTAGES OF RESPONDENTS TOTAL Yes 08 7.4
No 88 75.3 Not Aware 21 17.2 Total 117 100% Source: Field survey data, 2010.
The table above indicates that any member of the excutive arm of government may not have been involved in any known advocacy activity(ies) in support of the tuberculosis control programme with 8(7%) answering in the affirmative,while 88(75.3%) is on the contrary, while
21(17%) contends that they are not aware.
TABLE 7.1.8
WHO PROVIDES DRUGS / BASIC NECCESITIES USED BY THE PATIENTS?
RESPONSE OPTION NUMBER OF PERCENTAGE OF RESPONDENTS TOTAL Response partner/Donor Agency 87 74.4 State government 4 3.4 Non-Governmental 26 22.2 Organization(NGO) Not Aware 0 0 Total 117 100% Source: Field survey data, 2010.
The respondents’ response to the question above indicates that 87(74.4%) saying it is the
Development Partners (DPs) that provides the drugs and other basic requirements that are used
171 for the execution of the tuberculosis control programme, 4(3.4%) say it is the state government while 26(22.2%) opines that it is the Non–governmental organization. Here, it should be noted that there is the tendency to confuse Development partners (DPs) with a Non Governmental
Organization (NGO). However, what is obvious from the response is that those who affirm that the Development Partners (DPs) and or Donor Agency provides the drugs and other basic requirements got it right. This is clearly stated in the memorandum of understanding (MoU) binding the implementation of tuberculosis (TB) control services.
TABLE 7.1.9
HAS THERE BEEN DRUG STOCK–OUTS IN THE COURSE OF PROVIDING TB CONTROL SERVICES?
RESPONSE OPTIONS NUMBER OF PERCENTAGE OF RESPONDENTS TOTAL Yes 74 63.2 No 35 29.2 Not Aware 8 6.8 Total 117 100 Source: Field survey data, 2010.
The response to the question above was overwhelming with all the respondents to the questionnaire responding to it. In the response 74(63.2%) affirms that there has been drug stock–outs in the course of implementing the TB control services 35(29.9%) says no while
8(6.8%) were indeterminate.
The medication regimens for the management of tuberculosis are in three categories, each corresponding to the category of the patient that is, New Patients, Relapse (Previously treated patients) and children. The duration of treatment for each of this category is eight (8) months and more recently it is six (6) months. As in all other diseases condition, it is important that the duration of treatment is strictly adhered to and when this is not obtainable, it creates serious complications such as drug resistance for the patients with its attendant impact on public
172 health given that it is an air–borne disease. Drug resistance creates the problem of resistance strains for the tubercle bacilli thereby rendering the drugs impotent and contributes to the low quality of the programme.
TABLE 7.1.10
HOW FREQUENT HAS BEEN THE DRUG STOCK–OUTS?
RESPONSE OPTIONS NUMBER OF PERCENTAGE RESPONDENTS OF TOTAL Every year 68 63 Once in two years 20 18.5 Once in three years 20 18.5 Total 108 100 Source: Field Survey data, 2010
This is another follow–up question intended to ascertain the frequency of drug stock– outs in the tuberculosis control programme. From the response, 68(63%) of the respondents contend that the drug stock–outs situation in the programme has been occurring every year.
Twenty (20) or 18.5% of the respondents say it is once in two years while 20(18.5%) opine that it occurs once in every three years. Those who contend that it occurs in every year are an overwhelming majority of 68 or 63% of the 108 that responded to this question. The fact is, from the information available. It has been occurring every year in the last couple of years.
Factors responsible for this include but not limited to customs clearance at the port leading to over delay, failure of the government to pay their counterpart funding so that the drugs could be shipped on time and other sundry issues that tasks the political will of the government towards the programme.
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TABLE 7.1.11
DID THE STATE GOVERNMENT STEPPED IN TO SAVE THE DRUG STOCK – OUTS SITUATION?
RESPONSE OPTIONS NUMBER OF PERCENTAGE RESPONDENT OF TOTAL Yes 25 22.1 No 36 31.9 Not Aware 52 46.0 Total 113 100 Source: Field survey data, 2010.
An analysis of the response to the question of whether the government did stepped in to remedy the frequent drug stock–out situation clearly shows that 25(22.1%) says yes 36(31.9%) are contrary, while 52(46.0%) said they are not aware if the government ever stepped in to ameliorate the drug stock–outs situation. It raises the issues of the lack of interest on information bordering on one’s job by the employee and this may affect productivity and or the delivery of services.
TABLE 7.1.12
ON WHETHER THE STATE GOVERNMENT ALLOCATES FINANCIAL RESOURCES IN HER ANNUAL BUDGETS FOR THE TB CONTROL SERVICES.
RESPONSE OPTION NUMBER OF PERCENTAGE RESPONDENTS OF TOTAL Yes 37 31.9 No 27 23.2 Not Aware 52 44.8 Total 116 100 Source: Field survey data, 2010.
The response to the question of whether the state government usually allocates financial resources in her annual budget for the TB control services indicates that 37(31.9%) answer in
174 the affirmative, 27(23.2%) respond to the contrary while, 52(44.8%) were indeterminate. The greater number of the respondents who are not aware of the state of affairs concerning the allocation of financial resources is a reflection of the hoarding of information from the employees by the government. It also shows the lack of interest on the part of the workers to consciously make effort to know what impacts on the delivery of their services. Also, from the budget highlights for the health sector in the years 2004-2010, it is obvious that the state government has not been allocating financial resources for the tuberculosis control services.
TABLE 7.1.13
WHETHER THE BUDGETTED FINNANCIAL RESOURCES ARE USUALLY RELEASED FOR THE SERVICES OF TUBERCULOSIS CONTROL?
RESPONSE OPTION NUMBER OF PERCENTAGES OF RESPONDENTS TOAL Yes 11 10.8% No 33 32.4% Not Aware 58 56.9% Total 102 100% Source: Field survey data, 2010.
The table above shows that 11(10.8%) of the respondents to this question says that the budgeted financial resources are usually released by the government for the tuberculosis control services, 33(32.4%) said no while 58(56.9%) express lack of knowledge about it. The information about budgets as well as the release of financial resources remains a closely guarded secret in most government agencies despite the passage of the freedom of information (FoI) act by the government.
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TABLE 7.1.14
ON HOW THE RELEASED FINANCIAL RESOURCES HAS AFFECTED THE CONTROL OF TUBERCULOSIS.
RESPONSE OPTION NUMBER OF PERCENTAGE RESPONDENTS OF TOTAL Positively 8 9.0 Negatively 21 23.6 Cannot say 60 67.4 Total 89 100 Source: Field survey data, 2010.
It is obvious from the table above that 8(9.0%) of the respondents to this question are of the opinion that the release of financial resources affects the programme positively, 21(23.6%) are in the contrary while 69(67.4%) contend that they do not know the impact of the release of financial resources to the programme. This is perhaps due to the lack of information about it.
TABLE 7.1.15
ARE THERE HEALTH IMPACTS FROM THE IMPLEMENTATION OF THE TUBERCULOSIS CONTROL SERVICES IN RIVERS STATE?
RESPONSE OPTION NUMBER OF PERCENTAGE RESPONDENTS OF TOTAL Yes 80 69.6 No 08 6.96 Not aware 27 23.5 Total 115 100 Source: Field Survey data, 2010
The analysis of the response as contained in the table above indicates that 80 (69.6%) did respond in the affirmative, suggesting that there are health impacts from the implementation of the tuberculosis control services of the State, while 8 (6.9%) were contrary. Interestingly, 27
(23.5%) are not aware, of any health impacts from the implementation of the tuberculosis
176 control services on the society. The message as contained in the expression of those who responded in the affirmative is very clear for any discerning mind.
TABLE 7.1.16
HAS THE DEVELOPMENT PARTNERS/DONOR AGENCY BEEN FULFILLING THEIR EXPECTED ROLE?
RESPONSE OPTIONS NUMBER OF PERCENTAGE RESPONDENTS OF TOTAL Yes 89 76.7% No 17 14.7%
Not Aware 10 8.6% Total 116 100%
Field data survey data, 2010.
Beyond the issue of the involvement of Development Partners (DPs) in the delivery of tuberculosis control services, we went further to know if they are actually playing their role as contained in the memorandum of understanding. The response above indicates that 89(76.7%) affirms that they have been playing their own role, 17(14.7%) are of the contrary opinion while
10(8.6%) contends they are not aware. Indeed, the overwhelming response in the affirmative clearly represents the situation on ground. In fact, it is the general believe of the programme officers that without the Development Partners (DPs) perhaps they should not be talking about the control of tuberculosis through the delivery of the services.
Although, we had provided the logical Data framework (LDF) as our guide for data analysis; we also acknowledged the fact that social analysis is known to parade an avalanche of techniques for data analysis for which the choice of any technique is highly dependent on the needs of the research focus as well as the problem. In this regard, we stated that we will incorporate the framework used for the analysis of the health system in our data analysis. This framework basically focuses on the organizational structure, financing, allocation of resources 177 and service delivery. Interestingly; these are some of the hallmarks of political commitment. The framework/toolkit is reproduced below:
HealthSystem(s) Components
External Health System(s) Healthcare Financing and Needs Information Environment Structure and Delivery Resource Assessment System(s) (PLEST) organisation Allocation
Vertical Programme Components
Political commitment, legislative External Environment context, demographic trends, socio-cultural content
TB organisational system structure and Health system relationships, laboratory and drug structure and organisation distribution networks.
Disease control system, service Linkages with other Healthcare delivery, care process, patterns vertical programmes Delivery of provision and utilization, (e.g. parallel TB Human Resources Programmes; HIV/AIDS Substance Abuse;etc) Financing Financing arrangement and resource allocation
Needs Levels of mobidity and mortality, Assessment cure, transfer, loss rates , drug resistenace rates
Infrastructure; flows; use of information Information for decision making, content of reutine system data sets, quality assurance, tuberculosis classification system
PLEST: Political; Legal; Economic; Socio-Demographic; Technological
Toolkit model: Adapted for rapid systems & contextual analysis & for Tuberculosis Programme
Source: European Journal of Public Health vol.14 2004 No.3
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From the framework above, there are two broad strands: health system(s) components and the vertical programme components. The health system elements or political economy within which the system operates encompasses the general health system while, the vertical programme components is mainly concerned with the programme issues and in this case, tuberculosis. However, in this analysis, we will be mainly concerned with the issues bordering on the vertical programme component with specific reference to tuberculosis.
Notwithstanding the above constituents of the vertical programme, but in line with the focus of this study, we are concerned with the external environment, health system structure and organization and financing. This is anchored on the fact that the questionnaire that was administered and which the responses have been analysed above, elicited answers to questions that bear relevance to these areas and for this study.
THE EXTERNAL ENVIRONMENT
The concept of the external environment as used here implies issues/factors that are not strictly programme-based. These are usually described as social determinants of health, and are undoubtedly capable of impacting on the delivery of tuberculosis control services. Such factors are listed to include political commitment, legislative context, demographic trends, and socio- cultural context. We shall however, be concerned with political commitment and legislative context as they have been dealt with in the questionnaire.
Political commitment is of cardinal importance in any programme implementation irrespective of the sector that is involved. “In TB control, political commitment is absolutely essential for scale-up, impact, and sustainability of effective interventions. Therefore, sustained political commitment is among the five core elements of the DOTS strategy. The commitment of governments to specific policies and programs is notoriously difficult to measure in a quantitative fashion, especially in complex integrated or decentralized health systems.
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Nevertheless, it is possible to broadly gauze whether support is strong, moderate, or weak”
(WHO, 2004:78). It was also echoed in 2006 in the stop TB strategic plan.
In recognition of the importance of political commitment and in solidarity with the standards as set by the WHO, the African Heads of State and Government in 2001 conveyed an
African Summit on HIV/AIDs, Tuberculosis and Other Related Infectious Diseases in Abuja,
Nigeria and came out with the Abuja Declaration on HIV/AIDs, TB and Other Related
Infectious Diseases. In part of it, they declared as follows:“We gathered in Abuja to undertake a critical review and assessment of the situation and the consequences of these diseases in Africa, and to reflect further on new ways and means whereby we, the leaders of our continent, can take the lead in strengthening current successful interventions and developing new and more appropriate policies, practical strategies, effective implementation mechanisms and concrete monitoring structures at national, regional and continental levels with a view to ensuring adequate and effective control of HIV/AIDs, Tuberculosis and other Related Infectious Diseases in our Continent”. (African Summit, 2001:1).
Beyond this, the Ministers of Health of the African Union met in a special session in
2004 at Geneva, Switzerland and resolved to “mobilize total political commitment and leadership at all levels and facilitate greater involvement of communities and civil society in meeting Africa’s health challenges in the 21st century” (African Union Health Ministers
Statement, 2004). Further, to demonstrate their political commitment to the fight against tuberculosis and other diseases, a ‘special summit’ of the African Union on HIV/AIDs, TB and
Malaria(ATM) was equally conveyed at Abuja, Nigeria in 2006 with the theme “Universal
Access to HIV/AIDs, Tuberculosis and Malaria Services by a United Africa by 2010”
In a report by Public Health Watch (Open Society Institute, 2006) on TB policy in
Nigeria, it was contended as follows “Despite expressions of political will to control tuberculosis (TB) and a clearly articulated national TB policy, implementation has been severely hampered by a lack of funding. A recent grant from the Global Fund to fight AIDS, 180
Tuberculosis and Malaria is expected to help close the government’s budgetary gap by providing new resources for TB control. However, government delays in disbursing even the limited funding that has been allocated to TB control are still widespread. Insufficient domestic budgetary allocations have also made it more difficult to attract additional support from the
Global Fund in the past” (Open Society Institute, 2006:36).The logical interpretation of this observation is that expressions of political will do not translate into its execution or implementation.
The World Health Organization’s report on TB for 2009 has maintained that: “scaling up implementation of all components of the stop TB strategy while maintaining strong basic DOTS services requires sustained political commitment including the existence of a national strategic plan for TB control and the percentage of total funding required for TB control that is funded from domestic sources’’. (WHO, 2009:37)
The response to the question of whether the state government has any policy in place that supports the implementation of tuberculosis control services was that of non-assertiveness either on the affirmative or to the contrary. Those who affirm were 29% of the respondents, 33% were on the contrary while 38% indicated that they were not aware if any policy was in place. The implication of this is that it is obvious that in Rivers State, there exists no policy in place by the government towards tuberculosis control services. Given that no policy exists, it means that the state has failed to uphold her stand on the issue of political commitments as demonstrated in the various resolutions. By not clearly articulating a policy, for the implementation of TB control, the state has failed in her responsibility of being at the driving seat for the proper control of tuberculosis.
Given the above, it follows that there is no legislation in place as passed by the legislature and assented to by the executive on the issue of proper control of tuberculosis. The absence of Legislative action by the state which is one of the constituents of the external
181 environment in the framework for capturing of communicable diseases is an indication of the non-commitment of the state to the proper and effective control of tuberculosis.
Furthermore, the absence of a legislative context for tuberculosis is an indication that TB control is not among stated priorities by the government. As an indicator, if TB control has been among stated priorities; “it is a qualitative indicator that notes whether TB control in particular, or communicable disease control, in general, is among the stated health and development priorities of a government or specifically, the ministry of Health, the indicator provides a minimal indicator of government support for TB control and its integration within the array of public health, poverty reduction, or development objectives and priorities. However, the absence of any mention of TB control or communicable disease control may be a signal of important deficiencies in support for TB control and or engagement of TB control implementers in health or development planning”. (WHO, 2004:81).
FINANCING:
The issue of financing arrangements and resource allocation is of utmost importance for any organization to function appropriately. Much as it is of great importance to any organization; it is also a component of this framework that is used in the analysis of specific programmes and or capturing communicable diseases. As an indicator, it captures financial resources committed to TB control programme from the government. It is defined as “the percentage of the NTP budget, as defined in the MDP or annual plan of activities, that is funded by the National government” (WHO,2004 : 93). That is:
Total funding from the government for the annual plan of activities X 100 Total budget required for full implementation of the annual plan of
Activities (consistent with MDP)
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From the above, it measures the governments’ level of financial commitment to tuberculosis control. In measuring it, data on available funding should be compiled and compared with the budget defined in the annual plan of activities. For this to be effectively carried out, the components of the national tuberculosis programme budget must remain fairly consistent in order to make comparisons over time.
An admission of the relevance and necessity of the availability of financial resources to the execution of programmes was made by the leadership of the African state at the African summit on HIV/AIDs, Tuberculosis and other Related Infections Diseases at Abuja, Nigeria in
2001 when they asserted as follows: “We commit ourselves to take all necessary measures to ensure that the needed resources are made available from all sources and that they are efficiently and effectively utilized. In addition, we pledge to set a target of allocating at least 15% of our annual budget to the improvement of the health sector. We also pledge to make available the necessary resources for the improvement of the comprehensive multi-sectoral response, and that an appropriate and adequate portion of this amount is put at the disposal of the National
Commissions/Councils for the fight against HIV/AIDs, Tuberculosis and other Related
Infectious Diseases (African Summit, 2001: 5)
A further show of commitment to the issue of sustainable financing for the TB control programme was also made by the leadership of the African states in 2006, at Abuja during the special summit of African Union on HIV/AIDs, Tuberculosis and Malaria (ATM). As an aspect of the way forward, they contended thus” there is national and international consensus on the strategic direction required for an effective response to TB. What is required is even greater commitment to the actual implementation of proven interventions to meet global control targets.
Countries must ensure predictable and sustained financing with support from donors. The World
Health Assembly Resolution on “Sustainable financing for tuberculosis prevention and control”
(WHA 58:14) expressed the commitment of member states “to ensure the availability of sufficient domestic resources and of sufficient external resources to achieve the internationally
183 agreed development goal relevant to tuberculosis contained in the United Nations Millennium
Declaration” (African Union Summit, 2006:15)
Ironically, as it can be seen in the state governments budgetary allocation to health services (not to mention of TB); it is obvious that expressions of political will does not usually translate into its implementation in our clime. In a Report on TB policy in Nigeria’ by Open
Society Institute (Public Health Watch, 2006: 36-40), it is asserted that “Despite expressions of political will to control TB and a clearly articulated national TB policy, implementation has been severely hampered by a lack of funding… unfortunately, the resolve reflected in these public statements has not been reflected in funding allocations, either in the federal or state budgets. TB awareness at the state and local level is low, although federally led DOTS expansion efforts have motivated some state government officials to become more involved in
TB sensitization and advocacy activities”. According to the Global Fund to Fight Aids, TB and
Malaria, as cited in Guardian(April 9,2013:9) “Effective funding means that collective efforts could turn what scientists call high transmission epidemics into low-level endemics, essentially making them manageable health problems instead of global emergencies”
An overview of the state governments’ budgetary allocation to health services as highlighted in the previous chapter shows that the highest allocation of 4.2%, amounting to
#18,000,000,000.00 of the total budget of #429,000,000,000.00 was made to the Health services in 2010. However, this is far short of the 15% that was pledged by the African Leaders to be allocated to health services.
Secondly, a critical review of the allocations to the various units and programmes within the Ministry of Health for the period under review indicates that it was only between 2008- 2010 that plan for the allocation of financial resources were made to the programme. However, the issue of its release remains doubtful.
Thirdly, an analysis of the allocations to the various units /programmes also shows that contributions to international organizations within the period were equally zero. This would
184 have been the counterpart funding for the programme as agreed to in the memorandum of understanding thus, forging a global partnership for development. This further demonstrates the lack of political commitment on the part of the state towards the programme.
HEALTH SYSTEM STRUCTURE:
The proper implementation of any programme is dependent on its institutional arrangements that conform to the standards as set for it and the availability and utilization of resources. In the case of tuberculosis (TB) programme, there is a programmatic structure that has its origin from the World Health Organization. In line with this, every tuberculosis (TB) control services is expected to be patterned along this line.
For Rivers State, it is obvious that the programme is structured along the lines as set by the adopted structure from the international standards. However, the nature of the terrain of some of the Local Government Areas, the size and unequal distribution of population makes the universal application of the organizational structure of the programme ineffective. For example, the programme provides that each Local Government Area has a manager (supervisor) but in practice, some Local Government Areas (LGAs) should have more than one.
The fact is, the organizational structure is a core aspect and function of the career public servants who ensures that they carry out their duties. This fact was much acknowledged by the special summit of the African Union (2006) when they asserted thus:
“Many constraints faced by vertical programmes have their roots less in the technical content of the programme but rather in health system policy, structure and organization. For the realist, it is not the programmes that work but rather it is the underlying reasons or resources that they offer subjects that generate change”.
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7.2 THE HEALTH RELATED IMPLICATIONS FROM THE IMPLEMENTATION OF
THE TUBERCULOSIS CONTROL PROGRAMME IN RIVERS STATE.
In the preceding section, we have seen how the political will which manifests as politics impacted on the implementation, management and control of tuberculosis in Rivers State. This was achieved through the robust analysis of the respondents’ responses to the questionnaire that was administered with support of the documents that were reviewed.
We will proceed here by examining the health related implications from the implementation of tuberculosis control programme. It will therefore be in our interest to reproduce the epidemiological indicators of tuberculosis (TB) as contained in the annual report for tuberculosis and Leprosy control for the year 2010.
Epidemiological Indicators 2005 2006 2007 2008 2009 2010
Total Number of TB Patients Registered 1643 1982 2217 2225 2198 Total Number of new smear-positive cases 1202 1232 1361 1242 1499 Total Number of new smear-negative cases 300 591 678 787 554 Total Number of Extra-pulmonary TB 23 33 35 53 12 Relapses/Failures/Others 89 121 143 143 99 Case Detection Rate(CDR) per 100,000 34.2 38.9 40.9 39.3 ? Cohort Reports Cure Rate 67.9% 65.5% 75.3% 83.6% Treatment Completion Rate 11.3% 14.0% 5.2% 6.1% Treatment Success Rate 79.2% 79.5% 84.5% 89.7% Defaulter Rate 15.1% 13.6% 9.1% 7.5% Death Rate (Died) 9.6% 4.5%
Source: Rivers State TB & Leprosy Control Programme Annual Report for 2010
Recalling that “the goal of the National Tuberculosis Programme is to reduce significantly, the burden of tuberculosis (TB) by 2015 in line with the Millennium Development Goals
(MDGs) and the Stop TB partnership targets. The targets for TB control are:
v To detect at least 70% of the estimated infectious (smear-positive) cases.
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v To achieve a cure rate of at least 85% of the detected smear-positive cases.
v By 2015 reduce TB prevalence and death rates by 50% related to 1990 level
v By 2050 eliminate TB as a public health problem (<=1/1,000,000 population)”(NTBLCP
Workers Manual 2008:9)
Generally, “the consequencies of tuberculosis on society are immense. Worldwide, one person out of three is infected with tuberculosis-that is 2 billion people in total. Global estimates of the burden of tuberculosis-related disease and deaths for 1997 indicated that 8 million people developed active tuberculosis every year and nearly 2 million died. Tuberculosis accounts for
2.5% of the global burden of disease and is the most common cause of death in young women, killing more than all causes of maternal mortality combined. Tuberculosis currently holds seventh place in the global ranking of causes of death, and, unless intensive efforts are made, is likely to maintain that position through to 2020, despite a substantial projected decline in disease burden from other infectious diseases” ( Smith, 2004:233).
From the epidemiological indicators highlighted above, it is evidenced that the total number of patients has been on a steady and spiraling increase except for the year 2010 in which there was a slight decrease in the total number of patients from that of the previous, although, there was a marked increase in the number of smear-positive patients (infectious cases).
The implication is that as long as the total number of patients unabatedly continues to be on the increase, and most significantly, the smear-positive cases, it indicates that tuberculosis is far from been under control in Rivers State. This is because, research and scientific evidence has shown that a single case of smear-positive (pulmonary) tuberculosis patient is capable of infecting at least fifteen (15) other persons. And that the chances of majority (about 10) of those people infected coming down with tuberculosis is high. This becomes a vicious circle with the continuous transmission of the disease in the society. The general populace is thus confronted with a precarious situation as the disease remains with them, with its attendant consequencies.
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Another significant highlight of the epidemiological indicators, which is an indication of the effectiveness or not of the state tuberculosis control programme, is the issue of the ‘Case
Detection Rate’ (CDR), which from the records remains at an average of a little above 35% for the period that is documented and under review.
It is asserted by Luelmo (2004:3) that “Detection of the most infectious cases of tuberculosis sputum smear-positivepulmonary cases-by case-finding in patients attending health facilities is an essential component of the control of tuberculosis. Its objective is to identify the sources of infection in the community, that is, individuals who are discharging large numbers of tubercle bacilli. Treatment of those infectious patients rapidly renders them non-infectious, thereby cutting the chain of transmission. A secondary benefit of case detection is to minimize the delay in initiating treatment, thereby increasing the probability of cure”. For him, (1) if the cases detected cannot be treated effectively because of lack of drugs, poor organization, or patients’ limited access to treatment services-the activity is of little value. Identification of cases without being able to treat them undermines confidence in the health system and increases the number of persistently infectious cases spreading drug- resistant bacilli. Where new cases are not yet treated satisfactorily and reliably cured, resources and efforts should therefore be concentrated on improving treatment outcomes rather than increasing case detection. (2) In addition to patients consulting for symptoms, the main target group for case detection is persons who attend health facilities for any reason and present with cough, i.e.cough of more than 2 or 3 weeks duration (Luelmo, 2004:3).
Recalling that among the targets for tuberculosis control, the first is ‘to detect at least
70% of the estimated infectious (smear-positive) cases. Given that the infectious (smear- positive) tuberculosis cases are those that are of public health importance and therefore one of the main focuses of the control programme; and the case detection rate has remained at an abysmally low as it is, it is a pointer to the fact that the control programme is far from achieving its goals and targets.
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Obviously, since the first and main instrument for the control programme has not been attained it means that there are multiple of cases out there continuously infecting others thus creating obstacles for the programme. And with this, we cannot talk of reversal of the prevalence of the disease in the state. In the contention of the World Health Organization
(WHO, 2006) “The stop TB strategy considers that public health services need to enhance their capacity to implement high quality DOTS, and emphasizes community involvement in TB care and a patient-centered approach. The stop TB strategy also emphasizes collaboration and synergy among the public, private and voluntary sectors. It considers the need for new partnerships and approaches, based on the increasing impact of HIV on the incidence of TB, particularly in sub-Saharan Africa. Sustaining effective TB control programs now means integrating them into primary health care and adapting them to ongoing reforms occurring within the health sectors across the globe”. A critical look at the state tuberculosis (TB) control programme gives one the impression that the issues raised above may be lacking.
Furthermore, another major health related implication from the implementation of the tuberculosis control services in the State, is the emergence of Drug Resistance Tuberculosis.
Drug resistance arises due to the improper use of antibiotics in chemotherapy of drug- susceptible tuberculosis patients. This improper use is a result of a number of actions, including administration of improper treatment regimens by health care workers and failure to ensure that patients complete the whole course of treatment. Essentially, drug-resistance arises in areas with poor tuberculosis (TB) control programmes.
For Smith (2004:3) “Drug resistance is an increasing problem in many countries, arising as a result of poor treatment organization. Poorly conceptualized control programmes, irregular drug supplies, and uncontrolled use of tuberculosis drugs in the private sector lead to drug resistance, which can be prevented with effective use of DOTS. WHO and IUATLD carried out a global survey of drug resistance from 1994 to 1997 in 35 countries. Overall, among people with newly diagnosed tuberculosis, there was resistance to at least one drug in 9.9% of cases,
189 and multidrug resistance (resistance to at least isoniazid and rifampicin) in 1.4%. A report on the second round of global surveillance, published in 2000, revealed a similar picture (a drug resistance in 10.7% of new cases, multidrug resistance in 1%). These reports confirm that the strongest risk factor for drug resisitance is previous tuberculosis treatment; 23.3% of such cases had resistance to at least one drug, and 9.3% had multidrug-resistant tuberculosis. Drug resistance reduces the efficacy of the standard treatment regimens recommended by WHO, with failure rates 15 times higher in patients with multidrug-resistant tuberculosis than in those with drug susceptible disease”
The measurement of drug-resistant TB globally has been standardized. “In 1994, WHO, the International Union against TB and Lung Disease, and other partners began the Global
Project on Drug Resistance Surveillance in order to standardize the sampling and laboratory methodologies used to measure drug resistant tuberculosis. Today, areas representing almost half of global TB cases have been surveyed” (WHO, 2006). “Presently, TB is the second greatest contributor among infectious diseases to adult mortality causing approximately 1.7 million deaths a year worldwide. WHO estimates that one-third of the world’s population is infected with mycobacterium tuberculosis. The WHO/IUALTD Global Project on Drug
Resistance Surveillance has found MDR-TB (prevalence>4% among new TB cases) in Eastern
Europe, Latin America, Africa, and Asia” (WHO, 2010).
Within the context of the issues raised above by the World Health Organization (WHO), and given the increasing trend toward globalization, trans-national migration, and tourism, all countries are potential targets for outbreaks of multi-drug Resistance tuberculosis (MDR-TB) and Rivers State being a highly cosmopolitan one will certainly not be left out of the MDR-TB.
MDR-TB is a specific form of drug-resistant TB due to a bacillus resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs.
According to Alexander, et al (2007:289) “Resistance to anti-tuberculosis (TB) drugs continues to present a major challenge to global public health. Resistance usually develops due
190 to inadequate TB management, including improper use of medications, improper treatment regimens and failure to complete the treatment course. This may be due to an erratic supply or a lack of access to treatment, as well as to patient non-compliance. However, the emergence and transmission of drug-resistant TB, including the recently detected extensively drug resistant TB
(XDR-TB) is driven, in part, by the synergistic relationship between TB and HIV (TB/HIV coinfection)”. It is possible to contend then, that one consequence of the HIV and TB coepidemics is the increasing occurrence of drug resistant TB.
In the contention of Alexander, et al (2007: 291) “XDR-TB is a global public health threat because it is virtually untreatable. It is currently more prevalent than global, regional, national or local public health systems have recognized, and there is no room for complacency.
Urgent action is needed to prevent XDR-TB from further dissemination. Global public health is now confronting a form of TB that responds poorly to available treatments and prevention efforts. The emergence of XDR-TB has the potential to reverse the gains made by TB and HIV control programs, with major implications for developing nations that have high rates of both
TB and HIV infection”.
Here, in Rivers State the gains made in tuberculosis control efforts has been at best minimal and when this drug-resistant tuberculosis is factored in, it reduces further to insignificance.
Following the above, as an implication of the ineffective implementation of TB control programme in Rivers State; is that the disease will acquire the status and domiciled as ‘endemic’ in the state. An endemic disease implies that there is constant rate of infection occurring in the community. This means that as new individuals are born, they become infected, are cured
(including self-cure) and retain the infection for life or become immune. In this respect, prevalence rates will measure the level of endemicity as it applies to the disease in the community while incidence rates will measure change in the level of infection over a period of time.
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One resultant effect of the endemicity of TB is that the efforts toward its control will continuously be diminished with poor cure rate. Continous endemicity of the disease in the society will probably lead to low productivity by the individuals. It is also likely to contribute to shortage of livespan and continous stigmatization of those affected and even their families. And, as this happens, the targets for the control programme will not be attained.
A possible impact of the ineffective implementation of tuberculosis control programme is the ‘Economic implication on the society’. It is a truism that tuberculosis affects disproportionately the productive age (15-50) of any population. This means that it has the potential of impacting negatively on an economy by creating economic and social burden for tuberculosis patients and their households, and by extension, the society.
In the first instance, the burden of tuberculosis disproportionately affects the poor. And
“Tuberculosis has a severe impact on the impoverishment of patients and their households. The major factors which lead to impoverishment are: The inability to work due to illness and treatment. The pathway to TB care is characterized by many, and repeated visits to different care providers, which are associated with both provider and patient delays. These costs add to the economic burden of households and lead to wider impacts such as children replacing the activities of their ill parents, and an inability to support school fees. Tuberculosis also has an impoverishing social impact” (Nhlema, et al; 2003:1-2).
Obviously, as Smith (2004:235) contended “tuberculosis hinders socio-economic development: 75% of people with tuberculosis are in economically productive age group of 15-
54 years. Ninety-five of all cases and 99% of deaths occur in developing countries, with the greatest burden in Sub-Saharan Africa and South-East Asia. Twenty–three countries together account for more than 80% of all cases of tuberculosis. Household costs of tuberculosis are substantial” See example of table below:
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Estimated household costs of tuberculosis
Cost to patient Bangladesh India South Africa Uganda (11) (12) (13) (14)
Direct Costs (US$) 130 41 99 68
Lost Work 57% NA NA 91%
Time Loss 14 Months 3 Months 4 Months 10 Months
Lost Income (US$) 115 89 272 161
Indirect cost as a percentage of 15 14 NA NA annual household Income
Total cost as a percentage of 31 20 NA NA annual household income
Source: Adapted from Smith, 2004.
As a compliment, Smith (2004:235) further contended that although the “direct” costs of diagnosis and treatment are significant for poor families, the greatest economic loss occurs as a result of “indirct” costs, such as loss of employment, travel to health facilities, sale of assets to pay for treatment-related costs, funeral expenses, and particularly lost productivity from illness and premature death. A study from Uganda found that 95% of subsistence farmers with tuberculosis reported a loss in production, and 80% of wage-earners had stopped work. A review of studies investigating the economic impact of tuberculosis showed that, on average, 3-4 months of work time are lost if an adult has tuberculosis, resulting in the loss of 20-30% of annual household income, and an average of 15 years of income is lost if the patient dies from the disease”.
This scenario creates a complex relationship between tuberculosis and poverty, “as the disease impoverishes those who suffer from it, and the epidemic is exacerbated by socio- economic decline. Poverty results in crowded housing with increased risk of transmission and in poor nutrition with increased risk of breakdown from infection to tuberculosis disease. The break-up of Soviet Union in the early 1990s and the subsequent economic decline and collapse 193 of health and social support structures led to a rapid rise in tuberculosis, with rates increasing by
7% per year in Russia Federation, Ukraine and other countries of the former Soviet Union. In
Cuba over a 3-year period, economic and nutritional hardship resulted in a striking increase
(24% per annum) in the tuberculosis notification rate. A strengthened programme allowed a renewed trend in transmission reduction, resulting in a renewed reduction in incidence” ( Smith,
2004:235).
Given the above, it also has the potential of impacting negatively on the economy of
Rivers State as time unfolds. One obvious health related implication from the implementation of the tuberculosis control programme is that the millennium Development goal related to tuberculosis (TB) will not be met in Rivers State. This will certainly have grave implications on the entire health sector, creating challenges and impediments for the system.
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TEST OF HYPOTHESES:
As noted by statisticians and scholars of social sciences, a test of hypothesis is a rule which when the sample values have been obtained, leads to a decision to accept or reject the hypotheses. It also measures the extent to which the sample departs from the hypothesis in some relevant aspect. If our obtained sample statistics should fall far away from the population value as to constitute an event with a small pre-sampling probability, the departure is said to be significant (Egbuolomi, 2001, Maccodo, 2002, Chibuzo, 2004).
Suffice here for the analysis of the study research hypotheses; the Chi-square (x2) test statistic as already established in chapter will be used at 0.05% level of significance to verify the significance of the test. The Chi-square formula already given is;
X2= Fo – fe 2 Σ Fe
Where
X2 = Chi-square Σ = Summation sign Fo = Observed frequency Fe = Total number of respondents divided by the number of categories.
SPECIFICATION OF RULE:
The decision rule is that, if the computed value of X2 is less than the critical value, the null hypotheses (H0) will be accepted and alternative (HA) will be rejected. On the other hand, I
2 2 the computed value X , is greater than the critical value X , the null hypothesis (HA) will be accepted at same confidence level.
HA: There is a relationship between the allocation and distribution of resources and the Implementation of the tuberculosis control programme.
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Table 7.1.12 Does the government allocates financial resources in her annual budget(s) for the tuberculosis control programme?
VARIABLES Response option Allocation of Implementation of Aggregate % resources to the TB the TB control control programme programme Yes 40 945.28) 45 (39.72) 85 No 74 (68.72) 55 (60.28) 129 Total 114 100 214
Source: Field Survey data, 2012.
Fe10 = 85 x 114/214 = 45.28
Fe 11 = 85 x 100/214 = 39.72
Fe 12 = 129 x 114/214 = 68.72
Fe13 = 129 x 100/214 = 60.28
CONTINGENCY TABLE (1)
FO FE FO-FE (FO-FE)2 (FO-FE02/FE 40 45.28 -5.28 27.8784 0.6156 45 68 5.28 27.8784 0.7112 74 68.72 5.28 27.8784 0.4057 55 60.28 -5.28 27.8784 0.4625 2.195
X2 = 2.195
X2a = (R-1)(C-1)
2 X 0.5, 1 = 3.841
2 2 Decision: Since X calculated is < X critical, we accept the HA and Reject the HO,
Result: There is a relationship between the allocation of financial resources and the implementation of Tuberculosis control programme.
196
HA2, There are health related implications from the implementation of the tuberculosis control programme.
Table 7.1.15 – Showing Health Related implications from the implementation of the Tuberculosis control programme
VARIABLES
RESPONSE Health related Implementation of AGREGATE % OPTIONS implications TB control YES 30(31.83) 35 (33.16) 65 NO 66(64.16) 65(66.84) 131 TOTAL 96 100 196 Source; Field Survey data 2012
X2 = ∑(fo-fe)2 Fe
Fe14 = 65 x 96/196 = 31.83
Fe15 = 65x 100/196 = 31.16
Fe16 = 131 x 96/196 = 64.16
Fe17 = 13 x 96/196 = 66.84
CONTIGENCY TABLE (2)
FO FE FO-FE (FO-FE)2 (FO-FE)2/FE 30 31-83 -1.83 3.3489 0.1052 35 33.16 1.84 3.3856 0.1021 66 64.16 1.84 3.3856 0.5277 65 66.84 -1.84 3.356 0.0565 0.7915 X2 = 0.7915
2 X a = (R-1)(C-1) 2 X 0.5, 1= 3.841 Decision: Since X2 calculated is < X2 critical, we accept the HA and reject the HO.
Result: There are health related implications from the implementation of the tuberculosis control programme. 197
CHAPTER EIGHT
8.1 SUMMARY
Within the context and framework of this study, it set out, to assess how politics, vis-à- vis political commitment by the political gladiators impacts on the implementation of the tuberculosis control programme in Rivers State; the government’s success or failure in upholding international health commitments and the implementation of the programme according to the plan. Succinctly put, the ultimate aim was to examine how the exercise of governmental power in the allocation and distribution of resources impacts on the implementation of the tuberculosis control programme.
The Marxian political economy analytical model was adopted as the theoretical framework with dialectical materialism perspective as the basis of our analysis. It is a philosophical and sociological science concerned with the most general laws and motive forces of the development of society. It has been used for social research from the days of Karl Marx in social, political and economic analysis.
Karl Marx first employed political economy as an approach for analyzing and justifying the root causes of conflicts and contradictions in human societies. Marx expressed the belief that the root cause of tension or conflicts in human society should be found in the relationship between the haves (Bourgeoise) and the have-nots.
Broadly, the defining index in Marxist political Economy is the determination of who benefits from the control and exercise of political power. Marxists argue that the exercise of power benefits those who control the state, a fact attributable to the partisan nature of the state.
Furthermore, scholars of the Marxist leaning subscribe to the view that the post–colonial state in
Africa is an instrument in the hands of the ruling class to serve a particular class interest. This suggests that the state pursues the interest of the capitalist class simply because the state is controlled by them.
198
The argument is that consequently, state policies (if any) are formulated not only to serve the interest of the ruling elites but also to perpetuate structures of alienation and deprivation of the poor/lower class by the ruling elites of the state given that tuberculosis is a disease of the poor. By using this theoretical framework as our guide for this study, it demonstrates that it is not in the interest of those who wield power of the state to sincerely provide an enabling environment (Legislation) as well as commit resources towards the proper control of tuberculosis as its eradication would have helped to reduce poverty in the society. In our clime, those who hold political power, that is, the capitalist class thrives on the misery of the people.
The issue is, as long as the interests of the ruling class are concerned, the utmost need of eradicating the disease in line with the Millennium Development Goals (MDGs) remains inconsequential.
The data sources were both primary and secondary. Primary data was sourced through self-administered questionnaire. The secondary sources of data include books, journals, magazines, newspapers, Government, as well as World Health Organization publications and others.
In sampling we designed and used both random/probability and non-random/non- probability sampling designs. In this regard, the simple random sample and the judgmental or purpose sample methods were used. This permits or creates the chance for the representation of all sectors or elements within the group. The judgmental or purpose sample was adopted to reach out to all persons or organizations that are involved in the tuberculosis control services in the state. A total of one hundred and forty (140) questionnaires were administered to programme officers and other stakeholders at both the state and Local Government Areas.
In data analysis, qualitative and quantitative descriptive analysis was adopted. The responses from the questionnaire survey were tabulated, coded and expressed as percentages to show the response rate by the respondents, and then interpreted. Furthermore, information from
199 the secondary sources was used in supporting them. Chi-square statistics (test) was used to determine the relationship between some of the varibles.
Our guiding hypotheses are:
(a) There is a relationship between the allocation and distribution of resources and the
implementation of the tuberculosis control programme.
(b) There are health related implications from the implementation of the tuberculosis control
programme.
In testing the hypotheses, the following analytical perspectives were used in the analysis:
i. Politics (Political Commitment) and the implementation of the tuberculosis control
programme in Rivers State.
ii. The health related implications from the implementation of the tuberculosis control
programme in Rivers State.
In the context of this study, the findings indicate that there is no policy (in the context of a legislative framework) that is in place for the control of tuberculosis in Rivers State. This therefore posses a great challenge to the proper and effective implementation of the tuberculosis control programme.
It is obvious from the scenarios that the programme officers/implementers of the tuberculosis control services that there exists an international standard for tuberculosis control
(ISTC) for which they are aware and tries to follow in the execution of their duties. What this requires is the political commitment that will be expressed in terms of the allocation of resources, as well as advocacy to galvanise support towards the programme, to enable them carry out their services effectively.
Furthermore, and most strikingly from the findings is that tuberculosis is not among stated priorities of the government and that is why it has not been effectively implemented. If it was among stated priorities as one of the indicators, there would have been a legislative action
200 for it by the state. The findings also show that the control team has not been provided with the essential requirements necessary to prosecute their work.
An important finding of the study is that the Development Partners (DPs) are those who provide drugs and other consumables used by the patients and not the government. The findings also indicate that there have been regular drug stock-outs (yearly) and that government never stepped in by way of buying drugs for the patients in order to remedy the situation. This, certainly, created some challenges for the control services as it will create room for drug resistance in the programme.
Another cardinal finding of the study is that government does not usually allocate financial resources in her annual budgets for the tuberculosis control services. This is equally corroborated by the allocations as contained in the state government’s budget that were highlighted. From the responses, it was also evident that top government officials have not been involved in any form of advocacy for the tuberculosis control services.
It is axiomatic from the findings that there may be continuous endemicity of the disease in the state and may at the long run cripple the economic potential of the state given that it is the active segment of the populace that are affected. As a contributory factor to this, Rivers state is home to hydrocarbon exploration which causes pollution of the environment that increases the risk of contacting respiratory infections. In this wise the the United states environmental protection agency (U.S EPA:1997) contends that “many scientific studies have linked breathing particulate matter to a series of significant health problems, including aggravated asthma, increase in respiratory symptoms like coughing, and difficult or painful breathing, chronic bronchitis, decreased lung function and premature death” This contrasts with The New
Partnership for Africa’s Development (NEPAD) Health Strategy which asserted that “Although there is need to address the full range of health problems affecting Africa, there is little doubt that the immediate priority must be to reduce the burden of disease caused by AIDS and also by
TB, malaria and childhood communicable diseases.The NEPAD disease control proposals are
201 broadly aligned to existing international or continental initiatives and the commitments of the action plans of the Abuja Declarations on Malaria and HIV/AIDS, TB and other Related
Infections and to securing the funding needed for their implementation” The ultimate is that the millennium Development Goal (MDG) target as it relates to tuberculosis control may not be attained because; there is a continuous transmission of the disease.
8.2 CONCLUSION:
From all that has unfolded in the course of this study, it is obvious that the exercise of power in the allocation and distribution of resources for the control of tuberculosis has been very weak. This is an indication of the lack of political commitment towards the tuberculosis control programme. This has inadvertently affected the effective implementation of the tuberculosis control programme and led to serious health implications for the people.
8.3 RECOMMENDATIONS:
The state should take steps and be committed to the followings in order to put the tuberculosis control programme on the path to attaining its goals and targets.
1) Take effective ownership of the programme such that it will no longer be operating, as well as seen as donor dependent; and embark on advocacy for the TB control services. 2) Provide the enabling legislative framework for tuberculosis control through the domestication of the policies so that tuberculosis control will be seen to be among stated priorities. 3) Ensure that budgetary provisions are not only allocated in the State’s annual budgets but are released to the tuberculosis control services. 4) Ensure that provisions for counterpart funding are not only made in the budgets, but are also promptly paid to the appropriate place. 5) Take steps to remove all the encumbrances that contribute to drug stock-outs in order to minimize the incidence of drug resistance in the programme. 6) Endeavour to continue to be committed to forging partnerships, both domestic and international towards the proper and effective control of tuberculosis.
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APPENDIX 1
Department of Political Science University of Nigeria Nsukka
Dear Respondent,
The questions that follow are aimed at obtaining information for a research on “Politics of Tuberculosis Control Programme in Rivers State, Nigeria, 2001-2010” You are earnestly invited to be part of this study by responding to the questions below. It is purely for academic purposes, and you are guaranteed the confidentiality of your information, strictly in accordance with research ethics. I will be grateful if honest, clear and objective responses are given. Thanking you, for your anticipated understanding and cooperation.
Promise Komene-Abanee Researcher
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PART 1:
PERSONAL DATA 1. Sex: Male Female 2. Age: 18-39 40 and above 3. Occupation: Civil Servant Public Servant 4. Marital Status: Single Married 5. Educational / Professional Qualification (Please indicate)…………………………… PART II: Instructions: Please answer the questions that follow: 1. How are you associated with the TB Control Services? (a) Who Representative /Staff (b) Development Partners/Donor Agencies Representative/Staff (c) The State Control Programme/Staff (d) Local Government Programme Office/Staff (e) NGOs in TB Control (f) DOTs Centre Staff/Focal person 2. How long have you been associated (working) with the TB Control Services? (a) 1-10 years (b) 11-20 years (c) 21 years and above 3. Are you aware of any set standards for the effective implementation of the TB Control Services both internationally and locally? (a) Yes (b) No (c) Not aware 4. Has the government enacted any law that supports the implementation of the tuberculosis control programme in Rivers State? (a) Yes (b) No (c) Not aware 5. Do you think that the control team has been provided with the essential requirements needed for their work by the government? (a) Yes (b) No (c) Not aware 6. If No, please rate in terms of percentages (a) Below 20% (b) Between 21 – 40% (c) Between 41 – 60% (d) Below 61 – 80% (e) Above 80% 7. Has any member of the executive arm of government been involved in any advocacy activity(s) for the tuberculosis control programme? (a) Yes (b) No (c) Not aware 8. Who provides the drugs/other basic necessities for the services used by the patients? 211
(a) Development Partners/Donor Agency (b) The State Government (c) The NGOs (d) Not aware 9. Has there been drug stock out at anytime in the course of providing the TB Control Services? (a) Yes (b) No (c) Not aware 10. If yes, how frequent do you think it has been? (a) Every year (b) Once in every two years (c) Once in every three years 11. Do you think that the State Government stepped in to save the situation? (a) Yes (b) No (c) Not aware 12. Do you think that the government allocates financial resources in her annual budget(s) for the TB Control Services? (a) Yes (b) No (c) Not aware 13. If yes, do you think that these financial resources are usually released for use by the TB Control Services? (a) Yes (b) No (c) Not aware 14. If yes, how has it affected the TB Control Services in terms of enhancing the provision of the services? (a) Positively (b) Negatively (c) Cannot say 15. If No, how has it affected the TB Control Services in terms of enhancing the services? (a) Positively (b) Negatively (c) Cannot say 16. Do you think that there are health impacts from the implementation of the tuberculosis control services? (a) Yes (b) No (c) Not Aware.
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Chi – square (X2) Standard
213