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NOT YET UHURU: What Kenya can learn from Cuba’s healthcare system

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The approach to provision of universal healthcare demonstrates that Kenyan political leaders are yet to develop a coherent philosophy to shape the nation’s development agenda. By REV. CANON FRANCIS OMONDI

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NOT YET UHURU: What Kenya can learn from Cuba’s healthcare system
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In his famous song Ayee Africa ee Africa oo Lipanda? (Ah Africa where is your independence?), the young Congolese musician Franklin Boukaka questioned the essence of independence from oppressive colonial rule. Why would the new African leaders indulge in luxuries and power while the masses they led were confined to squalor in his native Congo Brazzaville?

This, of all of Boukaka’s songs, was most popular on radio in the 1970s and remains to date. I doubt that the Voice of Kenya (VoK) radio presenters knew that they were playing a song outlawed in the country of its origin. A nimbus of sweetness in the music concealed the song’s subversive message. The emphatic climax of the song posed three questions: “I thought the colonisers left? Who then became independent? Ayee Africa where is your independence?”

The singer rebukes the insensitivity of the leaders to the needs of their citizens. One of the most beautiful African voices was, however, extinguished forever.  His song earned him silence on February 22, 1972.   Boukaka was executed on the orders of Joachim Opango in the crisis following a coup d’état that failed to topple Marien Ngouabi. However, his voice will continue to haunt our present context in Kenya and Africa as long as the benefits of our freedom are not realised.

Time has revealed the yawning gulf between the independence aspirations our forbearers struggled for and the realities we have experienced. The promissory note of freedom and prosperity has been unhonoured. The majority of Kenyans could not cash it. To paraphrase American civil rights icon Rev. Dr. Martin Luther King Jnr., it has been returned marked “insufficient funds”.  What was the point of the sacrifice for self-rule if wananchi (ordinary Kenyans) would be subjugated to oppressive poverty?  Whose independence was this?

Time has revealed the yawning gulf between the independence aspirations our forbearers struggled for and the realities we have experienced. The promissory note of freedom and prosperity has been unhonoured. The majority of Kenyans could not cash it.

The African leaders of the colonial days were clear about what they demanded. Freedom. While attending the American Committee of Africa’s Freedom Day in 1959, Hon. Tom Mboya, the then Secretary General of the Kenya African National Union (KANU) – who had just been elected head of the Pan-African people’s Congress in Accra, Ghana – gave a revealing interview to American journalists in a session with the National Broadcasting Corporation’s The Press. He was articulate, expressing an urgent need for independence. Mboya understood freedom to be achieving the right to self-determination and to have a government elected by the people, not imposed on them and, therefore, one that was responsible for and accountable to the people. That was the reason for the struggle for independence all over Africa.

The colonialist perceived Africans to be too tribal to rule themselves without resorting to chaos. Perhaps this is why the host, during the interview, pejoratively reminded Hon. Mboya that with freedom there goes responsibility for self-government. She expressed her apprehension about the ability and readiness of Africans to self-govern with these questions: “Now, how can you say that people are prepared for such a responsibility when illiteracy is 90 per cent in many parts of Africa? When governmental experience personally for many is tribal and there is major dependence for foreign aid for economic development…?”

Hon. Mboya concurred with her when he recognised the need for literacy and development in form of better roads and schools. He pointed out that “… the motive behind our struggle for independence is our recognition that these things are not possible under colonialism.” He refuted her characterisation of Africans, identifying it as a colonial fallacy.

The vision of achieving independence to advance ordinary African people described development in terms of people’s welfare, not economic indicators, such as Gross Domestic Product and Gross National Product or economic growth. It concurred with latter-day economists like Edgar Owens (1987) who suggests that development occurs when there is development of people (human development) and not development of things. According to the World Development Report (WDR 1991), “The challenge of development, is to improve the quality of life, better education, higher standards of health and nutrition, less poverty, a cleaner environment, more equality of opportunity, greater individual freedom, and a richer cultural life.”

It is this nexus between development and independence that Hon. Mboya had in mind when he said: “It is when people have attained independence that programmes such as more education, more hospitals, better roads, better houses can be implemented by a government concerned for its people.”

The Cuban example

The Cuba experience backs Hon. Mboya’s assertion, although he spoke before the Cuban revolution had taken place. The 1959 Cuban revolution that brought Fidel Castro to leadership transformed the tiny Caribbean Island of seven million people. Castro created a socialist programme that focused on transforming the lives of ordinary Cubans. Consequently, they were provided a completely free education system uniquely adapted to Cuban needs, from nursery to university. Douglas Kellner’s, in Ernesto ‘Che” Guevara World Leaders Past and Present, explains how prior to 1959, the official literacy rate for Cuba was between 60 per cent and 76 per cent. This was occasioned by both lack of education access in rural areas and a shortage of instructors. The Cuban government under Fidel Castro, beginning in 1961, focused on the countryside by constructing schools and training new teachers who taught the predominantly illiterate peasants (guajiros). At the end of the campaign, the national literacy rate rose to 96 per cent. By 2009, according to a 2012 Central Intelligence Agency report, literacy levels across the population of Cuba were 99.83 per cent. This became the foundation of the development of the Cuban people. Again, it was the citizens who volunteered to achieve this.

According to the World Health Organization (WHO), Cuba’s healthcare system is an example for all countries of the world. It is recognised for its excellence and efficiency. Those responsible for its success include family physicians, nurses and other health workers who labour to deliver primary healthcare and preventive services to their cluster of patients. It is a very localised system; the patients and their caregivers live in the same community. There are now about 2,500 patients per physician-headed office at the primary care level. Their healthcare is premised on the preventive health system, which has produced positive results. As a result, Cuba’s vaccination rates are among the highest in the world. The country’s life expectancy of 77 years is exceedingly impressive for a developing country. The infant mortality rate in Cuba has fallen from more than 80 per 1,000 live births in the 1950s to less than 5 per 1,000. The improved health outcomes are also be attributed to improvements in nutrition and education, which are key variables that address the social determinants of health. Today, health education is part of the mandatory school curriculum.

Despite its extremely limited resources and the negative impact of the American blockade and economic sanctions for more than half a century, Cuba has managed to guarantee access to healthcare for all segments of the population, which has enabled the country to obtain results similar to those of the most developed nations.

Cuba’s experience mocks our post-independence achievements. Our literacy levels are most disturbing. The key findings of Kenya’s national adult literacy survey in 2007 indicated that, on average, 38.5 per cent of the Kenyan adult population is illiterate, implying that more than one in three adults cannot read or write. This is despite the fact that they have been major increases in enrolment in educational institutions at all levels, and a plethora of education commissions constituted to rectify the education conundrum Kenya has faced since independence. Shockingly, this was almost where Cuba was in 1959.

Despite its extremely limited resources and the negative impact of the American blockade and economic sanctions for more than half a century, Cuba has managed to guarantee access to healthcare for all segments of the population, which has enabled the country to obtain results similar to those of the most developed nations.

President Uhuru Kenyatta’s decision to invite 100 Cuban doctors to serve Kenyans, therefore, speaks to us with a forked tongue. We are grateful that these specialists are contributing to ease the pressing healthcare needs in our hospitals. However, it should concern us gravely that the government refuses to undertake the arduous task of developing Kenya’s healthcare system to Cuban levels. Why import Cuban doctors when adopting their system is within our reach?

The celebrated Universal Healthcare proposal in the Jubilee government’s Big 4 Agenda misses the point of our healthcare needs. It assumes a solution by availing financial resources. It, therefore, proposes to reduce the cost and ensure universal access to quality and affordable healthcare by 2022. The government plans to ensure that every Kenyan is covered under the National Hospital Insurance Fund (NHIF) medical insurance cover. This plan will require: a strong collaboration between the NHIF and private sector insurance providers; reviewing the rules governing private insurers; lowering the cost of coverage; protecting both the government and Kenyans from fraud and abuse; and letting private insurers to invest more in providing medical coverage.

This solution is set up to profit the insurers and other supplies of medical products rather than ordinary Kenyans. We stumble not for lack of examples to emulate, but for refusal to care. WHO notes that lack of access to healthcare in most parts of the world springs not from lack of resources, but from a lack of political will on the part of leaders to protect their most vulnerable populations.

With limited resources, the Cuban health care system has solved problems that ours has yet to address. Even though their healthcare system addresses those problems in ways that grew out of Cuba’s peculiar political and economic history, the system they have created — with a physician for everyone, an early focus on prevention, and clear attention to community health — may inform progress in other countries as well.

With the strict economic embargo, Cuba has developed its own pharmaceutical industry and now not only manufactures most of the medications in its basic pharmacopeia but also invests in developing biotechnology expertise to become competitive with advanced countries.

On July 14, 2014, WHO General Director Margaret Chan urged nations to follow the example of Cuba and phase out the curative model, which is ineffective and more expensive. She noted that Cuba’s healthcare system is based on preventive medicine and the results achieved are outstanding. “We sincerely hope that all of the world’s inhabitants will have access to quality medical services, as they do in Cuba,” she said.

Shouldn’t we have developed access to health services first? Shouldn’t we have provided for effective and relevant personnel and medicine before provision of funding? Shouldn’t we be demanding an effective healthcare system that puts the lives of Kenyans above “tenderpreneurs”?

The spectre of revolt looms large

What did our leaders do once in power?  What can explain the obscene affluence of a few in the sea of poor Kenyans?  A 2014 survey conducted over a span of eight years by New World Wealth, a South African-based research firm exposed a grim picture of wealth distribution in Kenya. It showed that 46 per cent of the country’s 43.1 million people live below the poverty line, surviving on less than Sh172 ($2) a day. The report further stated that: “nearly two-thirds of Kenya’s Sh4.3 trillion ($50 billion) economy is controlled by a tiny clique of 8,300 super-wealthy individuals, highlighting the huge inequality between the rich and the poor”.

Shouldn’t we have developed access to health services first? Shouldn’t we have provided for effective and relevant personnel and medicine before provision of funding? Shouldn’t we be demanding an effective healthcare system that puts the lives of Kenyans above “tenderpreneurs”?

Inequality is immoral.  Moreover, the proportions we have here kills. Göran Therborn, who has appropriately titled his book The Killing Fields of Inequalityhighlights several ways in which inequality kills. It violates basic human rights. It excludes “people from possibilities produced by human development.”  It is divisive; it tears people and families apart, it creates exorbitant squandering, self-indulgent profligacy and, therefore, dehumanises both the poor and the rich.

This appalling situation is a result of political leadership bereft of a moral guiding philosophy. Leadership is viewed in transactional and contractual terms; it is a means to acquire wealth. This may explain why we are confronted on a daily basis with grand scandals of greed, corruption, and looting of public or state resources. Isn’t this what Jean-Francois Bayart described as the “politics of the belly”?  Do leaders care that they took an oath to serve the people of Kenya?

Prof. Aloo Mojola of St. Paul’s University in Limuru, Kenya, explains our reality as one “peopled with many atomistic leaders and a populace whose one and only preoccupation is personal gain and aggrandisement at whatever cost.” He further observes that for the vast majority, the present African situation could simply be characterised as Hobbesian. This description is derived from the words of the English political philosopher Thomas Hobbes (1588-1679), who in the mid-17th century wrote in his classic text Leviathan (1651): “The condition of man … is a condition of everyone against everyone…in such a condition there is no place for industry…” Sadly, for these Hobbesians, “the notion of right and wrong, justice and injustice have there no place…force and fraud are…(the) two cardinal virtues”.

This appalling situation is the result of political leadership bereft of a moral guiding philosophy. Leadership is viewed in transactional and contractual terms; it is a means to acquire wealth. This may explain why we are confronted on a daily basis with grand scandals of greed, corruption, and looting of public or state resources.

Unless our leaders adopt a covenantal approach that obliges leadership to better the lives of ordinary citizens, we will be stuck in this quagmire. Our leaders must develop a political philosophy that puts Kenyans at the centre of their agenda. The depth of our problem is explicit, particularly when government policies lean more towards sustaining local and foreign entrepreneurs rather than solving citizens’ problems.

What options remain for citizens when their government fails perpetually to secure their wellbeing? Thomas Jefferson and his colleagues in the American Declaration for the Independence of 1776 were emphatic that the task of government was securing its citizens’ rights to certain unalienable rights which were: “Life, Liberty and the Pursuit of Happiness.” It further provided for redress if the government fails to live up to this call when it stated: “That whenever any Form of Government becomes destructive of these ends, it is the Right of the People to alter or abolish it and to institute new government, laying its foundation on such principles, and organizing its powers in such form, as to them shall seem most likely to effect their safety and happiness.”

The spectre of revolt looms large over Kenya. The youth have lost faith in law reforms or societal reorganisation. They dismiss the “building of bridges” – the now famous handshake between President Uhuru Kenyatta and Rt. (Hon.) Raila Odinga – as a political gimmick that is slowing down the country’s transformation. Revolution is what they are working at. I doubt that they have thought through the end-product of their craving.

Tanzania’s founding President Dr. Julius Nyerere was disturbed and horrified when he realised that he had become the architect of a government-sponsored system of inequality. He was moved to do something about it. His Ujamaa system of African socialism offered a response and attempt to remedy this situation. Aren’t our political leaders able to develop a coherent philosophy to shape our nation’s development agenda?

The spectre of revolt looms large over Kenya. The youth have lost faith in law reforms or societal reorganisation. They dismiss the “building of bridges” – the now famous handshake between President Uhuru Kenyatta and Rt. (Hon.) Raila Odinga – as a political gimmick that is slowing down the country’s transformation.

Since political leaders have failed Kenyans in this respect, can religious leaders provide alternative leadership and nudge the country towards the poor who are perpetually left out? The similarities between Kenya and Latin American countries are striking. David Tombs, in Latin American Liberation Theology, illustrates how the great Latin American independence movements, which had promised liberation and new hope through independence from the Iberian empire, only benefitted an elite sector of society. Here the Creole class assumed governance replacing the peninsulares, yet they did little to alleviate the struggles of the lower classes.

The clergy and theologians in Latin America were on the vanguard of change in addressing the grievances of the poor and transformation of their society. During the Conference of Latin American Bishops held in 1968 in Medellin, Colombia, the bishops agreed that the Church should take “a preferential option for the poor”.  One of the architects of this movement was Father Gustavo Gutierrez, a Roman Catholic priest from Peru, who acknowledged to have been inspired by the Cuban revolution of 1959.  He laid out clearly the concepts he referenced during this talk in 1968 in his 1971 magnum opus, “A Theology of Liberation”. Consequently, liberation theology emerged as a new way of “being human and Christian”.  In proposing a “preferential option for the poor,” the Church was encouraged to extend its work to directly address the struggles of the impoverished and to work specifically to ameliorate “physical and spiritual oppression”.

Rather than small ineffective reforms, liberation theology supported work towards systemic change and even the possibility of revolution as a means of freeing the poor from oppression. While violence was not encouraged, it was justified as a possible last resort or necessity of the revolution.

We must credit liberation theology for changing the role of the Church in Peru and all of Latin America forever. By giving a voice to the impoverished, liberation theology held the Church accountable for the welfare of the lower classes, recognising the essential role of social justice in Christian teachings. The Christians demanded that the Church do more than simple charity and work towards playing a more active role in the promotion of systemic change. This movement realigned the power structures of Latin American society and showed that religion could deliver change in society by forcing the hands of politics.

Where are the Kenyan theologians who will develop a theology that will focus the Church away from solely eternal salvation to the more pressing necessity of earthly liberation of the poor from oppression and suffering? The genius of the religious figures like Gustavo Gutiérrez was in integrating the liberation of the working class into Biblical interpretation.

Independence in Kenya has proved not to be the low-lying fruit ordinary folks anticipated. Prof. Micere Githae Mugo’s (1973) poem “I Took My Son by the Hand”, in David Rubadiri (ed), (1989), depicts this sorry state in the dialogue between a mother and her son who yearned for the fruits of independence.

“Mother?” he asked, “Do we have matunda ya uhuru in our hut?”

Mother: “I laughed foolishly”

Son: “Mother!”

Mother: “Yes son? ”

Son: “Do we have some?”

Mother: “Silence…”

Son: May I eat one, when we get there?

Mother: “Move on son darkness is looming fast around us”.

There is a possibility to reorient the policies of our nation towards the vulnerable. It should take all of us to achieve this – the government, civil society, and religious communities. If we do not sincerely address the dire challenges faced by the poor, we must get ready for chaos.

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Rev. Canon Francis Omondi is a Priest of All Saints Cathedral Diocese of the ACK, a Canon of the All-Saints Kampala Cathedral of the Church of Uganda, Adjunct Lecturer at St. Paul’s University, Limuru, and Research Tutor at the Oxford Centre for Religion and Public Life. Views expressed here are his own.

Politics

Lagos From Its Margins: Everyday Experiences in a Migrant Haven

From its beginnings as a fishing village, Lagos has grown into a large metropolis that attracts migrants seeking opportunity or Internally Displaced Persons fleeing violence.

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Lagos, City of Migrants

From its origins as a fishing village in the 1600s, Lagos has urbanised stealthily into a vast metropolis, wielding extensive economic, political and cultural influence on Nigeria and beyond. Migration in search of opportunities has been the major factor responsible for the demographic and spatial growth of the city as Lagos has grown from 60,221 in 1872 to over 23 million people today. The expansion of the city also comes with tensions around indigene-settler dynamics, especially in accessing land, political influence and urban resources. There are also categories of migrants whose status determines if they can lay hold of the “urban advantage” that relocating to a large city offers.

A major impetus to the evolution of modern Lagos is the migration of diverse groups of people from Nigeria’s hinterland and beyond. By the 1800s, waves of migrants (freed slaves) from Brazil and Freetown had made their way to Lagos, while many from Nigeria’s hinterland including the Ekiti, Nupes, Egbas and Ijebus began to settle in ethnic enclaves across the city. In the 1900s, migrant enclaves were based on socio-economic and/or ethnicity status. Hausas (including returnees from the Burma war) settled in Obalende and Agege, while the Ijaw and Itsekiri settled in waterfront communities around Ajegunle and Ijora. International migrant communities include the Togolese, Beninoise and Ghanaian, as well as large communities of Lebanese and Indian migrants. The names and socio-cultural mix in most Lagos communities derive from these historical migrant trajectories.

Permanent temporalities

A study on coordinated migrations found that, as a destination city, Lagos grew 18.6 per cent between 2000 and 2012, with about 96 per cent of the migrants coming from within Nigeria. While migration to Lagos has traditionally been in search of economic opportunities, new classes of migrants have emerged over the last few decades. These are itinerant migrants and internally displaced persons.

Itinerant migrants are those from other areas of Nigeria and West Africa who travel to work in Lagos while keeping their families back home. Mobility cycles can be weekly, monthly or seasonal. Such migrants have no address in Lagos as they often sleep at their work premises or in mosques, saving all their earned income for remittance. They include construction artisans from Benin and Togo who come to Lagos only when they have jobs, farmers from Nigeria’s northern states who come to Lagos to work as casual labourers in between farming seasons (see box), as well as junior staff in government and corporate offices whose income is simply too small to cover the high cost of living in Lagos.

While people from Nigeria’s hinterland continue to arrive in the city in droves, the wave of West African in-migration has ebbed significantly. This is mostly because of the economic challenges Nigeria is currently facing that have crashed the Naira-to-CFA exchange rates. As a result, young men from Togo, Ghana and Benin are finding cities like Dakar and Banjul more attractive than Lagos.

Photo. Taibat Lawanson

Photo. Taibat Lawanson

Aliu* aka Mr Bushman, from Sokoto, Age 28

Aliu came to Lagos in 2009 on the back of a cattle truck. His first job was in the market carrying goods for market patrons. He slept in the neighbourhood mosque with other young boys. Over the years, he has done a number of odd jobs including construction work. In 2014, he started to work as a commercial motorcyclist (okada) and later got the opportunity to learn how to repair them. He calls himself an engineer and for the past four years has earned his income exclusively from riding and repairing okada. Even though he can afford to rent a room, he currently lives in a shared shack with seven other migrants.

He makes between N5000 and N8000 weekly and sends most of it to his family through a local transport operator who goes to Sokoto weekly. His wife and three children are in the village, but he would rather send them money than bring them to Lagos. According to him, “The life in Lagos is too hard for women”.

Since he came to Lagos thirteen years ago, Aliu has never spent more than four months away from Sokoto at a time. He stays in Sokoto during the rainy season to farm rice, maize and guinea corn, and has travelled back home to vote every time since he came to Lagos.

 

The second category of migrants are those who have been displaced from their homesteads in Northern Nigeria by conflict, either Boko Haram insurgency or invasions by Fulani herdsmen. The crises have resulted in the violent destruction of many communities, with hundreds of thousands killed and many more forced to flee. With many who initially settled in camps for Internally Displaced Persons (IDP) dissatisfied with camp conditions, the burden of protracted displacement is now spurring a new wave of IDP migration to urban areas. Even though empirical data on the exact number of displaced persons migrating out of camps to cities is difficult to ascertain, it is obvious that this category of migrants are negotiating their access to the city and its resources in circumstances quite different from those of other categories of migrants.

IDPs as the emerging migrant class in Lagos 

According to the United Nations High Commission for Refugees, two of every three internally displaced persons globally are now living in cities. Evidence from Nigeria suggests that many IDPs are migrating to urban areas in search of relative safety and resettlement opportunities, with Lagos estimated to host the highest number of independent IDP migrants in the country. In moving to Lagos, IDPs are shaping the city in a number of ways including appropriating public spaces and accelerating the formation of new settlements.

There are three government-supported IDP camps in the city, with anecdotal evidence pointing to about eighteen informal IDP shack communities across the city’s peri-urban axis. This correlates with studies from other cities that highlight how this category of habitations (as initial shelter solutions for self-settled IDPs) accelerate the formation of new urban informal settlements and spatial agglomerations of poverty and vulnerability.

While people from Nigeria’s hinterland continue to arrive in the city in droves, the wave of West African in-migration has ebbed significantly.

IDPs in Lagos move around a lot. Adamu, who currently lives in Owode Mango—a shack community near the Lagos Free Trade zone—and has been a victim of forced eviction four times said, “As they [government or land owners] get ready to demolish this place and render us homeless again, we will move to another area and live there until they catch up with us.”

In the last ten years, there has been an increase in the number of homeless people on the streets of Lagos—either living under bridges, in public parks or incomplete buildings. Many of them are IDPs who are new migrants, and unable to access the support necessary to ease their entry into the city’s established slums or government IDP camps. Marcus, who came from Adamawa State in 2017 and has been living under the Obalende Bridge for five years, said, “I am still managing, living under the bridge. I won’t do this forever, my life will not end like this under a bridge. I hope to one day return to my home and continue my life”.

Blending in or not: Urban integration strategies 

Urban integration can be a real challenge for IDP migrants. Whereas voluntary migrants are often perceived to be legal entrants to the city and so can lay claim to urban resources, the same cannot be said about IDPs. Despite being citizens, and despite Nigeria being a federation, IDPs do not have the same rights as other citizens in many Nigerian cities and constantly face stigmatisation and harassment, which reinforces their penchant for enclaving.

The lack of appropriate documentation and skillsets also denies migrants full entry into the socio-economic system. For example, Rebekah said: “I had my WAEC [Senior Secondary school leaving certificate] results and when Boko Haram burnt our village, our family lost everything including my certificates. But how can I continue my education when I have not been able to get it? I have to do handwork [informal labour] now”. IDP children make up a significant proportion of out-of-school children in Lagos as many are unable to get registered in school simply because of a lack of address.

Most IDPs survive by deploying social capital—especially ethnic and religious ties. IDP ethnic groupings are quite organized; most belong to an ethnic-affiliated group and consider this as particularly beneficial to their resettlement and sense of identity in Lagos. Adamu from Chibok said, “When I come to Lagos in 2017, I come straight to Eleko. My brother [kinsman] help me with house, and he buy food for my family. As I no get work, he teach me okada work wey he dey do.”

The crises have resulted in the violent destruction of many communities, with hundreds of thousands killed and many more forced to flee.

Interestingly, migration to the city can also be good for women as many who were hitherto unemployed due to cultural barriers are now able to work. Mary who fled Benue with her family due to farmer-herder clashes explained, “When we were at home [in Benue], I was assisting my husband with farming, but here in Lagos, I have my own small shop where I sell food. Now I have my own money and my own work.”

Need for targeted interventions for vulnerable Lagosians

“Survival of the fittest” is an everyday maxim in the city of Lagos. For migrants, this is especially true as they are not entitled to any form of structured support from the government. Self-settlement is therefore daunting, especially in light of systemic limiting factors.

Migrants are attracted to big cities based on perceived economic opportunities, and with limited integration, their survival strategies are inevitably changing the spatial configurations of Lagos. While the city government is actively promoting urban renewal, IDP enclaving is creating new slums. Therefore, addressing the contextualised needs of urban migrant groups is a sine qua non for inclusive and sustainable urban development.

“I am still managing, living under the bridge. I won’t do this forever, my life will not end like this under a bridge. I hope to one day return to my home and continue my life”.

There is an established protocol for supporting international refugees. However, the same cannot be said for IDPs who are Nigerian citizens. They do not enjoy structured support outside of camps, and we have seen that camps are not an effective long-term solution to displacement. There is a high rate of IDP mobility to cities like Lagos, which establishes the fact that cities are an integral part of the future of humanitarian crisis. Their current survival strategies are not necessarily harnessing the urban advantage, especially due to lack of official recognition and documentation. It is therefore imperative that humanitarian frameworks take into account the role of cities and also the peculiarities of IDP migrations to them.

Lagos remains a choice destination city and there is therefore need to pay more attention to understanding the patterns, processes and implications of migration into the city. The paucity of migration-related empirical data no doubt inhibits effective planning for economic and social development. Availability of disaggregated migration data will assist the state to develop targeted interventions for the various categories of vulnerable Lagosians.  Furthermore, targeted support for migrant groups must leverage existing social networks, especially the organised ethnic and religious groups that migrants lean on for entry into the city and for urban integration.

*All names used in this article are pseudonyms

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Politics

It’s a Nurses’ Market Out There, and Kenyans Are Going For It

Nurses are central to primary healthcare and unless Kenya makes investments in a well-trained, well supported and well-paid nursing workforce, nurses will continue to leave and the country is unlikely to achieve its Sustainable Development Goals in the area of health and wellbeing for all.

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It’s a Nurses’ Market Out There, and Kenyans Are Going For It
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Nancy* is planning to leave Kenya. She wants to go to the United States where the nursing pastures are supposedly greener. I first met Nancy when the country was in the throes of the COVID-19 pandemic that tested Kenya’s healthcare system to breaking point. She was one of a cohort of recently graduated nurses that were hastily recruited by the Ministry of Health and thrown in at the deep end of the pandemic. Nancy earns KSh41,000 net with no other benefits whatsoever, unlike her permanent and pensionable colleagues.

When the then Labour and Social Protection Cabinet Secretary Simon Chelugui announced in early September 2021 that the government would be sending 20,000 nurses to the United Kingdom to help address the nursing shortage in that country, Nancy saw her chance. But her hopes were dashed when she failed to raise the KSh90,000 she needed to prepare and sit for the English language and nursing exams that are mandatory for foreign-trained nurses. Nancy would also have needed to pay the Nursing Council of Kenya KSh12,000 for the verification of her documents, pay the Kenya Medical Training College she attended KSh1,000 in order to get her exam transcripts, and apply for a passport, the minimum cost of which is KSh4,550 excluding the administrative fee. Nancy says that, contrary to then Health Cabinet Secretary Mutahi Kagwe’s disputed claims that a majority of applicants to the programme had failed the English language test, most nurses simply could not afford the cost of applying.

Of the targeted 20,000 nurses, the first 19 left Kenya for the UK in June 2022. But even that paltry figure represents a significant loss for Kenya, a country where the ratio of practicing nurses to the population is 11.66 per 10,000. The WHO considers countries with less than 40 nurses and midwives for every 10,000 people to not have enough healthcare professionals. Nearly 60 per cent of all healthcare professionals (medical physicians, nursing staff, midwives, dentists, and pharmacists) in the world are nurses, making them by far the most prevalent professional category within the health workforce. Nurses offer a wide range of crucial public health and care services at all levels of healthcare facilities as well as within the community, frequently serving as the first and perhaps the only healthcare provider that people see.

Kenya had 59,901 nurses/midwives in 2018, rising to 63,580 in 2020. Yet in 2021, Kenya was proposing to send almost a third of them to the UK to “address a shortfall of 62,000 in that country”.

The growing shortage of nurses in the UK has been blamed on the government’s decision to abolish bursaries and maintenance grants for nursing students in 2016, leading to a significant drop in the number of those applying to train as nurses. Consequently, the annual number of graduate nurses plummeted, reaching the current low of 31 nurses per 100,000 people, below the European average of 36.6 and half as many as in countries like Romania (96), Albania (82) and Finland (82). Facing pressure to recruit 50,000 nurses amid collapsing services and closures of Accident & Emergency, maternity and chemotherapy units across the country, the UK government decided to once again cast its net overseas. Established in 1948, the UK’s National Health Service (NHS) has relied on foreign healthcare workers ever since staff from the Commonwealth were first brought in to nurse back to health a nation fresh out of the Second World War.

The UK government’s press release announcing the signing of the Bilateral Agreement with Kenya states that the two countries have committed  “to explore working together to build capacity in Kenya’s health workforce through managed exchange and training” and goes as far as to claim that “with around only 900 Kenyan staff currently in the NHS, the country has an ambition to be the ‘Philippines of Africa’ — with Filipino staff one of the highest represented overseas countries in the health service — due to the positive economic impact that well-managed migration can have on low to middle income countries.”

It is a dubious ambition, if indeed it has been expressed. The people of the Philippines do not appear to be benefiting from the supposed increase in capacity that the exchange and training is expected to bring. While 40,000 of their nurses worked in the UK’s National Health Service last year, back home, according to Filipino Senator Sonny Angara, “around 7 of 10 Filipinos die without ever seeing a health professional and the nurse to patient ratio in our hospitals remains high at 1:50 up to 1:802”.

Since 2003 when the UK and the government of the Philippines signed a Memorandum of Understanding on the recruitment of Filipino healthcare professionals, an export-led industry has grown around the training of nurses in the Philippines that has attracted the increased involvement of the private sector. More nursing institutions — that have in reality become migrant institutions — are training nurses specifically for the overseas market, with the result that skills are matched to Western diseases and illnesses, leaving the country critically short of healthcare personnel. Already, in 1999, Filipino doctors had started retraining as nurses and leaving the country in search of better pay.

It is difficult, then, to see how the Philippines is an example to emulate. Unless, of course, beneath the veneer of “partnership and collaboration in health”, lies the objective of exporting Kenyan nurses with increased diaspora remittances in mind – Kenyans in the UK sent KSh28.75 billion in the first nine months of 2022, or nearly half what the government has budgeted for the provision of universal health care to all Kenyans. If that is the case, how that care is to be provided without nurses is a complete mystery.

Already in 1999, Filipino doctors had started retraining as nurses and leaving the country in search of better pay.

For the UK, on the other hand, importing nurses trained in Kenya is a very profitable deal. Whereas the UK government “typically spends at least £26,000, and sometimes far more, on a single nurse training post”, it costs only £10,000 to £12,000 to recruit a nurse from overseas, an externalization of costs that commodifies nurses, treating them like goods to be bought and sold.

However, in agreeing to the terms of the trade in Kenyan nurses, the two governments are merely formalizing the reality that a shortage of nurses in high-income countries has been driving the migration of nurses from low-income countries for over two decades now. Along with Ghana, Nigeria, South Africa and Zimbabwe, Kenya is one of the top 20 countries of origin of foreign-born or foreign-trained nurses working in the countries of the OECD, of which the UK is a member state.

Faced with this reality, and in an attempt to regulate the migration of healthcare workers, the World Health Assembly adopted the WHO Global Code of Practice on the Recruitment of Health Personnel in May 2010. The code, the adherence to which is voluntary, “provides ethical principles applicable to the international recruitment of health personnel in a manner that strengthens the health systems of developing countries, countries with economies in transition and small island states.”

Article 5 of the code encourages recruiting countries to collaborate with the sending countries in the development and training of healthcare workers and discourages recruitment from developing countries facing acute shortages. Given the non-binding nature of the code, however, and “the severe global shortage of nurses”, resource-poor countries, which carry the greatest disease burden globally, will continue to lose nurses to affluent countries. Wealthy nations will inevitably continue luring from even the poorest countries nurses in search of better terms of employment and better opportunities for themselves and their families; Haiti is on the list of the top 20 countries supplying the OECD region.

“Member States should discourage active recruitment of health personnel from developing countries facing critical shortages of health workers.”

Indeed, an empirical evaluation of the code four years after its adoption found that the recruitment of health workers has not undergone any substantial policy or regulatory changes as a direct result of its introduction. Countries had no incentive to apply the code and given that it was non-binding, conflicting domestic healthcare concerns were given the priority.

The UK’s Department of Health and Social Care (DHSC) has developed its own code of practice under which the country is no longer recruiting nurses from countries that the WHO recognizes as facing health workforce challenges. Kenya was placed on the UK code’s amber list on 11 November 2021, and active recruitment of health workers to the UK was stopped “with immediate effect” unless employers had already made conditional offers to nurses from Kenya on or before that date. Presumably, the Kenyan nurses who left for the UK in June 2022 fall into this category.

In explaining its decision, the DHSC states that “while Kenya is not on the WHO Health Workforce Support & Safeguards List, it remains a country with significant health workforce challenges. Adding Kenya to the amber list in the Code will protect Kenya from unmanaged international recruitment which could exacerbate existing health and social care workforce shortages.”

The WHO clarifies that nothing in its Code of Practice should be interpreted as curtailing the freedom of health workers to move to countries that are willing to allow them in and offer them employment. So, even as the UK suspends the recruitment of Kenyan nurses, they will continue to find opportunities abroad as long as Western countries continue to face nurse shortages. Kenyan nurses will go to the US where 203,000 nurses will be needed each year up to 2026, and to Australia where the supply of nursing school graduates is in decline, and to Canada where the shortage is expected to reach 117,600 by 2030, and to the Republic of Ireland which is now totally dependent on nurses recruited from overseas and where working conditions have been described as “horrendous”.

“Adding Kenya to the amber list in the Code will protect Kenya from unmanaged international recruitment which could exacerbate existing health and social care workforce shortages.”

Like hundreds of other Kenyan-trained nurses then, Nancy will take her skills overseas. She has found a recruitment agency through which to apply for a position abroad and is saving money towards the cost. She is not seeking to move to the UK, however; Nancy has been doing her research and has concluded that the United States is a much better destination given the more competitive salaries compared to the UK where nurses have voted to go strike over pay and working conditions. When she finally gets to the US, Nancy will join Diana*, a member of the over 90,000-strong Kenyan diaspora, more than one in four of whom are in the nursing profession.

Now in her early 50s, Diana had worked for one of the largest and oldest private hospitals in Nairobi for more than 20 years before moving to the US in 2017. She had on a whim presented her training certificates to a visiting recruitment agency that had set up shop in one of Nairobi’s high-end hotels and had been shortlisted. There followed a lengthy verification process for which the recruiting agency paid all the costs, requiring Diana to only sign a contract binding her to her future US employer for a period of two years once she had passed the vetting process.

Speaking from her home in Virginia last week, Diana told me that working as a nurse in the US “is not a bed of roses”, that although the position is well paying, it comes with a lot of stress. “The nurse-to-patient ratio is too high and the job is all about ticking boxes and finishing tasks, with no time for the patients,” she says, adding that in such an environment fatal mistakes are easily made. Like the sword of Damocles, the threat of losing her nursing licence hangs over Diana’s head every day that she takes up her position at the nursing station.

“The nurse-to-patient ratio is too high and the job is all about ticking boxes and finishing tasks, with no time for the patients.”

Starting out as an Enrolled Nurse in rural Kenya, Diana had over the years improved her skills, graduating as a Registered Nurse before acquiring a Batchelor of Science in Nursing from a top private university in Kenya, the tuition for which was partially covered by her employer.

Once in the US, however, her 20 years of experience counted for nothing and she was employed on the same footing as a new graduate nurse, as is the case for all overseas nurses moving to the US to work. Diana says that, on balance, she would have been better off had she remained at her old job in Kenya where the care is better, the opportunities for professional growth are greater and the work environment well controlled. But like many who have gone before her, Diana is not likely to be returning to Kenya any time soon.

*Names have been changed.

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Why Azimio’s Presidential Petition Stood No Chance

In so far as the court had nullified the 2017 elections, the evidential threshold required for any subsequent electoral nullification was going to be substantially high for any petitioner.

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Why Azimio’s Presidential Petition Stood No Chance
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Even before the 9 August general election, it was expected that the loser of the Kenyan presidential contest would petition the Supreme Court to arbitrate over the outcome. Predictably, the losing party, Azimio La Umoja-One Kenya Coalition, petitioned the court to have William Ruto’s win nullified on various procedural and technical grounds. Azimio’s case was predicated on, among others, three key allegations. First, that William Ruto failed to garner the requisite 50 per cent plus one vote. Second, that the Independent Electoral and Boundaries Commission (IEBC) chairman Wafula Chebukati had announced the outcome without tallying and verifying results from seven constituencies. Finally, that the commission could not account for 250,000 votes that were cast electronically.

As we know, Azimio lost the case as the judges dismissed all the nine petitions that the party had filed, unanimously finding that William Ruto had won fairly.

Adjudicating electoral fallouts

Since its inception in 2010, the Supreme Court has played a decisive role in adjudicating fallouts linked to contentious presidential politics in Kenya, with the court deliberating on the outcome of three out of the four presidential elections held after its inauguration. Prior to this, the losing party had no credible institutional mechanism of redress and electoral disputes were generally resolved through mass political action (as in 2007) or consistent questioning of the legitimacy of the winner (as in 1992 and 1997).

The Supreme Court’s presence has, therefore, been crucial in providing losers with an institutionalised mechanism to channel dissent, with the court operating as a “safety valve” to diffuse political tensions linked to presidential elections. It is, hence, impossible to conceive of the relatively peaceful elections held in 2013, 2017 and 2022 without the Supreme Court whose mere presence has been key in discouraging some of the more deadly forms of political rivalry previously witnessed in Kenya.

Relentless petitioning

While the Azimio leadership were right to petition the court in the recent election, first because this successfully diffused the political tensions among their supporters, and second because the court was expected to provide directions on IEBC conduct in future elections, it was clear that Raila Odinga’s relentless petitioning of the court in the previous two elections, and the nullification of the 2017 elections, was in essence going to be a barrier to a successful petition in 2022.

In so far as the court had nullified the 2017 elections, the evidential threshold required for any subsequent electoral nullification was going to be substantially high for any petitioner. The relentless petitioning of the court and the nullification of the 2017 elections had in essence raised the bar for the burden of proof, which lay with the petitioner(s) and, therefore, reduced the probability of a successful petition.

The Supreme Court’s presence has been crucial in providing losers with an institutionalised mechanism to channel dissent.

The reason for this is both legal and political. Legal in the sense that the IEBC is expected to conduct the elections under the law, which, among other issues, requires that the electoral process be credible and the results verifiable before any certification is made, otherwise the election is nullified, as was the case in 2017. It is political because the power to select the president is constitutionally, hence politically, delegated to the Kenyan people through the ballot, unless electoral fraud infringes on this, again as was the case in 2017.

The court in its deliberation must, therefore, balance the legal-political trade-off in its verdict in search of a plausible equilibrium. For instance, while the majority of Azimio supporters had anticipated a successful petition based on the public walkout and dissent by the four IEBC commissioners, it seems that the decision to uphold the results displayed the court’s deference to political interpretation of the law by issuing a ruling that did not undermine the Kenyan voters’ right to elect their president.

While the settlement of legal-political disputes by a Supreme/Constitutional court is a common feature across democracies, and continuously being embedded in emerging democracies like Kenya, it does seem that in this election, the political motivations for upholding the vote outweighed the legal motivations for nullifying it. In essence, the court demonstrated its institutional independence by ruling against the Kenyatta-backed Azimio candidate due to insufficient evidence.

Supreme Court power grab 

A counterfactual outcome where the evidential threshold for the nullification of presidential results is low would foster a Supreme Court power grab, in lieu with the 2017 nullification, by marginalising the sovereign will of Kenyans to elect their president.

In many ways, nullification of the results would also have incentivised further adversarial political behaviour where every electoral outcome is contested in the Supreme Court even when the outcome is relatively clean, as in the case of the 2022 elections.

It is this reason (among others) that we think underlined the Supreme Court justices’ dismissal of Azimio’s recent petition. The justices ultimately dismissed the evidence presented by the petitioners as “hot air, outright forgeries, red herring, wild goose chase and unproven hypotheses”, setting a clear bar for the standard of evidence they expect in order to deliberate over such an important case in the future.

In essence, the court demonstrated its institutional independence by ruling against the Kenyatta-backed Azimio candidate due to insufficient evidence.

Since the earth-shaking nullification of the 2017 elections, the Supreme Court transcended an epoch, more political than legal by “invading” the sovereign space for Kenyans to elect their president, thereof setting a precedence that any future successful petition to contest a presidential election requires watertight evidence.

In a sense, Azimio were victims of Odinga’s judicial zealotry and especially the successful 2017 petition. In so far as the evidence submitted to the Supreme Court by Azimio in 2022 was at the same level or even lower than the 2017 base, their case at the Supreme Court was very likely to be dismissed and even ridiculed as the justices recently did.

The precedent set by the 2022 ruling will, actually, yield two positive political outcomes. First, it will in the future weed out unnecessary spam petitions that lack evidence and rather increase needless political tensions in the country. Second, it has signalled to future petitioners, that serious deliberations will only be given to petitions backed by rock-solid evidence.

Missed opportunity

From the recent ruling, it is evident that the judgement fell far below the precedent set in 2017. The 2017 Supreme Court ruling that the IEBC should make the servers containing Form 34A publicly available, was crucial in improving the credibility of the 2022 elections, by democratising the tallying process. At a minimum, the expectation was that the justices would provide a directive on the recent public fallout among the IEBC commissioners with regard to future national tallying and announcement of presidential results.

By dismissing the fallout as a mere corporate governance issue, the justices failed to understand the political ramifications of the “boardroom rupture”. What are we to do in the future if the IEBC Chair rejects the results and the other commissioners validate the results as credible?

Additionally, by ridiculing the petitioners as wild goose chasers and dismissing the evidence as “hot air”, the justices failed to maintain the amiable judicial tone necessary to decompress and assuage the bitter grievances among losers in Kenya high-octane political environment.

In a sense, Azimio were victims of Mr Odinga’s judicial zealotry and especially the 2017 successful petition.

The Supreme Court ought to resist the temptations of trivializing electoral petitions, as this has the potential of triggering democratic backsliding, where electoral losers might opt for extra-constitutional means of addressing their grievances as happened in December 2007. It is not in the petitioners’ place to ascertain whether their evidence is “hot air” or not, but for the court to do so, and in an amiable judicial tone that offers reconciliation in a febrile political environment.

The precedent set by the 2017 ruling that clarified the ambiguities related to the IEBC’s use of technology to conduct elections, set an incremental pathway towards making subsequent elections credible and fair, and increased public trust in the key electoral institutions in Kenya.

The justices, therefore, need to understand that their deliberations hold weight in the public eye and in the eyes of political leaders. Therefore, outlining recommendations to improve the IEBC’s conduct in future elections is a bare minimum expectation among Kenyans. In this case, while they provided some recommendations, they failed to comprehensively address the concerns around the walk-out by the four IEBC commissioners.

At the minimum, chastising the IEBC conduct was necessary to consolidate the electoral gains made thus far but also recalibrate institutional imperfections linked to how elections are to be conducted and, especially, contestations around the role of the commissioners in the national tallying of results in the future.

This article is part of our project on information and voter behaviour in the 2022 Kenyan elections. The project is funded by the Centre for Governance and Society, Department of Political Economy, King’s College London.

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