Nurses, Soro Soke! Speak up!

1. NURSES; A VOICE TO LEAD FUTURE OF HEALTHCARE IN NIGERIA
A keynote speech delivered by Amara Chizoba. BNSc, MPH, PhD(in view)
missiontoelderlies@gmail.com, +2347088698103
Future of healthcare
I have had the opportunity to work in different spheres of nursing; clinical practice, nursing
education, public health, research and now global health going forward. Though I’m currently
moving towards global health, I would say research and clinical practice are most interesting to me.
So when I recently had an encounter with two types of nurses in a hospital where I played a role of
patient’s relative, it gave me a long thought about the current state of clinical practice and state of
healthcare in Nigeria. An encounter that left me with a thought on ‘’what can nurses do differently
and complementarily to ensure their voices are heard and how can their voices lead the future of
health care in Nigeria?’’
The future of healthcare is built on goals of sustainable development goal and Universal health
coverage. The goals of UHC, according to WHO is defined as ensuring that all people have access
to needed health services (including prevention, promotion, treatment, rehabilitation and palliation)
of sufficient quality to be effective while also ensuring that the use of these services does not expose
the user to financial hardship. Please note that clause ‘’use of these services should not expose the
users to financial hardship’’. On the other hand, the overall goal of sustainable development goal, as
adopted by all United Nations Member States in 2015, is a universal action to end poverty, protect
the planet and ensure that all people enjoy peace and prosperity (and I categorically add health to
that list) by 2030. Please note the deadline which is 9 years from now. Remember that saying that if
you do not plan to succeed, then you are planning to fail? I believe the drivers of SDGs and UHC
have done a good job so far as the plan to succeed in this future of healthcare goals are already
written and shared to perceived implementer including Nurses. However, I need you to remember
that planning is only one determinant of success. If you recall the steps of project and program
management, you will agree with me that other major determinants of success after planning include
implementation then monitoring and evaluation and of course re-planning or in other words re-
strategizing. I can tell you the success of MDG were partially achieved because of planning but it
could have been fully achieved if there was room for re-strategizing along the cascade of
implementation, monitoring and evaluation.
Let me bring the above point home. So I work in the public health sector where I have worked with
CDC funded implementing partners for the past eight years to deliver on goal of preventing, treating
and managing infectious diseases. On one of our trips from the health centers that we support, while
reminiscing on our then recent observation, we came to a conclusive understanding which was
‘’Nigeria health system no dey work depends on who dey manage am’’. Which means in simple
terms that Nigeria health system seem not to be effective because of those managing it. We made
this non-imperative non-deferential hypothesis because we just observed and compared this super

2. effective HIV program we manage- under the management of Non-governmental organization (ie
Center for clinical care and clinical Research Nigeria-CCCRN), as compared to the TB program
managed directly by National TB and Leprosy Control Program. ‘’Give NGOs the health system of
Nigeria and in a short while you will be shocked at the effectiveness’’, he added. Sincerely Islept
over that though for close to one week. Why? The HIV and TB programs were being implemented
within the same environment and relatively similar staff so why then will the HIV program have an
upward achievement line against the target while the TB program achievement have an epileptic line
graph against the target. May be we can advocate that a part of the health care system be sub-granted
to NGOs so that my colleague and I will have study groups to test our hypothesis. But one thing we
can take away from this illustration is that the future of healthcare we desire will not just work, we
must make it work by engaging the right human and financial resources to plan, and not just plan
nut to implement, monitor and evaluate the plan and as needed re-plan or re-strategize. And I do
hope this lesson can be effected in the ongoing plans to achieve UHC and SDG even as the timeline
approaches if our goal remains to create the future of healthcare we desire and planned ab initio.
The future of health care in Nigeria
According to Ubochi et al in their review titled ‘’ Building a strong and sustainable health care
system in Nigeria: The role of the nurse”, a healthcare system is an organization of people,
institutions, and resources that deliver health care services to meet the health needs of target
populations. Such a healthcare system must have a good health services, a well-performing health
workforce, and well-functioning health information system that ensures equitable access to essential
medical products, vaccines and technologies, a good health financing system and good leadership
and governance for quality, efficiency, acceptability, and equity. However, availableevidenceposits
that the Nigerian healthcare system has failed in all these indices. Examining the Nigeria health
system, it is obvious that Nigeria has fallen below WHO minimum expectations of a strong and
sustainable health care system. For instance Nigeria was ranked 187 out of 190 countries by the
World Health Organisation (WHO) (2000). This ranking used five indicators including: levelof
population health, health inequalities (or disparities) within the population, health system
responsiveness, distribution of responsive within the population and the distribution of the health
system financial burden. Further assessment by the Legation Prosperity index published in 2017
ranked 149 countries on the level of prosperity rank, based on physical and mental health, health
infrastructure and preventive care. The Nigerian health care sector once more ranked 142 out of 149
countries (Legatun Prosperity Index, 2017) This substantiates the earlier report and further portrays
the poor state of the Nigerian health care system (Ojewale et al., 2018).
Should I continue with the woes in our healthcare system?
According to the 2018 budget, Nigerian healthcare spending is ₦1800 ($5) per head, when the 340
billion health budget is calculated on per capita basis. It is needless to make comparism with other
African countries including South African which proposed a health budget of R205.446 billion
($17.1 billion) in 2018 representing $299 per head when compared to its population of 57 million,
yet Nigeria is the country with the highest economy (Ojewale et al., 2018).

3. In the midst of all these woes in our healthcare system, can Nurses be a voice to lead
Nurses by virtue of their education, expertise, numerical strength and position as the first point of
contact with patients, are well positioned to champion health care transformations.
Nurses function from initiation of care to evaluation of care outcome and are the only professionals
with undisputed presence in the three levels of care in the Nigerian health system. Nurses today are
better equipped to supplement direct medical services with other important components of
comprehensive patient care such as patient education, and view patientsholistically(Butler and Diaz,
2017).
So what does future of health care mean to you as Nurses and what does it mean to Nigerians.
Can we start by first proposing what future of health care could mean for Nigerians. I will love to
call back to your memory om that popular story that made headline at some point. The news had it
that there was this man who once wrote that Nigeria is not a place to have any medical emergency as
the hospitals are not prepared to effectively manage it. Days down the line, the man was jogging
early in the morning and was hit by a car. He was taken to the hospital where there was firstly not
enough bed for admission, then health team were not fully on ground that early in the morning, then
blood transfusion was needed but not enough blood in blood bank and the reasons continues until
the man died. It was a sad story as his was a resemble the case of JOB who said ‘’what I greatly
feared has befallen me’’. This man was an average Nigerian who must have observed or heard of the
gaps in the health care and desired a future of health care where there is adequate facilitystructure,
sufficient health care professionals and available health materials like blood. Unfortunately, he is not
alive to witness this future but this is the future of health care – say with addition of accessible and
affordable health care- that the Nigerians envisage. I believe it’s possible to because if it is working
in developed countries, Nigeria – a developing country and dream and act in that direction to
achieve this goal.
Then again, what does future of healthcare mean for Nurses. Just last week, my darling sister put to
bed in a popular hospital in one of the neighboring state. Yes, thanks for saying congratulations, we
appreciate. Before we were discharged from the hospital, I had an encounter with two kinds of
nurses. One type of nurses who have a poor attitude to work, shouts at patients and instructs their
caregivers to conduct virtually all nursing procedures using improvised materials without as little as
giving the basic guide close to Nurses guideline. The other type of nurses I encountered also were
the type that fundamentally have a positive attitude to work who as calmly as possible explained to
patients how to carry out the nurses’ procedure which they couldn’t do due to high workload thus
had to task shift to patients’ relatives.
So what is the vision of future of healthcare. The vision is already embed in the SDGs and UHC.
Now there is a saying that the change we desire is possible and it begins with you. Indeed, the future
of health care we desire to see in Nigeria is possible and it begins with us the nurses. After all they
say the strength is in the numbers and which other health profession has the number we have. But
in addition to the numbers, we need the resources for our voices to be heard.

4. Nurses unique contribution to the present and future healthcare system; How can nurses’
voices lead the future healthcare system –
 Through Speaking and writing more
 Through collaboration between nurses –through establishing mentor-mentee program for
nurses, strengthening collaboration among nurses in home country and those in diaspora
and creating platforms for nurses’ conferences that give nurses opportunity to speak
 Through wealth creation
So, nurses ‘Soro soke’ Speak up
Before I highlight how nurses can speak up as a voice to lead future of health care, please permit me
to conclude that my story on the two types of nurses I encountered while caring for my sister after
delivery in the hospital. In the advent of the poor attitude to work, I wanted to correct the wrong
attitude of the nurse and everyone present echoed ‘’don’t question his attitude oo, or you will have
problems with them’’. Excuse you? ‘’How do we change this poor attitude if no one lends his voice
and speaks up? Of course I know what those my ‘’fellow patients’ relative’’ didn’t know. They didn’t
know that there are more nurses with a fundamental positive attitude to work irrespective of the
difficulties of the healthcare system in Nigeria. They didn’t know that the bad eggs should not be
allowed to spoil the good eggs thus speaking up about the bad attitude and corrective the other
colleagues in love can bring behavioral and attitudinal change and better still, can address the root
cause of such poor attitude if it is not inherent. So they were surprised when they saw me work back
to that unit in company of the chief matron and this particular young nurse who exhibited a poor
attitude to work. They were even more shocked when the young nurse apologized to every one for
his poor attitude to work and took the first step of doing it better there and then. So was my aim of
speaking up as a nurse achieved? Yes! It showed the onlookers the side of nurses with positive
attitude to work (in this case, the chief matron), it corrected a wrong attitude and instituted a better
practice in the nursing services in that unit and I’m sure the ripple effect will be felt in other units as
this would be a topic of discussion in the next nurses meeting. So my principals and colleagues,
speak up and let your voices lead the future of health care in Nigeria
Now let’s look at how Nurses are and can become a voice through speaking and writing.
Actually, a nurses should start talking where and when they need to talk. This point resonates with
that my recent personal experience where I had to really talk, to make my voice heard in order to
make a change. But where else should nurses voice lead? Of course in the corridors of health
practice and health profession. I literally mean when sited among other colleagues and you get an

5. opportunity to speak up and make contributions, please seize the opportunity and make sure your
voice is heard. And please let them know u=you are a nurse while doing that. In 2016, Iwas invited
to speak on one of my research findings at an international conference of Researchers and CEOs in
public health practice, held in Abuja. While I was being introduced by obviously two doctors who
moderated my session, they introduced me as Dr Amara. So when I mounted the podium and
finished speaking, I deliberately and sharply corrected them as I reintroduced myself as a Nurse not
a doctor. Boy, I could feel the silence and hear the drop of a pin in the room. You could see the
astonishment in their looks ‘’like seriously?’’. Of course like seriously, Iam a Nurse. I primarily
chose nursing and not any other profession and I intend to lead with my voice as a nurse and make
us proud. Did I tell you that after I identified as a nurse, that I connected with lots of other nurses
who rallied around me afterwards with whom I conducted other researches that got us international
recognition? Yes, that’s the power of making your voice heard as a nurse and for the nurses.
Still on making your voice heard. Peradventure you were not given the podium to make your voice
heard like I was, I recommend you take the podium yourself and speak. You are thinking that’s too
bold, right? That’s not feminine, a gender norm closely associated with nursing, right? No my dear,
if that’s your thoughts then you are wrong and let me prove it. I was in London attending women
leaders in global health conference as a key contributor, and while in that meeting, I learnt
something I will never forget. A female public health specialist- Dr Ayoade Alakija,- made a
profound statement that we still quote as we meet in subsequent meetings, ‘’woman, stop
complaining that you are not being given a sit on the table. If they don’t give you a sit, pull one for
yourself and make your voice to be heard so loudly that you cannot be ignored. Then watch them
offer you an executive sit when next you show up’’. Why did I say that statement was profound and
how can we relate it to how nurses voice can lead? Still referring back to my time at the hospital
where my sister put to bed. When I got talking with one of the nurses to understand why some of
the nurses demonstrated such poor attitude to work, because left for me, I am in nursing because I
am passionate about caring for those that need it so I couldn’t understand why a fellow nurse will be
acting so rudely to same patients entrusted into his care. One among many reasons for the poor
attitude she highlighted was that the nurses were not treated well; in terms of poor remuneration and
high workload. Yet they cannot talk because they are afraid of losing their jobs thus what I
witnessed was sheer transfer of aggression to the patients. Then she concluded; ‘’can you blame
them?’’ So I left with thoughts like ‘’what can the nurses do to ensure their voices are heard. How
can their voices lead the future of healthcare in Nigeria.’’ Then I could relate the scenario to the
words of Dr Ayoade Alakija, ‘’if they don’t give you a sit at the table pull a sit’’. And I’m saying to
nurses today, don’t dwell on the complain that they (who are the they by the way) are not giving us
opportunity to make our voices heard. Dear Nurse, pull your microphone and speak up! Let me
remind us that winning is sometimes a game of number and strength of contribution and we have
both. I hope you are not forgetting that by numbers and strength of contribution, nurses form 60%
of the health workforce in Nigeria. So whose voice should be heard louder than ours? Comrades,
let’s echo our contribution in one accord. Trust me our voices will be so loud that we can’t be
ignored and when next we show up, the ‘’they’’ willgive us the sit we deserve at the table!

6. Beyond speaking, we need to write, starting with appropriate documentation of service provision.
My HOD in Nursing department in Ebonyi State University, Ms Regina Ogudu of blessed memory
dropped it in my consciousness that as nurses, we do a lot and documenting the nursing procedure
in patients’ folders preferably using nurses careplan is almost the only way to prove our indomitable,
indispensable and indelible contribution to the health care of the patients. She also added that this
evidence of documentation is almost the only evidence we can use to negotiate for compensation
and recognition commensurate to our contribution to the team. So for the times I worked in the
clinical setting Inever managed a patient without appropriate documentation and use of nursing
careplan clearly placed in the folder. How can I? I was thought by the best. This effort on
documentation laid a foundation for me and led to my flare for research writing. In my current
practice in public health, I wouldn’t be part of any intervention practice without developing a
research protocol that would convert that intervention to an implementation research, for
presentation and publication. Thus twenty-two of my research presentations and publications are
specifically implementation research. Iso much did this in the organization I worked with that the
management handed me the portfolio of research coordinator, where I led a team of other health
professionals like nurses, doctors, pharmacy, laboratory specialists etc in research writing, having
over 20 publications and international presentations as success story. But who led the team and gave
a voice to using research finding to improve best practices towards impressive future of public
healthcare? A nurse through writing.
That brings me to the conclude on this point on how nurses voice can lead the future of healthcare
in Nigeria through writing, and specifically through research writing and publication. As important
as nursing research is to serve as a voice to lead, According to review by Ekaete et al in titled;
‘’assessing Nurses’ Capacity for Health Research and Policy Engagement in Nigeria’’ Studies in
Nigeria and from other countries have identified many barriers that prevent nurses
undertaking research activity and utilization of research findings to include lack of adequate
staff and excessive work load, lack of experienced nurse researchers, cost, lack of
organizational support, unavailability of internet services and lack of nursing research mentors
and leadership in the dissemination of research findings. (Ekaete et al 2012)
I know workload is much for nurses but like one of my mentors in nursing – Dr Emilia Iwu- would
say ‘’it’s easier to succeed in research when you conduct research in the line of your practice’’. So if I
encourage you, if you are an ICU nurse, conduct and participate in research like ‘’prognosis of ICU
cases or effect of nursing procedures on improving the prognosis of certain cases in ICU; a case
study of your hospital’’. Collaborate with other nurses in other hospitals, states and even nations to
harness larger sample size in order to increase the power and generalization of your research finding.
Remember the goal of your research is to contribute to science and best practices towards a better
future of healthcare. Some researchers are experts in reviews and meta-analysis and your finding can
form a pool of data a harmonized finding that can contribute to decision making towards the future
of healthcare you envision. For instance, one of my studies on TBA-PHC Integration (TAPIn)
model to improve PMTCT in Nigeria was recognized as a strong contributing model for public-
private health system collaboration in context of Africa by UNAIDS sciencenow. So nurses must

7. participate in research writing –either as the study lead or co-author- in order to make their voices
lead.
But before I conclude on this point on writing, another key area on writing is definitely research
writing. Among my closest mentor is Prof Echezona Ezeanolue. Very dear to my heart. He is about
the highest grant awardee in Nigeria. If you know of another, please show me because I would love
to connect with him/her. Prof told me that since I love research, I can be paid doing research
through applying and winning research grants as principal investigator (PI) or as co-PI. Of course
we met a hitch on majority of the grants as PhD is usually criteria for getting the grant as PI. Which
is why I’m in a hurry to round up my PhD in program. But if not applying as a PI, the nurse can
participate in the grant writing and implementation as a co-Pi or implementation team. Google
research grants for nurses and you would be shocked at number of search results that would show
up. A journey of a thousand mile starts with a step so take the step today. Take online and
YouTube classes on research. Read and start writing today because your voice as a nurse must be
heard.
Moving further, if nurses finally starts speaking up through talking and writing, these nurses voices
will be heard in tickles as it’s currently the case. But if strong collaboration is established for and
among the nurses, I bet you the collective voice of nurses will surely lead the future of healthcare in
Nigeria. Let’s remember that the strength of Nurses are also in their number. According to World
Health Organization on ‘’The Strategic Directions on Strengthening Nursing and Midwifery Services
2011-2015’’, in the African continent, it is estimated that nurses constitute about 80% of the health
care professionals. Let me repeat that, nurses constituteabout 80% of the health care
professionals in Africa which is not far- fetched from that of Nigeria. In Nigeria, Nursing is
the nation's largest healthcare profession, with Nurses comprising the largest component of
the healthcare workforce, are the primary providers of hospital patient care, and deliver most of
the nation's long-term care. So why would nurses voice not lead?
Therefore, there is urgent need to institute collaboration between nurses –through establishing
mentor-mentee program for nurses. I am currently a mentee in Mentor-mentee program of
Department of Global health studies from University of Rwanda and I am a mentor in research
program of Acta scientific journal and I tell you that I have neither met my mentor nor mentees
physically. Our meetings are online through zoom, skype, Whatsap and phone calls. But surely
learning and guidance are going on. Nurses also need to strengthen collaboration among nurses in
home country and between nurses in home country and those in diaspora. Let me once again bring
to our notice that still According to World Health Organization on ‘’The Strategic Directions on
Strengthening Nursing and Midwifery Services 2011-2015’, 1 in every 20 nurses migrate to work in
diaspora. Why not create a platform that connect the two groups so there can be transfer of
knowledge, information and even resources from nursing system of developed countries to that in
Nigeria. Thirdly, there is need to create more platforms for nurses’ conferences that give nurses
opportunity to speak. Thanks once again to this conference organizers and my amazing model in
nursing, Joy Unigwe, for this rare privileged and believing in a nurse like me to share my thoughts
and experiences with colleagues. That’s a way to give nurses voice to lead.

8. Now, in addition to all these, while we use our voices to lead, through talking, writing and
collaboration, it is paramount that we understand that the listening ears sometimes have a way of
inclining faster to the voice with the resources, I mean financial resources and if I must be blunt, the
voice with the money. A certain wisest man that ever lived in a certain generation once left us with a
certain profound saying in a certain book called the book of Ecclesiastes and Iquote ‘’Now there
lived in that city a man poor but wise, and he saved the city by his wisdom. But nobody remembered
that poor man. 16
So I said, "Wisdom is better than strength." But the poor man's wisdom is
despised, and his words are no longer heeded. (Ecclesiastes 9:15-16). That tells us that people heed
to voice of they that have the resources. Nurses have the human resources no doubt. But I believe
we can do better to have the material resources through research, writing and publication but much
more than that, Nurse can have the financial resources directly through funding and indirectly
through wealth creation. And what if I tell you that one way that nurses can create wealth as source
of fund to serve as a driver and voice of future healthcare in Nigeria can be through blockchain
technology? That is another keynote speech for another day.
In closing, I will leave you with this thought. I was in New York to receive an award of young
African leader in global health from Consortium of Universities for Global Health. Before the day
of the award ceremony, the Executive director – Dr Keith Martin- walked up to me and said ‘’Hi
Frances, you remember that last year in Washington, you had raised your voice to ask why such a
global health consortium isn’t talking about aging and health so this year, we have added healthy
again in the plenary session. I look forward to having you around to make your contribution’’. Oh
wow was my response. Because I remember how passionately Ispoke about that from previous year
and though I seemed to be the only one that spoke in that direction, that one voice made a whole lot
of difference to the point that healthy aging is now in fore front of discussion in that international
meeting with impacts rippling to other offshoot of meetings and conferences around the globe. May
be that voice they heard stood me out by the next year as the global health award recipient. So once
again speak, and when you do, make sure they remember that it is a nurse that is speaking.
Therefore, ladies and gentlemen, you can be sure that it is voices that will lead the future of
healthcare in Nigeria and globally. Nurses’ voices can be among the loudest if we take more
conscious steps to speak, write, collaborate and even step into wealth creation. So Nurses soro soke!,
let us speak up and let our voices lead!
Good morning and have a fruitful conference.