Restructuring Primary School Health Services in Nigeria for a Sustainable Solution to Global Pandemics

This paper focused on restructuring of primary school health services in Nigeria for a sustainable solution to global pandemics with a view to identifying and addressing the challenges of the program in the primary schools. The study was a descriptive survey guided by 3 research questions. The population of the study consisted of 298 teachers and 300 pupils drawn from 30 public primary schools in Edo, Delta and Lagos states in Nigeria. The instrument for data collection was the questionnaire. Data collected were analyzed using simple percentages that were presented in bar-charts. The paper reveals that the effects of school health problems are enormous as their effects can result in increased national mortality and morbidity, poverty and national stigmatization. The study concludes by suggesting among other things, the use of health education to teach the child to improve their own health and to realize the part they can play in protecting the health of others in the community. In this way, primary school health services now serves as a sustainable solution to both national pandemics like Lassa fever and other global pandemics like Ebola virus, SARS flu and others. Various recommendations were also made.


Introduction
Nigeria as a nation is a signatory to the attainment of the United Nations Sustainable Development Goals (SDGs) of 2030 and as such should key into the realities that will actualize its realization by 2030. This paper is interested in achievement of goals number three and four which are concerned with good health and well-being as well as quality education.
Health can be used to express a persons' mental or physical condition and is viewed as a condition of being free from illness or injury or a state of being well or free from disease as stated in the Merriam-Webster online dictionary and the Oxford Online Dictionary (2016). Collins dictionary (2020) also defined health as the condition of a persons' body and the extent to which it is free from illness or able to resist illness.
Over the years, the term "health" has been given various meanings. At a time health was taken to mean only physical wellbeing and this definition or description of health takes into account only the physical condition of a person with the passage of time, people began to give health a broader meaning. It was in this regards that Oleribe et al (2018) redefined health because of criticisms on the narrow concept encompassing physical wellbeing.
Thus they redefined health as "a satisfactory and acceptable state of physical (biological)), mental (intellectual), emotional (psychological), economic (financial), and social (societal) wellbeing". They further explained that the result would be increased productivity, constructive contributions and meaningful living in a collapsing and crumbling society. This is why smith and Hart (2014) stated that "if a child's physical and mental health needs are met in the early years, children are more likely to be ready to learn and are more likely to succeed in fulfilling their full life potential". They reiterated the fact that it is well documented that children learn better and thrive better when they are healthy, safe, and engaged which makes it very important that the primary school setting should promote, protect and support the wellbeing of children and their families. Toma et al reiterated the importance of a healthy school environment. Osanyin (2012) is of the view that the local and state governments' regulations are to provide guidelines in the school environment to reduce health risks in children, parents and staff. The regulations set standards for building equipment, learning materials, playground areas, food services etc. The extent to which teachers are knowledgeable about each child's development and how the teacher facilitates that development is important.
Traditionally, teachers have been expected to act In-loco parentis (that is teachers as parents' proxies). Ekanem (2004) has stated that commonly the teacher is expected to act with a parent's reasonable care in respect of pupils' safety and general welfare. Just as in the home, children need affection from their parents so also do they need attention from the teacher when they are in school.
In the same vein, Nakpodia (2019) described the doctrine of In-loco parentis as teachers in the school having and exercising some rights and duties of parents on the learners within the school system. It is also recognized that in terms of expressed contract, teachers have duties of parents within and outside the school. The responsibilities being that while children are in school, teachers are made to take up the full obligation of caring for them. It is based on this that teachers have the right to mold the children's moral character, assist them in mental and physical development.
Ransome Kuti (1994) opined that a healthy school environment is that one that takes into cognizance the physical, psychological, social and intellectual wellbeing of the child, and that it should provide clean and safe environment that will ensure both teachers and learners' happiness and the effective performance of their educational functions. He continued by stating that invasively, an unhealthy school environment will breed teachers and learners that are not intellectually and physically sound thereby affecting the future of the nation. He listed activities that should be included in a well-organized school health services to include but not limited to: Pre -enrolment medical examination; periodic medical examination; health, education; provision of good sanitary conditions of the school environment; pre -employment medical examination for teachers, food vendors and cooks in the school; provision of sick bay or first aid materials; maintenance of sickness absence record etc.
He concluded by saying that some benefits of a good health system are early detection of physical, nutritional, social and psychological problems that may impair learning and the tracing of immunization defaulters.

Primary Education in Perspective
The outcome of the declaration of the world conference on education held in Jomtien, Thailand and framework of action on Education For All (EFA) was the recommendation of the concept of "Basic Education" Which all countries were to adopt. It was in compliance with this recommendation that the then Nigerian president formally launched the 9-3-4 Universal Basic Education (UBE) program on the 30 th of September, 1999. An initiative that was supposed to help achieve the Millennium Development Goals (MDGs) which had to do with providing educational opportunities for all.
Primary Education according to the Nigerian National Policy on Education (FRN 2013) "is the education given in institutions for children aged 6 to 11 plus. Since the rest of the system is built upon it, the primary level is the key to the success or failure of the whole system". This implies that primary level of education is the basis of all other levels of education in Nigeria.
The primary level of education is that level which marks the transition from the home or nursery school. It is duration both of early and late childhood and characteristically marked in both growth development and psychological perspective. It is a period of great physical and mental development. It is because of this that Osanyin (2002) stated that the potentials of this group of people should not be wasted or cut short as such, the health of a school child should be taken very seriously because, the child is a future leader of any nation and a healthy nation is a wealthy nation.
One of the rights of the child drawn from and in consonance with the Universal Declaration of Human Rights, article 30 is the right of every child to access quality health services.
School health problems in Nigeria and other developing countries are many and vary from place to place (Bisi Onyeamaechi et al, 2017). It is advisable that school health services not only concentrate on the physical health aspects of the school child but also the psychological, social, nutritional, economic, moral and mental health aspects because the school is supposed to be concerned with the all-round development of the child.

Health Conditions
Any condition that interferes, disrupts, or affects the normal body functioning can be regarded as poor health condition given the various definitions of health and wellbeing. These can be regarded as problems that can affect the body's physiologic process resulting in deviation from normal health. Studies have shown that health problems can be caused by physical, psychological, emotional, social, mental, environmental, nutritional and economic factors (Poland and Lee, 2002). Poor health conditions are caused by different factors and vary from one place to another. They cause illness or sickness and even death.
School health problems in Nigeria and many other West African countries are many and vary from one place to another. According to Kuponiyi, Amoran and Kuponiyi (2016) school health services are geared towards preventive, educative, curative, referral and even follow -up. The health of the school child is very important and should not be toiled with because the child of today is the leader of tomorrow and a sick nation is a poor and weak nation.
Some common health problems among primary school age pupils can be classified into one or more of the following: i. Accidental problems ii. Sanitary problems iii. Economic problems iv. Nutritional problem v. Social problems vi. Infectious or communicable disease.

Accidental Problems
An accident is an undesired or unwanted event which could allow a hazard to cause harm or injury, loss or death to person and/or damage to property, environment or loss/interruption of work, Okpanku (1996). An accident is an unforeseen course or event without an apparent reasoning Accidents such as falls, cuts, abrasion, sprains and strains are common among school children. All accidents are either directly or indirectly attributable to human failings. Children will naturally love to play and sometimes their play could become very rough. It is therefore advisable that a teacher or an adult should always be assigned to watch the children during their play periods.
The school environment should also be such that would not encourage learners to have accidents. For instance the floors should not be broken. Furniture's should be safe and playgrounds, classrooms and the school environment in general should be free from materials and objects that can cause harm to the learners and other adults in the school because according to Okpanku (1996) the total loss both in human and economic resources and personal tragedies involved in accidents are virtually impossible to measure. He further stated that it is important to note that those accidents or incidents without any loss bearing, damage or injury which the school and its authorities ignore are on the increase and later cause serious accidents. All sources of accident or accident prone areas in the school should be properly taken care of so that learner's health is given top priority in the school.

Sanitary Problems
Sanitary condition of the school environment and the pupils is very important. Ogbebor (2010) is of the view that every school should pay attention to its water supply, disposal of excreta and rubbish, prevention of disease breeding and the condition of its buildings with regards to overcrowding, ventilation and lighting. Problems can arise if there is a poor source of drinking water in the school and if there are no or poor toilet facilities. Poor physical care of the learners can also expose them to health problems such as ringworm, eczema etc. which can affect their academic performance in school. Ogbebor (2010) also, suggests the use of health education to teach the child to improve their own health and to realize the part they can play in protecting the health of others in the community.
To do this, the child must be given knowledge of how the body works, of the causes and prevention of the important diseases. Important topics like personal cleanliness and hygiene in the home, school and community should be taught to the children.

Economic Problems
Economic factors such as poverty level and illiteracy are some basic or root causes of school poor health conditions among school children which could have resulted in the parents not been able to give proper care and attention to their wards in school. The inequality in socio-economic background affects the child's education. Ezewu (1983) listed factors such as educational level, occupation and income of the family as determining the status of a family and this in turn affecting the family attitude and values in life. Maduekwe (2015) stated that marginalized people in the society would include women, rural dwellers, nomadic groups, illiterate adults and poor citizens.

Nutritional Problems
This is usually caused by intake of foods that lack or have excess of some particular nutrients resulting in some of these problems; dwarfism, kwashiorkor (protein deficiency), Marasmus (protein and caloric deficiency), obesity (excessive fat), Anemia (shortage of red blood cells). Nutritional problems arise majorly as a result of illiteracy, poverty, ignorance, faulty dietary pattern and lack of care. Ogbebor (2010) reiterates the importance of school feeding, he is of the view that if children are to study well they should have something to prevent hunger, a school meal will provide opportunity for making sure each child gets what might be missing from his diet, especially protein and vitamins and foods given should always be ones that are locally suitable and can form part of the child's local diet.
Ogbebor (2010) also suggests using school feeding as an aid to the teaching of nutrition and new food habit or even as a lesson in agriculture especially if the school has a garden which produces sufficient food for use by the learners.

Social Problems
Deviancy, alcoholism, cigarette smoking are some social problems which though not too common among pupils but are sometimes present among teachers, guardians and parents and have social effect on the child. Social problems that can exist among the primary school children are shyness and inferiority complex.
Onoyase (2013) is of the view that social problems among pupils and learners resulting in deviance which, is unwillingness to conform with the standards of behavior of that particular society or school as the case maybe, can be caused by many factors such as lack of parental care, lack of school materials, broken homes, and some other roles played by the society to have made the child a deviant.
Co-operation between home and school, parent's show of concern for their children's welfare and teachers good behavior at all times are some of the ways to ameliorate social problems.

Infectious or Communicable Diseases
These are diseases that can be transferred from one person to another. These are common among primary school pupils and most times occur in epidemics. They are caused by bacteria, virus, fungus, parasites or nematodes either through direct or indirect contact with infected persons. Some very common infectious or communicable diseases in West African countries include conjunctivitis, louse infestations, dysentery, ringworm, measles, scabies, diphtheria, poliomyelitis, influenza and smallpox. Some of these diseases can be prevented from assuming epidemic proportions in schools by paying attention to environmental hygiene, immunization and early diagnosis and treatment (Ogbebor,2010).
Immunization against such diseases as smallpox, poliomyelitis, tuberculosis, diphtheria, tetanus and typhoid can be done in the school and quite often, Ogbebor (2010) believes it can be used as a way of persuading the rest of the community to be immunized. In most West African countries, children with certain infections and diseases are excluded from school for a period of time or the period the disease or infection lasts.

The Problem of the Study
Research has shown that school health problems in developing countries especially in West Africa are many and vary from one place to another. The health of the primary school child is to be handled with all seriousness because the child is the future of the nation and a healthy nation is a wealthy nation. It is against this backdrop that the researcher seeks to find out the extent to which the primary school health services are able to detect health problems that may impair learning and the extent to which the primary school health services can provide sustainable solution to global pandemics.

Research Questions
• Research Question 1: What are the common health problems among primary school pupils?
• Research Question 2: What factors are responsible for the occurrence of these health problems? • Research Question 3: What are some of the ways the primary school health services can help curtail these health problems?

Sample and Participant Selection
The researcher employed the services of 3 research assistants for data collection. They covered 10 primary schools each in Lagos, Edo and Delta states of Nigeria. The sample consisted of 298 teachers and 300 pupils as shown in the distribution.

Assessment and measures
The questionnaire was the only instrument that was used for data collection; a detailed questionnaire for the teachers and a less detailed one for the primary learners who could read and write. The questionnaires consisted of two sections. Section A provides personal information of respondents while section B provides respondents perception about the study. Simplicity and clarity were considered in choosing the items in the questionnaire in order that respondents could understand and fill correctly.

Ethical consideration
The respondents were adequately briefed on the purpose of the study, their consent sought for and obtained by the research assistants and were also assured of the confidentiality of their responses

Research Question 1: Sought the common health problems among primary school pupils?
Responses from the sampled teachers are given below.

Research Question 2: Sought factors responsible for the occurrence of these health problems?
Responses from the sampled primary school teachers revealed that the health problems among pupils in the primary schools are usually as a result of many factors which include though not limited to: the family, school and government: The Family: Poverty and ignorance on the part of parents and guardians can make them not take nutrition serious. Unhealthy home and environment also result in poor health. The pupil's responses also revealed their parents/ guardian's occupation and the type of health providers they visit when they do not feel fine and how it could affect their health.

Research Question 3: Sought some of the ways the primary school health services can help curtail these health problems?
The teachers' response to the question whether the health services in their school had adequate structures in place to curtail health problems revealed that that majority of the schools health services especially the public primary schools needed restructuring. Teachers' responses to basic hygienic or preventive facilities that can be provided by the school health services to help curtail these health problems include: -Provision of buckets with tap heads to encourage frequent hand washing in the primary schools -Good toilet system -Good source of drinking water -Teaching of health education -Knowledge of communicable diseases -Sick bay in the schools -First aid materials in the school -Immunizations in the school -Periodic health screening in the schools -Keeping health record of pupils.

Discussion
From the teachers responses, the most common sickness among primary school children in Nigeria and in most west African countries is malaria, this is confirmed by researches like that of Aregbeshola and Khan (2017).
The findings also reveal the fact that the family , the school and the government has a role to play in ensuring maximal health for the child as stated in Nash (1997) and Ebong (2000) children are born with natural capabilities that needs to be boosted, positive or negative progress affects these areas. For instance, malnourished children may be less able to learn and children with learning problems have been found to have low esteem.
The findings have revealed the fact that most of the primary schools need to restructure their health services so that so as to curtail the effects of school health problems. The effects of school health problems are enormous as their effects according to Ogbebor (2010) are produced directly on the pupils, their parents and later effect on the society at large. Some of the effect include though not limited to physical impairment like stunted growth, hearing difficulties, structural defects from accidents at school, mental, intellectual and academic retardation, social impairment like school dropouts, involvement in negative social vices and the effect on their families and society like irresponsible citizenry, increased national mortality and morbidity, poverty, national stigmatization.

Conclusion
The main aim of the paper was to assess how primary school health services in Nigeria could be restructured to serve as a solution to global pandemics. The paper has revealed that the effects of school health problems can result in increased national mortality and morbidity, poverty and national stigmatization.
The study also proffers basic hygienic or preventive facilities that can be provided by the school health services to help curtail these health problems like provision of buckets with tap heads to encourage frequent hand washing in the primary schools, good toilet system, good source of drinking water, knowledge of communicable diseases. Ogbebor (2010) also, suggests the use of health education to teach the child to improve their own health and to realize the part they can play in protecting the health of others in the community. In this way, primary school health services now serves as a sustainable solution to both national pandemics like Lassa fever and other global pandemics like Ebola virus, SARS flu and others.

Recommendations
On the basis of the findings and conclusion reached on this paper and based on the fact that curtailing illnesses and maintaining good health habits is much easier and less expensive than treating and curing avoidable illnesses, the following recommendations were made that: • Schools should teach health education and good hygienic habits to the pupils like encouraging frequent hand washing and also school environment should be safe while at the same time good source of drinking water and good toilets should be provided in schools. • Periodic physical medical examination of pupils and even teachers can also go a long way to help.
• It is also good that every primary school is provided with basic first aid materials in schools.
• There should also be immunization and vaccination of pupils from time to time against infectious and communicable diseases. • There is the need for proper record keeping especially in the area of school health records and records of sicknesses and immunization should be kept properly. • The school should also ensure that playgrounds are safe for children. Also, children should be properly supervised during play. • Early referral of sickness or any condition that is beyond the school health service personal to handle is very important. • There is need for parents, community and government and non-government organizations to be involved in the school health program.