Dr Faisal Shuaib is the Executive Director / CEO of the National Primary Health Care Development Agency (NPHCDA). In this interview by SAM NWAOKO, he speaks on Nigeria’s recent clean bill on Polio, health fund management by states and other primary health care issues. Excerpt:
Your agency disbursed N13.2billion to the 36 states and the FCT for the rehabilitation of PHCs. How many have spent the money as agreed and how do you ensure that the defaulters are sanctioned?
The NPHCDA received the N13.2 billion in two tranches, the first tranche of N5.88 billion was released in June 2019 which was subsequently disbursed to 16 states. In September 2020, a second tranche of N7.3 billion was disbursed comprising N5.88 billion from Federal Government and N1.4 billion from the World Bank. Same has been disbursed to all 36 states and the FCT. So far, seven (7) states including the FCT (Abia, Niger, Osun, Ebonyi, Delta, and Anambra) have met all requirements and have been authorised by the NPHCDA to disbursed funds to over 1200 PHCs. The funds to be disbursed for the 1st two quarters are to be utilised for basic “face-lift of the PHC Facilities’, purchase of medicines and commodities. Facilities that do not submit retirements or spend money disburse to them as stated in their business plans will not receive additional funds from the SPHCB/As.
In way of sanctions there is an accountability framework and key performance indicators that are built and applied to the states. States who decline to send money to PHCs or do not sanction a PHC that has defaulted in terms of eligible expenses, would be initially warned and the state Governor would be informed if the financial variation is less than 10%. Subsequent infractions, or in cases where infractions are not successfully redressed, or variations are greater than 10%, will lead to the state being suspended from benefitting from the Basic HealthCare Provision Fund till all outstanding issues are resolved. Starting from next year, persistent failures to meet the key performance indicators would also result in withholding of funds from the states.
High child and maternal mortality rates are live issues here. What efforts has your agency put into eradicating this scourge?
The rate of maternal and child mortality in Nigeria has remained at an abysmal rate over the last 30 years and beyond (NDHS 1990-2018). Hitherto, Nigeria made no progress towards achieving the Millennium Development Goals for Maternal Mortality, thereby ranking very low amongst the community of nations. Drastic actions are required if Nigeria is to make progress towards the maternal and child mortality targets of the Sustainable Development Goals.
It is out of this concern that we established the National Emergency Maternal and Child Health Intervention Centre (NEMCHIC) . Recognising the fact that majority of these deaths occur in our communities, the centre has identified high impact interventions that will bring about a rapid reduction in these rates. These interventions factor in the demand and supply side of the maternal and child death equation by addressing the delays to care at both community and health facility levels.
So far, we have supported 15 states in the country to set up a replica of the NEMCHIC- State Emergency Maternal and Child Health Intervention Centres (SEMCHICs), and Local Government Emergency Maternal and Child Health Intervention Centres (LEMCHICs). We are currently in the process of supporting SEMCHICs to implement the high impact interventions that will bring about rapid and sustainable reductions in the number of women and children that die from preventable causes in our communities and our country as a whole.
With these interventions in place, we have begun to see significant improvements in the uptake of ANC and Skilled Birth Attendance, which are critical determinants of the survival of a Pregnant woman and her unborn child.
How much of cooperation do you receive from state governors and governments to deliver on your mandate?
The National Primary Health Care Development Agency engages the States through three (3) major Coordinating Platforms: Executive Secretaries (ESs) of State Primary Health Care Boards (SPHCBs).
Through these Platforms, NPHCDA is able to engage seamlessly with the State Governors in the areas of Fund releases, Counterpart funding of Programmes (Polio Eradication Initiative; Measles, Yellow Fever Campaigns, MNCH Weeks, mI-MOP, Strengthening of RI; PHC Revitalization; Implementation of BHCPF etc).
Also, through the HCHs/ESs SPHCBs they are able to transfer PHC workers and their salaries to SPHCBs, establish LGHAs as enshrined in the PHCUOR Guidelines; National Structures like NERICC, NEMCHIC were replicated at the state levels as SERICC and SEMCHICs, respectively.
All these resulted in a better Cooperation and coordination of programmes and feedback.
Dilapidated structures are the face of PHCs in Nigeria. Are you not worried about this? How do we get the facilities right?
The state of primary health care (PHC) infrastructure in Nigeria is sub-optimum and is a serious concern to all.
You could recall that in January 2017, President Muhammadu Buhari launched the primary health care revitalisation agenda. Under the leadership of the National Primary Health Care Development Agency and its partnership at state, local governments and donor agencies, the agenda is committed to making at least one PHC in each of the 9556 political wards (approx.10,000) fully functional during the eight-year tenure. What it means is that each of these PHCs will be renovated/upgraded structurally from the buildings, floors, roofs, windows as well as reliable water and power sources. The other critical components of the revitalisation agenda are adequate and well-trained human resources that could manage the PHCs on 24 hour basis as well as the availability of appropriate equipment, drugs and other health commodities.
In fulfillment of this commitment, the Federal Government has completed 2,511, state governments have been able to deliver 557 while development partners, have completed 355 and LGAs 10, bringing the total to 3,433 Primary health care facilities revitalised nationwide.
In addition, we are planning a post- polio certification PHC Summit which we would bring together all stakeholders to a round table discussion with the aim of mobilising heavy investment into the PHC space in order to address the challenges of the system. Aside from seeking increased funding for infrastructural upgrade from national and state sources, adoption of PHCs by communities and affluent individuals may be the way to go.
Adequate personnel and equipment is another issue. There appears to be quacks everywhere. What is the way out on this?
The inadequacy of primary health care workers both in numbers and capacity is well known. Data from the Health Facility Survey of 2019 clearly demonstrated that less than 22% of publicly owned Primary Health Care facilities have up to two midwives to deliver health services to the populace. Even where they exist, their skill set is often sub-optimal to deliver adequate quality services. Lack of necessary equipment for service delivery is also a major problem resulting from either non-availability of these equipment right from the onset or failure of the authorities to replace obsolete or broken-down equipment. The low stock of qualified health workers results in the existence of large numbers of quack health workers practicing in the PHC space, with many community health extension workers fronting as doctors and village health workers with little or no knowledge or skills of delivery of maternal and child health services masquerading as nurses and midwives.
How do you get funds and what measures are in place to insulate the agency from the old controversy of mismanagement of funds?
NPHCDA gets its funds through appropriation of the Federal Government; World Bank Loan Facility (NSHIP, ADDITIONAL FINANCING etc.)
Nigeria exited polio recently. There are fears it may come back from our porous borders. What measures are you putting in place to prevent this?
We have taken a number of steps to prevent resurgence or importations since two countries (Afghanistan and Pakistan) are still endemic. We have sustained our current certification standard AFP surveillance even in the midst of COVID19 through implementation of what we call surveillance contingency plans, which ensures detection, testing and reporting of cases continues at the current levels.
Vaccination of travellers coming from endemic countries who do not have evidence of polio vaccination 2 weeks before arrival to our country through the international airports and sea ports. We have also strengthened our land borders to ensure that individuals especially children are vaccinated at these crossing points. This we are doing through active collaboration with our colleagues at the Port Health division of the FMoH. We have also strengthened our cross-border collaboration to ensure synchronisation of our surveillance and SIAs activities with Niger Cameroon Benin Republic and Chad. These activities include ensuring Surveillance and Immunisation within the IDPs and refugees’ activities along our land borders to ensure polio does not come back. Targeted polio campaigns are being conducted in identified high-risk areas to boost immunity of the eligible children at risk. Surveillance is also being strengthened to detect possibility of any re-occurrence for timely intervention.
How much involvement has your agency got in promoting female literacy and empowerment which are very essential ingredients of sound health?
There is global evidence linking female empowerment to the improved health status of women, their children and their communities. In recognition of this, the NPHCDA has centred empowerment as a critical pillar of the CHIPS Programme. Through its Female Empowerment Pillar, the CHIPS Programme provides CHIPS Agents (mainly female) with the opportunity to improve their literacy levels and income generation skills, through existing adult literacy and skills acquisition schemes in implementing States.
To improve literacy level of the CHIPS Agents NPHCDA is collaborating with the Federal Ministry of Education to enroll them into adult literacy programmes through the state mass literacy agencies, while FMWASD, NDE and other relevant MDAs and partners have been engaged to facilitate the enrolment of CHIPS Agents on relevant skills acquisition schemes.
Any specific program on combating malaria?
As one of the major contributors to maternal and child mortality and morbidity, combating Malaria is a key target of the CHIPS Programme. A primary role of the CHIPS Agent is to provide counselling and health education on malaria prevention, including Long Lasting Insecticide treated Nets (LLINs) use, proper hygiene practices, WASH, and also distribute LLINs to pregnant women.
Additionally, they provide integrated community case management of malaria, pneumonia and diarrhoea to children under-5. As part of this, they are trained to identify, diagnose and treat uncomplicated cases of malaria, and to quickly identify danger signs of severe malaria and ensure referral to the nearest health facility. They are provided with the relevant commodities e.g. thermometer, RDT kits and ACT, to ensure effective service delivery for this. CHIPS Agents also play a critical role in data collection at the community level, all of which supports appropriate decision-making to better enable us address challenges and better tailor interventions.
What advice do you have for stakeholders in the healthcare sector in Nigeria on how to make Nigeria disease free?
There are several causes of diseases. Some of these diseases can be prevented while some cannot. We are all responsible for the health security of our nation, and not just the government.
On the government side, health is the responsibility of the three tiers of government. The national government is responsible for the development of standards, guidelines and provision of tertiary care; while the states / LGAs are responsible for secondary and primary health care. For vaccine preventable diseases (VPDs) like tuberculosis, diphtheria, pertussis, polio, hepatitis B infection, haemophilus, pneumonia, measles, meningitis and yellow fever, the Government has done a lot through the National Primary Health Care Development Agency (NPHCDA), working with states and LGAs to ensure that all eligible persons are immunized. This has resulted in a significant decline in these VPDs in the country. For instance, the World Health Organization has just declared Nigeria polio free. Again, some regions in the country (SE and SW) have already eliminated measles. The Federal Ministry of Health (FMoH) and other MDAs under the FMoH (also supported by donors and partners) are doing quite a lot to keep the nation free from communicable and non-communicable diseases. Efforts are ongoing to increase access to vaccines for immunization services on an equitable basis through Cold Chain expansion at National (3Hubs) and service delivery levels (CCEOP) through partnership with Gavi and World Bank (WB.)
On the part of the individuals, most diseases require our personal hygiene, lifestyle etc. Example is the ongoing COVID-19 pandemic in the country where observance of hygiene and IPC skills are important. We advise Nigerians to be conscious of their personal hygiene, clean environment and positive lifestyle to reduce and avoid coming down with diseases. Attention to good healthy eating also promotes health security. There is a popular saying that prevention is better than cure.” So, the culture of prevention is highly required from us Nigerians to keep Nigeria disease free.
For the other stakeholders (partners, donors, Civil society organisations etc.), we solicit for their continuous support for the planning, implementation and evaluation of identified priority interventions that will keep Nigeria disease free.
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