Faisal Shuaib was appointed Director-General of the National Primary Health Care Development Agency, NPHCDA, in January. In this interview with Bisi Abidoye, Ayodamola Awoseye and Nike Adebowale of PREMIUM IMES, he speaks on the strategic ways the agency is trying to address the fundamental issues in primary healthcare in Nigeria.
PT- In terms of capital expenditure, what are the major concerns of your agency in the 2018 budget currently before the National Assembly?
Faisal – The major thrust of the agency’s mandate is to provide quality healthcare services to all Nigerians by providing technical and implementation support to states and local governments, setting standards, regulating and providing oversights to ensure that Nigerians have access in an equitable manner to primary healthcare services where they live and work.
In the 2018 budget, one of the important areas that we are focusing on is that the basic healthcare provision fund sees the light of day, so that one percent of the consolidated revenue fund gets appropriated for the health sector. We feel that will be a giant step in achieving universal health coverage for Nigerians. We have been in engagement with the National Assembly on how this can be made possible.
If we want to strengthen primary healthcare, then we need to make the funds available that will ensure that we have quality PHCs in Nigeria. Primary health care is the foundation of any health care service. The reason why we have people going abroad, people unsatisfied with our health system, is because the foundation is really poor. If the foundation is poor, how do we expect to have a solid building on a weak foundation?
Apart from advocating the provision of the basic healthcare provision funds, we are also prioritising the availability of vaccines against preventable diseases. What we are doing this year, is ramping up the budgetary allocation for vaccines. Apart from the regular vaccines, we are also trying to introduce new vaccines into the immunization schedule.
We are also trying to ensure that apart from providing the funds for the vaccines, that we have enough funds, domestic resources for the job of completing polio eradication. We have gone a whole year without a single case of wild polio virus and ordinarily, we would have started the countdown to polio eradication. But because we still have local government areas, some districts that we don’t have access to, we cannot say we have interrupted polio. The Boko Haram insurgency is the only reason why we have not been declared polio free and it is the reason why we do not have access to those LGAs. So, we are making increased budgetary availability for polio eradication.
Lastly, we are rolling out a focused renovation and revitalization of primary healthcare services across the nation. We are looking at it from both the supply and demand side. The supply side is around how we are able to provide the equipment, the drugs, the human resources and a functional health facility for people. But we cannot provide that if we don’t have the demand side, where people come from the community to use the health facility, because then we have an imbalance.
So we are rolling out a community health workers programme, that we called Community Health Influencers, Promoters and Services, CHIPS. These are women that are identified, approximately 10 per ward, who would promote hygiene, who would speak to community members about the need to go to health facilities when they are sick, they will provide first aid, they will encourage immunisation, they will encourage women who are pregnant to go for antenatal care, so that by going for antenatal care, they are likely to deliver in the hospital. And that will reduce the number of out of hospital deliveries that occur in the household and probably lead to bleeding and death in most rural areas. So those are some of the items we are focusing on in the 2018 budget.
PT- On the Consolidated Revenue Fund, was it anticipated in preparing the budget? Because a senator just said the National Assembly may have to force the implementation of the 2014 National Health Act, which has a provision for this.
Faisal- The basic healthcare provision funds is not within the Primary Health Care Development Agency, it is a sector-wide provision. The National Primary Health Care Development Agency just gets 45 per cent of the funds, NHIS also gets 50 per cent, then the Federal Ministry of Health gets five per cent.
Yes, it was not part of the submission of the executive branch of government to the National Assembly. But because of the advocacy and conversation that have taken place, we have been able to sensitize the National Assembly and they are also saying that this is the part of the law and it is within their remit to discuss with the executive arm and see the need for the one percent of the consolidated revenue fund to be made available. I think they are in conversation around how that can be possible.
PT: Was not taking cognisance of the Act an error of omission on the part of the Executive in preparing the budget?
Faisal- No, it is not really an omission. It is a question of, within the scarce resources that are available, how do you balance all the investment that you have to make? For instance, you have to invest in power, invest in water, invest in health. How do you balance that within a tight fiscal space that we are experiencing?
Now, I know the executive arm of government is interested and see the value in making this fund available. There is alignment across board, across stakeholders that we do need additional funding, we need additional domestic resources for the health sector. But how do we get it? Sometimes, we always have to remember that it is not about how much money we give but how judiciously are those funds being used? So those are conversations, those are issues that need to be addressed.
PT- You spoke about vaccination programmes as part of your major concerns, what steps are policymakers taking to get Nigeria to start producing vaccines?
Faisal- That is again a major thrust of the National Primary Health Care Development Agency.
On one hand, we have been procuring vaccines in the last few years, at some point we also realized that because we have a large market in West Africa, let alone the whole of Africa, there are conversations around how we can initiate local vaccine production. You might be aware that a few weeks ago, the Federal Executive Council approved a joint venture between the Federal Government of Nigeria and May and Baker. So work is going on, on how local vaccines production can start with those kind of joint ventures.
But apart from that, we are also exploring the engagement with other partners. For instance, Cuba which is a very small country compared to Nigeria, produces all the vaccines that they require. So we are also engaging with the government of Cuba to see how is it that they are able to produce their vaccines. Are there simply technology that we can use in Nigeria to also get the same quality of vaccines? So we are looking at different ways to ensure we start local vaccine production within the shortest possible time. And I am sure this is a priority again for the government. Because this government wants to institute local vaccine production within the next two years, so that no matter what happens, the ingredients for local vaccine production would have been put in place by this government. So that no matter what happens in 2019, we can only move forward and ensure that subsequent processes continue.
PT – How would you describe the state of PHCs in Nigeria today, noting the major challenges that they face?
Faisal- Clearly, we have come a long way from several decades in terms of improvement we have seen in primary healthcare delivery. But as of today, there is no single person in Nigeria who would tell you he is happy with the status of primary healthcare in Nigeria, unless that person is not in touch with reality.
Our primary healthcare services are sub optimal in most places and that is why we still have high maternal and child mortality indices globally. This is why it became very critical that when Mr President (Muhammadu Buhari) assumed office, he laid out his vision that, no matter where people live, no matter where they come from, we should reduce the inequality that exists between the rich and the poor, the haves and the have not, when it comes to access to primary healthcare services. Whether you live in the urban area or the rural area, there should not be inequality in primary healthcare services.
The Minister of Health took this vision and has rolled out the 10,000 functional PHCs target, and ensure that at least we have one functional PHC per ward. If that happens, that means people have to walk very short distances to have access to PHC. That is not just about renovation; that is also ensuring that you have the right quality of human resources, there are enough drugs, enough commodities so when people visit the facility, they are able to get the type of treatment that they require. Pregnant women, children will all have access to PHC so they wouldn’t die from complications before they could get to a secondary health facility, which is several kilometres from where they live.
PT- How far have you gone in the implementation of the revitalisation of 10,000 PHCs?
Faisal- We cannot renovate 10,000 PHCs within one year, so what we did is in every senatorial district, we get one PHC and this brought us 109 PHCs; and there was one more in Fuka in Niger State; that was where we had the Lassa fever outbreak. So what the government did is, we are going to renovate these 110 PHCs, equip them, renovate them, make sure they have adequate human resources, make sure they have power and water. Out of this number, we have been able to provide equipment, human Resources and drugs in 95 out of the 110. So we feel confident that, to be able to reach that 110 mark, the balance of 15 that we have not done are in progress and we are hopeful that by the end of the year, we will be able to finish up and move ahead in providing other resources in these PHCs.
The goal of reaching 10,000 functional primary health centres is not one that is being borne by the federal government alone. PHC services is within the remit of the local government, so what the federal government is doing is supporting and advocating the state governments that have also identified some health facilities they are going to renovate; and that is already taking place in several states. We also have development partners such as UNICEF, EU, MNCH through DFID that are also renovating PHC facilities. Some of them have up to 1,000 PHCs that they will renovate over the next two years. So, putting all these together and working together we can now begin to move an inch closer to reaching the 10,000 PHCs goal. What is going to be critical is how are these PHCs managed or are sustainable?
PT – Are the state and local governments allowing your agency play the role of coordination?
Faisal- Absolutely! We enjoy an incredible collaboration with the states and LGAs. The states understand that we have the expertise at NPHCDA to provide oversight and coordinating roles in terms of how we work together to ensure there is less fragmentation, there is less concurrency and mal-alignment of governance of PHC services. Working with the states and LGAs, this is how we have been able to implement the Primary Healthcare Under One Roof policy, which seeks to consolidate all of these fragmented authority and management of primary health care between local, state and federal governments. Consolidating all of the management under one plan, one monitoring evaluation system that is encapsulated within an institution known as the State Primary Health Care Development Agency. So, we have a situation where a worker is a staff of the LGA. For the PHC Under One Roof, we have been able to implement in all the entirety, all states apart from Bayelsa have already established laws asking all the LGA health workers to move to the State Primary Healthcare Development Agency. We are still waiting for Bayelsa to pass that law, I know it is held up in their State Assembly. In some states, there is still work in progress in finalising plans for the primary healthcare agency. While some states have done an incredible job, we still have states where it is not working as it should be and that is why we have been advocating to the governors and providing from the NPHCDA.
PT- A few months ago, our reporters went to some states’ rural areas to take a look at the PHCs. Some are dilapidated, some are uncompleted and those completed are not in use. What are you doing to discover such projects and also put them into use?
Faisal- We are just beginning to get reports from the fields, from the people we sent out to carry out a detailed assessment of all of these facilities across the nation. To say, which are the poorly renovated health facilities, which are the dilapidated health facilities, which are the facilities started and completed and those started and not completed? So that we don’t keep having people year in year out, saying they want to start a health facility that will not be completed. Such unfinished projects are littered everywhere in the country. So we are taking stock of them all and prioritise each of them. If a National Assembly member comes to us to say, ‘I want to build a PHC’, we will tell them that next to your village is an uncompleted one, ‘can you complete that and probably share credit with your predecessor for ensuring that the health care facility becomes functional?’
We also want to be able to sit here at NPHCDA with all the photos of the PHCs to be able to show people who want to see the state of health facilities in their villages. To tell them the number of staff there, the last time it was renovated, if it is a 9 a.m. to 5 p.m. PHC, or is it a five-star PHC? Such rankings will be available to them. That is the kind of assessment we are doing, so that we move away from a situation whereby we have PHCs that have not been taken over and equipped.
We also get in touch with private sectors, individuals in communities to know how they are working towards having a quality PHC. That is part of the PHC revitalization we have embarked on and at this point, we are like 50 percent of the way in terms of getting all the data that we need to know their locations and status.
PT- Nigeria is the only country in Africa yet to be declared Polio free, in spite of huge resources committed to the project by all tiers of government and development partners. Why is this such a hard nut to crack?
Faisal- We have gone a whole year without a single case of wild polio virus and ordinarily, would have started the countdown to polio eradication. But because we still have local government areas, some districts that we don’t have access to, we cannot say we have interrupted polio. The Boko Haram insurgency is the only reason why we have not been declared polio free and it is the reason why we do not have access to those LGAs – the Lake Chad Basin and probably two to three local government areas. So, potentially, we are looking at 200,000 eligible children. And those children with numbers like that, they can sustain polio transmission. However, some of these children are moved with their families when there is an attack. So it is a dynamic situation. We are yet to access those people and find out what is the level of polio transmission among the communities. Until and unless, we are able to reach these kids with the vaccines and we have gone everywhere and ensure there is no transmission, we are not going to be quick to say we have interrupted polio virus.
PT- You earlier spoke about the Community Health Influencers and Promoters of Health Services, CHIPS, that you are initiating. Could you tell us more about this?
Faisal- CHIPS is a new innovation of the primary healthcare. It is new only because we are scaling up and then harmonising the different community health programmes. We are also introducing new things that can improve community health programme. These workers are women that have at least elementary school education who will be selected in their wards. We are looking at having 10 women per ward who will be trained for six months to treat simple conditions, like a child who gets injured after playing football can get first aid treatment. If a child has diarrhoea, this kind of women will teach the parent or guardian how to do Oral Rehydration Solution and then give ORS to the parent. If a woman delivers a baby, they will encourage her to go for routine immunisation. They will also encourage pregnant women to visit health facilities for antenatal activities to prevent maternal and child mortality in such communities. Since they have been visiting health facilities for antenatal, when the time for delivery comes it will be easy for them to go to the health centre. They will also promote hygiene, encourage environmental sanitation. It is there in Rwanda, Ethiopia.
Community health workers make huge difference in health outcome. The reason why it has not been in existence in the past is because people say it is too expensive. But is it more expensive than the number of women who die in our communities? This is also to encourage women who like to give health talks in communities. Some of them are retired nurses, while some are young people, if they are trained, they see it as an honour to go from one house to another talking to their community members, encouraging them and they may do it for nothing.
In this next few weeks, Mr President will be launching this programme and we have to have rounded up the media campaign. But we have been engaging with traditional bodies, religious bodies as well as professional bodies to educate them about the community health workers. We are excited about the programme and we know it can make a huge difference in community healthcare in Nigeria.
PT- What makes CHIPS different from the Community Health Extension Workers, CHEW, and the Junior Community Health Extension Workers, JCHEW?
Faisal- What have happened in the last few years is that we have Community Health Extension Workers and the Junior Community Health Workers. It was envisioned that these people will work in the communities and also carry out extension works in the communities. But in reality, this has not happened. Most of the community health extension workers are really bugged down by work within the health facilities, because there is so much work already in the health facilities. So we say, stay in the health facilities and do all the work, but they will provide supervising support to the CHIPs. On a weekly basis, they enquire how many people they treated and give medical advice in the community. And if there is an emergency, the CHIPS refers them to the PHC, so there is a connection between them.