Faisal Shuaib is the Executive Director, National Primary Health Care Development Agency (NPHCDA). In this interview with PREMIUM TIMES’ Ayodamola Owoseye and Nike Adebowale, he speaks on the strategic ways the agency is trying to address fundamental issues in primary healthcare delivery in Nigeria, especially through the Community Health Influencers, Promoters and Services (CHIPS) programme.
Premium Times: President Muhammadu Buhari recently launched the Community Health Influencers, Promoters and Services (CHIPS) programme. What is the scheme all about?
Faisal: In principle it is a potentially high-impact intervention that will see the deployment of community-based health workers in nearly 10,000 wards of Nigeria.
The question will be how does this differ from the services of the Midwives Services Scheme? The Midwives Services Scheme was a noble idea to increase the number of skilled birth attendants all over the country. Because of the uneven distribution of available skilled manpower, the scheme was targeted at recruiting available midwives all over the country to go to places that are less endowed with these human resources. The midwives are a different cadre, they are individuals who had gone through school of nursing and midwifery, and there is a basic that they have secondary school education before going through the school of nursing and midwifery to become a midwife.
The Community Health Influencers, Promoters and Services are community-based individuals who have been selected in collaboration with traditional leaders, religious leaders, opinion leaders, youth and community based organisations. These are people in the community that are of good standing, that everybody in the community agrees ‘this a good lady, morally upright and is known and lives in the community’. Once that person has been identified and selected by the community members, they are trained over the course of three to six months. Not only in classroom-based training, but also practical field experience. These individuals will be responsible for basic interventions in the community.
In an emergency situation for instance, somebody has an injury and the person is bleeding, these individuals will be able to take steps to arrest the bleeding. If somebody has fever in the community, because they will have backpacks that contain rapid diagnostic kits, they will be able to do an assessment and carry out tests that will show that the sick individual may be carrying malaria parasites. Once that has been diagnosed, they will have free medications, anti-malarials that they can give to people in the community.
They do not work for the health facilities like the MSS scheme, they are based and work in the communities. You may be familiar with the village health workers, community mobilisers, traditional health attendances and corps agents that are sponsored by different development partners. The requirements for these roles that they play vary from one development partner to another. The emoluments differ. The expectations also differ. What we are saying is, let us harmonise all of them and then scale up across board.
With all of these different interventions we will properly have between 20, 000 to 25, 000 people across this different cadre. That falls short of our requirements in Nigeria. We are saying that first, we are going to standardize the work that they do so everybody who is a CHIPS agent would be required to have at least elementary school education.
That is distinct and different from the traditional birth attendants, the TBAs are typically not educated. The illiterate women who live in the communities, they also help with births. But what we are saying now is that we have identified that because they don’t have the right skills, sometimes when they take births, those births might be attended to with complications such as death of the mother or the child.
Now we want to be more rigorous in their selection. Now we want to set a bar below which we will not accept for Nigerians. Nigerians deserve better and it is possible to up-skill them. Apart from choosing them, those of them who qualify would be trained over the course of three to six months and then deployed. We are harmonizing all those different interventions that are community-based and calling them CHIPS agents.
If you see a CHIPS agent anywhere in the country, exactly the same standard is what should be expected from them. It would also be known very clearly what they are able to do and what they are not able to do. It is expected that they should be able to treat simple aliments such as malaria, diarrhea. And if a woman has bleeding during pregnancy, they will be able to do the right thing, ranging from advising them to go to the health facility, or if they are in a community where transportation is difficult to the health facility, they have the drugs that they can give to help reduce they bleeding and can be a lifesaver before the woman is transported to the health facility.
Bleeding in pregnancy is one of the highest causes of maternal mortality. Nigeria happens to be among countries with the highest level of maternal and child mortality. So, imagine if so many women are dying from bleeding during pregnancy, and we now have somebody in the community that can stop that bleeding with one wonder drug. Amazing what we can achieve!
PT: The CHIPS agents are expected to be up to 200,000. Do the existing agents count up to that?
Faisal: We are saying we will be employing at least 200, 000 CHIPS agents because we are conceptualising it and allowing the states to be able to take some decisions around the exact numbers these CHIPS agents will be per ward.
Not all wards are equal, there are some wards that are densely populated while some are sparsely populated. We are giving the guidance that they do need between 10 to 20 CHIPS agents per ward. It is in harmonising and consolidating all of these community health workers that we will get numbers up to 200,000. The calculation is that if we are getting 10 to 20 CHIPS per ward, and we have about 10,000 wards in the Nigeria, that makes it almost 200,000.
PT: You mentioned that these agents will have supplies with them, medicine, diagnostic kits, among others. How will this programme be funded from the perspective of the federal government, especially with the funding challenges faced by the MSS?
Faisal: It is great that you talked about the MSS. The challenges that we are having with the MSS is because those nurse and midwives were earning about N30, 000 and it became difficult for some states to keep up with the payment.
Apart from that, because some of them were taken from their homes, from their communities across to some other places, they became very lonely and do not want to work staying so very far away from home and not even getting their regular salary. So they moved back. Some of the states could not sustain the over N30,000 per month that was required.
In this case, we are conceptualising and decentralising the approach. The different tiers of government have their responsibilities, the federal government has the responsibility in terms of what NPHCDA is doing and the Federal Ministry of Health. We are helping with providing the standards and regulating with how they are going to be deployed. We are providing training for these individuals, whether those that are starting from scratch or those that need to be up-skilled.
And after they have been deployed in collaboration with the states, we will monitor the programme. At the national level, we are working with our development partners, we are working with the private sector to get the commodities that are required to help with the training.
As for the stipends and some of the commodities that are required, it will be the responsibility of the states. So the states will be at liberty to decide how much money they can pay these CHIPS agents. We will give them a guidance, perhaps N5, 000 or N6, 000, knowing fully that N5, 000 in a rural area is not same as N5, 000 in the urban area.
We will also want the states to be able to sustain the payment of these stipends. We want the state to also sit down and discuss with stakeholders. The governors have a very important role to play. The governors might say in some of these communities, it is a recognition of somebody’s importance to be selected as a CHIPS agent and that alone is enough compensation. That will vary from the guideline that we have provided. But for sustainability, the local people have to take that decision.
I will give an example, the TBAs do not get any kind of stipend from the government. The TBA could help with delivering a baby and what the parent could give is properly food items or an item of clothing to say thank you. They can do that for several households with same amount and for them, they are satisfied. For them, the satisfaction and the joy of rendering these services is enough for them.
If the government then decides that they can pay them in addition to the items they are getting, that will be based on the ownership of the state government, local government leaders in the state, in the spirit of self-reliance and sustainability, which is very key. We cannot mandate that they pay a certain amount when it would be difficult to sustain it. We have to use the funding that will be part of the annual budget for these agents, because the states have to recognise that this cadre of workers are very important, especially in those rural areas where we do not have health coverage.
In the urban areas, there are cases where they would be very useful. In the areas towards promoting health issue, providing information around health issues that are a little bit confusing to community members, and also promote the attendance of anti-natal care and provide information around immunisation and why immunisation is very necessary. Issues around the poor coverage that we saw in the 2015/2016 immunisation survey, sometimes it is due to the lack of information. People do not understand why immunisation is valuable.
But because these people have been trained, they can sit with a mother and take time to explain to her why it is very necessary to take her kids for vaccinations. We find that they will be able to impact a positive change when it comes to health-related behavior change communication.
PT: What are the responsibilities of the local government in the implementation of the programme (CHIPS)?
Faisal: When it comes to the local government, as you are aware, we are now operating primary health care under one roof, and primary health care staff are now being deployed to the State Primary Health Care Development Agencies.
There will be a role, especially supervisory and monitoring, for the LGAs as well. Because they are people that are closest to our communities, they will be able to supervise the work that these CHIPS agents are doing.
PT: Will CHIPS agents be gender selective or cut across both genders? And how are we going to recognise them in the society and monitor that they do not step beyond their given specifications of duty?
Faisal: CHIPS agents will not be gender selective. Our experience, however, is that in most places, if you want an access to households, it is easier for females to have access to households and discuss with other women, be they ones who are pregnant and children.
Women will be more apt to listen to women like them. But we are not saying that it is absolutely in everywhere in Nigeria that it has to be females. There are places where males can also play some roles. There are roles around engagement with traditional rulers, that are community-based and those roles are probably better conducted by males. But we do envisage that most of the CHIPS agents will be females.
In ensuring that they do not go outside the boundaries of what they have being trained to do, at least once every week, CHIPS agent will have a supervisor who goes with her to the communities. For instance, if you have 10 CHIPS agents in a ward, that means, you have a minimum of two supervisors. One supervisor for five CHIPS agents. So one day a week, the supervisor will go to the community with each and every one, monitoring what they are doing.
Even the two supervisor will have a supervisor from the nearest health facility ensuring that there is clinical supervision. To ensure that they are doing the right things and asking them questions, doing on-the-job training to remind them what they are supposed to do.
At the level of the LGA, the LGA will supervise the clinics, who supervises the supervisors that supervise the CHIPS agents.
We have an accountability framework that tends towards zero tolerance to CHIPS agents trying to manage disease conditions that are above their training. That is why we emphasise that most of their roles will be to influence decision-making process. That is to say, if someone is sick, instead of waiting until complications arise, the will quickly take decision to go the health facility.
Sometimes, death in the community due to complications of labour is because there is a delay in taking decisions about going to the health facility, there is a delay in actually going to a health faculty, and when they get to the health facilities, a delay in being attended to. These delays lead to complications that make us reach a point where death becomes irreversible. The CHIPS agent will help women take that decision to go and seek help as early as possible. So that by the time any complication would arise, they are already in the health facility and being taken care of.
As part of our training, it would be spelled out very clearly to the CHIPS agents that this is a professional cadre, and any attempt to move outside what they are asked to do will be sanctioned immediately. We will jealously guide what they are supposed to do, knowing very clearly that we have community health extension workers (CHEWS), Junior Community Health Extension workers (J-CHEWS) who also have their terms of reference and we do not want any tension to arise between this cadre of workers and the CHEWS. It is very clear where we want them to work in the communities and they have supervision from the CHEWS around what they are able to do and what they are not able to do.
PT: There has been a constant rivalry among workers in the health sector, so how do you intend ensuring harmony among the CHIPS agents and the CHEWS, especially in terms of structure and information dissemination?
Faisal: I think we are very clear in our communication that the CHIPS agents resides in the communities. They do not work in the health facilities, they are below the CHEWS and J-CHEWs. Their entry requirements completely differ from the CHEWs and J-CHEWs.
The J-CHEWs work in the health facilities, but what we have observed is because of the scarcity of human resources to work in health facilities, you find situations where the CHEWs and J-CHEWs spend most of their time in the health facilities. The part of their work which necessitates them to come into the society and do extension work has been relegated to the background. That is the gap the CHIPS agents are filling. The CHIPS agents must live in their wards and cannot crisscross to another ward or work in the health facility.
There is a clear distinction around what they are meant to do, so there would be no rivalry. In the progression of their career, we want a situation that over time, when CHIPS agents begin to think they want to do more with themselves, we will encourage them to write exams that will admit them into schools of health technology where they can learn and become J-CHEWs, CHEWs or environmental officers.
For the TBAs who are illiterates and do not meet entry requirements for the CHIPS agents, we are looking at linking them up with adult literacy classes since we want basic minimum of elementary school education for the CHIPS agents.
We do not want to deny the TBAs who want to be CHIPS agents because of their education status. We will try to encourage them to do adult literacy training, because we are aware it is possible to compress the six years elementary training into a shorter time. With this and the testimony of good standing from their community, we will be able to engage them as CHIPS agents. All we are doing is establishing a pattern for job creation and empowering many women.
What we are doing is tapping into the resources of many women who have the passion and aspiration of helping their society by providing them the skills with potential resources to assist their communities.
PT- The CHIPS programme was recently launched by the president and is to be duplicated in the 36 states of the country? What have been the responses from the states governors, local governments regarding the budget of their states for the programme?
Faisal – Their responses are phenomenal. We have been amazed by the response we have gotten from most of the states. Some of the state governors have been calling to say the programme is such a legacy they want to leave for their people.
They have been excited that they will be able to provide emergencies and basic healthcare to people who would not have been easily able to get it. The president has given a go ahead to the Federal Ministry of Health and the NPHCDA to roll this out all across Nigeria and that is exactly what we are doing.
We already have discussions with some governors in states like Jigawa, Kebbi, Sokoto, Bauchi, Bayelsa, among others. So many states are saying they would like to implement the programme but it has to be conceptualised in a way that they can sustain on their own based on the resources that are available to the states.
People are really excited about the huge impact this will make in the community level. When you look at statistics, it is very clear that we are not doing very well when it comes to providing primary health care services. We are not doing very well when it comes to emergency management of some of the conditions. One million women and children under that age of five die every year. 33, 000 women dying from preventable causes, during child birth as a result of pregnancy complications every year. 940, 000 children under five die every year from two preventable diseases like pneumonia and diarrhea.
A major factor that leads to these deaths is the delay in going to the health facilities, lack of health facilities close to the people or because they cannot afford it. The key intervention here is that the drugs, the testing that is being done at the door step of our communities will be done free of charge. We will be using media houses to let people know that this programme are free and community members are not expected to pay for them. This is another bold step that the Federal Government is taking towards providing equitable health care across the country.
Last year, the president commissioned Kuchingoro PHC as part of PHC revitalization. We encourage women to take their kids for immunization services and we are saying they also need to go for anti-natal services. But if the PHCs are not functional, there will be nowhere for them to go. So we are doing it across both streams so that complimentary to each other, we have a functional PHC, one for each of the 10,000 wards and also recruiting CHIPS agents who will provide health behavior change communication. They will encourage people to go to the health facilities and linking them up to health facilities.
Over the course of the next two years, as we continue to revitalsie and make functional health centres, we are also providing community-based interventions that will reduce the high numbers of women and children who die. All of these working together is targetted towards achieving universal health coverage for all Nigerians, irrespective of where they live or where they work.
PT: It was said last year that 109 health centres will be retivitalised as part of the 10,000. Premium Times visited some of the PHCs and most of them are abandoned, locked up and those renovated are not being used. What is being done about that?
Faisal – The way the revitalisation process is structured, it is not meant to happen within a year, it is meant to happen over the course of several years. It is not just the federal government who is doing it. It is a collaborative effort with development partners, state governments and the private sector.
What the FG is doing is putting funds dedicated from the Saving One Million Lives programme and we are renovating health facilities. Apart from renovating it, before it is said functional, it needs manpower, equipment, utilities and drugs.
All of that is happening. Maybe some of the health facilities that you have gone to have not been handed over to the communities because we do not even have the human resources. We have started the process of mobilizing about 1,600 basic midwives who will be deployed to health facilities to help manage some of the health facilities.
We are looking at also to getting funds from the Basic Health Care Provision Funds, which hopefully will provide the resources that equip and provide commodities for some of these health facilities.
It is work that is in progress. There is also the part that the state governments are doing. The state governments are renovating, some NGOs such as MNCH2, UNICEF are also working to renovate some of these health facilities all across the land. Clearly, it will be a misunderstanding of the aspirations to say it is just 109 every year. There is a whole lot more than the 109 health care facilities that are going to be renovated.
PT: Are you saying they are yet to release funds for those that are not yet done? Because there was a PHC Premium Times visited in Kano State which is meant to serve 10 communities but was abandoned and in dilapidated state.
Faisal: I do not know which PHC you have visited. But clearly, because it is not just the federal government that is doing the renovation, the state government is also renovating them. Are these health facilities visited within the remit of the list the federal government is trying to renovate/or is it just on the state list?
That needs to be determined. There are some states where the federal government has renovated some PHCs and then when you go to the list of PHCs that are supposed to be renovated by state government, they are also there and they have plans to renovate them, not realising that the federal government has renovated them. It is a joint effort by different people and there are different stages of getting those renovations done.
In 2018 budget, there are funds that have been set aside to renovate health facilities. One thing that we have done at NPHCDA is that we have written to the National Assembly and we are following up to say that since 2001, there have been almost 1,000 primary healthcare centres that are abandoned.
We need to take a decision around what we are going to do. We probably do not need new construction of PHCs in every village, we need to look at those that have been abandoned and finish them up so that they do not go to waste. We are getting support from the National Assembly members that there is a need to set aside funds to finish some of these abandoned primary health care centres.
We need to also ensure at same time that we have the human resources that will work in these health centres. We are working with the Nigerian Governors Forum to see how we can do a comprehensive audit to know the human resources required in each state and how to tap into those who have been trained but do not have work, or those retired but not tired in order to deploy them into these facilities to make them functional.
The president have been very clear about it the he wants PHCs to work, he wants equity, accessibility to these primary health care centres and it is something that we have prioritised and are working towards.
PT: In the last two years, Nigeria has tackled about eight major diseases, which all started from the rural areas. How are CHIPs agents doing in terms of responses?
Faisal – One of the activities of the CHIP agents is to collect household health-related data and transmit to the next level which is the PHCs ad that information will move from the PHCs to the LGAs. That process is called surveillance. And if there is a case of yellowing of eye, which is associated to yellow fever, and the CHIPs agent notices it, she notifies by reporting it and transmitting the information to the PHCs.
This will help improve the long chain that happens before cases of diseases are reported. Ordinarily, you see people in the community who are sick and because they do not have money to go to the health facilities, they lie down at home and even die. The CHIPs agents, based on their training, will be able to pick infectious diseases and help minimize the spread by quickly doing a referral and notifying appropriate authority.
It provides for early warning and detection of diseases and outbreak. This data being transmitted is usually being worked upon at the local level and not necessarily getting to the national level before action is taken.