Ruby Rabiu
9 July 2009
interview
Abuja — How has the journey been since you took over? Are there any lessons and challenges?
The health sector as you know is a complex sector. It has many entities, the federal, state and the local governments. So in trying to galvanize movements, one has to take into account the roles of these stakeholders, and try to work with them. It has been quite an intensive period trying to coordinate with the various stakeholders in our immunization programmes and reposition our primary health care programmes. Beyond that we have made some progress over the last six months.
At the immunization front and also on the primary health care front, as well as at the agency level. If you look at the polio issue which we started with, at the last review meeting in Otta we were pleasantly informed by the experts that we are making progress in terms of coverage, and reducing the immunity gap between some of the previously high risk states. Also on the measles front, this year we had far fewer cases, than in the previous year, which was mainly due to the integrated measles campaign which took place after I took office which is encouraging. Recently the national midwives service scheme which is funded by the MDGs office, in collaboration with the ministry of health and the NPHCDA, and we are very excited about the prospect of using it to revitalize the primary health care centers, and placing human resources at the front line. So those efforts put together have given us reason to be optimistic that we are beginning to improve in reorganizing things from where we found them. In terms of the agency itself we have made a few strides in the right direction, in terms of restoring the integrity of the institutions, financial management system, procurements, strategizing , structure as an agency and have made a few changes. We have tried to bring in the idea of team work, accountability, transparency, and now a greater desire to communicate with the media and to the Nigerian public and our various partners, and also internal communication with our staff to improve the services of the agency.
The focus of the government is on improving the primary health care centers at the rural and state levels, but since this administration took over there has been no noticeable improvements so far , what is the way forward?
The primary health agenda started in 1978, and in 1988, the national health policy said the primary health care is the central strategy for Nigeria's health system improving approach. In 2004 we still said the same thing as a national health policy, and in 2008 we were in a position that we could not still have a functional primary health care system. So over a thirty year period we have not been able to achieve the system that we are striving to get. So if I tell you, that in six months I will fix Nigeria's primary health system, then you will know that I am not being honest with you. So we know that this will not change overnight, what we have began doing is to put in place the building blocks on how to move forward.
First to put the PHC agenda at the centre of health care discussion, and we have managed to do that. There are other competing aspects of the health system but PHC is the center agenda which the health system needs to focus on to get an outcome, which is being advocated extensively . We are trying to reach intergovernmental allies to improve on and get the state and local governments to buy into this PHC agenda. We have had two rounds of advocacy to the governors fora and at every opportunity we advocate that we need to have increased investments at the state and local governments towards the PHC. We have participated in the summit of the national assembly, trying to position the PHC in the context that will ginger action. We have flagged off or launched the first national data base of the of the PHC facilities in the country, which is more than 20,000 facilities which we have cataloged and prepared them into a data base, and flagged it off on April 3RD, on the side of the national council of health meeting.
It is the first data base that tells you where all the health care facilities are, what kind of services they have, where they are located and all that, and that is an important contribution to be recognized. Beyond that, the human resources issue, the federal government in this year's appropriation of the 2009 budget which we have begun to implement, has placed some funding for the national midwives service scheme, which intends to place 2500 midwives in PHC centers to help deal with infant and maternal mortality issues. That is an important step, it is a stop gap measure, an intervention by the federal government. Contingents from the local and states are actually stepping in to absorb the midwives over time, and that is an important contribution, which should be recognized as a major step to dealing with maternal mortality issues and resuscitating primary health care.
There are several other efforts we have done in terms of improving middle level management capacity and their training, which was conducted in the north west zone,in Argungu and Dutse recently, is a step to strengthen the middle level capacity at the state. We have also revised our policies on immunization, we have developed a country multi- year plan for immunization and had multi high level advocacy behind that agenda. All these plans and efforts are building blocks which we intend to consolidate on, and over time the changes that people are expecting will materialize.There are many more developmental issues that are linked to the problems we are having in the health sector, so I believe that the building blocks will be put in place. We have strategies that we have articulated as an agency and more broadly in terms of the health system. We have a new minister in the health sector, and a vision that has primary health care at the centre, but to manifest it we need the state and local government to buy into it. We have done a lot in terms of improving surveillance, for instance for the cerebro spinal meningistis outbreak. We have had training to build the capacities of our frontlines and that of our health workers. These are all efforts that if implemented will take us to our desired goals.
What has been the reaction of the local and state governments to the idea of resuscitating the primary health care centers?
A few weeks ago, there was a meeting with the state task force. In attendance were commissioners of health and state task force members came. We had one also in January in Gusau, and one of the feedbacks we received is that the federal government in January said it was going to do a few things in areas of advocacy and other things, and the government has done its part. So now it is left for the states to do its part. Now we have seen in the high risk states during the immunization programme, 80% of them have task forces established, that is an important sign of progress, and more than half of them have actual work plans for what they intend to do. That political commitment we were pushing for, is beginning to translate at the state level, and the LGS. A few weeks ago the chairman of Kumbotso, a local government in Kano state, said he is committed and will do whatever it takes, within the resources available to the local government to see that health issues are attended to. I believe that there are many local government chairmen who will do the same. Part of why they are saying that ,is because we have made it clear, that health is the priority and the primary health care is the way to touch the lives of your people. Beyond just verbal commitments additional resources should be provided and used for the benefit of the people, and we hope that it will continue. We cannot just back off and say that from now on they can continue on their own. We have to continue to sustain the momentum we have begun to generate. We want to set the expectation right, things will not change overnight, but we intend to be consistent to keep the efforts over time.
What are the lessons learnt from these outbreaks which has bedeviled the country in recent times, and what mechanisms have been put in place to forestall future occurrences.
Talking about the cerebro spinal meningitis, for the last 50 years or so, we always have this outbreak on a yearly basis. This year we had it, but the expectation was that it was going to be a big one. In 1996, 200,000 cases of meningitis happened in this part of the world. But this year we had a lesser number of cases, it would have been worse had we not taken the steps we took and intervened. In January we heard that there were cases in Senegal, and the first state we approached was Sokoto State. We gave them thousands of doses of cerebro spinal vaccines and they used it, and so the epidemic was less severe in Sokoto than last year. We also mobilized quickly and bought 237 million naira worth of vaccines through UNICEF which we distributed to the ten most affected states free, for them to use. Then we mobilized through UNICEF and WHO for additional vaccines, to the extent that by the end of the epidemic, which is quickly coming to an end ,we had about 8 million doses of the vaccines which has made a big difference. Had we not intervened as aggressively as we did, we would have had a lot worse outbreak than we did last year. Through our minister, we have made strong positions to the international bodies that Nigeria should have access to the meningitis congregate vaccines, which is a new vaccine that has a much longer protection. So the international communities has made arrangement for Nigeria to be covered by 2012, but we have argued, that Nigeria should be prioritized, and that vaccines should be made available to us. In terms of governance response, the minister established the emergency response team, which includes the agency because we provide the vaccines. This coordinating mechanism has functioned effectively during the lassa outbreak and the meningitis. We also had occasions to train laboratory personnel and state health officials twice, one in Kaduna and the another Keffi, known as the integrated disease surveillance and response. We did those in the first quarter of this year. What have we learnt?, you know this is our first year and so we have learnt that we should not wait for an epidemic to happen before we respond to it. We have placed an order for millions of doses of cerebro spinal meningitis vaccines to be provided to us, and we will get them in stock and by the end of the year. we will have a large number of the vaccines and be in position to immunized at the earliest onset of the season. We hope that it will reduce the cases that we see next year and if the congregate vaccines are made available to us by the international bodies, because of the limited supply we will over the next few years there will be consistent efforts by the government to purchase the level of vaccines that we require. We should work towards reducing the cases of meningitis.
What was the circumstance that lead to the deaths of so many people, if the response of the government to the outbreak was as quick as you so put it?
It is difficult to prove for you the counterfactual, what could happened that did not happen, the point I am making is that, had we not responded, thousands more would have died, like people died in 1996. the meningistis outbreak comes in waves, every ten to twelve years there is a major wave, 1996 was the last waves that had 200,000 cases recording more than 25,000 thousands in one season because of the technicalities of the epidemic, this one in 2009 was supposed to be the major one, and could have gotten to that 200,000 cases if not more, but because we intervene we have had less cases than we could have seen. How do I prove to you that negative, I can't, all I can say is that the earliest response in January to alert the state and the borders and to provide the vaccines was swift. We trained and invited states in Kaduna, and also provided disease surveillance training in January and February and put pressure on our international partners to come quickly. These things that we done in my eyes is making improvement. We are thankful that we are able to reduce the number of lives that could have been lost. We have made major efforts and these efforts have made impacts, and we intend to consolidate on the gains we have made. The ministry of health is responsible for the drug part while ours is on the surveillance and immunization part. But onces you have the case, it is more or less the treatment site, and that I believe there are several efforts in that regard. The case fatality for cereospinal meningitis this year was 4.4%, and that is much lower than in some developed countries who had the outbreak. If you check the literature, one will see that 10-15% people die when they have meningitis even if you have the treatment, but for us in this country, this particular epidemic the case fatality was less than 10%. So we believe that we have made a difference, because a lot of deaths was averted.
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