USAID ACQUIRE-Fistula Care Project has done much to advance effective service delivery on Vesicovaginal fistula (VVF) in Nigeria. The Project Manager, Efem Iyeme Efem, advocates at least one VVF centre in every state in Nigeria to maximize VVF care around the country in this interview with Onimisi Alao.
Why did you choose Ogoja and Ilorin as project sites: Is VVF more prevalent in these two towns or did you pick them as referral centres for the South - South and North Central sub-regions respectively?
Fistula is found everywhere in Nigeria. It is not only a problem of the north. Our activities in Ebonyi State have clearly shown this. The challenge for Nigeria is to ensure that every state has at least one fistula center to attend to the women who have VVF. The General Hospital Ogoja is uniquely positioned to serve the five local government areas in Northern Cross River where Fistula is very prevalent. It is close to their communities and clients can easily access the facility. For Ilorin, there is also a great need there. The Hospital at Sobi is also well placed to serve communities.
We understand that there are plans for the takeover of the Katsina center by the federal government. How far has this plan gone?
It is still a work in progress. Things do not just happen that quickly. On our part, we will do as much as we can in terms of advocacy to help the process but it depends on the speed at which the two governments - state and federal operate.
What is the rationale behind the takeover of the center by the federal government?
The federal government is moving towards setting up regional centers of excellence that will bring more specialized hands to attend to very complex fistulae. These centers will be training centers and will work to ensure that those that are challenging in the regions are referred to the center for further attention. We on our part, see this as the way to go, rather than have a National Center of Excellence in Abuja
Would it not have been better for the federal government to build its own centers from the scratch while allowing the present centers to run side by side?
That would not reflect prudent use of funds. Taking over the centers and upgrading them adequately will be the best approach. In Nigeria, we are always fond of new constructions but we forget that those facilities need to be maintained. If the Federal Government constructs its own centers, where will the staff come from? You will find that all the staff from the state facility will apply to join Federal and in so doing, the state facility will become abandoned and gradually dilapidate into oblivion, like many structures in Nigeria. So yes, we support the takeover and the funds that should have been used for more construction can be used to improve the facility.
What has been your role in Federal Government's involvement in VVF projects with resultant takeover of the Ebonyi centre?
The US Government, through USAID has played, and continues to play major role in the support of the Ebonyi Center. Along with other partners, support repairs of women with fistula, raising the awareness of the services of the center, thus increasing uptake, worked with the staff of the facility and government of the state on the idea to have the government take over the center to relieve the state of the burden of attending to clients from other states and also that of paying for staff from their meager purse. We also worked at the Federal level and the National Council of health Level to prepare the grounds for this and advocate for it to happen. So while we may not have been out there carrying placards to ask the government to take it over, in the idea and the subsequent groundwork, we played great role.
Are you comfortable with the situation at the Ebonyi center since the takeover by the federal government?
We believe that things are going well, so far, though from our perspective, the pace should be faster. However, knowing how the Federal Government works, I will give them kudos for moving this fast and this far, in the process.
From your experience, would you say that the incidence of VVF in Nigeria has reduced, or has remained constant since you started your VVF project in the country?
It would be hasty to say so, given that we do not have the benchmarks to prove that. With time, through the National Obstetric Fistula Working Group, we should be able to determine what the actual incidence is, and from there, determine if an impact has been made. Suffice to say however that our project, along with others have clearly raised the profile of the condition and made people more aware of it. We have succeeded in showing that this is also a condition that women in the south suffer and so gradually, others factors that cause Maternal Morbidity, when attended to adequately, will reduce, leading to even more reduction in the incidence of fistula.
Funding has remained a major constraint in the fight for the reduction of VVF in the country, with zero allocation by most states and the federal government for VVF services. How can this situation be reversed?
There has been some positive action in this regard, thanks to our direct discussion with some of these states. Bauchi Government is taking the lead on this. They have so far allocated N120 Million to addressing fistula activities in the state. This is a good start. Other states may not have included direct budget line for fistula, but have increased their allocation for Maternal Health. While we applaud them also, we would like to ask that they follow the lead in Bauchi State to not only earmark funds for Fistula, but actually "EYEMARK" it for use in fistula intervention.
Stakeholders have suggested the mainstreaming of VVF services in maternal and primary healthcare programmes, do you think this will help draw attention to VVF as a major factor and in so doing attract more funding to it?
The USAID/Fistula Care project has actually been the project that started championing this in Nigeria from the first day it was launched in Sokoto on February 5, 2007. We believe that mainstreaming fistula repairs as part of the routine health care delivery system will be the way to go, and have those regional centers of excellence to attend to fistula clients with complex conditions. So yes, we advocate for it. We have even developed a framework which we call "Levels of Care Framework" that, if introduced by the states and the Federal Government, will lead to mainstreaming fistula as part of the routine health care delivery system. We have also introduced "Integration" as a short cut process, where fistula is integrated into Family planning such that women who come to seek for services are educated about fistula and how to prevent it. We are in the process of talking to other intervention area managers on the need to expand this integration approach. This will gradually move us away form vertical programming to an integrated one, which will save cost and maximize staff usage.
Has government at all levels demonstrated the requisite political will to fight VVF in Nigeria?
Well, you know, as they say, "Talk is Cheap". We have had governments that have said the right things but short on action. However, we also have had governments that have taken the bull by the horn and come through with their plans. Bauchi is one of those states that have really shown that they can put their money where their mouth is. Ebonyi of course was another state that took it to the next level, leading to the takeover of the facility by the government. So, Ebonyi is really the state to emulate on this. The immediate past administration in Zamfara State did a great job supporting fistula and the women of the state benefited a lot. The first Trained the Trainer of fistula Surgeons that we supported was from Zamfara, thanks to the support of the then government. We are currently in discussion with the new government to see how we can improve upon the foundations laid by the former administration for the good of the women of the state. Sokoto state on the other hand has been working quietly to improve the services at the facility. They have increased the number of wards and given the facility a facelift. Of course you know that Katsina is where it all started and they are moving towards a well deserved Federal Government takeover. Overall, we would like to see governments who cannot afford to take on fistula as a main project, support their women to seek repairs in other states. If we can repair several women with fistula from Lagos State - the center of Excellence - then, every state in Nigeria and indeed every government should know that they have to do something about fistula in their states.