The health security of a nation comprises the activities that lessen adverse public health incidents and ensures a healthy and productive population. It is vital to developing strong and resilient health systems that can prevent, detect, and respond to infectious disease threats, wherever they occur. Nigeria has experienced outbreaks of infectious diseases such as Lassa fever, cerebrospinal meningitis, Ebola, COVID-19 and resurgences of yellow fever and monkeypox. The Ebola outbreak in the West African Democratic Republic of Congo was described as the second-largest outbreak of the strain. Likewise, in the wake of its unprecedented impact on human health and economies, COVID-19 is considered one of the most important global health crises of our time.
It may never be possible to address every infectious disease outbreak that surfaces but there are certain things that nations and communities can do to reduce the likelihood of occurrence of epidemics. This is known as Emergency preparedness, a programme of long-term development activities whose goals are to strengthen the overall capacity and capability of a country to manage efficiently all types of emergency and to bring about an orderly transition from relief through recovery and back to sustainable development.
Epidemic preparedness enables government and its health agencies from the national to communities to detect, contain, respond and stop disease outbreaks effectively. The COVID-19 pandemic has exposed the ways in which epidemic preparedness and response are under-prioritised and under-resourced.
The Nigeria Centre for Disease Control (NCDC) is Nigeria's national public health institute with the mandate to protect Nigerians from the impact of communicable diseases of public health significance, amongst other responsibilities. As part of her mandate, the NCDC supports states in responding to small outbreaks, and leads in the response to large disease outbreaks. Prior to the confirmation of the first COVID-19 case in Nigeria, the NCDC put the National Emergency Operation Centre (EOC), on high alert mode; monitoring the spread in other countries, carrying out risk assessments and strengthening Nigeria's preparedness.
Nigeria is a Federal Republic with a Presidential system. The constitution provides for separation of powers among the three tiers of government, which are the federal, states and local governments. So, this means that states have the responsibility to cater for the health of their citizens especially as health is on the concurrent legislative list. Therefore every state is directly responsible for the preparedness and response efforts to curb infectious disease outbreaks in its domain. However, despite Nigeria's high burden of epidemic-prone diseases and many outbreaks, the preparedness and response approach and resources at the state level have differed considerably from one state to another.
"There is a great need for us to prioritise healthcare across all levels in Nigeria. When this is done, then we will see more commitment to the health system and the country's health system will improve", Dr Muktar Mohammed, National Incident Manager, Presidential Task Force on COVID-19 said, speaking at a multisectoral forum on Epidemic Preparedness and Response Financing (EPR) in Nigeria organised by the Legislative Advocacy Initiative for Sustainable Development Goals (LISDEL).
Advocacy as a Tool for Effecting Change
Kano state reported its first COVID-19 case on 11th April 2020 and soon became an area of concern in Nigeria's COVID-19 because of increased cases of unexplained deaths in the state. The state has a history of dealing with certain endemic diseases such as meningitis and other seasonal outbreaks.
The existence of these issues informed the selection of Kano State by the Legislative Advocacy Initiative for Sustainable Development Goals (LISDEL) supported by Global Health Advocacy Incubator as a focus state to advocate for budgeting for epidemic preparedness at the state level, under the Prevent Epidemics project which is being implemented by Nigeria Health Watch, BudgIT and LISDEL.
Although Kano State recorded successes in dealing with these outbreaks, the emergence of COVID-19 posed a huge threat to the state. This was reiterated in comments made by Abdullahi Hamza, Kano State Coordinator for the Prevent Epidemics project. "When COVID came, there was a lot of confusion because the response mechanisms were the conventional ones that were been used to handle other outbreaks and at that time, the infectious disease hospitals were not functioning at an optimal level," he said.
LISDEL with support from Global Health Advocacy Initiative (GHAI), started advocating for the creation of a budget line for epidemic preparedness in Kano State in 2020. According to Julianna Aribo-Abude, Executive Director, LISDEL, "At the beginning of the project, we conducted a stakeholder analysis to know who the key players were in improving domestic financing. Then we also carried out an analysis on budgets and budget trends. All these informed the stakeholder engagement".
LISDEL leveraged the existing state budget process and actively engaged with the Commissioner for Health, members of the state legislature and the Executive Governor of Kano State.
Hamza also reiterated that the next step of the advocacy process, was the sensitization of the different stakeholders on the importance of state budgeting for epidemic preparedness.
The need to secure the 'buy-in' of stakeholders was key in the advocacy because a number of stakeholders did not initially understand the need and importance for states budgeting for epidemic preparedness. "Why are you calling for it? COVID has come and God has helped us to overcome it. Don't you know that's inviting trouble for yourself?" said one of the stakeholders during the sensitization meetings. This necessitated more advocacy to ensure that each stakeholder understood the importance of state taking charge and budgeting for epidemic preparedness.
On February 25, 2021, LISDEL hosted a multisectoral forum on Epidemic Preparedness and Response Financing. In attendance were some key stakeholders that they had been engaging with in Kano State.
In his address at the forum, the Kano State Honourable Commissioner for Health, Dr Aminu Ibrahim Tsanyawa, said the state created a budget line of NGN300 million in the 2021 budget for epidemic preparedness and an additional NGN2 million per Local Government Area was allocated for epidemic preparedness. He also emphasised the importance of financing health security. "If there is anything we have learnt from this COVID-19 era, it is the importance of preparedness and the importance of health financing for health security", he said.
This was made possible by Civil Society Organisations who actively engaged with the government as well as the Commissioner for Health, members of the state legislature and the Executive Governor of Kano State who all took ownership at different stages of the project.
Crucial Next Steps for Advocates and the Government of Kano State
It is one thing to allocate the funds in the budget and another thing for the funds to be released and utilised properly. The release of these budgeted funds for epidemic preparedness activities must be advocated for alongside accountability in the appropriation of the released funds.
The creation of a legal framework for the sustainability of funding for epidemic preparedness is important for not only Kano State but other states that should follow Kano State's lead. Good implementation, monitoring and evaluation are important processes that must be initiated to promote accountability of budgeted funds and provide justification for increased investments. There private sector should also be involved for sustained funding for epidemic preparedness at the state level because COVID-19 has shown the impact that disease outbreaks can have on the economy and businesses.
COVID-19 has also shown that "without health, we have nothing" and disease outbreaks affect health systems and economies negatively. Kano State's decision to create a budget line for epidemic preparedness is an example that other states should emulate. The anticipated cumulative actions by states would improve Nigeria's preparedness to detect, prevent and respond to infectious disease outbreaks.