COVID-19 has exposed lapses in Nigeria’s heath sector – Expert

Dr. Kingsley Ochei is an infectious disease expert with Management Sciences for Health (MSH), a global health nonprofit that supports countries to build stronger health systems. He is a public health practitioner with over 17 years professional experience in project management, health system strengthening and surveillance of public health disease at the national and international levels. In this interview conducted online by Musa Umar Bologi, he speaks on what Nigeria must do to improve its health system to fight priority diseases such as Lassa fever, HIV, COVID-19, among others. Excerpt.

Nigeria is currently dealing with its largest Lassa fever outbreak, while at the same time dealing with COVID-19. It is also responding to diseases like HIV and Tuberculosis, etc. Isn’t all this too much for the country? What is the lesson here?

Despite the COVID-19 pandemic, it is important to highlight that this year, there was a decline in case fatality of Lassa fever, from 23% in 2019 to 19% in 2020. The Nigeria Centre for Disease Control (NCDC) also supported peer-to-peer training by creating exchange programmes between states, treatment centres and laboratories. On the 24th of January 2020, the NCDC activated a national Lassa fever Emergency Operations Centre (EOC). This was in response to an increase in Lassa fever cases at the beginning of the year, exceeding the threshold for an outbreak. Since the beginning of the outbreak, 979 confirmed cases, including 188 deaths have been recorded from 27 states and the Federal Capital Territory as at 19th of April 2020. However, the Lassa fever case count has significantly declined in the last three weeks and has now dropped below levels considered to be a national emergency.

The lesson here for policy makers is to strengthen the epidemiology division of the public health department in each state for surveillance and rapid response to diseases of public health importance based on the priority diseases as listed by the World Health Organization (WHO). Lassa Fever, Yellow Fever, TB, HIV, Meningitis, Cholera, Ebola and COVID-19 are among the priority diseases. EOC centres should also be opened in each state to address any emergency outbreak of diseases.

There are public health specialists who see legislation, especially by the National Assembly, as a way of making it mandatory for the government to make enough budgetary provision for health care. What’s your take on that?

Yes, legislation is one of the ways of making it mandatory for the government to make enough budgetary provisions for healthcare. The WHO recommends that a country should spend at least 5% of national income or Gross Domestic Products (GDP) on healthcare services and delivery. But it is difficult to determine what a country should spend on maintaining and improving its population’s health without knowing the health challenges faced. Out of the nearly 91 billion naira capital allocation for the health ministry in the 2020 budget, 44.5 billion naira is for the Basic Health Care Provision Fund (BHCPF), leaving N46.5 billion for other activities. You will recall that during the 2020 budget, the government didn’t anticipate the outbreak of Coronavirus. The pandemic obviously will affect the 2020 budget allocations for health services. Moving forward, it is the responsibility of every government through legislation to adequately budget for national health emergencies like COVID-19 and continue to maintain the funding stream.

For a long time now development partners and donors like the World Bank have been urging a thorough revitalization of the Primary Health Care (PHC) system for case management of diseases like malaria and to manage nutrition in children and pregnant women. Where are we on this after so many programs?

The revitalization of the PHC system is an ongoing process. Current efforts are aimed at helping Nigeria achieve the principles of PHC, which are accessibility, public participation, health promotion, appropriate technology and intersectoral cooperation. The PHC is a grass root management approach to providing health care services to communities. This means that it is the lowest of the three tiers of health care services and the first contact a person has with the health system when they have a health problem. Apart from World Bank, USAID, CDC and Global Fund have been working with partner organizations like Management Sciences for Health (MSH) and others to provide adequate infrastructure, diagnostic medical equipment, drugs and well-trained medical personnel to support the Nigeria government to strengthen the primary healthcare system.

Any specific example in this regard?

Consider malaria for example; MSH projects have contributed towards reducing the malaria burden in Nigeria to pre-elimination levels, and bringing malaria-related mortality to zero, by supporting the national and 13 states’ malaria elimination programs to implement vector control, case management, monitoring and evaluation, procurement and supply chain management, and health systems strengthening interventions. The projects have trained over 30,000 health workers on malaria case management, routine Long Lasting Insecticide Nets distribution, Monitoring and Evaluation/HMIS and Malaria Health Products Logistics Management System. All these projects have significantly impacted on the PHC system management of malaria in children and pregnant women. Also, through the Resilient & Sustainable Systems for Health (RSSH) project, MSH has been supporting the Government of Nigeria to improve the health and well-being of the Nigerian people by identifying and addressing systemic issues affecting the optimal delivery of health services in Nigeria. The RSSH grant is working with the NCDC for example to strengthen laboratory systems across the country.

The country has also received a lot of support from UNICEF in the area of nutrition for malnourished children. All these are making significant impact on the primary health care management in states supported. More effort is however needed to cover the entire country.

The world has changed since the outbreak of COVID-19. Social norms have changed, and businesses are rethinking how they work. How do organizations adapt to this new normal, while protecting workers safety?

COVID-19 is a novel disease. The first index case for Nigeria was diagnosed on 27th February 2020. As at 30th April 2020, we have a total of 1932 confirmed cases in 35 states with 319 discharged cases and 58 death fatalities. The number of confirmed cases has also increased globally with 3,090,455 confirmed cases and 217,769 deaths in 210 countries. Since the outbreak of the pandemic, countries have devised various ways to curb the spread by developing good infection prevention and control (IPC) practices. The lockdown policy in many countries had significant impact on the social, physical, economic and political.

In view of the mode of spread of the Coronavirus, every organization is expected to re-think their work processes which should include among others the “work from home” policy. MSH as one of the implementing partners for instance is delivering on her project objectives by working remotely from home after training the staff on IPC. It is expected that all organizations should maintain IPC, personal hygiene, remote working processes. Every organizations should develop appropriate policies in accordance with NCDC regulations and guidelines and informed by industry best practice regarding social distancing and protective equipment, temperature checks, testing, isolating, and contact tracing, sanitation, among others.

Moving forward, what specific actions do you suggest the Nigeria government take to strengthen its health infrastructure to fight pandemics like COVID-19?

Over the years, little attention has been paid by government on the health sector in Nigeria. The resultant effect is the decay in the public health facilities. The COVID-19 pandemic exposes this lapse for which government going forward should seek to address. The pandemic has also shown that we have capable medical personnel, particularly the Medical Laboratory Scientists, Doctors, Pharmacists and Nurses that can rise to the occasion any day to address the issues around health security. Nigeria has over 42 tertiary health institutions, over 30,000 Primary and numerous secondary health facilities. But none of these has the infrastructural requirements for COVID-19 diagnosis and treatment monitoring due to lack of basic infrastructures, equipment, adequate personnel and biosafety requirements to combat the pandemic. Most of the facilities are biosafety level 1 (BSL1). Going forward, government and public-spirited individuals need to invest in the upgrade of health facilities, particularly the laboratories to a BSL 2+ and BSL3. There is also the need for the provision of at least one public health laboratory and isolation centres in the 36 states plus FCT with the state-of-art equipment.

And how do we ensure frontline health workers are protected?

Records available as at today shows that about 113 health workers in Nigeria are in various isolation centres having been infected with Coronavirus in their line of duty due to lack of Personal Protective Equipment (PPE). Provision should be made available in the budget for training/retraining of healthcare workers, health life insurance, availability of PPE, etc. The Nigerian government need to embark on massive recruitment of healthcare workers to support improvement of healthcare delivery services in primary, secondary and tertiary health facilities while ensuring the establishment of public health laboratories in 36 states plus FCT. The infrastructural requirement will include but not limited to uninterrupted power supply/ backup power supply, running water and biosafety equipment [biosafety cabinets, heat ventilating and air-conditioning (HVAC) system, safety centrifuges] and other safety apparatus.

COVID-19 seems to have pushed other diseases to the background. Any suggestion about how to ensure other health services continue even amid COVID-19?

COVID-19 is a global pandemic of public health concern. Other diseases such as Lassa fever, Yellow fever, Cholera, HIV and tuberculosis has either preventive or curative measures. Their mode of spread is also known and can be curtailed. The mode of spread of COVID-19 is such that if much attention is not paid to it, it has capacity to wipe out a whole community or nation. There are already established disease programmes for HIV, Malaria and Tuberculosis. Despite the global focus on COVID-19, the other disease intervention programmes need to maintain focus towards combating the spread of the diseases. This calls for health system strengthening efforts. What I will suggest at this point is, since all these programs, interphase with government health workers for effective delivery, government should ensure adequate healthcare workers are employed in our health institutions, so services continue without hitch.

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