Preparing against pandemics, public health challenge

•Experts at 63rd National Council on Health recommend framework to secure country’s future, drive new order

Medical experts have recommended strong and resilient health system as best line of defence against pandemics and public health challenge.

The experts at 63rd Regular National Council on Health (NCH) meeting, which took place in Abuja, December 5 to 9, 2022, said a key lesson is the continental realisation by Africa that it needs a new public health order that is resilient, adaptable, and ready to cope with any disease threat. They called for new public health order that rests on four pillars: strengthened continental and national public health institutions; local manufacturing of vaccines, therapeutics, and diagnostics; attraction, training, and retention of a public health workforce; and fostering of respectful local and international partnerships.

According to the experts, the four pillars are the frameworks to secure the country’s future and drive the new public health order and guarantee development. They said its success would depend on investment along these four identified elements.

The NCH, as provided for in the National Health Act (2014), is the highest policy making body on matters relating to health in Nigeria. The membership comprises the Minister of Health who is the Chairman of the Council, the Minister of State for Health (Vice-Chair), State Commissioners for Health of the 36 States, and the Secretary of Health and Human Services Secretariat, Federal Capital Territory Administration (FCTA).

The theme of NCH was ‘Building a Resilient and Sustainable Health System for Improved Health Outcomes and Universal Health Coverage.’ The sub- themes include: ‘Health Care: The Road to Sustainable Health Care in Nigeria’, ‘Climate Change and Health: Deliberate Action Towards Safeguarding the Health of Nigerians’, ‘Preparing for the Next Pandemic: Strengthening Local Vaccines Manufacturing and Biologicals for Improved Outcomes’, ‘Building Essential Partnerships, Mobilising Resources and Investments for Improved Health Outcomes’, ‘Leveraging big Data & Nigeria’s Digitisation Agenda to improve Population Health and Harness Demographic Dividends’, and
‘NHIA Act: A Veritable Instrument for Health System Strengthening and Attainment of UHC’.

The Minister of the Federal Capital Territory Authority (FCTA), Mallam Mohammed Bello, who was the Chief Host, performed the opening ceremony; while Minister of Health, Dr. E. Osagie Ehanire, presented the keynote address. The Minister of State for Health, Joseph Ekumankama; Permanent Secretary, Federal Ministry of Health, Mahmuda Mamman; Secretary for Health and Human Services Secretariat, FCTA, Dr. Abubakar Tafida, addressed the NCH.

A Consultant Public Health and Community Health Physician, the Permanent Secretary of the Delta State Ministry of Environment, Dr. Mininim Oseji, delivered the keynote paper. Other notable scholars and technocrats spoke on the sub thematic areas. Goodwill messages were received from representatives of traditional rulers, armed forces, and development agencies/partners including the World Bank Group, United States Agency for International Development (USAID), European Union, United Nations Children Emergency Fund (UNICEF) and World Health Organisation (WHO).

Director, Health Planning, Research and Statistics (DHPRS) Federal Ministry of Health, Dr. Ngozi Azodoh, said in addition to the objective of complying with the provisions of the National Health Act 2014 (Law setting up the NCH); the 63rd NCH received reports and reviewed the activities/work of the various tiers of government since the last NCH and in the last four years of the current administration, adopted new policy positions on key issues relating to health, and further consolidated and escalated efforts towards the achievement of the Sustainable Development Goals (SDGs), especially SDG3 in Nigeria.

Stakeholders and key actors from all levels within the health sector in Nigeria participated in the meeting. Ehanire in his keynote address said the theme of this year’s conference was adopted after careful thought to encourage stocktaking of the country’s journey towards achieving the Sustainable Development Goals, bearing the reality of the times in mind, as well as ultimate goal of attaining a system that ensures all people have access to needed health services, (including disease prevention, health promotion, treatment, rehabilitation and palliative services).

Ehanire said the services are to be of sufficient quality, while also ensuring that using these services does not expose users to financial hardship. He also reviewed achievements of the health sector in the past year.

On Nigeria’s efforts on COVID-19 and health security, Ehanire said: “A strong, resilient health system is the best line of defence against pandemics and any public health challenge. The COVID-19 pandemic is still raging, but the National Health Sector COVID-19 Pandemic Response Action Plan (NAHCPRAP) continues to guide the country’s response as the Ministry constantly leverage lessons learned from it to strengthen the health security network.”

He said its success would depend on investment along these four identified elements. “Here at national level, we provide essential leadership to build requisite capacity and strengthen our national public health institutions to detect, and rapidly respond to public health threats. The capacity for oxygen production has been expanded so that in no distant time, we will be able to have nationwide oxygen sufficiency. A vaccine manufacturing policy has been developed and we have taken advanced steps towards local manufacturing of vaccines, therapeutics, and diagnostics,” the minister said.

On health sector reform, Ehanire said: “In the year 2000, the WHO ranked Nigeria as 187 out of 191 countries in overall efficiency of national health systems. It was a call to action and since that time, several health sector reform programmes have been implemented, all of which had varying levels of success with none unfortunately being sustained. On the January 27, 2022, the President of Nigeria inaugurated a health reform committee under the chairmanship of the Vice president Prof Yemi Osibanjo to commence implementation of a health sector reform programme, the objective being to reengineer our healthcare delivery system to become in the President’s words ‘people-centric, modern and virile’.”

Ehanire said the government thus embarked on a process of comprehensive health system reform to modernise and stimulate economic potentials of the health sector.

He said a consultation paper, as framework for deliberation towards successful health sector reform was developed and considered at the just concluded retreat where a first draft of policy recommendations for a holistic health system reform is a work in progress. “We are certain that we are on the path to getting it right and in a sustainable way,” the minister said.

On the National Health Insurance Act (NHIA), Ehanire said the goal of universal health coverage as the foundation of the country’s health care strategy is now supported with the NHIA, recently signed into law by the President, to make health insurance mandatory for all citizens. He said the complementary effect on health financing would increase the fiscal space for health and support providers to deliver, and users to demand higher quality of healthcare with time.

Reacting on the implementation of National Strategic Health Development Plan (NSHDP) II, the minister said the NSHDP II (2018- 2022) was approved at the 61st National Council on Health and the Federal Executive Council in 2018 and launched by Mr. President in January 2019. He said since the start of implementation, joint yearly reviews conducted in 2018 and 2019 revealed operationalisation of the strategic plan as slow.

The minister said, in 2021, the Mid Term review revealed progress in NSHDP II performance towards achieving set targets. According to him, considering the late take off of the Plan, the refocus of health sector priorities and development and implementation of a health sector reform programme, the NSHDP II life span should best be extended and content updated in ways that align with the original priorities of the Plan.

On vaccination for COVID 19 and others, Ehanire said the country is making progress towards achieving our targets for COVID 19 vaccination. He said despite challenges, including vaccine hesitancy and security concerns in many parts of the country, a total of 57,882,237 (51.1 per cent) of eligible persons have been fully vaccinated while 70,355,856 (62.9 per cent) have received at least one dose of COVID-19 vaccine so far.

The minister said the country can achieve 70 per cent coverage needed to acquire herd immunity against COVID 19 virus by the end of the year if states and local governments put more efforts in mobilising and vaccinating eligible people.

Regarding circulating variant polio virus type 2 (cVPV2), Ehanire said the virus detected in Nigeria has significantly reduced by 85 per cent, with deployment of the new oral polio vaccine (nOPV), injectable polio vaccines (iPV) and continued efforts of routine immunisation. He said the country’s routine immunization is showing progress despite Covid-19 pandemic, as indicated in the 2022 Multiple Indicator Cluster Survey (MICS)/National Immunisation Coverage Survey (NICS) results. He said Nigeria is among 10 countries where COVID- 19 pandemic has not significantly distracted from routine immunisation coverage.

The minister said Nigeria’s application to introduce HPV vaccine has been approved and HPV will now become part of the routine immunisation schedule from next year. He said the plan follows the successful introduction of Rotavirus in northern Nigeria, with ongoing introduction in the south, to drastically reduce infant mortality from diarrhoeal diseases.

On climate change and flooding, the minister said the devastating impact of climate change in Nigeria is demonstrated by the recent unprecedented flooding events in the country, which contaminated water sources, washed away farmland, carried raw sewage and toxic waste from hazardous sites, causing increased disease outbreaks as well as mental health issues from loss of livelihoods.

Ehanire said the Ministry of Health is working with other Ministries Departments and Agencies (MDAs) to put in place a robust, long-term plan to mitigate adverse effects of flooding on health through the development of a contingency plan for flooding.

On human resources for health, the minister said resilient health systems require among other things, a sufficient number of qualified health workers. He said challenges of training, capacity to employ, deploy and retain health workers still plagues the country’s system and requires sustained investments and collaboration among relevant sectors and tiers, to ensure balance in health system and population needs.

In this regard, Ehanire said the Federal Ministry of health collaborates with States and agencies to mobilise, consolidate, and align investments to support training and retention of health workforce. He said this collaboration is currently developing a strategy to mobilise Nigerian diaspora experts to mainstream them into the health workforce through both virtual and in- person engagement, this engagement would include training of human resources for health to enrich local capacities to replace those emigrating.

On primary health care, the minister said: “Primary Health Care is no doubt the foundation on which our health care system is built. Its strength is crucial to the functioning of all levels of healthcare. The PHC summit held earlier this year highlighted this and brought together top-level government officials, senior executives and the private sector to discuss plans to reset the Nigeria PHC system by 2030. Innovative financing mechanisms to increase number and quality of healthcare workers, upgrade facility infrastructure, modernize information, data management and technology systems and prioritise community participation, transparency and accountability to all stakeholders were discussed.”

On Strengthening and Utilizing Response Groups for Emergencies (SURGE), the minister said Nigeria still faces diverse health emergencies including Lassa fever, cholera, yellow fever, meningitis on yearly basis, as well as the consequences of the humanitarian crises occurring in conflict ridden parts of the country. He said Nigeria made progress in strengthening response capacity through creation of Nigeria Centre for Disease Control (NCDC). However, Ehanire said COVID 19 exposed weaknesses in few areas and gaps in planning, limited availability of trained human resources, shortage of diagnostics, infection prevention and control commodities and stockpiles and in funding, among others.

The minister said taking stock of response to COVID 19, one of the lessons learnt was that the agility with which countries were able to manage surge health workforce demands, made the difference between successful and struggling responses.

He said recommendations to deal with gaps at global and regional levels are translated to solutions that reflect local needs warranting World Health Organisation African Region (WHO AFRO) to launch three flagship projects for improving capacities of Member States to prepare, detect and respond to public health emergencies.

The minister said the Government of Nigeria is committed to ensuring roll out of this initiative to all states of the federation using a phased approach. To kick off, six states: Abia (SE) Edo (SS), Yobe (NE), Kano (NW), FCT (NC), Lagos (SW) were selected based on set criteria to implement phase 1.

He said after a five-week intensive training, they would graduate the first cohort of SURGE responders for health emergencies. “In line with our ONE health approach, the cohort is multi-disciplinary and made up of persons from various related MDAs (Ministries of Health and agencies, Ministries of Agriculture, Environment, Women Affairs, Humanitarian Affairs, Defense, Road Safety, Residents of Field Epidemiology & Laboratory Training Program (NFELTP) and representatives from Phase 1 states. These trained SURGE responders can deploy to support public health emergencies across the country and even beyond,” he said.

On Basic Health Care Provision Fund (BHCPF) and health care financing, the minister said the operationalisation of the gateways of the BHCPF continues to record great strides, with up to N101 billion received up to October 2022 and these funds have been disbursed to over 7, 600 primary health care facilities across the country. According to the 2020 National Health Account, total government health expenditure was 14.6 per cent of total health expenditure, with expenditure on primary healthcare accounting for only 4.6 per cent of current health expenditure, a pointer for more investments in the revitalisation of Primary Health Care centres (PHCs). He said general health expenditure as a percentage of General Government Expenditure increased from 6.2 per cent in 2019 to 8.2 per cent in 2020, a reflection of the increased spending on health, relative to other sectors during COVID-19.

Ehanire said although general government health expenditure increased, it was not enough to reduce out of pocket expenditure which increased from 71.5 per cent in 2019 to 72.8 per cent in 2020, still far off our target of less than 40 per cent.

The minister said joint effort is still required to drive the quest to reduce out-of-pocket expenditure, improve health system efficiency, increase government spending on health care and expand prepayment coverage and financial risk protection mechanisms.

On National Emergency Medical Service and Ambulance System (NEMSAS), Ehanire said NEMSAS is designed to provide “pre-hospital care” in the form of ambulance services, to promptly transport persons with acute illness or injury to hospitals and emergency medical treatment services for immediate initial care, without such hindrances as police reports or payment before service with the objective to increase access to healthcare and reduce mortality and morbidity rates to improve health care outcomes.

The minister said NEMSAS, as an information and communication technology-driven emergency medical service is effective, efficient, and timely and operates in partnership with private health sector operators. It has been established with a pilot ongoing in Abuja, Federal Capital Territory (FCT). He said an MOU was signed at the commencement of this programme in the FCT between the Federal Ministry of Health, Association of Private Medical Practitioners, Guild of Medical Directors, Federal Road Safety Corps, and The Federal Capital Territory Administration. He said the scheme’s operations commenced in the FCT on October 14, 2022 with recorded successes which will scaled up to an additional four States in January and all states across the nation eventually.

On investment in health and strategic partnerships, the minister said COVID-19 drew attention to vast opportunities for strategic partnerships and investment in health. Ehanire said capital flight from medical tourism continues to put pressure on scarce foreign exchange reserve. He said government is exploring partnerships that will produce investments in the health sector especially taking into consideration existing opportunities in manufacturing medicines, laboratory supplies other health related consumables, construction of medical facilities, super specialist hospitals as well advancement in health technology.

He said one of such partnerships is with AFREXIM bank for which Nigeria won a bid to host the regional center for medical excellence. The minister said the groundbreaking has been done to kick off the super hospital and the African Medical Centre for Excellence will provide specialist care and training of specialist human resources for health. “A conducive environment for the establishment of more of such super centers across the country is at our fingertips,” Ehanire said.

On big data and digital health, the minister said the digital world now generates data at an increasing rate and this is increasingly in use as a tool for addressing issues of health and health living. Ehanire said the Nigeria Digital Economy Policy and strategy has a vision “to transform Nigeria into a leading digital economy providing quality life and digital economies for all and the health sector has developed a National digital health strategy (2021-2025) with a vision of applying it to accelerate progress towards UHC in Nigeria.

“The Federal Ministry of Health is at the forefront, making sure we maintain stability in our health sector and meet health needs of our growing population. I implore you to continue to put your best foot forward to change and sustain progress we desire,” the minister said.

Permanent Secretary, Federal Capital Territory Administration (FCTA), Mr. Olusade Adesola, represented at the occasion by Dr. Abubakar Tafida, in he remarks, said highlighted the importance of improved healthcare and hence the need for government to prioritise the health sector. Adesola said some states including the FCT had shown some progress in healthcare delivery. In conclusion, he called on all participants to enrich the deliberations that will bring about improved health care for citizens.

Secretary for Health and Human Services Secretariat, FCTA, Dr. Abubakar Tafida, represented by Dr. Ibrahim Abubakar, in his address welcomed all stakeholders and stated that improving the health of the population is a major issue in development and there was the need for the government to make deliberate efforts in putting policies and actions in place to achieve this improvement.

Tafida said the FCT administration had upgraded its integrated Disease Surveillance and Response system as well as established an Emergency Operation Centre (EOC). He finally prayed for all stakeholders’ cooperation during these intensive meetings and brings forth their best thought to ensure Nigerians enjoy the needed health care they deserve.

WHO Representative to Nigeria, Dr. Walter Kazadi Mulombo, said deliberate effort has been made to replicate systematic areas across the six pillars of the health system including primary health care, climate change, strengthening local manufacturing of vaccines, big data for health, health insurance and building essential partnership.

Permanent Secretary, Ministry of Environment, Delta State, Asaba, Dr. Mininim Oseji, in a keynote, defined Universal Health Coverage as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship.

Oseji said to determine how to sustain health system, the country needs to first develop strategies to sustain the system’s building blocks which are: leadership/governance, health care financing, health workforce, medical products and technology information and research and service delivery.

On preparing for the next pandemic: strengthening local vaccine manufacturing and biologicals for improved outcomes, Oseji said the Federal Ministry of Health should revisit the Memorandum of Understanding (MoU) signed by May and Baker on local vaccine production in 2017. “There should be a long term plan to be self-reliant in vaccine production including that of COVID-19 vaccine,” she said.

A recommended short-term action plan for promoting local manufacture of vaccines and other medicinal products in the African Region includes:
•Determination of successfully completed clinical trials on local vaccines and other medicinal products in Africa. Conducting a systematic review can do this
•Determination of potential investors in local manufacture of vaccines and other medicinal products
•Market successful local vaccine and other medicinal products, as well as conduct advocacy to national governments to use the products derived from indigenous research
•Conduct rigorous phase IV trials to determine adverse effects of foreign and locally made vaccine and other medicinal products
•Publish results in reputable journals

Chief Executive Officer (CEO)/Executive Director, National Primary Health Care Development Agency (NPHCDA), Dr. Faisal Shuaib, in his technical presentation, titled ‘Primary Health Care: The Past, Present, and How to Secure the Future for Sustainable PHC in Nigeria’, said as a way of addressing the challenges for optimal performance of the PHC, a 10- year Strategic Plan was developed based on the listed four point agenda: access and service delivery through PHC revitalisation; health promotion and demand stimulation, programme with enabling environment in place to support the delivery of the strategy.

Shuaib, who was represented by Dr. Ngozi Nwosu, said the 10-year strategic plan implementation had commenced with revitalisation of the PHCs across the country using the findings from the 2019 PHC assessment to identify facilities for revitalisation.

Shuaib said for successful transformation of the PHC system, the focus was on health system strengthening through strength all the pillars of the health system.
He made the following recommendations:
• The National Health Insurance Authority Act (2021) should be implemented to change the financial landscape of the PHC
• Implementation of innovative mechanism to prefund at least the first 2 years of the 10-year plan
• Scale up of domestic and global resource mobilization through innovative financing
• Additional funding for PHC revitalisation through the BHCPF.
• Scale up public and private partnership to drive the PHC transformation.
• Increase contribution from the private sector through donation from the
Foundation.
• Repurposing of the existing funds towards the PHC revitalisation.