Muyi Aina, the Executive Director and Chief Executive Officer (CEO) of the National Primary Health Care Development Agency (NPHCDA) over the past one year, is a public health professional and management consultant with over 20 years of experience in healthcare and management consulting.
In 2010, he founded Solina Group, a management and healthcare consulting firm. Prior to this, he was an engagement manager at McKinsey and Company.
“We have accountability mechanisms now that did not exist before; one of them is that we’re digitising the process of disbursing the money.”
Aina holds a medical degree from the University of Ilorin, a master’s degree in public health from Harvard University, and a doctorate degree from Johns Hopkins University.
“The relationship was top-down, and what we’ve tried to do is to reposition the way the National Primary Health Care Development Agency engages with our state counterparts, whether it is state health commissioners, state primary health care development agencies, or other stakeholders at the sub-national level.”
In this exclusive interview with the BusinessDay media team led by its General Manager, Bashir Ibrahim Hassan, Aina spoke about the agency’s strategy to reduce the rate of maternal mortality, amongst others, and revitalise the National Primary Health Care delivery system in the country. Excerpt…
You have been in the health sector for a while now; how will you assess the primary healthcare delivery system in Nigeria? What is your mission and plan for the NPHCDA?
I have been around the health sector for a little while as a professional in the primary health care system. One of the things I have learnt is that supporting a system from the outside is different from when you’re inside. A lot of details are different in terms of how things work, as well as the resources and also the leverage and flexibilities that you have.
When we came in, we knew that we were most fortunate to have a Coordinating Minister for Health and Social Welfare who had also been in this role several years ago. As a matter of fact, his interests were heavily tilted towards primary health care, personally and professionally. We also have a Minister of State (Dr. Alausa, who has been reassigned to the Ministry of Education), who is a very astute clinician that has worked at all levels and is very familiar with what is important for the health outcomes of the people.
The president had set an agenda for the health sector. He wants to remove the label on Nigeria as the capital of maternal mortality during his time as President of Nigeria. He wants to crash maternal mortality and reduce unnecessary infant and under-five deaths in Nigeria. To stop women from dying, we have to identify the issues and what is killing them the most and tackle them head-on. The question was how and why colleagues and equally competent people who have worn the same shoes may have fallen short of the objectives they set for themselves and what we need to do to increase the chances of succeeding in this role.
I am not eager to jump to conclusions. So, when we came in, the Minister had articulated a blueprint for the health sector that really focused on saving lives and reducing pain for Nigerians. These include reducing maternal mortality and child mortality, decreasing stunting and malnutrition, improving the quality of our primary health care centres, increasing health insurance, strengthening local production of commodities for health care, and improving immunisation coverage. We have talked with all stakeholders, including staff, civil society, my predecessors, partners, states, etc., on these problems.
Can you explain what you mean when you say the health sector has failed Nigerians?
What I mean is when you’re not able to meet the basic requirements of people. For example, we have over 30,000 primary healthcare centres across the country, but how many of you will walk in there when you fall sick? We are tackling that head-on; we are doing so by developing our own roadmap as a National Primary Healthcare Development Agency through a collective and very inclusive process.
So, how was the relationship with the states before you came in, and how is it now?
One of the bones of contention was that the states were very consistent and clear that they were not happy with a top-down approach that we often take at the federal level, where we just hand them a letter on the program they should implement, the amount of money needed, and what they should do. States are the ones that have the health facilities and health workers, and they know day-to-day problems in their communities.
Frankly, they know better than we do. The relationship was top-down, and what we’ve tried to do is to reposition the way the National Primary Health Care Development Agency engages with our state counterparts, whether it is state health commissioners, state primary health care development agencies, or other stakeholders at the sub-national level. It’s more of a collaborative process.
So, the top-down approach has changed?
I would say it is changing, because every now and then, I still have to call my colleagues to point out to them what we agreed we’re not going to do. The feedback we are getting is that the states are very appreciative of that. We see more ownership and more engagement in our programs and in our objectives. As a matter of fact, many of them developed their own blueprints without us asking them to do it, and they provide us with reports on progress there.
When we decided to revitalise primary health centres and started the process of resource mobilisation, a number of states went ahead of us, using their own model, and they’re making the investments. As of today, almost 230 PHCs have already been fixed, either repaired or built from scratch by states themselves. The Federal Government has commenced the process of revitalising another 350 PHCs. We have mobilised substantial resources and will revitalise another 2,500 to 3,000 across the states. It was World Bank financing for the federal government and the states. We gave states a framework, but unfortunately, needs are not evenly distributed. We said one per ward, one per tribe, one per state, but in reality, people’s needs are quite different. And if I assume the same need for you that I assume for me, chances are one of us is not well served. So, we are moving away from a more equitable distribution of things.
We are also focused on the health workers. We don’t have enough, and the ones that we have are not properly distributed, but they are also not very skilled. So, what we’re doing is retraining 120,000 health workers across the country. That’s the mandate that the president gave. And as of today, I can tell you that we have trained over 40,000. We have 120,000 targets for four years, but in one year, we have done over 40,000. And we’re training them in what is called “integrated primary health care services.” We are also investing in equipment because you can have people, buildings, and not have the tools to work with.
Lastly, I think we’re all aware of the price of medicines and how it has changed in the last year. One of the things that the President has done is to enable certain interventions that will subsidise the cost of medicines for people at the grassroots.
What are those interventions to subsidise the cost of medicines for people at the grassroots?
One is that we’re doing some pooled procurement to lower the cost. We’re giving them some seed commodities, and we’re going to be working with them to make sure that they are recouping the cost from insurance payments. And where people are paying out of pocket because they’re not insured, they will also record and reproduce. So, we just have to manage the quality.
The second thing is that we’re going to be rolling out a series of medical outreaches. I’m also aware that the Ministry of Health has some medical palliatives. So, basically, we’ll be making medicines available at the grassroots to communities and to facilities in a way that people can access. The President has been very sensitive to the plight of the cost of medications. Even as Executive Director, I’m feeling the pain of the cost of medicines. So, these are the things that keep us awake at night.
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You’ve been the Executive Director and Chief Executive Officer of the National Primary Health Care Development Agency (NPHCDA) for one year, and we could see some progress and success. What have you achieved in the last year as the Chief Executive Officer of this very important agency?
We have a number of important priorities, but it really comes to five or six big ones, and I will take them one by one. The first one is primary health care revitalization. We are working to have functional 17,000 primary health centres. Ultimately, this is the minister’s mandate as guided by the president. We want to have 17,000 primary health centres.
First, we have defined what a functional primary health centre is. We have mobilised some of the resources. We have actually started the revitalization. Like I said, as of the last count, about 239 PHCs have been completed, and we are now working on about double that number. Contractors are there now, but I won’t count them until we are done. There are about 200 additional PHCs that we’re using global fund resources to revitalise. So that journey has started.
I also mentioned that we set a goal to retrain health workers. Many of these health workers have never been trained since they joined the service. Some who have been trained in the past have not been trained in 15 years. The minister gave an example of when we went to one facility in Sokoto, he asked for the training guide, and he was given the standard operating procedures (SOPs) that he produced 15 years ago when he was ED of NPHCDA. The conditions have changed and the medicines have changed.
That made it very obvious that there is a need for retraining, so we have developed the guidelines and the training manual. We have trained about 42,000 as of the last count.
The other thing that we set out to do was to revise the Basic Healthcare Provision Guidelines. You may be aware that the guaranteed funding for primary healthcare in Nigeria goes through a number of pathways: the NPHCDA, the National Health Insurance Authority, the National Centre for Disease Control, and the National Emergency Medical Transport Programme. The money was going to the states, and we met a lot of mismanagement. Some of it was deliberate, and some not, but it wasn’t spent effectively. Facilities were not getting enough; there was not a lot of transparency. It just wasn’t useful. There were a lot of problems. The Auditor-General did an audit when we came in that identified many problems. So, we have gone through the process of working with the states to identify the state-specific issues and remedy them, and to revise the process such that states will only receive money if they meet the bar in a mediation plan. We have accountability mechanisms now that did not exist before; one of them is that we’re digitising the process of disbursing the money.
We are limiting what they can spend the money on. A health facility cannot withdraw more than 10 percent of the money but can transfer it digitally. If you transfer, we can look at the bank statement and know what it was used for. That’s easier to track.
We have also established something called the Performance and Financial Management Officers (PFMOs), which is in collaboration with President Bola Ahmed Tinubu’s social accountability programme officers. It will be deployed in each local government to also monitor.
When the states give us their reports, we have these external mechanisms to check. We have established a partnership with the Independent Corrupt Practices and Other Related Offences Commission (ICPC). I have also had a conversation with the Director General, State Security Service (SSS) to get them involved in this process.
We are rolling out a dashboard for people to identify which PHCs are near them. I think we will roll it out before the next two weeks as part of Basic Healthcare Provision 2.0. So, we have revised the guidelines for the Basic Healthcare Provision Fund, but we want to still do a little bit of work to revise it and finalise it.
Back to the success stories
On routine immunisation, we were stagnated with the coverage of routine immunisation. So, we changed our tactic to identify children that we have missed repeatedly. They are not ghosts. So, we then established something called Identify, Enumerate, and Vaccinate. If we do a mini-census of the children and check their vaccination status, then we can at least track, and that’s helping. During our campaigns, there was a raging diphtheria outbreak, and the minister quickly constituted an emergency diphtheria task team that I co-chaired with the DG Nigeria Centre for Disease Control (NCDC) at the time. We were able to curtail the outbreak through a very systematic emergency response and reduce the number of deaths. There was a cholera outbreak a few months ago, and we were able to mobilise new vaccines and respond very quickly, thereby saving lives.
In fact, Nigeria was the first country to use the pentavalent meningococcal pentavalent vaccines.
Then the flood happened in Borno State, and we anticipated that if people were interacting with some kind of dirty water that the flood brought to them, there was a risk of cholera. We were so fortunate that we were able to draw on some of the vaccines that we had gotten, even though for other states. But through vaccination and also other interventions like better hygiene, the states were putting their outbreaks under control. We moved some of these vaccines to Borno, Yobe, and Adamawa. So, there was an outbreak of only 17 cases, and nobody died. In that situation, you could have had hundreds of deaths. Those are the kinds of things that we don’t often talk about.
You see, in health, when you win, it’s not very obvious. Nobody wakes up in the morning and says, I’m not sick today. Somebody is doing something right. When you lose that, it’s obvious.
Another thing that we have done is that we have secured resources, and we defined the 10 most affected states for maternal mortality. We have identified about 150 local governments that we really need to intervene in. We have secured some initial resources to recruit midwives, so we are starting the process of recruiting midwives, training them, and deploying them throughout the states. We are letting states know that it’s their responsibility to hire them, and we give them resources to pay their salaries, but for a few years. That way, it’s required that they integrate them from the beginning; that’s what we want to do now.
The federal government has disbursed over N100 billion under the Basic Healthcare Provision Fund (BHCPF). This fund is for states to improve basic health care. Data shows that some states are not able to access the funds that are available for them. Although you talked about some of the factors, how well are states accessing the funds that are available for them to help in the work that they are supposed to do?
There are two implicit questions in what you’re asking. One is on the barriers that stand in the way of states accessing interventions, whether it is a federal government direct intervention or a development partner intervention that is accessed through the federal government. Some of the barriers are that there are some accountability requirements. We need to spend the money in some way so that there’s some sense of value for money. Many times, the problem is not even that the money is being stolen or anything; it’s the capacity at that level to account for the money.
Transparency is not always there, so typically when a state is unable to access, it’s two things: either there is a counterpart payment requirement that the state has not paid, or they have collected a first tranche and have not been able to retire it to be able to get a subsequent tranche. Those are usually the barriers.
So, what has changed since your assumption of office? What is the agency doing to rally states to tap this critical fund? How is the agency working to ensure transparency and accountability in the utilisation of the scarce resources?
When you work with the states in designing the framework, they’re better prepared. We’re also organising technical assistance in the way that we’re supporting states. Right now, we’re in advanced stages of developing annual operational plans with all 36 states through the Sector Wide Approach (SWAP) Coordination Office of the Federal Ministry of Health & Social Welfare. They will define their priorities for primary health care and what they want to achieve. How many primary health centres they want to revitalise, how many health workers they want, where the resources would come from, among others. So that we can then work with them to see how to fill the gaps or how they can prioritise living within their means. You see, all of these interventions are a small part of the cost of delivering health services. It’s not all of it. Just running and maintaining the facilities on a state level is helping the states to think through how they coordinate and get the biggest bang for that money, but they’re not spending enough.
One of the things that we’re also pushing now is using some of these interventions to incentivise them to spend more. I said earlier that we have this intervention where we will give money to states to hire health workers, but you see, the way it will work is for states to hire the health workers and put them on their payroll.
Nigeria received malaria vaccines a few days ago; 846,000 doses, and about over 100,000 more are expected to make it one million. How much was spent to procure this vaccine? But one million doses cannot cater for the target population. Are there plans to procure more, and when should we expect that?
There are a number of things. I think the malaria vaccine is a very important tool in the control of malaria in Nigeria. Malaria is a disease that everybody can agree is a priority for us. We really welcome the arrival of the malaria vaccine. It’s important to know that it’s a more recent vaccine than many vaccines, so they’re just expanding the production of it. In fact, it took the goodwill of the President for us to get some at this time. Evidence shows that it is reliable; the government would not give anything to Nigeria that is not reliable.
The National Agency for Food and Drug Administration and Control (NAFDAC) has reviewed and determined it fit and safe for Nigeria. The World Health Organisation has recommended it and specifies how we’re going to use it.
Now, because it’s a new tool, it’s still quite expensive. So even though people don’t pay for it, all of these vaccines and medications are paid for by somebody, regardless of where the money is coming from. We have partners like Gavi Alliance, other overseas partners, and private foundations that donate because they want to expand our access to some of these tools. Now, that’s still at a cost, and there’s still only so much they can pay for.
But more importantly, there’s a supply constraint because it is also very expensive; it’s not the kind of vaccine that you want to waste. So, it’s also important for us as a country to deploy it and learn.
We introduced the human papillomavirus vaccine this year, and we achieved about 90 percent coverage of our target. Never has that actually happened.
So what is the cost of this vaccine, because you just talked about how expensive it is?
I don’t think I can tell you off the top of my head, but it is very expensive. The reason I know is that the government pays a counterpart fund. Even though we get our generous global partners to donate some of our vaccines, the government pays a counterpart fund, which is almost 90-100 million a year for these vaccines Nigeria is paying every year. We did an analysis to see which vaccines are really costing us more money; the malaria vaccine will account for almost a third, and we have several antigens in our national program, or even more. The malaria vaccine alone will account for a third of what you will pay. It is justifiable, but we need not waste that money. So, that’s why we selected high-volume locations to start and learn.
Also, we would achieve the best result with the malaria vaccine when we combine it with other tools such as insecticide-treated nets and seasonal chemoprophylaxis. When used well together, they provide up to 92 percent protection. We’re trying to learn the best way to do this before we expand.
Your agency was scheduled to begin vaccination against Mpox on October 8, but that did not take off as cases of Mpox rose in the country. Why did the vaccination not commence?
The Mpox vaccine was a generous donation; we got 10,000 doses of it. We even had to give $1,000 to Rwanda, which was more desperate because they had outbreaks. We don’t have outbreaks yet, but they have outbreaks around them, and they didn’t have access to it. So for that, we’re also prioritising frontline health workers, people who are most exposed. We are prioritising people at the borders of entry so that if you’re coming from another country and you’re exposed to somebody who has it, you’re less likely to get it. But our plan was to deploy it within a couple of weeks.
Nigeria was declared wild polio virus-free in 2020, but we are witnessing a continued transmission of the circulating vaccine-derived poliovirus type 2 (cVDPV2), which you said had become intense at the last meeting with Northern leaders in Abuja. Should we be concerned about a potential outbreak? What is the agency doing to stop this transmission?
Let’s be clear: Nigeria was declared wild polio-free in 2020, and we have remained wild polio-free. However, unfortunately, the virus happens to be a smart one. So, over time, in other places, it starts to mutate. So, we got a circulating variant poliovirus, which has now also spread across states. So, we started the chase again. One of our priorities, when we came in, was to look at the problem and the interventions that have been deployed, and it turns out that in our assessment, we’re doing large-scale campaigns, but we are missing the same set of people repeatedly.
This is part of what I said earlier on identifying the children, the identity of their parents, and where they live so as to follow up and vaccinate them. That way, we would know who hasn’t been vaccinated.
We work with the communities, traditional leaders, and religious leaders to try to reach them. We completely revised our eradication strategy for that, and it takes a bit of time before you will see the results. But the trend in the virus suggests that we’re going to get much less than we got last time.
Should we be concerned about another outbreak of polio in Nigeria?
I don’t think we need to be concerned about a major outbreak of polio. We certainly hope not. There already is an outbreak of the circulating variant, and that’s what we’re on top of. When there is a case, we go and vaccinate around it; that’s how we are controlling it. In the 1st week in November, we’re starting a mass vaccination campaign across 20 states. It’s important that the immunity in the population is elevated. That’s why we have this mass campaign, and that is why we’re doing it.
The way to not have another outbreak is for people to get vaccinated. As a government, we’re trying to do the campaign. But there’s a need to get the people to understand that the vaccines are safe and that the government and our partners mean well. Our partners mean well. We’re trying to prevent another outbreak.
What is your call to Nigerians? What type of support are you asking Nigerians to give?
I think Nigerians are not expecting too much. I think Nigerians are asking us to fulfil our covenant with them as a government. The President is truly committed to this, not because I’m in the government, but if I didn’t believe that, I would not be part of the government. I had a job that I was doing before this that paid well.
We ask that Nigerians give us a little bit of time, be patient, ask us questions, challenge us, but understand that it takes time to repair a system that has been damaged over many years. You don’t just turn it around overnight.
Secondly, we have to make difficult choices. One of the fundamental principles of reversing your fortunes and starting to improve your economy is to start to live within your means. A lot of the reforms that are going on really target that. It’s important that Nigerians are patient for good reasons, but a little bit of patience and a little bit of engagement. Engagement in that when we have programmes, they should please participate. When we provide services, they should take advantage of them; they should trust that the government is not out to do damage when offering health intervention. There will always be false information out there; there will always be misinformation, especially in the era of social media, but Nigerians need to understand that the government cares about them.
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