INDEPTH |NCDC: The triumphs and travails of Nigeria’s premier public health institute

Established in 2011, the Nigeria Centre for Disease Control (NCDC) is mandated to enhance the country’s “preparedness and response to epidemics through prevention, detection and control of communicable and non-communicable diseases.”

 

 

Until November 2018 when President Muhammadu Buhari assented to a bill for an act establishing the Nigeria Centre for Disease Control (NCDC), as a full-fledged parastatal of the federal government, the NCDC lacked a legal mandate. This development meant improved access to human and financial resources to the agency which subsequently led to the enhancement of its emergency coordination, surveillance, and risk communication capabilities.

Although the NCDC did quite effectively responded to numerous public health emergencies across Nigeria – most notably the 2014/2015 Ebola Virus Disease (EVD) outbreak in West Africa – its greatest test came with the outbreak of the coronavirus in Nigeria on February 27. As at the time COVID-19 arrived in Nigeria, only four laboratories had the capacity to test for the rampaging virus.

As at today, the NCDC has managed to build a network of 28 government-owned laboratories with the capacity to test for COVID-19 across the length and breadth of Nigeria. Nonetheless, despite its relatively impressive record in preventing and containing the outbreak of diseases including COVID-19, Nigeria’s premier public health institute is constrained by myriad challenges, principally funding. For instance, while the 2018 operations manual of the statutory Basic Health Care Provision Fund (BHCPF) says 2.5% of the Fund should go to the NCDC, the 2020 guidelines completely excludes the agency from accessing the Fund.

 

How NCDC has fared

Almost a decade ago, the NCDC was kicked off in a two-room apartment and with only five staff! Today, its Abuja headquarters occupy two multistory edifices while its staffing has increased to about 300. The agency eventually became the model based on which the ECOWAS Regional Center for Disease Surveillance and Control (ECOWAS/RCDC) and the Africa Centres for Disease Control and Prevention (Africa CDC) were established in 2016 and 2017, respectively.

Prof Abdulsalam Nasidi, pioneer CEO of the NCDC said when he became the head of the institution in 2011, what he realized was that whenever there was an epidemic outbreak in any part of Nigeria, before a response was initiated, the epidemic would have already taken its course. As a response, he said, the NCDC came up with an Emergency Preparedness and Response (EPR) Plan; funded through a World Bank grant and the Country Coordinating Mechanism of the Global Fund to fight HIV/AIDS, TB and Malaria.

“It was thanks to these grants that we were able to strengthen our laboratories and state-level epidemic divisions as well as introduced the Nigeria Field Epidemiology and Laboratory Training Program (NFELTP). Prior to the introduction of the NFELTP, Nigeria had less than 30 epidemiologists, now no Nigerian state has less than five or six epidemiologists,” recalls Prof Nasidi who was also the pioneer executive director of ECOWAS/RCDC.

Dr Chikwe Ihekweazu, the current CEO of the NCDC believes the establishment of his agency became necessary because Nigeria’s erstwhile framework for preparing and responding to epidemics was not fit for building an effective health security architecture. “It requires a certain level of expertise, reactiveness and proactiveness which couldn’t be achieved within a ministry structure hence the need for a specialized agency, as it is the case in other countries of the world,” he told Newspage.

Nonetheless, Ihekweazu said until the 2014 Ebola outbreak in the country, many were unconvinced of the necessity for an institution such as the NCDC in Nigeria. He said it was the Ebola epidemic that made it clear to all doubting Thomases, the obvious need for an agency to prevent, detect and respond to the threats of infectious diseases in the country.

“My first big goal when I came into office [in 2016] was to pull through the required bureaucratic milestones to fully establish the agency. We took the bill through the two chambers of the National Assembly and got Mr President to sign it in November, 2018,” he recalls. “We are still a small agency of 300 staff responsible for the health security of a country of 200 million people, and with many threats of infectious diseases. I don’t think we are anywhere close to where we need to be but we have laid a strong foundation; I think we are slowly gaining the confidence of the Nigerian people on the necessity of our existence.”

Tanimola Akande, a professor of public health at the University of Ilorin cum member of the National Implementation Steering Committee of the National Health Act (NHAct), agrees. He believes Nigerians were now better aware of the NCDC and its functions – unlike during its early days, when the agency was barely known to the public. “It was until six years later when it got its legal backing that people began to hear about the NCDC. Of recent, much is being known about it – even before the COVID-19 pandemic. As at today, it appears they have woken up from their slumber and Nigerians are aware of the NCDC and what its functions are.”

“The NCDC has gone through a lot of transformation – from an organization that is barely known to being the centre-stage of the country’s health security architecture,” says Dr Gafar Alawode, project director of the Prevent Epidemics (PE) Project, aimed at boosting domestic spending on epidemic preparedness and response. “I think the current leadership [of the NCDC] has done a great job of repositioning the institution to face the challenge of health security in the country.”

Likewise, Dr Ifeanyi Nsofor, director of policy and advocacy at Nigeria Health Watch, thinks securing a legal recognition by the NCDC in 2018 had helped improved access to funding for the agency which subsequently enabled it to strengthen Nigeria’s epidemic preparedness mechanism. “Before 2018, surveillance data collection was purely paper-based which meant, if there was an epidemic outbreak, before data got to Abuja, the epidemic would have already taken its course.”

Dr Nsofor said thanks to the NGN316 million it received from the BHCPF in the first quarter of 2018, the NCDC was able to deploy the digital open-source software called Surveillance Outbreak Response Management and Alert System (SORMAS), which now allows for real-time outbreak and epidemic surveillance in Nigeria. “The NCDC’s next target is setting up of Public Health Emergency Operations Centres (PHEOCs) across 23 of the 36 states of the federation, which will enable the states to respond to outbreaks before the NCDC comes in.”

Despite the significant milestones it has attained from its inception in 2011 to date, the NCDC’s effectiveness as the first-line of defense against epidemics and pandemics in Nigeria is being inhibited by a wide-range of issues, namely funding, policy and structural challenges.

 

NCDC’s funding constraint

Section 14 (2) of the NCDC Establishment Act, says “there shall be credited to the NCDC Fund, 2.5% of the 5% Basic Health Care Provision Fund established under section 11(1) of the National Health Act”. Hence, other than receiving funding from the federal government’s annual budget, the NCDC is also supposed to receive the statutory 2.5% of the BHCPF, according to the 2018 BHCPF Operations Manual. This BHCPF implementation structure splits 5% of the Fund’s allocation for emergencies into two equal parts – one for medical emergencies and the other for public health emergencies.

Consequently, out of the 2018 annual budget of the BHCPF (which was to the tune of N55.9bn), the sum of NGN13.78bn was approved and made available (during Quarter 1 of 2018) to the implementing agencies, namely National Health Insurance Scheme (NHIS), National Primary Health Care Development Agency (NPHCDA), the Department of Hospital Services (DHS) as well as the NCDC.

Out of the NGN13.78bn, the total amount released to the NCDC for the first quarter of 2018 was NGN361.59 million. Since then, no releases had been made to the agency from the BHCPF. Regrettably, the revised (2020) BHCPF guidelines completely excludes the NCDC from accessing funds from the BHCPF. Subsequently, the agency which has since inception remained largely dependent on donor funding, has now become even more donor-dependent, to the consternation of healthcare financing stakeholders in Nigeria.

Prof Oyewale Tomori, the foremost Nigerian virologist and former Africa regional virologist at the World Health Organization (WHO), is among those concerned that the NCDC lacks enough resources (human and financial) to deliver on its mandate hence its dependence on foreign assistance.  He described the NCDC as being “overwhelmed” adding that the agency had nevertheless done well given the circumstances it has operated in throughout the last decade.

“I am not too happy that our NCDC depends so much on foreign assistance because at the end of the day, all these donors are coming with their own agenda. For example, when USAID and others who support HIV/AIDS and TB eradication in Nigeria were having problem with sample collection and transportation, they introduced what they called National Integrated Sample Referral System (NiSRN) and set up over 400 labs to collect and process samples.

“Now, the question is: What happen to the labs when they leave? Ideally, before they set up those labs, Nigeria should have told them: ‘Since you are going to leave in five years, we will put up a mechanism to take over the labs when you go.’ Today, if international support stops for NCDC, I am not sure they will be able to do the work they are doing because a lot of their work is supported by donors. It just shouldn’t be [so],” Tomori told Newspage.

Akande agrees. “Unfortunately, a lot of the funding for the NCDC comes from donors, as a nation, we shouldn’t rely on donors to fund our health security. Because it means if the donors pull out, the NCDC will be in trouble, so it should be adequately funded.”  Ihekweazu says the NCDC need more financial resources to enable the agency fund the training of its lab scientists as well as build a purpose-built infrastructure to support its work.

“No medical lab graduate of a Nigerian university is [automatically] ready to work in a lab like ours – without training and mentorship. When I came into office, the National Reference Laboratory was but an empty space, which we have now built. What we need ultimately is a campus, a purpose-built centre with the right infrastructure, equipment and human resources. Funding epidemic preparedness is like paying for fire insurance, you are paying for something you hope not to need but you have to do it to ensure you have it when you need it; it is a painful investment. But the COVID-19 experience has made people realize it’s a necessary one.”

 

Policy and structural challenges

The 1926 Quarantine Act “provide for and regulate the imposition of quarantine and to make other provisions for preventing the introduction into and spread in Nigeria, and the transmission from Nigeria, of dangerous infectious diseases.”  Amongst others, the Act empowers the President to declare any infectious disease as ‘dangerous’ and any area in or outside of Nigeria as an infected area, and consequently issue regulations aimed at preventing the spread of any dangerous infectious diseases.

In the aftermath of the outbreak of the coronavirus pandemic in Nigeria, Speaker of the House of Representatives (HoR) Femi Gbajabiamila, had sponsored a bill entitled, “Control of Infectious Diseases Bill 2020.” The bill which seeks to repeal the Quarantine Act drew a lot of criticisms from Nigeria’s public health stakeholders including the CEO of NCDC who said he first saw it on the social media. Among other shortcomings, critics of the bill say it arrogates too much power to the chief executive of the NCDC.

Dr Ihekweazu, who agrees the bill arrogates too much powers to the CEO of NCDC, says the initial move to repeal the Quarantine Act by the HoR was made ‘in a rush’ without due consultation with key stakeholders including the NCDC – the very reason why the bill became controversial. He however said, afterwards, there had been series of consultations with stakeholders including the NCDC.

“I hope the next version of the bill will be more representative of the needs of the people, and I think it’s important for us to define when extra powers are needed for public health purpose. I personally do not think it’s necessary for any leader of the NCDC – either myself or anyone else – to have so much powers (as contained in the Control of Infectious Diseases Bill 2020). I think it was unnecessary but that has been taken care of by subsequent consultations.”

Dr Alawode believes Nigeria’s health security laws were either outdated or duplicative. “I think we need a more holistic approach that will give appropriate powers to the various institutions, taking into cognizance the governance structure of Nigeria which is decentralized and federal in nature, such that the subnational entities enjoy a certain level of autonomy. We need a law that reflects the local context, international health regulations and makes a provision for adequate funding.”

The Nigeria Governors’ Forum (NGF) was among stakeholders who expressed serious reservations about the new Control of Infectious Disease Bill, describing it as ‘undemocratic’ and ‘conflicting with the constitution’. Amongst other failings, they said the bill had taken away the powers of state and local governments. Conversely, Tomori thinks in a situation of a national emergency such as the COVID-19 pandemic, the country should always act as one.

“When you are in a national emergency, there is nothing like a state. But it is the semi-autonomous nature of the states that allows them to behave as such. That’s why I think, before setting up of the Presidential Task Force on COVID-19 (PTF), the President ought to have called all the state governors and told them: ‘This is a national emergency and we need to act as one country.’ So, there is a kind of policy incoherence which is why different states have different policy guidelines for reopening schools and worship centres.”

 

Is the NCDC overburdened?

Many health policy experts consider the NCDC as currently being overburdened thus the necessity of its replica at the state level, to enable the states tackle their health security challenges, while the NCDC provides technical and policy oversight – since health is on the concurrent list i.e the responsibility for health is shared by both federal and state governments. They argue that just like agencies such as NPHCDA and NHIS have their state counterparts, the NCDC should also have its own state-level version. Others think strengthening the existing epidemic divisions at the various State Ministries of Health (SMOH) is the answer.

“We need a stronger institution at the state level that will work with the NCDC such that while the NCDC provides policy direction, the state-level institution will implement. However, the shortcoming of such an arrangement is that, if there is a semi-autonomous institution at the state-level, the state governors may be compromising such an institution. Overall, the key thing is having adequate political support, funding and institutional capacity,” Alawode told Newspage.

Yet, Dr Ihekweazu believes the NCDC’s responsibilities are at both federal and state levels, arguing that the various states of the Nigerian federation were not on the same level – in terms of capacity to respond to disease outbreaks.

“We never go to the states to provide a primary response, our strategic objective is to build the capacity of the states to do so. So, most of our efforts are in preparedness, we want the states to be independent and self-sustaining so they have less and less need for the NCDC. However, we understand that the states are not on the same level. Moreover, there is a level of expertise you can have at the federal level and not [necessarily] have at the state level. We need to define when the states need to be supported, which should be dependent on their capacities.”

Prof Nasidi says while the idea of having subnational CDCs was very expensive it, however, provides an effective strategy for timely response to outbreak of infectious diseases. “Countries like China run a system whereby each district or region has its own CDC, which is very effective but expensive. In Nigeria, we rely on the departments of public health at state ministries of health working with the NCDC. That system is also okay but where there is a missing link is between the Local Government Areas (LGAs) and the states, so we have to look for a way to bridge that gap.”

Tomori recalls with nostalgia the days when he said Nigerian states had strong epidemic divisions arguing that such divisions were now almost dead across most of the states. “I remember in the ‘80s and ‘90s, we used to have an annual meeting of state epid divisions, where we meet and look at the challenges at the states and their plans for responding to such challenges. This was usually done around October, before the states prepare their budgets. All that is now gone, everything is concentrated around the NCDC – the states have abandoned their roles.”

 

BHCPF and defunding of NCDC

The BHCPF was established by Section 11 of the National Health Act of 2014. The Fund is meant to be a vehicle for supporting the effective delivery of primary healthcare services i.e provision of a Basic Minimum Package of Health Services (BMPHS) and Emergency Medical Treatment (EMT) for all Nigerians. It is statutorily funded by at least, 1% of the Consolidated Revenue of the Federation (CRF), and grants by international donors, amongst other sources.

The 2018 BHCPF guidelines explicitly states that 50% of the Fund will go to the NHIS while 45% will go to the NPHCDA. According to the guidelines, the remaining 5% was for emergencies out of which 2.5% will go to the NCDC for public health emergencies while the remaining 2.5% goes to Department of Hospital Services for medical emergencies. Contrarily, the 2020 revised guidelines didn’t allocate the 2.5% of the BHCPF to the NCDC.

“The 2018 version of the BHCPF guidelines allotted a specific proportion of the Emergency Gateway Funds for the NCDC and this provision is captured in the law that set up the agency. However, NCDC was not recognized as a recipient of the Emergency Pathway in the 2020 version of the guidelines,” said a statement by the Health Sector Reform Coalition (HRSC), a group of Nigerian civic and media organisations advocating for health sector reform.

In his response to the move that has been likened to defunding of the NCDC, Dr Ihekweazu say while the 2.5% of the BHCPF was not sufficient enough to fund Nigeria’s health security needs, however, he believes considering the guaranteed nature of the funds, they should not be ignored. “I think we do need an emergency clinical service, we need ambulances but not at the expense of an existing responsibility that is important for the country, considering the outbreaks we are [currently] experiencing and considering Nigerians’ vulnerability to more outbreaks.

“I don’t think the 2.5% is sufficient to fund our health security needs but because the funds are guaranteed, they provides us with some stability, since no one knows when an outbreak will happen; outbreaks don’t necessarily follow Nigeria’s budget cycles. That is why the funding stream is very important and I continue to advocate for it. We can ring-fence it, we can say it can only be used for certain types of [public health] emergencies but to take it away is a tragedy for the country.”

Dr Nsofor concurs. “Removal of the 2.5% of the BHCPF meant for the NCDC which was appropriated by Mr President, was a great injustice to Nigerians. It’s definitely a huge setback because what was released to the NCDC from the BHCPF was what was utilized in setting up of the PHEOCs, the network of molecular laboratories as well as deployment of the SORMAS. So, removing it is a huge drawback to the work the NCDC is doing.”

Felix Obi is a research fellow at the Nigeria Health Policy Research Group (HPRG) cum Africa representative on the board of Health Systems Global (HSG). Obi, who thinks there was but a thin line between medical emergencies and public health emergencies, said whereas the entire 5% of the BHCPF was initially solely meant for the EMT gateway, the NCDC was later able to successfully advocate for 2.5% of the BHCPF to go to public health emergencies.

“However, there was a general understanding that the 2018 BHCPF guidelines was developed without due consultations with states and some key stakeholders. Subsequently, during the National Council on Health 2019 in Asaba, the states complained that the 2018 BHCPF guidelines were developed without due consultation with them. Other stakeholders complained that the guidelines were heavily influenced by donors. Therefore, a consensus was reached to revise the guidelines in accordance with the NHAct.”

Obi reasons that even as the revised (2020) BHCPF guidelines allocate the 5% of the BHCPF to EMT, doing so did not preclude public health emergencies. “Although the NCDC was not mentioned [in the 2020 BHCPF guidelines] that doesn’t mean they should not receive funding from the EMT gateway. I think there is need for more advocacy to ensure public health emergencies are mainstreamed in the EMT gateway. While it is important that the NCDC is funded through the BHCPF, being an agency backed by law, it should be able to receive significant budgetary funding.”

Obi, who was a member of the Health Financing Technical Working Group that drew up the 2018 BHCPF guidelines, described the entire BHCPF as an unpredictable funding source, one that depends on the Consolidated Revenue Fund (CRF), which he said, keeps fluctuating. “For example, what we had as 1% of the CRF in 2018 was much higher than what we had in 2020. The government need to think of other sources of sustainably funding our healthcare system. Currently, the NCDC is getting a lot of funding from the government and partners because of COVID-19. Beyond COVID-19, how can the NCDC be sustainably funded?”

The bottom line is: As the country’s national public health institute, the NCDC is desirous of being adequately funded by the federal government – either through the BHCPF or otherwise. Doubtlessly, our failure to sufficiently fund the institution presents a grave danger to the health security of the 200 million people who call Nigeria home. More than ever before, the COVID-19 pandemic has proved to us, beyond a reasonable doubt, the capacity of infectious diseases to wreak havoc on lives and livelihoods. For sure, the socioeconomic impact of the pandemic will stay with us for many years to come.

Although no one knows what the next pandemic will be or when it will break out, what we all know is: Adequately funding the NCDC will enable the agency strengthen our epidemic preparedness and response mechanism, before the next pandemic. Our failure to prepare ahead of the next pandemic will only lead to another unnecessary cycle of loss of lives and livelihood by millions of Nigerians. As they say: “He who fails to plan, prepares to fail.” May we not have to endure the devastating impact of another pandemic, as we did COVID-19!

 

This solutions-based story was produced with the support of Nigeria Health Watch, through the 2nd Prevent Epidemics Naija Fellowship, aimed at raising the profile of epidemic preparedness and generating support for robust epidemic preparedness funding.