Nigeria: Leveraging Joint External Evaluation to Improve Health Security at Subnational Level
When the first case of COVID-19 was confirmed in Nigeria, Dr Johnson Simon Mafuka, who heads the infectious diseases unit at the Federal Medical Center (FMC), Owerri, Imo State, said that they knew it was a matter of time before the first case was. arrive in the state. At the time, the facility had the only isolation center in the state, but shortly thereafter the government built an Emergency Operations Center (EOC) to help build its capacity to respond to the next infectious disease threat. This is a positive step because a Public Health Emergency Operations Center (PHEOC) can help coordinate disease surveillance and organize and structure the response in the event of an outbreak. However, beyond investing in the right structures, preparedness also means continuously assessing the state’s overall capacity to respond to events that threaten its health security.
A brief history
In 2018, Nigeria developed the National Action Plan for Health Security (NAPHS) to strengthen the implementation of International Health Regulations (IHR) core capacities, a costed multi-year roadmap to strengthen the health security of the country. NAPHS has captured the country’s health security priorities, brought together sectors that embrace a One Health approach, and identified partners who have responsibility for responding to public health threats that occur naturally or as a result of events. deliberate or accidental, at the national level.
However, prior to NAPHS, there was the Joint External Evaluation (JEE) which is conducted every five years. The JEE is a voluntary external assessment of a country’s ability to detect, arrest and prevent disease threats. Predetermined core technical areas are used to assess a country’s capacity and readiness. The JEE guides the development of the NAPHS, thereby ensuring that available funds, technical capacity and other resources are focused on and prioritized on the key gaps identified.
Nigeria conducted a JEE in June 2017, which identified critical gaps that needed to be filled to protect the nation from the next major event. A mid-term JEE was conducted in 2019 to help assess improvements over the previous one. It also provided an opportunity to review progress and identify challenges in the implementation of NAPHS. Lessons learned from this self-assessment demonstrated the importance of continuous self-assessment in determining a country’s level of pandemic preparedness and developing plans to strengthen core health security capacities, particularly during periods between one public health event and another.
The 2017 JEE and the 2019 Mid-term JEE assessed Nigeria’s capacity to prevent, detect and respond to a health emergency at the national level, with no provision made to assess capacities at the sub-national level . To address this deficit, the Nigeria Center for Disease Control (NCDC) has developed the “Strengthening States for Health Security” strategy. Their objective was to provide the necessary support to improve the capacity to prevent, detect and respond to infectious disease outbreaks at the sub-national level in Nigeria. This could not be done effectively without first assessing their capacity, therefore the JEE tool was adapted to measure capacity at the sub-national level, narrowing down the technical areas to 15 of 19. The tool was tested in Enugu and Kano State.
“We are ready to learn”
Although Imo State has not yet conducted a state level EEJ, the State Commissioner for Health, Dr Prosper Ohayagha agreed that it was best to be prepared for threats for public health before they occur, and as such the state is open and ready to learn from these assessments. because the JEE “is not about today but about tomorrow”.
This is an important assertion because only when states assess their preparedness will they be able to identify gaps that will leave them vulnerable to future outbreaks. Any weak link in the process invalidates efforts to strengthen other areas. State Epidemiologist, Hyacinth Egbuna said they are already learning useful information from peers like Enugu State who have conducted their JEE.
The JEE recommends a unique and multi-disciplinary approach and one of the steps taken before Enugu State conducted its JEE was to obtain multi-sector buy-in from all ministries involved in the One Health response strategy. The technical area team leaders conducted a self-assessment test using the same guidelines used by the external evaluators. Their self-assessment scores were then compared to the findings of the external evaluators. This was followed by meetings to validate the findings and recommend actions to address identified gaps.
This is the same route the Imo State assessment will take, said Dr Oyeladun Okunromade, deputy director of surveillance at the Nigeria Center for Disease Control (NCDC). While Imo State is expected to be one of the seven states where the JEE will next be conducted, she stressed that the first step is a voluntary expression of interest. Among other things, states must also be willing to act on the results after the evaluation, commit sufficient human resources for the evaluation and work with other health actors. After the assessment, States must develop an action plan to address the identified gaps.
As efforts are put in place to conduct JEE in Imo State, it is important to remember that citizens are important stakeholders to engage with proactively, at every stage of the process. . This should not be an afterthought as building trust and partnership with the public is important for public health initiatives like JEE to be successful.