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Assess. Learn. Improve: Enugu State’s Journey to Closing Health Security Gaps

The sub national joint external evaluation is a voluntary, multistakeholder assessment that helps states determine their readiness to prevent, detect and respond to public health threats. Photo credit: Nigeria Health Watch

By Chibuike Alagboso and Kenneth Ibe (Lead Writers)

The re-emergence of infectious diseases is inevitable, as humans continue to interact with the environment in different ways and live in closer proximity to animals. Given that infectious diseases can often start in communities, the value of building stronger and more resilient health systems capable of quickly detecting, preventing and responding to public health threats cannot be overemphasised.

However, every strong and resilient health system is only as strong as its weakest link. Therefore, Nigeria as a signatory to the International Health Regulations (2005) conducted a Joint External Evaluation (JEE) in 2017 to appraise the nation’s health security strengths, identify weaknesses and assess the resources required to strengthen the country’s ability to prevent, detect and respond to infectious disease outbreaks.

The findings from the 2017 JEE and mid-term JEE in 2019 enabled the assessment of gaps in Nigeria’s preparedness and response to infectious disease outbreaks. The JEE was developed to assess the capacities of countries at the national level, with limited focus at the sub-national. An assessment was also carried out to establish the legal frameworks and IHR technical areas that were the responsibility of state governments.

The modification of the JEE tool to administer it at subnational level highlights the need to strengthen the public health capacity at the sub-national level and to plug health security gaps, as the focus has been at the national level.

Leadership, evidence of work done: Recipes for successful assessment
State level JEEs have been conducted in two of Nigeria’s 36 states — Kano and Enugu, with Enugu being the first state to pilot the sub-national exercise. Enugu State is a major economic hub in southeastern Nigeria, however, like other states in the country, it has its fair share of gaps responding to infectious disease outbreaks. Therefore, when the Nigeria Centre for Disease Control approached the state Commissioner for Health, Dr Emmanuel Ikechukwu Obi with the idea of conducting a state JEE, he welcomed it wholeheartedly. “I knew that it was going to be useful for us to carry out an evaluation of the state’s level of preparednessSo, the political buy-in to carry out the JEE in the state was there.” Dr Obi hoped that the evaluation would provide insights into Enugu State’s health security strengths and existing gaps.

Only when states evaluate their state of preparedness will they be able to identify gaps that will leave them vulnerable to future disease outbreaks. Photo credit: Nigeria Health Watch

Having the Commissioner for Health firmly on board was critical for getting the necessary buy-in of relevant officials from all the ministries in the state, in order to work with a multisectoral team. This was a critical next step in the process as the evaluation adopts a one-health approach. The state then received the necessary ethical approval documentations in readiness for the evaluation which took place in April 2021.

Using the modified JEE tool, fourteen technical areas — legislation, food safety, laboratory system and others, were assessed. The results were verified by external multidisciplinary evaluators coordinated by the NCDC in 2021. At the end of the exercise, Enugu State received a ‘ReadyScore’ of ‘34’ which according to, means that the state was not ready to prevent, detect and respond to public health threats at the time of the assessment. According to the Prevent Epidemics measurement metrics, for a state to be considered better prepared, it must achieve a ‘ReadyScore’ of between 80 and 100.

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Taking lessons forward
Speaking on the state’s ranking, state Epidemiologist, Dr Chinyere Ezeudu said, “We accepted our score and are ready to improve on it”. She added that in the past, response to public health events had been the sole responsibility of the Ministry of Health. The assessment helped them understand the need to work in collaboration with the ministries of Agriculture and Environment as well as with the private sector in line with the one-health approach to responding to public health emergencies.

The Joint External Evaluation helped us understand the need to work in collaboration with the ministries of Agriculture and Environment as well as with the private sector. Photo credit: Nigeria Health Watch

Ezeudu said the state was intentional about addressing the weaknesses highlighted by the JEE. For instance, there was no legal backing for most of the response activities in the state as they had an obsolete public health law. “But with support from the NCDC and other partners, we updated these laws to an acceptable standard”.

Another weakness the assessment identified was ‘low laboratory capacity’ and the NCDC again supported the establishment of a public health laboratory at the University of Nigeria Teaching Hospital (UNTH). While it is capital intensive to set up an optimum reference laboratory, they worked with the recommendations of the evaluators to leverage existing structures like the UNTH, said Roseline Okolo, laboratory pillar lead and focal person at the public health department of the state’s Ministry of Health.

To improve their low rating in the food safety technical area, the state now closely checks food handlers in the state to prevent outbreaks of food borne diseases.

Effective documentation — a critical lesson learned
We did fairly well on surveillance and are building on that by continuously organising trainings to build the capacity of our Disease Surveillance and Notification Officers,” Ezeudu said, adding that there have been improvements in the state’s health security, because they have focused on closing the gaps identified during the assessment.

Subnational levels are the first line of defense during public health emergencies. They need to be well equipped with the tools necessary for detecting, preventing, and responding to infectious disease outbreaks. Photo credit: Nigeria Health Watch

Being the first state to pilot the sub-national JEE in Nigeria, they were supported by the NCDC, Public Health England (now UK Health Security Agency), Resolve to Save Lives, World Health Organization (WHO), United Nations International Children’s Fund (UNICEF) and other partners, and this helped to mitigate challenges. However, documentation was one challenge they faced during the assessment. “We realised that we had done a lot, but documentation was a problem and the JEE assessment is an open assessment. If you have done something, you must show it,” Ezeudu said.

She encouraged states intending to conduct the assessment to take documentation seriously. “Document all your activities. If you have a meeting, keep minutes, attendance, reports from trainings, outbreak response activities,” and this cuts across all ministries not just health, she said, adding that the importance of effective documentation was a major learning for them for them during the assessment.

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Enugu State has shown that it is important to take proactive steps to identify core capacities and resource, as well as the policy gaps at the sub national level. It helps states understand what they must do to better prevent, detect and respond to epidemics. As Dr Obi aptly put it, “all these efforts today are investments for tomorrow because we will become clients of the health sector we create today”.
This narrative was done as part of the #COVID19NigeriaStories documentation project on state-level responses to COVID-19, implemented by the Nigeria Centre for Disease Control and Nigeria Health Watch with support from the Ford Foundation.

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