Larry Brilliant, a renowned epidemiologist, once said that “outbreaks are inevitable, but pandemics are optional.” Globally, this inevitability of outbreaks has been even more evident in the last 2 years. In 2022 alone, in addition to the ongoing COVID-19 pandemic, a case of Circulating vaccine-derived polio virus (cVDPV) was detected in the United States in July, Uganda declared an outbreak of Ebola in September and in Nigeria, there has been an ongoing cholera outbreak which was exacerbated by the current flooding situation.
Outbreaks are local
Nigeria has, in recent years, recognised the need to decentralise health security and boost capacity at the sub-national level to prevent, detect and respond to infectious disease outbreaks. Speaking at a health security policy dialogue in July 2022, Dr Ifedayo Adetifa, Director General, Nigeria Centre for Disease Control (NCDC) said decentralising health security begins with states realising that they have the power and responsibility to build the systems to respond to health emergencies, to improve outcomes and overall public health of their people.
To build these systems, states must first assess where their strengths and weaknesses lie. One way in which this assessment can be carried out, is assessing the IHR capacities at the sub-national level using an adapted Joint External Evaluation (JEE) tool. The tool was previously administered only at national level. This strategy was developed in recognition of the overarching need to provide a clear picture of core health security capacities and gaps at sub-national level.
The adapted JEE tool was previously administered in two states — Kano and Enugu. However, Dr Oyeladun Okunromade, Head, IHR Unit, NCDC revealed that it has now been administered in an additional 5 states — Borno, Jigawa, Yobe, Kaduna and Kebbi and they are currently supporting other states to conduct their own state-based evaluations. This assessment is a must for any state committed to effectively strengthening its health security because, how can a state strengthen its ability to prevent outbreaks without first identifying the existing gaps?
Oyo State’s health security
Oyo State takes pride in its health security efforts as, according to the state epidemiologist, Dr. Akinfemi Akinyode, before the COVID-19 pandemic they had a robust surveillance system. This included community informants in each of the 351 wards supporting the disease surveillance and notification officers (DSNOs) in the 33 Local Government Areas (LGA) of the state, for quick disease detection and reporting “because we know that diseases are local”. The pandemic however necessitated the state to further strengthen the system by improving laboratory networks, establishing an infection prevention and control system, and activating a rapid response team across all LGAs.
Dr Georgina Odaibo, Head of the Department of Virology, College of Medicine, University of Ibadan, is particularly proud of the state’s laboratory network which has contributed to the surveillance, investigation, and control of outbreaks in the state. However, there are challenges, and she believes that a JEE will help identify “what we have been doing well, what has not been done well and then provide an opportunity for us to look at how to cover those identified gaps or challenges”
For Dr. Akinyode, a state-based assessment is important as “an assessment will assist us to measure our status and to monitor our performance. It is something that I will highly recommend.” According to the NCDC the sub national evaluation was designed to allow for the development of an evidence-based objective review of health security capacity for advocacy and the identification of gaps to develop a workplan that will guide health systems strengthening and resource prioritisation.
The way forward
After the first national JEE conducted in 2017 and a midterm JEE in 2019, Nigeria developed a National Action Plan for Health Security (NAPHS), as a clear roadmap to address the major gaps identified by the evaluation. Although the COVID-19 pandemic was unprecedented, having this national plan helped direct the pandemic response as authorities knew what the weaknesses were. A state action plan for health security (SAPHS) will be an invaluable reference point during an outbreak. Kano and Jigawa State are a step ahead as each have developed state health security action plans.
In an article titled ‘3 things we can do right now’, Bill Gates believes that one of the three things we can do to prevent the next pandemic is to strengthen health systems. The others are, to make and deliver better tools and improve disease monitoring. Although some progress has been made nationally, it is now the responsibility of states and local governments to replicate the results at the sub-national level. It is important that governments at all level work together to strengthen Nigeria’s capacity to prevent and detect health threats posed by infectious diseases and to respond quickly to minimise harm when they do occur.
A country is only as strong as its weakest link and until every state can quickly and effectively prevent, detect and respond to public health threats, Nigeria will continue to remain vulnerable to all public health threats.
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.
This work in Nigeria of decentralizing health security is impressive and must be shared widely. Very commendable!
As a former member of the Private Sector Roundtable of the GHSA, I am pleased to see the JEE being adapted for state/province-level work. It is a great tool for promoting transparency and accountability.
One question: is the private sector engaged in the Nigerian states who have conducted a JEE? Thank you.
Great piece. No doubt strengthening health security of Nigeria both at the national and sub-national level is critical given the global outbreak of infectious diseases. States need to strengthen their health security architecture because disease outbreaks begins and ends in communities.
Health security at the subnational level can not be overemphasized. It is the framework on which the national health security rests on. So it must become centre stage. Nigeria has been doing a lot in this regard through the Nigeria Centre for Disease Control and it’s partners, but I hope to see stronger ownership at the state level.