FROM DONOR-DEPENDENDENCE TO GOVERNMENT-GUIDANCE: A PREREQUISITE TO "LET COMMUNITIES LEAD" THE HIV RESPONSE

 

Figure 1 – NSHIP seven strategies. Source: Powerpoint presentation titled “NASCP Government-to-Government funding opportunity: 5-year overview of NSHIP”, 2023

Today is World AIDS day and as one of those persons living ‘off’ HIV (I currently work and get paid within the HIV programme space), it isn’t out of place to join Persons Living ‘with’ HIV (PLHIV) within Africa’s largest economy in being mindful of today and the near future by resonating with this year’s theme – “Let communities lead”. Thankfully, we are no longer in the epidemic mode of HIV. But, like their heroic counterparts conquering the virus across the rest of the world, a PLHIV in Nigeria is likely to be more interested in tangible and sustainable social protection steps in which he/she is involved in its conceptualization, implementation, regulation, and monitoring, than the fanfare and formal commemorative events that greet the day. This is not to discountenance the important public awareness on evergreen preventive behaviours that sound like “don’t share sharp objects; abstain from casual sex or use condoms; screen all blood specimens before transfusion; know your HIV status every 6 months”. These non-discriminatory enlightenment pieces are elicited among the populace every 1^st day of December, year in, year out. Yet, can communities living with, at risk of, or affected by HIV take the lead when government, which ought to protect and guide them, appears to have devolved a greater part of that social contract to external helpers? Let’s start to internalize and regurgitate like a rhythm, that while the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned?

However, the fate of over 1.63 million PLHIV in Nigeria who are on daily treatment for this virus should now rest more on what government at all levels do than what development partners such as the U.S President’s Emergency Plan For AIDS Relief (PEPFAR) and Global Fund have continued to do for 20 years. As we celebrate the scientific breakthroughs in the efficacy of Anti-Retroviral Therapy (ARV) that now cause majority of PLHIV to live long, the concern, nonetheless, is that donors’ contribution to HIV epidemic response in Nigeria is about 81% of the total funding basket. This revelation was brought to fore via a presentation made by the National Coordinator of the National AIDS, Viral Hepatitis & STIs Control Programme, Dr. Adebobola Bashorun, at a Ministerial press briefing held yesterday (30th November, 2023) by the Minister of State for Health, Dr. Tunji Alausa, at Barcelona Hotel, Abuja, to commemorate this year’s World AIDS day.  While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned?

Be it the health sector HIV/AIDS response that is led by the National AIDS, Viral Hepatitis & STI Control Programme (NASCP) of the Federal Ministry of Health (and its equivalent State AIDS, Viral Hepatitis & STI Control Programme – SASCP across the 36 States & FCT) or the non-health sector response that is coordinated by the National Agency for the Control of AIDS – NACA (and its equivalent State Agency for the Control AIDS – SACA across the 36 States & FCT), it is discomforting that the foreign benefactors of an oil-rich Nigeria have had to bear the larger chunk of the funding commitment for two decades. Whereas the estimated 1.9 million PLHIV in Nigeria are not foreigners and taking the wise counsel of the holy books, shall we continue in this anomaly of letting foreign governments & organizations shoulder government’s duty that grace may abound? While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned?

With less than 15% of annual national budget consistently allocated to healthcare over the past 20 years (in defiance of the famous 2001 Abuja declaration) by each of the Federal and State governments; less than 10% health insurance coverage across the country; and 75-80% of Total Health Expenditure (THE) being from Out-Of-Pocket Expenditure (OOPE), our collective hope of having communities lead the HIV/AIDS response through their prominent participation in HIV/AIDS policy-formulation, operationalization and providers’ oversight remains a wild imagination. The danger of low political will to appropriately cost, make budgetary provisions for, and ensure timely releases to aptly support the entire HIV response including community-led effort is that over 200 million Nigerians stand the risk of being infected by 1.63 million PLHIV whose treatment may be compromised should the donors backtrack. While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned?

Assuming without conceding that Nigeria’s HIV/AIDS response had a matching order to transition from a donor-dependent state to a government-guided status on or before 1^st December, 2027, are the seven critical areas of the response requiring the political will and corresponding actions of the Government of Nigeria (GoN) and 36 State governments (plus Fdederal Capital Territory – FCT) being consciously fortified? The seven strategies enunciated in the mandate of the Nigeria Sustainability & HIV Impact Project (NSHIP), which is a Government-to-Government (G2G) grant/award by the United States, through the United States Centre for Disease Control (US-CDC), to the Nigerian government, via NASCP of the Federal Ministry of Health, is an apt reminder of the obvious gaps that need to be urgently filled as prerequisites for communities to be in the forefront of the response. While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned? 

At both the national & subnational levels, the first strategy in this illustration - leadership & governance for HIV/AIDS response - entails among other things, not having to wait for the donors & their Implementing Partners IPs) to initiate routine HIV/AIDS programme coordination activities. The second, Integrated service delivery, is about collapsing the near-parallel HIV/AIDS structure into the central hospital system in Nigeria, so that a PLHIV as a recipient of care within the hospital (primary, secondary & tertiary) will no longer be isolated but have his/her healthcare needs attended to by all other health workers who manage all other acute and chronic ailments in the general in-care settings of our hospitals. A robust business system for resource allocation involves having a grant & financial management system to receive possible future funding support from willing donors, as a third strategy. The inclusion of comprehensive HIV services in the various health plans (formal, informal & vulnerable) of the National Health Insurance Authority (NHIA), State Health Insurance Agencies – SHIAs(of 36 States & FCT) and Private Health Insurance (called Health Maintenance Organization – HMOs) as well as ensuring that all PLHIV in Nigeria have health insurance cover for both HIV/AIDS-related and all other non-HIV/AIDS-related (or general) healthcare services are the high points of the fourth strategy. Furthermore, the fifth NSHIP strategy places premium on having a strong & reliable data system thar harmonizes the existing (though segregated) electronic record system for HIV/AIDS programme with a hope-to-be universally available Electronic Medical Record (EMR) system in Nigeria to inform prompt & requisite actions. An effective government-led supply chain system for HIV pharmaceuticals and laboratory commodities (and a ‘possible’ consideration of the dynamics of making these supplies available in Nigeria’s local & open market or even local production of same, for future cost efficiency & affordability) constitute the sixth strategy. Lastly, the availability (quantity) and capacity quality) of Human Resource for Health for effective service delivery of HIV care particularly among frontline health workers is key to ownership & sustainability. While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned?

With health being among the residual powers in the 1999 constitution of the Federal Republic of Nigeria (as amended), these seven strategic areas that define government ownership & sustainability of the HIV/AIDS response cannot be strengthened at the Federal level alone with the sub-national units left as weak platforms, especially knowing that majority of PLHIV live within the 36 States and 774 Local Government Areas (LGAs). Consequently, the individual roles of the various State actors - Department of Public Health (DPH) within each State’s Ministry of Health, State AIDS Programme Coordinator (SAPC), State Agency for the Control of AIDS (SACA), State Hospitals’ Management Boards (HMB), State Primary Health Care Development Boards (SPHCDB), State Health Insurance Agency (SHIA) and Drug Management Agencies (DMA)/Logistic Management Units (LMU) have to be clearly defined under the headship of the Honourable Commissioners for Health, supported by the Permanent Secretaries. While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned?

The body of Civil Society Organizations (CSOs) such as Network of Persons With HIV/AIDS in Nigeria (NEPWHAN) and its sundry affiliate groups supporting PLHIV must also re-define their roles within the emerging reality of community-led sustainability effort, especially to focus on cogent issues such as demand-creation for health insurance among its members and the sustenance of the expansive community interventions within the HIV/AIDs programme. Laudably, the National Clinical Mentorship Programme (NCMP), put in place to create a critical mass of over 300 Nigerian Medical doctors who are specially trained and employed by the US-CDC as National & State Clinical Mentors, are now domiciled under NASCP. However, will they be absolved by the Federal & State governments to retain their expertise? While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned?

Assuredly, stakeholders have the Renewed Hope mantra of the current administration of President Bola Ahmed Tinubu, GCFR, which was recently publicly echoed, as a comforting pledge to change the narrative.  At the 3^rd Biannual (HIV/AIDS) Program Performance Review & Stakeholder Engagement Meeting held in Abuja on the 19^th & 20^th October, 2023 and organized by the US-CDC, the Federal government’s political commitment to lead from the front in achieving the United Nations 95:95:95 goal was put forward by the Special Adviser to the President on Health, Dr Salma Anas Kolo. At the event which had 19 State Commissioners for Health and several local & foreign HIV/AIDS stakeholders in attendance, Dr. Adebobola Bashorun, National Coordinator of NASCP and Prof. Aliyu Gambo, Director-General of NACA also made individual but similar pledges of stronger Federal government (executive arm) commitment to the country’s HIV/AIDS programme, while admonishing the States to follow suit in the spirit of ownership & sustainability. In addition, the current (10^th session) House of Representatives also has a standing committee called the House Committee on AIDS, Tuberculosis & Malaria (ATM), in an apparent demonstration of uncommon legislative commitment and political will towards HIV/AIDS response. While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned?

Finally, the ‘technical’ functions of the donor agencies (PEPFAR, made up of US-CDC and United States Agency for International Development – USAID) and their IPs (APIN, ECEWES, CCRN, IHVN, CIHP etc.) will still be very useful in supporting the government-guided structures and community-led interventions in the event of donors’ drawback. The IPs will therefore not be redundant in the envisaged new order. Looking critically ahead, overall measures aimed at Health System Strengthening (HSS) are required to safely warehouse and improve on the gains of the past twenty years of HIV/AIDS response in-country for the communities to even stay alive, let alone have the capacity to lead. This significance explains the modelling of the seven NSHIP strategies of HIV/AIDS programme ownership & sustainability after the World Health Organization (WHO)’s six building blocks of a health system. Lest I forget, the tenets of fiscal transparency and accountability, which the donors have practised for twenty years, must be an integral part of the transition process from donor-dependency to government-guidance that will in turn permit a community-led HIV response. While the extinction of donors’ support may be much later than envisaged, can the escalation of governments’ effort be miles earlier than envisioned? In other words, donors’ withdrawal may be far but government’s wherewithal should be near.

 

Dr. Adetolu Ademujimi, a Medical Doctor, Author, Reformer, Coach, Public Policy expert and Social entrepreneur, is the Health Finance Specialist, NSHIP, NASCP who can be reached in Abuja via ademujimi@yahoo.co.uk or aademujimi@nascp.gov.ng