In its determination to boost access to health services across the country, especially at the primary health care level, the Nigeria government recently launched Community Health Influencers, Promoters and Services (CHIPS) in Lafia, Nasawara State. In this exclusive interview with our Bureau Chief, ‘Tayo Albert, Executive Director, National Primary Health Care Development Agency, Dr Faisal Shuaib, said the programme aims to engage about 200,000 people in the country, and harmonize similar programmes of government in the nation. Excerpts:
The CHIPS has just been launched in Nasarawa state by President Muhammadu Buhari, can you tell us what this programme is all about?
CHIPS is an acronym for Community Health Influencers, Promoters and Services as you said that was launched by Mr President to action his desire to have quality health care taken to Nigerians where they live. The CHIPS programme is really a consolidation of all the community health interventions that currently exist in a fragmented manner. What we are doing now is approaching it differently.
We are standardizing the protocols in terms of the basic criteria, the basic educational qualification that is required for you to be qualified, the kind of trainings that you get. These trainings were given to the CHIPS agents. The trainings would be for between three to six months. What is different with the CHIPS programme is that we are now saying that the traditional leaders, political leaders, religious leaders will be involved in their selection processes.
You may be aware that there are traditional birth attendants in communities who may be completely illiterate. There have been instances where women have lost their lives during births because traditional birth attendants do not have the kind of training or skills required to perform a safe delivery. What we are saying is we must standardize in terms of what basic qualification is neeeded. For the CHIPS programme, it has to be basic elementary qualification. Then, they are trained between three to six months. Then, they are taken through a practical process to really manage situations.
Even when they start working, they have supervisors, supervising the work that they do practically every week. So, we are now saying the volunteer community mobilizers that are sponsored by UNICEF, the CORPS, the Village Health Workers by the Gates Foundation, the TBAs, all of those fragmented interventions by development partners will now be harmonized and scaled up. Government is now taking leadership.
But, apart from harmonizing them, because overall, we are looking at about 25,000 of these community health workers, with the launching of CHIPS by Mr. President, the scale up will require that you have between 10 to 20 CHIPS agents per ward all over Nigeria. So, a total number of wards in Nigeria put at nearly 10,000, we are looking at nearly 200,000 CHIPS agents, who will be selected, trained all across Nigeria. This will essentially make the programme the largest collection of community health workers anywhere in Africa.
What is the relationship between the CHIPS agents and similar frontline health workers at the local government level?
They are completely distinct. The CHIPS agents have a different qualification, they have different training; they have a different kind of expectation. Their work is below the level of community health extension workers, even the community health officers. These individuals will be based in communities; they are not in the health facilities. These other individuals like you all know really focus on working in the health facilities. The original plan was for community health extension workers to still do some community works, but because there is a shortage of these cadres of workers, and because they are mostly based in the health facilities or the urban areas.
So, in the rural areas, we are left with the situation where women can get pregnant, they go into labour, they deliver all by themselves at home or they are supported by relatives or traditional birth attendants who are not well-trained. But, with the CHIP agent, we have at least in each ward between 10 to 20 women who have skills to ensure that they are able to identify dangers in their ward, such as when they see a woman in labour and tell her you cannot have this baby at home, you have to go to a health facility so that you can get proper care from a skilled birth attendant.
So, they are really different. one thing that we very conscious about is that we don’t want to roll out people who will be going to the communities and start pretending that they are doctors or nurses or they are midwives. Theirs is to provide basic interventions. Theirs is to encourage women and children to go to the health facilities for treatment. They influence health behaviour of people that live in our communities. They promote immunization by encouraging women to go for antenatal care.
That is just where we are focusing on. And, then, in the communities, one of the reasons we have high morbidity and mortality among women is because they delay in seeking care. So, people in the communities, whether because they don’t have the money or because they are not well informed, they stay in their homes until it gets late and they reach the health facilities at a point when it’s too late. But, if you have these CHIPS agents knocking and asking “is there anybody sick in this house?”, if for instance a child has fever, and the mother say “hey, my child is not well,” the CHIPS agents have rapid diagnostic kits that they can use to access fever, and also do simple blood test like malaria blood test and find out if the child has malaria.
If the child has malaria, they have free medicines that they can give to the kid so that the child will feel better. If it is condition that requires immediate referral, they will link up the family with the next level of care. It is something that is really thought out and very distinct from current cadre of health workers that we have in our communities.
How would the communities easily identify these agents so that they are infiltrated by other persons?
First and foremost, even with their designation as CHIPS agents, they have to work in close collaboration with the communities. So, community members will have an input in selecting somebody who is of good standing. That is why traditional leaders, community leaders even the youths will say “these women are women of good reputation, we can trust them with our lives, we can trust them with our families. So, in selecting them, they are not going to be strangers. You cannot crisscross from one ward to another ward and say you want to go and be a CHIPS agent, or you leave one local government area and say you want to be a CHIPS agent in another local government area.
Apart from that, they are going to carry means of identification, they are going to be wearing aprons that are orange in colour, they have bags that have particular logos that cannot be falsified. And, clearly, these people live in communities and are involved in socio-economic enterprise of the community, people know them. Nobody is taking them for community health extension workers or nurses. It is very clear what their roles are and we will ensure that there is a clear line that is drawn between what they can do and between what they cannot do.
What modalities have you put in place to have the buy-ins of stakeholders, especially the state governments?
One of the challenges that we faced with the midwives service scheme is around ownership. A lot of states were not able to pay the salaries of some of the midwives. And, the midwives were taken from some of their states and recruited in another states. Midwife for instance from Enugu living in Zamfara without their relatives or family members. After sometime, they became homesick and went back, and some remained. That is why with the CHIPS programme, we are conceptualizing it. The Federal Government is not saying states should pay a specific amount of money, while the guideline around how they should operate, we also provide the guideline around the kind of stipend that will be required.
In the end, it depends on how the states are able to determine based on socio-economic realities of the states. So, the stipend you pay for instance in Lagos will be completely different from a stipend you pay in a place like Yobe. We are asking the governors to take a decision around the number of CHIPS agents they can comfortably pay for, where they are needed, and where they need to be, especially in rural areas.
It is because it is context specific. We have contextualized it and allowed the states to take some of those decisions in a way that they can ensure that it becomes sustainable. The Federal Government cannot be responsible for everything, but there is strict demarcation on the roles and responsibilities of the different tiers of governments. From our conversations with many of the states, they understand clearly what their roles are, and the local government areas know what their roles are. It is also very clear what the Federal Government is doing around making sure there is a standard protocol across the nation, there is a standardization in terms of how we select people, using the criteria that we set for selection and also providing trainings for these individuals.
We are working together with our partners, especially UNICEF, the Gates Foundation, Plan International to ensure that all of these are harmonized. Sustainability is very good. There is no point launching a programme that will not be sustained. So, we have actually included sustainability factors in our roll out plans.
How will NPHCDA fund this project given the huge fund required to implement it?
In the first place, that is why we’ve decentralized and said the states have to own this. At the Federal level, we are very clear about what we can provide. We can provide the standard, we can provide the training for the CHIPS agents. We also realize that the National Assembly members are also very keen about the roll out of the CHIPS. In 2018 budget, we’ve made some provisions for the CHIPS programme around trainings and all of those responsibilities that the Federal Government is expected to manage. We have development partners and private sector that are very interested in contributing to the CHIPS programme because they see it as a veritable way of changing some of the poor health indices that we have. So, it is not going to be government alone, it is going to be a public-private partnership…As it stands now, a lot of the costs will be borne by the states. And, the states will have to, on their own, look at this programme and say “how can this programme better health coverage for the citizenry as we gear towards universal health coverage?”
You have been on the saddle of the agency for one year, what would you say have been your achievements?
One year went by so fast, but I think there are a few things that we can look back and say we’ve done a great job… This is really a collaborative effort from NPHCDA staff, our development partners and the private sector. All we’ve been able to do is to bring people together, drive it towards one goal: moving away from fragmented approach to now people working together around what we need to do for all Nigerians. So, we talked about the need for us to eradicate polio. Since I have been the ED of the agency, we’ve not recorded any case of polio; that is good. So, that means we are keeping on track our record to ensure we keep polio at bay. One of the things that we also talked about was to strengthen routine immunization. We’ve rolled out a National Emergency Immunization Coordinating Centre to bring greater urgency and intensity in the work around routine immunization so that our kids are protected from vaccine-preventable diseases.
We said we would change the image of National Primary Health Care Development Agency, do assessment of where we are as an agency, we’ve done all of that. We’ve seen that a lot of people who were redundant, we’ve done a lot on task-shifting them. A lot of people coming to work and having nothing to do, they are now being task-shifted and they are getting into more programmatic work, making them more available for programmes such as the CHIPS, strengthening of routine immunization. I think from what I’m hearing, people are happy that because they have so much more to do. We’ve just wrapped up a financial process management review. KPMG has just finished that and they’ve made recommendation around how we can tighten some of our controls and implement those processes. We feel that we have an agency that will be better at ensuring that finances are better managed and there are fewer leakages. This aligns totally with President Buhari’s anti-corruption agenda.