Pol­i­tics is mak­ing Zam­fara’s health sec­tor sick

Weekly Trust - - Front Page - Judd-Leonard Okafor

For 10 years, the pri­mary health cen­tre in Gi­dan Goga, an out­back of Maradun coun­cil area of Zam­fara, didn’t hos­pi­talise any pa­tient: it had no beds for ad­mis­sion; all it had were bro­ken. A health com­mit­tee struck up in the com­mu­nity by a non­govern­ment or­gan­i­sa­tion work­ing to im­prove ma­ter­nal, new­born and child health swung into ac­tion.

It mo­bilised a to­tal N30,000 in do­na­tions from res­i­dents. In­stead of buy­ing new beds, it got a res­i­dent ar­ti­san to re­pair the bro­ken beds in two ex­changes. The first ex­change was cash pay­ment for half the beds; the sec­ond was the scrap beds.

Binta Dahiru was the first pa­tient to be hos­pi­talised af­ter the re­pair.

Be­fore, I would not have al­lowed my­self to be ad­mit­ted here. I would have rather stayed at home to get the treat­ment there, she says.

Al­most ev­ery­body would have pre­ferred to stay at home.”

The change in Gi­dan Goga is in­dica­tive of the work that non­govern­ment or­gan­i­sa­tions have been do­ing in Zam­fara, fill­ing gaps where gov­ern­ment spend­ing is un­able to meet health needs.

The World Bank bankrolled a pro­ject to help Zam­fara meet its health needs, spark­ing a trans­for­ma­tion that’s swept through Zam­fara in the first half of 2018.

The pro­ject was tagged Sav­ing One Mil­lion Lives Ini­tia­tive Pro­gramme-forRe­sults (SOML).

SOML aims to in­crease the use and qual­ity of high im­pact re­pro­duc­tive, child health and nu­tri­tion in­ter­ven­tions. It awards bonuses in mil­lions of dol­lars to states that show re­sults for money spent on health.

Zam­fara joined in, net­ting more than N9 bil­lion for im­prov­ing its health in­dices in less than a year. But the bonus has be­come the source of se­ri­ous con­tention that threat­ens the sur­vival of SOML in the state.

Sources in­side the pro­gramme and de­vel­op­ment partners in Zam­fara have

ex­pressed dis­plea­sure and an­noy­ance at the changes to SOML in the state. In­sid­ers in­volved with the pro­gramme spoke with Daily Trust Satur­day, and re­quested their iden­ti­ties not be re­vealed. How many lives saved?

Along­side states im­ple­ment­ing SOML, Zam­fara got $1.5 mil­lion last year to start the pro­gramme. The money is domi­ciled with the Cen­tral Bank of Nige­ria, in a sep­a­rate ac­count not linked to the state’s fi­nances.

By na­ture, SOML is domi­ciled in the state health min­istry; a pro­gramme man­ager draws up pro­cure­ment re­quests sub­ject to ap­proval of the health com­mis­sioner or per­ma­nent sec­re­tary.

But work­plans are ap­proved by the fed­eral health min­istry.

One in­ter­est­ing thing about the SOML is that you are given six pil­lars and asked to de­vel­op­ment a work­plan suit­able for your own state, suit­able for your own level in terms of health in­dices, says Katsina State health com­mis­sioner Mary­atu Us­man.

When your per­for­mance is mea­sured, it is based on your own base­line.

Zam­fara’s health in­dices, and base­line, were some of the low­est na­tion­wide. Its ma­ter­nal mor­tal­ity ra­tio was 1,049 per 100,000 live births; 60 out of ev­ery 1,000 born died in in­fancy, and by the age of 5 years, a to­tal of 176 of ev­ery 1,000 chil­dren will have died. A third of all ma­ter­nal and child deaths was linked to malaria.

Among chil­dren aged un­der five, 19 in 100 were too short for their age, a con­di­tion called stunt­ing. Only 21 in 100 chil­dren were fully im­mu­nised. Just two in 100 women of re­pro­duc­tive age used a con­tra­cep­tion to space births or pre­vent un­wanted preg­nan­cies. Among women who got preg­nant, only 11 in 100 gave birth in health fa­cil­i­ties.

For chil­dren, only around seven in 100 were ex­clu­sively breast­fed. Less than two in 100 chil­dren slept un­der in­sec­ti­cide-treated nets. Only 18% of chil­dren aged un­der five di­ag­nosed with malaria were treated us­ing rec­om­mended artemisinin-com­bi­na­tion ther­apy.

With $1.5 mil­lion, es­ti­mated at N540 mil­lion, Zam­fara looked to low-hang­ing fruits to change its for­tunes.

NGO partners al­ready worked in the ar­eas where Zam­fara had chal­lenges. In­sid­ers say nearly ev­ery health in­ter­ven­tion in Zam­fara is sup­ported by partners.

They helped flesh out a work plan, paid con­sul­tants hired by the gov­ern­ment and pro­vided lo­gis­tics for re­view meet­ings.

In one re­view meet­ing, other states were scor­ing 75-80% and Zam­fara scored only 2%, a source said.

A fo­rum of health partners met with Zam­fara State Gover­nor Ab­du­lazeez Yari, and pre­sented the in­dices, and the story changed com­pletely, the source said.

Zam­fara’s partners con­tin­ued their work; the $1.5 mil­lion filled in the gaps.

Dis­tri­bu­tion of in­sec­ti­cide-treated nets con­tin­ued, mo­bil­i­sa­tion of women for an­te­na­tal care in health fa­cil­i­ties, where they could un­dergo HIV test­ing be­fore re­fer­ral if pos­i­tive, went on; work con­tin­ued to im­prove im­mu­ni­sa­tion cov­er­age. The work­plan cov­ered all six ar­eas the SOML is con­cerned with.

Com­pared with where it was com­ing from, Zam­fara moved light years. Its base­line was sub­tracted from its per­for­mance, and the dif­fer­ence mul­ti­plied by $205,000. It hit gold

Along with Katsina and 10 other states, Zam­fara qual­i­fied for any dis­burse­ment from the SOML.

The rest did not qual­ify and were given $1m as loans, one source close to the pro­gramme re­vealed.

When­ever they make any im­prove­ment, that money will be de­ducted.

Zam­fara also emerged na­tional cham­pion, net­ting an ad­di­tional $1m in bonus. Of­fi­cials put its to­tal prize at $10.6 mil­lion, val­ued at more than N3.8 bil­lion to­day.

The money was meant to fur­ther Zam­fara’s progress, but spend­ing it has be­come the hot potato that’s di­vided state of­fi­cials and partners in Zam­fara. Right in the mid­dle is the state gov­ern­ment it­self and the women and chil­dren who com­prise the mil­lion lives to be saved. Sour taste and strange bed­fel­lows

Zam­fara’s emer­gence as a na­tional cham­pion hasn’t gone down well with states in the north­west.

We un­der­stood the tech­ni­cal­ity of how that re­sult was ar­rived at, said Musa Dutse, state pro­gramme man­ager for SOML in Kaduna State.

Sav­ing One Mil­lion Lives re­wards you for im­prove­ment, not ab­so­lute re­sult. It re­wards you for mov­ing from point A to point B.

Kaduna still works with de­vel­op­ment partners on SOML. Katsina has taken a dif­fer­ent path: pre­vi­ously NGOs, with fund­ing from in­ter­na­tional donors, de­signed and ex­e­cuted pro­grammes from start to fin­ish. Katsina has taken on that role us­ing SOML fund­ing.

Lo­cal partners feel en­tirely cut out of SOML work­plans and pro­grammes in Katsina, but the state isn’t budg­ing.

Us­man, Katsina’s health com­mis­sioner, says SOML has helped the state build the ca­pac­ity of its of­fi­cials to de­sign, im­ple­ment

and mon­i­tor pro­grammes, tak­ing on roles in health where other state gov­ern­ments would sit with folded arms. Money problems

States im­ple­ment­ing SOML have moved on since the con­tro­ver­sial re­view that ranked Zam­fara cham­pion.

Zam­fara it­self has stalled and shifted gears from health to pol­i­tics.

Stake­hold­ers watch­ing SOML have raised con­cern about its in­de­pen­dence. And de­vel­op­ment partners, like in Katsina, have been cut off SOML im­ple­men­ta­tion.

By De­cem­ber 2017, Zam­fara had N124m in bal­ance from the orig­i­nal $1.5m. The first tranche from the bonus $10.6m it re­ceived marked the start of SOML problems in Zam­fara.

Some state of­fi­cials, in­clud­ing the gover­nor, Daily Trust Sau­r­day was told, un­der­stood the bonus to be a free­bie for the state gov­ern­ment to spend at will.

With that un­der­stand­ing came a clam­p­down on im­ple­men­ta­tion.

There are con­cerns in the state that the money is be­ing held back to fund elec­tion cam­paigns or grat­ify cronies.

The sus­pi­cions arose when Zam­fara’s work­plan af­ter the re­view shifted fo­cus from its low-hang­ing fruits to mas­sive con­struc­tion projects said to have noth­ing to do with pri­mary health care.

One of Zam­fara’s SOML plans was to ren­o­vate ma­ter­nity units of pri­mary health cen­tres statewide one in each of the 147 po­lit­i­cal wards. The state has 676 pri­mary health cen­tres.

In­stead, ren­o­va­tion of three gen­eral hospi­tals en­tered the work­plan. Be­fore SOML, the state gov­ern­ment had al­ready ren­o­vated gen­eral hospi­tals in seven lo­ca­tions.

Of­fi­cials, in de­fence of adding ren­o­va­tion of gen­eral hospi­tals to SOML plan, said it was to key into the fed­eral gov­ern­ment’s drive to re­vi­talise one pri­mary health care in each ward.

The ren­o­va­tion was to go on along­side ren­o­va­tion of en­tire pri­mary health cen­tres, in­stead of ma­ter­nity units as had been pre­vi­ously planned. Zam­fara al­lo­cated N5.5m per fa­cil­ity.

At that cost, it was de­cided the bud­get would only cover the com­plete ren­o­va­tion for 30, us­ing SOML fund­ing, leav­ing out 117.

The cost of ren­o­vat­ing the bal­ance 117 fa­cil­i­ties would be borne by the state gov­ern­ment.

It meant SOML fund­ing would move from pri­mary health care to ren­o­vate gen­eral hospi­tals in Kaura Namoda, Gurmi, and Tsafe, as well as up­grade an­other gen­eral hos­pi­tal at Talata Ma­fara where the state gov­ern­ment is look­ing to site a univer­sity and a teach­ing hos­pi­tal.

Partners work­ing on SOML in Zam­fara say the large-scale con­struc­tions were ar­bi­trar­ily in­serted into the work­plan against due process. There were no bids for con­tracts, in­stead bills of quan­tity were in­serted, they told Daily Trust Satur­day.

SOML was still run­ning on the bal­ance N124m from the first $1.5m be­fore its bonus came in. The first tranche of the bonus was 25% of $10.6m.

Sud­denly the com­mis­sioner said the gover­nor said we should stop spend­ing, a source closely in­volved in de­vel­op­ing the states work­plan, said.

“Why? He said we had started touch­ing that money the one that came in sec­ond tranche [the first tranche of Zam­fara’s re­ward.]”

An­a­lysts look­ing into Zam­fara’s work­plan for 2018 say up to 80% of SOML fund­ing has been bud­geted for ac­tiv­i­ties that have no im­pact on pri­mary health care and con­trib­ute noth­ing to the in­di­ca­tors on which Zam­fara will be as­sessed at the next re­view.

For in­stance, progress in malaria control is mea­sured in terms of net dis­tri­bu­tion. But you can now see them chip­ping in pro­grammes like sea­sonal malaria ther­apy, which re­quires pro­cure­ment, said a source.

The com­mis­sioner men­tioned is Lawal Li­man, who emerged chair­man of the All Pro­gres­sives Congress in Zam­fara in May. By civil ser­vice rules, he also should have quit his po­si­tion as com­mis­sioner when he went into pol­i­tics.

Ef­fec­tively, Zam­fara did not have a health com­mis­sioner, and no one else was named af­ter Li­man’s move into pol­i­tics. But sources say he kept control of the health min­istry even af­ter en­ter­ing ac­tive pol­i­tics.

With elec­tion fever brew­ing, SOML was of­fi­cially em­broiled in the pol­i­tics of Zam­fara.

One source said: “Zam­fara’s own pol­i­tics is dif­fer­ent. It is only in Zam­fara that we don’t have con­tes­tants yet, the source at the health min­istry said in Oc­to­ber.

“We couldn’t do elec­tion. In im­ple­men­ta­tion now, we haven’t done much. That’s since around Au­gust. As for ac­tiv­i­ties, we haven’t done much.

“The partners are not happy. No­body is happy. You have been do­ing some­thing yield­ing re­sult. You have no rea­son to de­vi­ate from that sys­tem and then adopt an­other one,” said the source.

The fear is some peo­ple will be ap­peased by award of con­tracts. There are lots of is­sues peo­ple are not happy with.

Ex­pla­na­tions of­fered fol­low a nar­ra­tive: with the left­over N124m still run­ning, the state gov­ern­ment ex­pected SOML would get a reg­u­lar $1.5m ev­ery year.

Any ad­di­tional fund over the $1.5m was for the state gov­ern­ment.

But when the first 25% of $10.6m bonus was not enough to pay for planned con­tracts, the or­der came to halt SOML. And the halt was never com­mu­ni­cated in writ­ing.

Zam­fara SOML pro­gramme man­ager Sabitu Tsafe would not re­spond to ques­tions about the pro­gramme.

The first money we re­ceive is about 25% of the to­tal money which is not enough for the ren­o­va­tions at hand. As a re­sult, we sus­pended all the ac­tiv­i­ties, an in­sider said.

An­other source close to Zam­fara’s work­plan said, “I be­lieve they just want to mis­man­age the money and go, but our prob­lem in Zam­fara is that no­body wants to talk.” Daily Trust Satur­day in Novem­ber reached Suleiman Gummi, the for­mer health com­mis­sioner un­der whom SOML started, to get his sense of im­ple­men­ta­tion.

Gummi had handed over to Li­man af­ter a cab­i­net shuf­fle in Jan­uary. He said since hand­ing over and leav­ing the min­istry, he couldn’t give ac­count.

I handed over the af­fairs of the min­istry for the past eight months. It is not fair for me to give ac­count of that min­istry, he said. Days later, Daily Trust Satur­day reached Li­man, who headed Zam­fara Health Min­istry when SOML was halted.

He said: “Bet­ter speak to the per­ma­nent sec­re­tary. I’m not in a po­si­tion to speak to you now on that. Let me talk to the per­ma­nent sec­re­tary to talk to you” Daily Trust Satur­day had pre­vi­ously in Oc­to­ber vis­ited Zam­fara and spo­ken with the per­ma­nent sec­re­tary, Habibu Yalwa. He said he had no per­mis­sion to com­ment on SOML, in­sist­ing the com­mis­sioner al­ready months away in pol­i­tics since win­ning APC state chair­man­ship in May was the face of the pro­gramme.

He noted that up un­til then, no re­place­ment had been named for Li­man, nor did he defini­tively re­sign his po­si­tion as com­mis­sioner.

And that stalls the pro­gramme, inas­much as it needs ad­min­is­tra­tive ap­proval.

Daily Trust Satur­day asked whether the state gov­ern­ment con­trols SOML, even though funds are sep­a­rate from Zam­fara’s cof­fers.

The in­sider at the health min­istry replied with a yes. Who ap­points the com­mis­sion­ers? “Who are the ap­prov­ing of­fi­cers for SOML? The com­mis­sion­ers and the perm secs are the ap­prov­ing of­fi­cers. If you don’t have ap­proval, what do you do?”

“In as much ev­ery­thing you have to do, you have to write and ob­tain ap­proval and that ap­proval is not forth­com­ing, what do you do?” he said.

Zam­fara’s SOML raises ques­tions: how much control the state has over SOML fund­ing and de­ci­sions and how much the na­tional of­fice of SOML in the fed­eral health min­istry have over work plans it approves for states.

Daily Trust Satur­day had been in touch with SOML na­tional co­or­di­na­tor Ibrahim Kana but reached him with fur­ther ques­tions about the pro­gramme’s in­de­pen­dence while he was away in Wash­ing­ton, DC.

He re­sponded to the first ques­tion: “We ap­prove plans for the states but not nec­es­sar­ily telling them what to do. The main fo­cus of the pro­gramme in terms of funds flow is re­struc­tur­ing its flow, al­low­ing states take sub­stan­tial de­ci­sions with re­spon­si­bil­ity. How­ever, we re­serve the right to pre­vent states from spend­ing their funds on ar­eas we know are not go­ing to in­flu­ence [pri­mary health care]. This hap­pened at var­i­ous times when states want to build big hospi­tals or di­ag­nos­tic cen­tres. We also re­serve the right to send au­di­tors to them.”

To the sec­ond ques­tion, he re­sponded: “The fact that the state does not have a com­mis­sioner doesn’t pre­vent them from work­ing. We op­er­ate with the sys­tem and not per­sons or in­di­vid­u­als. We ex­pect the per­ma­nent sec­re­tary to convene a steer­ing com­mit­tee meet­ing and forge ahead. Af­ter all, [fol­low­ing] tran­si­tions, there are no com­mis­sion­ers, so it is not new.”

Hauwawu Mo­hammed and Jum­mai Abubakar work at a pri­mary health cen­tre at Tudun Wada, right in the heart of Gusau.

On av­er­age, up to 40 women at­tend an­te­na­tal clinic there weekly, and three give birth ev­ery day.

The ma­ter­nity room con­tains two beds do­nated by a non­govern­ment or­gan­i­sa­tion. Four more do­nated beds are used in one ward. A sec­ond ward has no bed at all.

Drugs in the cen­tres phar­macy come in two kinds: one sourced free from the an­ti­malaria partners and an­other sub­sidised on a re­volv­ing fund model.

Both women feel their pa­tients are bet­ter off, they say on a visit to the cen­tre.

Across health cen­tres, di­lap­i­da­tion in the face of mil­lions of naira that can make a dif­fer­ence is ap­par­ent, says one source, who works with a de­vel­op­ment partner in the state.

As it is now, it is only in Zam­fara that if you go to most of our fa­cil­i­ties some­times the of­fi­cers in charge of those fa­cil­i­ties es­pe­cially those lo­cal gov­ern­ment ar­eas, they have to be chas­ing an­i­mals, she said.

“In so many places, you will see de­liv­ery beds sup­ported by stones in Zam­fara State. In most cases, a woman will be in labour and rain will be drip­ping on her head. And we have the re­sources, but we are not will­ing to ad­dress it.”

Ma­ter­nity ward at a PHC in the cap­i­tal of Zam­fara, months af­ter SOML was halted

Drugs are de­liv­ered as free or sub­sidised, de­pend­ing on de­vel­op­ment partner fund­ing

Vac­cines Com­mis­sioner Us­man presents cer­tifi­cates to moth­ers who have com­pleted im­mu­ni­sa­tion for their chil­dren

Katsina bat­tles to im­prove child im­mu­ni­sa­tion to push its SOML base­line

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