The call came in July 2016, late one evening after my wife went to sleep: it was a senior Nigerian government official telling me that I would be announced as the new head of the Nigeria Centre for Disease Control (NCDC) in the morning. By accepting the appointment, I was rocketed into the middle of a new administration and an incredibly high-stakes challenge for transformation, where the outcome could be the difference between life and death for millions of Nigerians. Given that I had spent a lot of energy complaining about all that was wrong with the Nigerian health system, like many in my generation, I really had no realistic option but to accept this responsibility, despite the news of my appointment being so sudden.
The NCDC was established in 2011, but by 2016 it was still not in a position to fully deliver on its mission, to protect the public health of Nigeria’s citizens. Though I’d trained as a medical doctor in Nigeria, I had spent my career working in national public-health institutes, from Germany to the UK to South Africa. I shared my concerns about the state of NCDC with our leaders, raising the issue that the agency was critically underfunded, it did not have a legal mandate to carry out its functions, but it still had to contend with increasingly frequent public challenges like Ebola and Lassa fever. Nigeria is the most populous country in Africa, with an estimated 200 million people. The country is divided into 36 states, plus the Federal Capital Territory (FCT), each with their own state Ministry of Health structure, which has made coordination and centralising public health an incredible challenge. In addition, the Nigerian government allocation to the NCDC was only about $4 million in 2018, roughly 0.03 per cent of the US CDC’s equivalent $11 billion for the same year. Nonetheless, I was encouraged to proceed with the building of a strong institution and was assured of the necessary support.
During my first week on the job, I sat in my new office and went over the issues I could already identify. The challenges were significant. As an example, despite being a national public-health institute, it lacked a functional national reference laboratory; the outbreak-surveillance system was paper-based, with data entry into Excel sheets needing to be done manually. The workforce – around 70 people in total – was too small for the work that needed to be done and unprepared for the intensity of performing our jobs during an outbreak. While many of the staff were motivated, they lacked critical management mechanisms and performance requirements, such as clear job descriptions and a well-defined strategic direction of the organisation. There were also quite a few challenges with the office infrastructure, such as the dispensers procured for hand-sanitisers; these had become commonplace during the Ebola outbreak but now lay empty and washroom facilities for staff were barely functional. We were a public-health institute that did not fully practice what it preached. I immediately knew that transforming this institution would truly mean “building the ship while sailing”.
One of the first things I did was to call my network from around the world to tap people who could help me in the building process. A year earlier, I worked on behalf of WHO on the Ebola response in Liberia. It was during this mission that I first connected with the Tony Blair Institute for Global Change (TBI). Most partners supporting the government were focused on providing technical support, such as improving disease surveillance or labs. But I saw then that TBI was the glue that held together several aspects of Liberia’s response, working largely behind the scenes to make sure that the crisis-management structures were able to function, despite the chaotic context of the outbreak. This demonstrated the potential in applying more holistic approaches to the strengthening of health systems, focusing on institution-wide reform and strengthening rather than on specific technical areas – because once the institutional changes are made, the technical advances naturally follow.
I invited TBI to support the work that needed to be done at NCDC – institutional strengthening and capacity-building – putting in place the systems and processes that would enable me to effectively run the organisation. They agreed to work with us, pro bono for six months, initially doing a scoping of what would be required and supporting in the development of a strategy that we would revisit and revise several times over the next five years together. This scoping period was crucial in determining NCDC’s capabilities, potential, context and pathways for change, which also served as a key point for relationship-building and stakeholder buy-in. But perhaps even more important than a strategy is its implementation: how you turn the vision into reality. With funding from the Bill & Melinda Gates Foundation, we were able to keep working with TBI, which provided collaborative and embedded support to the institutional strengthening and capacity-building of the NCDC. The implementation plan included clear, actionable and monitored performance indicators and timelines, with each strategic goal adopted by an owner – a department in NCDC.
Though TBI is accustomed to delivering holistic organisational change at the centre of government, I was made aware that this was the first time TBI was working not through a prime minister or president’s office, but directly with a public-health institution. By applying its delivery model of institutional strengthening and capacity-building across the agency, TBI helped us to prioritise, to plan, and to develop internal structures, systems and monitoring mechanisms to bring about change. Additionally, the support from TBI helped to mentor staff and enabled them to rise to the challenges set for them.
TBI’s approach differed from traditional capacity-building approaches as it took a holistic view of the strategic needs of the organisation, rather than being focused on a specific technical or skills area. Often, consultants working on institutional building come for a few days or weeks and leave, but the TBI staff truly embedded themselves within the organisation. They sat with us each day and were with us each step of the way, helping us strengthen our systems, mentoring our staff and expanding our capacity to make real change. Many consultants prescribe a pre-defined strategic plan but do not provide longer-term support with implementation. I appreciated the fact that TBI was embedded within the organisation, as this meant that the team could effectively coordinate workstreams and monitor the progress of each department as they made effort to achieve the strategic goals.
By improving how the NCDC functioned, technical improvements and better outcomes of our work naturally followed. Other partners supporting in the areas of surveillance or epidemic preparedness could focus on their areas of delivery. In terms of technical wins, we were able set up the national reference laboratory, and transitioned from manual paper systems recording disease outbreak across the 36 states and the FCT to a unified digital disease-tracking surveillance software (SORMAS). Our website and social media platforms became trusted destinations, where more than 1.1 million Nigerians come to access information. The building of NCDC was truly a collaborative effort with many dedicated and committed partners playing a significant role. But one of our most important victories came in 2018, when the bill for an act to establish the NCDC was signed into law and the institution was given a mandate, confirming that its future was solid and our mission was valued.
By the time the Covid-19 pandemic challenged global health systems in 2020, NCDC’s institutional-strengthening journey had made the organisation better equipped to respond to the pandemic. We had built up our institutional and technical capacity, established a network of partners and built up our surveillance infrastructure, so we were able to quickly mobilise these structures, systems and skills to respond to the Covid-19 outbreak.
We were able to set up additional emergency operation centres (EOCs) in 12 states, having done this in more than 20 states pre-Covid-19. We deployed response teams to 32 states concurrently at the peak of the pandemic. We expanded our digital disease surveillance system to run in all 36 states and the FCT, which has enabled us to share Covid-19 data from across the country, every single night since the beginning of the pandemic. Most importantly, countless lives have been saved.
Refining each system helped the entire organisation run smoothly and has allowed us to keep improving, knowing we have a solid foundation and scaffolding to build on. The Covid-19 crisis has transformed not only our own capacity, but also the public-health architecture in Nigeria. We were able to use our Covid-19 experience to accelerate our capacity-building and institutional-transformation journey: internal structures were strengthened, coordination was enhanced and our knowledge-management processes were improved, consolidating learnings to build a stronger agency that is more resilient to inevitable future crises. I am incredibly proud of our steady transformation over the last five years and all that has enabled us to deliver on our mandate, to protect the health of Nigeria and prevent, detect and respond to infectious disease outbreaks. Our work is not done yet: We must keep pushing, till we deliver.
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