The National Agency for the Control of AIDS (NACA) was recently in the eye of the storm over an indictment for mismanaging grants disbursed to it for AIDS intervention in Nigeria by Global Fund. Its managing director, Prof. John Idoko however stated in this interview with Frederick Adegboye that the agency’s only failure was in oversight administration something he ascribed to a systemic weakness.
How would you react to the seeming indictment of NACA by Global Fund of mismanaging funds disbursed to it for AIDS intervention in the country?
The Global Fund issue is like a wakeup call for us, let me start from there. It appears many people don’t understand what the issues are. There are two issues; there is an audit report which is like something that is done in every institution, then there is an investigation which is trying to look at the issues of fund misappropriation etc. But they all relate to NACA because NACA is the principal recipient. And the way the Global Fund works is like this: funds are given to us as principal recipients. There are three principal recipients for HIV; NACA, ARFH and Society for Family Health. We are like conduit pipes through which money flows to the sub-recipients; the sub-recipients are the ones who disburse money to the facilities that I may call the sub-sub-recipients. But the entire responsibility to oversee everything down the line and ensure we meet the outcomes of the various programmes lies with NACA. That’s the introduction to what has happened.
An audit was conducted through all the systems from NACA, to the sub-recipients, to all the facilities; and we have over 1000 facilities providing comprehensive HIV and AIDS services throughout the country. The most important things that were observed were that there is a systemic weakness through the system in our procurement supply chain, in data and programme oversights. In the central medical stores, we had some issues like expired drugs and inventory manifest. We noticed for example that in some facilities, specifically in Akwa-Ibom and some other states, data was not captured for a couple of months. We also noticed that in some of those facilities, doctors were not recording the information on clients as clearly and as completely as they should. That is one example. There were also stock-outs because the logistics management information was not being properly captured. In NACA itself, we had issues with documentation of supplies that were bought for us. They buy the supplies for us and we are supposed to collect the information from those who bought them. To be specific, the Global Fund serves as the invoices that we receive and we are to take custody of it; the proof of delivery was not just enough. All these relate to systemic weaknesses because the central medical store is operated by the Federal Ministry of Health, and we all know the store has a lot of challenges.
How do you hope to tackle this?
Going forward, we have said that we will ensure that inventory is properly cared for. We will work with the states’ logistics units to ensure that we have proper documentation of drugs movement, so that we don’t have such issues again. As far as data is concerned, we also want to ensure that we have dedicated data clerks to the level of secondary, if possible primary health care. In NACA itself, we have done a lot of restructuring even before the report came out. Our procurement is weak and the issue we have is that we didn’t provide enough oversight. We are also ensuring that infrastructures and data storage are improved upon by the use of electronics, and increased staffing, especially the logistics unit. We have just restructured our Global Fund team.
The second issue which I really don’t want to comment so much on is the fact that there was fraud in the Department of Planning and Research of the Federal Ministry of Health. They are our sub-recipients. The issue we had was that we didn’t provide enough oversight. Although we wrote some management letters, they didn’t respond. But we should have taken it further than that. EFCC is investigating, and I’m sure that in line with the strong principles of this government, all those who are found guilty will be prosecuted.
What measures or strategies are you putting in place to ensure that there are no new infections by 2030?
Well, let me correct that. It is not that there will be no new infection, but HIV will cease to be an epidemic or major public health concern. Since we don’t have a cure, there would be infections but it won’t be in the magnitude that we have now, where lots of people are going down with HIV. The strategy is very simple, and it has already been laid down by UNAIDS: ‘strategy of 909090’. It shows we need to identify up to 90% of people who are diagnosed with HIV and then link them up to treatment as we are already doing. If we can ensure that 90% of those who are positive get treatment; the last 90 is ensuring that as we treat them, they are suppressed biologically. That’s the point where when we take their blood, there is no virus in the blood, but there is still virus in the body, in some hard-to-reach places. That is the strategy. Now, how do we go on with this strategy? In the last three to four years, we have zeroed down on states that have more burden than others. And we know from the epidemiology of HIV in the country that 12 states and the FCT are responsible for over 60% to 70% causes of HIV, so we have put our energy and focus on those states. We try to put more emphasis on LGAs that have more HIV burden. We have also gone to look at key populations; looking at men who have sex with men, female sex workers, people who inject drugs, long truck drivers…. The micro of it is to treat as many people as possible. So the main aim is not only to give treatments, but to prevent it as much as possible through public counselling and awareness, which is the major obstacle of the strategy 909090. We also look at stigma, which is the major reason people will not go for test or treatment and so on. We also have gender issues, especially young, adolescent girls. We need to go after them and make sure they are protected. And you know about the issue of PMTCT. Finally, the guideline is ‘test and treat.’ With all these in focus, HIV will be decimated.
How well has the national anti-stigma law been disseminated?
The anti-stigma bill was approved by the former president in 2014 and became adopted in 2015. We have disseminated several copies to states’ agencies for the control of AIDS. We shall be working with them to ensure that they are distributed to civil society organisations, government institutions and private sector organisations. Aside that, some states have also passed their own version of the law.
Coming from a university community whose HIV programmes were once adjudged the best in the country, would you say you have enjoyed the job? Have you had occasions to regret taking up the job?
The answer is both. You know what they say about sweet and sour soup. What is sweet about it is that when I left my former job in Jos to come here, I came with a vision. The vision was to ensure that we decentralise comprehensive HIV services from teaching hospitals and big hospitals, down the line to state government hospitals, comprehensive primary health care centres and primary health care centres. And I think that to some extent, we have achieved some of that because the Ministry of Health, NACA and all our partners work in a way that each general hospital has a cluster of primary health care centres. So to some extent, I have enjoyed being part of putting all these together. Despite all the challenges we are having with Global Fund, there is really no institution near us that can operate in a global form. When I came in 2009, there were only 10 SACAs that were agencies, the rest were committees. Under my tenure, everything has changed; all of them have become agencies and the funding and services have increased. Despite the challenges, Global Fund has also expanded and the funding has increased. When I came in 2009, there were between 34,000 and 35,000 Nigerians who were benefitting from Global Fund services, but now we have over 150,000. I brought in more research such that it is now dependent on evidence and that is what has given us the leap in the last three to four years. There are also downsides; the government structure is weak. Secondly, it is not easy to coordinate so many players; we are coordinating government institutions, civil societies, communities, partners and private sectors. And then there is tension between all of them. Funding is also an issue; up till now, we depend heavily on donor funds, and donor funds are unpredictable and not sustainable.
How can government take full ownership of HIV programmes in the country, considering that “donor funds are unsustainable”?
I think government is already doing it; it’s just the pace. When you say government, it has to be government at the federal, state and local government level. The federal government has stepped up but they need to step up more because over the last four years, the funding for HIV has improved and increased, though not as substantial as we’d like it. But the commitment from the government at the centre is better than what it used to be. However, we do not see the same commitment in most of the states and local governments. We need to work as a team to carry out advocacy to these levels of government. Nigeria as a huge private sector also needs to support; we’re talking about resources not just money. Resources are people and other things we can find at community level. We also need to be innovative. We have seen countries come up with taxes; taxes from cell phones, airlines, tobacco etc. Some people have even suggested that money transferred from abroad be taxed, to improve the health of the nation.
