99633 Doing Development Differently (DDD): Do A Pilot for Politically Savvy, Locally Tailored and Adaptive Delivery in Nigeria A Pilot f country delivery case study Do Doing Development Differently (DDD): A Pilot f A Pilot for Politically Savvy, Locally Tailored and Adaptive Delivery in Nigeria c65 m76 y0 k0 c100 m90 y0 k0 c24 m32 y100 k0 c53 m17 y100 k0 c0 m10 y95 k0 c0 m100 y100 k0 The Nigeria Project Twitter:@Nigerian Project When instiTutions work: Nigeria’s Ebola Response MAY 2015 A partnership between the Governance Global Practice (GGODR) and the Health, Nutrition, and Population Global Practice (GHNDR) When Institutions Work: Nigeria’s Ebola Response This case study was written by Ritgak Dimka Tilley- a partner to Nigeria. The author is grateful to Benjamin Gyado as part of the Delivery Case Studies produced Loevinsohn, Katherine Bain, Marie Francoise Marie-Nelly, by the World Bank’s Nigeria Country Team. The Delivery and Oluwole Odutolu for comments and support on Case Studies series—part of the Doing Development earlier drafts, and Amanda Green and Sabrina Roshan for Differently initiative—aims to generate knowledge on their editorial support. The paper does not represent the what works in Nigeria and why. It is designed to help views of the World Bank’s Board of Directors, and any the World Bank continually improve its effectiveness as errors are those of the author alone. i Abbreviations and Acronyms Abbreviations and Acronyms AFP Acute Flaccid Paralysis BMGF Bill and Melinda Gates Foundation CDC Centers for Disease Control (United States) CNN Cable News Network (United States) DRC Democratic Republic of Congo DSNO Disease Surveillance and Notification Officers (DSNOs) EEOC Ebola Emergency Operations Centre EOC Emergency Operations Centre GPS Global Positioning System HIV Human Immunodeficiency Virus ICS Incident Command System IDSR Integrated Disease Surveillance and Response IMS Incident Management System LGA Local Government Area LSPHCB Lagos State Primary Health Care Board MDG Millennium Development Goal MSF Médecins Sans Frontières N 5 Nigerian Naira NCDC Nigeria Centre for Disease Control NFELTP Nigeria Field Epidemiology and Laboratory Training Program NDHS Nigeria Demographic and Health Survey NMA Nigerian Medical Association NPHCDA National Primary Health Care Development Agency PBF Performance-based Financing PHCA Primary Health Care Agency RBF Results-based Financing SIM Subscriber Identity Module SMS Short Message Service SOP Standards of Practice SWAT Special Weapons and Tactics TA Technical Assistance UNEP United Nations Environment Programme UNICEF United Nations Children’s Fund WHO World Health Organization ii Contents   Contents Abbreviations and Acronyms ii Executive Summary v The Development Challenge: An Unprecedented Outbreak with Worldwide Implications 1 Overview 1 Case Study Assessment Framework 2 The Delivery Challenge: Bringing Existing Government Resources to Bear in Response to an Urgent Crisis 3 The Ebola Crisis in West Africa 3 Public Health Surveillance and Emergency Response Systems in Africa 3 Disease Responses and Surveillance in Nigeria: Past Experiences 4 The Political Economy of Reform, Delivery, and Pockets of Effectiveness in Nigeria 6 Institutional Architecture of Nigeria’s Ebola Response 9 Organizational Structure of the Response 9 Information for Decision Making and Communication: Close Supervision, Mid-Course Adaptations, and Bringing the Public Along 9 Building on and Complementing Pre-existing Systems 12 Mobilizing Human Resources: Crowding In and Motivating the Right Individuals 13 Flow of Funds: Bridging Early Hitches to Evolve into Coordinated Federal-State Action 14 Greater Together: Federal-State Collaboration 14 Lessons Learned: What Can Nigeria’s Experience Tell Us about the Foundations of a Successful Emergency Response? 16 Fear as a Great Motivator for All 16 Technical Leadership Capacity Exists in Nigeria and Is Effective When Unleashed 18 Incentives and Health Workers’ Motivation: Bypassing Inertia While Motivating Passionate Individuals 18 Operational Efficiencies: Clear Roles, Responsibilities, Autonomy, and Proactive Communication 19 Technical Assistance: International Expertise Tailored to Local Reality Builds Trust and Results 19 Data and Information Sharing for Good Decision Making and Adaptive Implementation 20 Building on—and Strengthening—Pre-existing Systems 21 iii Implications of Nigeria’s Ebola Response for Service Delivery More Broadly 22 Bibliography 25 Figures Figure 1: Organizational Structure of the EEOC 10 Figure 2: Data and Decision-making Cycle 10 Figure 3: Flow of Information to and from the EEOC 11 Figure 4: Public Health Assets Identified and Utilized during the Ebola Response 12 Figure 5: Translating Fear into Action 17 Tables Table 1: Continuing Challenges in Meeting Nigeria’s Health Sector MDGs 7 Table 2: Juxtaposing Nigeria’s Traditional Health Care System with the Country’s Ebola Response 24 Text Boxes Box 1: Key Conclusions for Health Sector Reform and Service Delivery Systems vii iv Executive Summary   Executive Summary Nigeria is a country of immense natural resources and response. The aim is to distill lessons that may be potential, but the government’s capacity to deliver public applied to other emergency response initiatives, as well goods has generally been weak. Health sector outcomes as elsewhere in the health sector and in other areas of over the last decade have been mixed, with declining service delivery. These goals fit within the overall aim infant and child mortality rates but little progress in of the Doing Development Differently series, which reducing maternal mortality and continued high fertility. explores what works in Nigeria, how, and whether lessons Childhood malnutrition has actually worsened by some can extend to other areas of development. measures. It was against this backdrop that Nigeria faced the arrival What Can We Learn from Nigeria’s within its borders of the deadly Ebola Virus Disease Past Experiences with Disease in July 2014. The West Africa region has been ravaged by the worst-ever outbreak of the disease, with over Response and Surveillance? 20,000 recorded cases and 6,800 fatalities between A common feature in all of Nigeria’s responses to disease March 2014 and January 2015. Despite assurances that outbreaks, to date, is the presence of an accountability the Nigerian government was prepared to respond to mechanism through federal and state oversight an outbreak of Ebola, the country was caught unaware committees. In line with international recommendations, and forced to mount an emergency response. There was the country is shifting from reactive public health widespread fear that this would be the start of a rapid response systems that focus primarily on epidemiological global spread of Ebola, given Nigeria’s large and mobile interventions, to more proactive responses guided by population, the density of the city of Lagos (where the clearly defined management strategies. This evolution first case was identified), past coordination problems has resulted in part from capacity strengthening through within government, and persistent service delivery and the Polio Eradication Initiative, but countrywide systems governance challenges. are still a long way from ideal and the technical resources and capacities needed to effectively implement such Yet despite these serious concerns, the spread of Ebola response systems are lacking. was successfully contained in Nigeria. At 40 percent, the fatality rate of Nigeria’s cases was among the lowest Nigeria’s experience in responding to a lead poisoning recorded in an Ebola outbreak—half the overall case outbreak in the northern state of Zamfara in 2010 and fatality rate of 80 to 90 percent recorded for the current 2011, for example, demonstrates how a low level of outbreak. Nigeria’s response has been celebrated widely appreciation, a weak surveillance system, and consequent as swift and concerted, thanks to the joint efforts of delays in responding to a public health emergency led the federal government, the governments of Lagos and to significant, longstanding environmental damage, Rivers states, and international partners such as the mortality, and morbidity. World Health Organization, Médecins Sans Frontières, the United States’ Centers for Disease Control and In responding to annual outbreaks of Lassa Fever, key Prevention, and the United Nations Children’s Fund. The success factors have included effective coordination, World Health Organization declared Nigeria Ebola-free active case management, community mobilization, and on October 20, 2014, just three months after the virus evaluation of contacts and suspected cases. Many of made its way into the country. these factors had a positive influence on Nigeria’s Ebola response. On the downside, studies have identified This successful result came as a surprise to observers weaknesses in emergency preparedness, poor training given Nigeria’s limited progress in improving health of medical personnel, inadequate technical capacity, fear outcomes and service delivery over the past two among health workers, and lack of adequate equipment decades (Loevinsohn and Dimka 2014). This case study (Fisher-Hoch et al. 1995; Bassey et al. 2011; Adewuyi et al. seeks to understand why Nigeria’s Ebola response was 2009). so successful despite the challenging context. The case study will focus on institutional architecture and In the case of Nigeria’s Polio Eradication Initiative, political will, taking an exploratory qualitative approach the establishment of Emergency Operations Centers to examine the institutional dynamics and motivations (EOCs) at the national level and in five states created among various stakeholders involved in the country’s an institutional focal point for collaboration between v the government and its partners, facilitating data- few days of the outbreak, Nigeria’s president declared that driven decision making, operational management, and the government would do anything possible to contain implementation of strategies. The experience of the Polio it. The government took immediate action following this EOC’s management, from startup to project management announcement, re-establishing a relationship of trust and and surveillance using new technologies, was a critical reassurance between the government and its people. driver of the operational efficiency of Nigeria’s swift and successful Ebola response. Technical leadership. Nigeria’s Ebola response might have been ineffective without the technical leadership demonstrated by key health sector actors. The minister Institutional Architecture of health, for example, served as a “broker” between of Nigeria’s Ebola Response political and technical cadres, bringing infectious disease specialists and epidemiologists with decades At the outset of its response to the Ebola outbreak, of experience to the forefront of the response, and drawing on its experience with the Polio EOC, the Nigerian between the government and the Nigerian public, government established an incident management center regularly giving updates on the status of the outbreak, that morphed into the Ebola Emergency Operations on actions taken by the government, and on progress Centre (EEOC). Led by a core management team, the recorded. At the operational level, the index case in EEOC formalized the involvement of federal, state, and Nigeria’s Ebola outbreak could have been missed, given local government actors. Reporting lines were clear from that it presented in a private facility that did not have the start, and twice-daily supervision meetings allowed clear channels of communication with the public health managers to easily and quickly identify and address sector. Dr. Ameyo Adadevoh demonstrated exceptional implementation challenges. astuteness and professionalism in diagnosing Ebola and informing the relevant authorities. Importantly, Nigeria’s Ebola response was developed on the basis of pre-existing systems, taking advantage of Incentives for health workers. Paradoxically, the same physical and human resources already on the ground fear that drove Nigeria’s Ebola response threatened to while strengthening those that were functioning less well. derail it when health workers could not be mobilized. Development partner support was allocated strategically News emerging from other West African countries was using the existing and functional Development Partners’ revealing high infection rates among health care staff. Group as a platform for coordination. Moreover, local These risks—together with ongoing (pre-outbreak) teams whose expertise had been built over weeks of tensions between the Nigerian Medical Association and assisting the response in Lagos were mobilized to support the government over low wages and mismanagement— the response in Rivers State once cases were confirmed were a strong disincentive. The EEOC responded there. Some of these personnel are now among the team creatively to this challenge, devising an incentive-based of over 500 Nigerian volunteers supporting other West personnel mobilization strategy that drew on “per-shift” African countries hit by this crisis. payment premiums and hazard pay to attract workers. This payment model is largely credited for the success of the recruitment exercise, as for some it served as a What Can Nigeria’s Experience monetary match to the risk of exposure. in Battling Ebola Tell Us about the Foundations of a Successful Operational efficiencies. With a staff of 1,800, the EEOC’s task of meticulously reviewing large data inflows Emergency Response? with minimal errors and making and executing decisions Fear as a great motivator. Ebola’s arrival in Nigeria incited quickly required more than technical capacity. Nigeria’s fear and widespread panic. The disease was ravaging primary health care systems have struggled in the past Liberia, Guinea, and Sierra Leone, and many doubted with coordination and the translation of policies into that the Nigerian government could mount an effective practice. Despite initial funding delays, EEOC operations response within a complex, politically sensitive, and only were executed efficiently due to innovative streamlining partially functional institutional environment. There was a of procurement processes and stopgap funding from personal and individual fear due to the contagious nature Lagos State, which had the means and could leverage of Ebola, especially in light of the devastating impact the potential contributors from the private sector. Also disease had already had on other countries in the region. important was the fact that decision making took place In particular, the fact that the index case was a senior at the level of the response team/unit heads and at the diplomat motivated the country’s elite to act. Nigeria’s senior management/strategy group level. global reputation also seems to have been a factor, buttressed by visible changes in West Africa’s investment Technical assistance. The global threat posed by climate and the withdrawal of expatriate staff. Within a Ebola underlay the international response in Nigeria. vi Cooperation and coordination were greatly enhanced and upon confirmation of laboratory results. Moreover, by technical assistance that was already in place and following false rumors with tragic consequences, the therefore well positioned to broker international EEOC learned early on the importance of proactively   expectations and expertise within available systems. disseminating accurate information. The presence of development partners focusing solely on outbreak response encouraged local leadership, despite opposing political stances and different levels of What Are the Implications government, to focus on EEOC efforts and work together of Nigeria’s Ebola Response for toward a common purpose. Service Delivery More Broadly? Data and information sharing. The use of smartphones, This case study confirms the growing body of evidence adopted early in the response, allowed for real-time that pockets of effectiveness exist in Nigeria. Despite reporting and data tracking. As a result, the data the country’s international reputation for governance generated by the EEOC were of good quality, well challenges and ineffectiveness, the country is full of organized, accessible, and analyzable. Data from the potential and is able to act when certain factors are response flowed not only vertically, but also across teams, in place. In this case, the fact that Ebola was blind to catalyzing operational efficiency. A notable example is economic class and threatened the elite was a primary the transfer of patients from the surveillance team to motivator for the strong institutional response. Going the case management team with the onset of symptoms forward, it will be important for the Nigerian government Box 1:  Key Conclusions for Health Sector Reform and Service Delivery Systems Effective leadership. The unexpected policy response to the Ebola outbreak reveals strong political and technical leadership in Nigeria, which can be spurred to act if sufficiently motivated. In addition, despite systemic weaknesses, Nigeria can organize systems to be responsive and efficient. In the absence of an immediate public threat, the key to eliciting this leadership may lie in the packaging of narratives and findings on global health issues. Timely action. The timeliness of Nigeria’s Ebola response was critical to containing the spread of the disease. From an individual doctor’s quick thinking and strength in the face of pressure, to the federal government’s immediate declaration of a national public health emergency, the timely actions of key figures allowed Nigeria to put in place the systems needed for an effective response. This points to the importance of ownership and close ties between technical processes and government oversight. Meaningful autonomy. Giving mid-level managers control over their operations circumvents unwieldy bureaucracy that can throttle a rapid response. It allows them to find innovative solutions and can catalyze the efficient decentralization of functions. This is consistent with the findings of performance-based financing interventions, which show that health care results are achieved not by policy makers but by technical cadres at operational levels, particularly when they are granted autonomy. Well-designed incentives. Incentives can help motivate health care workers, but they must be packaged and offered in accordance with the broader economic, political, sectoral, and cultural context. Understanding situations where financial incentives can work alone and those where they need to be integrated with other nonfinancial incentives is central to the success of any such strategy. Existing assets. Identifying existing assets and resources—whether organizational, infrastructural, human, or fiscal—and quickly harnessing these techniques, technologies, and processes can yield rapid results while ensuring policy continuity. Data-driven decisions. Data should not merely be generated, but utilized. Making information available, if properly generated and adequately used, fosters the potential for real-time learning and application of lessons, which could prevent catastrophic mistakes and guide corrective actions. Relevant technical assistance. Technical assistance must be timely and provided by people who have an understanding of local systems, organizational culture, and sectoral and political dynamics. This is best achieved in collaboration with competent and highly motivated local experts. vii to remain vigilant, building on the effective platform A proactive communication strategy is required to build provided by the EEOC to strengthen its disease a broader coalition of support, and demand-side actors surveillance systems and continue efforts to ensure such as nongovernmental organizations play a helpful role. strong technical leadership and regular communication Delivery in this case was enhanced by the existence of with the public. systems and practices, although in a hybrid arrangement in which passionate individuals were “hired in” to deliver Strong, passionate leadership, coupled with first-class the response when official health workers were on strike technical capacity, are critical for effective delivery in or felt too threatened. Box 1 lays out several important Nigeria. Ensuring that such teams have clear roles and conclusions from this case study that apply to health responsibilities, strong internal communication, and sector reform and service delivery more broadly. freedom from political interference is also important. viii The Development Challenge:   The Development Challenge: An Unprecedented Outbreak with Worldwide Implications An Unprecedented Outbreak with Worldwide Implications Overview state of Nigeria’s health system to a lack of institutional organization, as demonstrated by the absence until Over the past year, the world has experienced its worst- five or so years ago of proper state-level coordination ever outbreak of the Ebola Virus Disease, with over 20,000 bodies for primary health care, as well as by limited recorded cases and 6,800 fatalities between March 2014 stewardship and financing. He argues that these have and January 2015. At the epicenter of this outbreak, in been compounded by other socioeconomic and political the West African countries of Liberia, Guinea, and Sierra factors, including out-of-pocket expenditures for health Leone, the unprecedented magnitude of the epidemic and lack of translation of policies into practice. Similarly, has proved overwhelming to both governments and assessments conducted by the World Bank (2012, 2014b) international agencies. The disease has also spread reveal a system burdened by weak governance and to Senegal, Nigeria, Europe, and the United States, poor accountability for results. Although 80 percent of albeit with much more limited impact. The outbreak is recurrent spending in the health sector is directed toward beginning to abate, and the World Health Organization health worker salaries, health worker performance (WHO) indicated that the number of confirmed cases remains poor (Uneke et al. 2007, World Bank 2014b). reported in the first week of May 2015 is at its lowest Reasons for this underperformance include underfunded, level in a year (WHO 2015). unsupervised health facilities with poor infrastructure, chronic drug stock-outs, and inadequate ratios of skilled The spread of Ebola was successfully contained in Nigeria, staff; poor human resources planning and management despite concerns about existing gaps in governance and practices and structures; lack of professional autonomy; health service delivery. The WHO declared Nigeria Ebola- long working hours; poor access to needed supplies, free on October 20, 2014, just three months after the virus tools, and information; inadequate career paths; and made its way into the country.1 Nigeria’s Ebola response limited or no access to professional development has been widely celebrated as swift and concerted, opportunities (Uneke et al. 2007). Years of poor service thanks to the joint efforts of the Federal Government of quality have engendered in the Nigerian public a deep Nigeria, the governments of Lagos and Rivers states, and mistrust of the health system and its service providers, international partners such as the WHO, Médecins Sans leading to underutilization of services. As a result of Frontières (MSF), the United States’ Centers for Disease these challenges, Nigeria’s health sector is often unable Control and Prevention (CDC), and the United Nations to deliver expected results. Children’s Fund (UNICEF). Given this context, this case study seeks to understand This successful result came as a surprise to observers the factors behind Nigeria’s successful Ebola response, given Nigeria’s limited progress in improving health with a focus on the institutional architecture and political outcomes and service delivery over the past two will, and to distill lessons that may be applied to other decades (Loevinsohn and Dimka 2014). A closer look emergency response initiatives, as well as elsewhere in at the underlying health system reveals fragmentation the health sector and in other areas of service delivery. between federal, state, and local government levels. These goals fit within the overall aim of the Doing The Federal Ministry of Health encompasses over 200 Development Differently series, which explores what agencies, many of which are defunct while others have works in Nigeria, how, and whether lessons can extend overlapping functions. Uneke et al. (2007) trace the poor to other areas of development. 1. To be declared Ebola-free, the country needed to go 42 days—a period double the incubation period—with no new cases, verify that it actively sought out all possible contacts, and show negative test results for any suspected cases. 1 Although the World Bank stood ready to provide the WHO; and the CDC. Interviews were also conducted assistance with Nigeria’s Ebola response if requested, and with representatives of civil society, including media and was proactive in seeking out a useful role if required, it risk management consultants and other stakeholders who was not directly involved in the events described in this were not directly involved in the emergency response. case study. This perspective offers a useful opportunity to step back and look at the large-scale institutional Interview notes have been supplemented with anecdotes and organizational factors that contributed to Nigeria’s harvested from electronic, online, and print media, based accomplishments in this area. on themes emerging from the literature and interviews. Key findings presented in this case study are substantiated with experiences from other health system interventions Case Study Assessment Framework by the Nigerian government. This case study takes an exploratory qualitative Limitations of this study include the small number of approach to understanding the institutional dynamics interviews and lack of access to internal documentation and motivations among various stakeholders involved from the Ebola response. Depth of analysis was sacrificed in Nigeria’s Ebola response. The work began with in favor of completing the case study rapidly so that a desk review of journal and media articles and knowledge about Nigeria’s successful response could be other publications, followed by interviews with key shared quickly, informing its transition-phase strategy stakeholders. Interviewees included officials of the Ebola and supporting the preparation of World Bank projects Emergency Operations Centre (EEOC), within the Nigeria to assist with the Ebola response in Guinea, Liberia, and Centre for Disease Control (NCDC); the Polio Emergency Sierra Leone. Operations Centre (EOC); the Lagos State Government; 2 The Delivery Challenge:   The Delivery Challenge: Bringing Existing Government Resources to Bear in Response to an Urgent Crisis Bringing Existing Government Resources to Bear in Response to an Urgent Crisis The Ebola Crisis in West Africa Public Health Surveillance Evidence suggests that the current Ebola outbreak began and Emergency Response Systems in a rural area of Guinea in December 2013. The outbreak in Africa was officially confirmed early in 2014, at which time it The CDC defines surveillance as “a watchful, vigilant seemed to remain within the borders of Liberia, Sierra approach to information gathering that serves to improve Leone, and Guinea. The outbreak spread fairly quickly to or maintain the health of the population” (WHO and urban and semi-urban areas. CDC 2001, 1). The use of epidemiological methods for surveillance is designed to equip “district and local health In April 2014, as Liberia sought to contain the outbreak, teams to set priorities, plan interventions, mobilize the Nigerian government stated that it was fully prepared and allocate resources and predict or provide early to respond to any outbreak of the disease within Nigeria’s detection of outbreaks” (WHO and CDC 2001, 1). This borders, including having available vaccines against Ebola. requires continuous and systematic collection, analysis, However, when a Liberian diplomat who had arrived in and interpretation of health data from credible sources Nigeria on July 20, 2014, was diagnosed with Ebola, Nigeria and dissemination of information to those who need to was caught unaware and forced to set an emergency know (Phalkey et al. 2013; Thacker and Berkelman 1988). response in motion. Twenty people became infected, with eight fatalities reported. At 40 percent, this case The first integrated disease surveillance guidelines for the fatality rate is one of the lowest recorded in an Ebola Africa region were published by the WHO and CDC in outbreak. The current regional outbreak, by contrast, 2001 to help African countries develop comprehensive reported an overall case fatality rate of 80 to 90 percent. surveillance systems that would be well positioned and equipped at all levels of health care service delivery to Ebola continued to ravage Guinea, Liberia, and Sierra identify priority diseases, periodically analyze surveillance Leone—countries whose infrastructure and health data, and identify and investigate public health threats. systems have been weakened by decades of civil war The WHO and CDC revised these technical guidelines (Liberia and Sierra Leone) and political upheaval (Guinea). in 2010 to incorporate key disease surveillance aspects Coupled with an emerging health worker crisis, following of the International Health Regulations of 2005 and infection and deaths among many health workers in heighten awareness of the importance and efficient use the region, the Ebola outbreak has revealed massive of core national capacities for surveillance, reporting, governance and systemic challenges in the affected notification, and verification. The revised guidelines also countries. Despite Nigeria’s more robust health system, sought to account for important developments in the fears trailed the confirmation of the virus in the country, previous decade (2001–2010), including the emergence of owing to concerns over the country’s large population, new diseases and evolving social and economic contexts. the density of the city of Lagos (where the first case was identified), and past coordination problems within the The 2010 guidelines identified large variations in the Nigerian government. implementation of the integrated disease surveillance 3 and response (IDSR) strategy among the 46 Sub-Saharan Disease Responses and Surveillance African countries. Gaps included the absence of district- in Nigeria: Past Experiences level data staff in 30 percent of the countries, the lack of epidemic management committees in 80 percent Nigeria has learned from experience in managing several of the districts, the absence of rapid response teams disease outbreaks in the past, including Lassa Fever and in 50 percent of the districts, a lack of logistics and lead poisoning, as well as from its efforts to eradicate communication capacities in most countries, and a polio. The institutional architecture, core operations lack of consistency in the use of monitoring indicators management, and overall success of these responses (WHO and CDC 2010). The guidelines emphasized the differed. These outbreaks attracted varying degrees of need for community surveillance. Similarly, St. Louis (2012) attention from federal and state leadership, and from identified elements critical to a properly functioning the international community, resulting in variations surveillance system, including leadership, prioritization in resource allocation, coordination, and response of diseases, standardization, interoperability, innovation, rates. Case studies of local government emergency and use of technologies and partnerships. preparedness and capabilities in Local Government Areas (LGAs) in Kaduna State revealed that the local The response portion of a surveillance system government met fewer than 50 percent of the criteria requires that many of the aforementioned resources laid out in the National Technical Guidelines for IDSR be put in place, including convening public health (Abubakar et al. 2010, 2013). This assessment points to a management committees, allocating adequate system that would be unable to respond to any public resources to response teams, and ensuring regular health emergency of significant magnitude or, at best, communications. The CDC recommends the use of an able to mount only a partial response. Incident Command System (ICS), similar to that used for military operations, that operates according to an This section reviews Nigeria’s experiences in disease effective plan and chain of command to respond to outbreak response, paying particular attention to public health emergencies. governance and systemic issues and comparing these experiences to what would be considered “good practice” An Emergency Operations Center often operates using an responses by international standards of disease control. ICS, and provides information, tools, and a management system during an emergency (WHO 2013). The EOC A common feature in all of Nigeria’s responses to adapts a “war room” approach, driven by accountability disease outbreaks, to date, is the presence of an to management, the need to deliver to avoid lags in accountability mechanism through federal and state team operations, and strict adherence to work plans oversight committees. Overall, it would appear that, in and timelines (Shuaib et al. 2014). In December 2013, the line with international recommendations, the country WHO undertook a systematic review to elicit country is shifting from reactive public health response systems experiences and “best practices” in establishing and that focus primarily on epidemiological interventions, managing EOCs, especially as there are no universally to more proactive responses guided by clearly defined agreed international guidelines on the structure, management strategies. This evolution has resulted partly organization, function, and monitoring of EOCs. from capacity strengthening through the Polio Eradication Emerging lessons from this review include: (i) formalizing Initiative, although countrywide systems are still a long coordination processes; (ii) streamlining operating parties way from ideal. On the downside, there is a dearth of for optimal use of resources; (iii) microplanning, and technical resources and capacities needed to implement continuously re-evaluating such plans even when there such response systems effectively. For example, technical is no outbreak; and (iv) detailed documentation, including capacity for laboratory diagnoses and logistics remains job and task descriptions and Standards of Practice (SOPs). weak due to the lack of equipment and trained personnel In addition, the review highlighted the critical importance (Akpan 2011). Similarly, Victor (2014) revealed that, of staffing and emphasized that training to recognize although health workers possessed a general knowledge threats and use communications systems should be of surveillance indicators in the Health Management based largely on evidence generated from thorough Information System, they did not accord them much assessments. Other components of a functional EOC importance nor did they have the computational or include strong data collection, review, and analysis, as well mathematical skills needed to analyze them. as taking advantage of data management expertise that is available before EOC activation for before, during, and Lead Poisoning Outbreak Response after the response. A good EOC is one that can respond The United Nations Environment Programme (UNEP) to different public health emergencies while maintaining describes the lead poisoning outbreak during 2010 and core functions in planning, finance, administration, and 2011 in Zamfara State, in northern Nigeria, as a “neglected logistics. and underfunded environment and public health 4 emergency” (UNEP 2011). Illegal gold mining by locals morbidity. This experience stands in stark contrast with resulted in elevated levels of lead in the environment. the country’s Ebola response, discussed below. Field surveys conducted by UNEP and the United Nations   Office for Humanitarian Affairs reported lead quantities Lassa Fever over 10 times above the limit in well water, over 150 times above the limit in soil, and over 500 times the limit in Lassa Fever is endemic in West Africa and responsible for the air—quantities that could be found in the air as well the death of 20,000 people per year in the region—more as dust on miners’ bodies, animals, and farm produce. than twice the current regional death toll from Ebola. These unusually high levels of lead resulted in countless Nigeria experiences annual outbreaks of Lassa Fever, fatalities, the exact number of which is unknown but including in Oyo State at the time this case study was includes 400 children, and left over 10,000 people at conducted during September and October 2014. acute risk of death or severe illness (Saleh 2011). One case study of the 2012 outbreak response revealed Human Rights Watch described Nigeria’s response to the major success factors as well as critical gaps in the response lead poisoning outbreak as “the latest testament to the system. Due to the nosocomial nature of that outbreak, Nigerian government’s failure to make the health of its a multidisciplinary hospital Lassa Fever management citizens a priority,” pointing to weaknesses in governance committee was given operational responsibility for the and in investments in public health. This statement most outbreak response, with technical oversight from national likely referred to the government’s delayed response to an and state task forces. early warning report from MSF, citing the growing number of deaths among children who showed similar symptoms Effective coordination, active case management, but did not respond to antimalarials or antibiotics. community mobilization, and evaluation of contacts Eventually, a team comprising the Federal Ministry and suspected cases have been identified as critical of Health, the CDC, the WHO, and the Nigeria Field elements in successful responses to Lassa Fever in Nigeria. Epidemiology and Laboratory Training Program (NFELTP) On the downside, studies have identified weaknesses joined MSF and the Zamfara State Government to carry in emergency preparedness, poor training of medical out investigations. This resulted in the establishment of a personnel, inadequate technical capacity (especially in National and Zamfara State Task Force. Funding support laboratory functions), fear among health workers, and was received in the form of a grant from the United lack of adequate equipment (Fisher-Hoch et al. 1995; Nations Central Emergency Fund. Blacksmith Terragraphics Bassey et al. 2011; Adewuyi et al. 2009). were responsible for environmental remediation. Fisher-Hoch et al. (1995) likened Nigeria’s 1989 Lassa Fever The overall response was multisectoral, with core response to that of the Ebola outbreak in Zaire (now the elements spanning the public health and mining sectors. Democratic Republic of Congo, DRC) in 1995. In both Policy responses included a move toward regulating Nigeria and the DRC, public attention to the disease arose mining activities and the adoption of case management only after its introduction to poorly functioning health and treatment protocols. Operational interventions facilities resulted in its proliferation and subsequent included training health care workers on accurate infection of health workers. Nearly two decades later, the diagnoses, strengthening surveillance systems for active region still struggles with some of these challenges. One case identification, and establishing a referral system. salient challenge has been the inability and insufficiency of equipment and expertise to adequately diagnose Lassa Despite some of the successes recorded, challenges Fever. Nigeria has two diagnostic centers, both based remained in coordinating clinical therapy with in Edo State. Yet the disease tends to be dispersed environmental remediation, and in managing logistics geographically, and prior outbreaks have involved 26 of and supplies. Large numbers of exposed persons were Nigeria’s 36 states as well as the Federal Capital Territory not able to receive chelation therapy, and discharged (Guardian News Nigeria 2014). patients often returned to unremediated communities. Compliance with new mining regulations was low, With the onset of the Lassa Fever season, an expert exacerbated by a lack of enforcement. Surveillance warned of a possible “hidden disaster,” citing concerns activities were restricted by inadequate logistics, that the regional shift in focus to Ebola may come at insufficient funding, and security challenges. the expense of the response to Lassa Fever. Ebola has claimed the lives of many health workers, some of The lead poisoning response in northern Nigeria whom were also experts on infectious diseases more demonstrates how a low level of appreciation, a weak broadly. This has certainly been the case in Sierra Leone, surveillance system, and consequent delays in responding where many of the staff of an infectious diseases faculty to a public health emergency led to significant, died in the current Ebola outbreak. With insufficient longstanding environmental damage, mortality, and technical capacity, one disease may be misdiagnosed 5 for the other. It is reported that some organizations have achieving its objectives by reinforcing a “sanctions and placed restrictions on travel for non-Ebola purposes, rewards” system. preventing the deployment of a group of experts who were to provide technical assistance during the region’s EOC operations are underpinned by a Management Lassa Fever epidemic season, at a time when local health Support Team that comprises local and international systems and human resources are overwhelmed with the experts and is involved in microplanning using tally Ebola crisis. On the upside, however, experts believe that analysis sheets and walk-throughs. Teams are equipped the capacity being built as a result of the Ebola crisis will with these operational plans for technical oversight strengthen early warning systems for other hemorrhagic and supervision, which are informed by analysis of fevers (Ruz 2014). performance data, even at lower levels, and subsequent development of strategies. Health teams work with the Nigeria’s experience in combating Lassa Fever shares some Outbreak Response SOPs, which have been revised and positive influencing factors with the Ebola response— disseminated once since the EOCs were established. namely strong coordination, active surveillance, and community involvement, discussed in depth in Prior to the establishment of the EOCs, Acute Flaccid subsequent sections. Paralysis (AFP) surveillance was carried out using local government structures. District Surveillance Nodal Polio Eradication Initiative: Emergency Officers (DSNOs) were responsible for surveillance, Operations Centre with oversight from the LGA and funding from the local government and the WHO. A review of the AFP system In October 2012, with funding from the Bill and Melinda identified the paucity of adequate data and surveillance Gates Foundation (BMGF) and support from UNICEF, documentation needed to analyze the performance WHO, CDC, Rotary, and eHealth Africa, Nigerian of reporting sites. AFP surveillance was laden with late national and state task forces set up a national EOC reporting and subsequently delayed classification by the and five state-level EOCs in high-risk states to oversee expert committee (Bassey et al. 2011). A WHO report the implementation of the Polio Eradication Initiative. recommended that DSNOs be under the supervision of The EOCs serve as the operational management unit, government and WHO structures at the state level to providing technical direction for the country’s overall ensure effective coordination of supervision. response to polio under policy guidance from the federal government. The EOCs are part of a larger polio Nigeria’s Polio EOC is significantly more advanced and, response ecosystem that includes the Presidential Task with polio eradication, has proven to be more effective Force on Polio Eradication, the National Primary Health than the country’s surveillance system. It does not Care Development Agency (NPHCDA), the Northern operate completely without the system, however, and Traditional Leaders Committee on Primary Health Care, pulls together financial and technical resources from and the Nigerian Governors’ Forum. various sources for its work. This has set a firm foundation for the Ebola response discussed below. The EOCs provide the setting from which government and partners work. Co-location offers the convenience of proximity for planning, decision making, and The Political Economy of Reform, implementation of strategies (NPHCDA 2013). Among the EOC’s key achievements in 2013, the Nigerian government Delivery, and Pockets of Effectiveness cites the coordination of inputs, strong implementation in Nigeria drive, and close monitoring. In addition to the Nigerian health sector’s institutional formation and its previous experience in crisis Decision making at the EOC is data-driven, identifying management, a third relevant contextual factor that critical gaps in programming and implementing strategies frames the Ebola response relates to Nigeria’s public required to address them. The EOC management team sector delivery capacity. It is common knowledge that the includes action-oriented national authorities on polio capacity of the state to deliver public goods has generally eradication from various government agencies, working been weak, and that Nigeria—a country of immense alongside technical experts from development partner natural resources and potential—is unlikely to meet many organizations. EOC management reports to the executive of the Millennium Development Goals (MDGs). director of the NPHCDA and to the minister of health on a weekly basis. The EOCs are also responsible for In the health sector, specifically, outcomes in Nigeria developing an accountability framework for stakeholders over the last decade have been mixed. Data from the last at all levels and for providing oversight and guidance in 6 Table 1:  Continuing Challenges in Meeting Nigeria’s Health Sector MDGs Indicator 2003 2008 2013   Infant mortality rate (per 1,000 live births) 100 75 69 Under-5 mortality rate (per 1,000 live births) 201 157 128 Maternal mortality ratio (per 100,000 live births) 800 545 576 Total fertility rate (number of children per woman) 5.7 5.7 5.5 Childhood malnutritiona/   Stunting (% children under 5) 42 41 37   Wasting (% children under 5) 11 14 18   Underweight (% children under 5) 24 23 29 a/ UNICEF defines (i) underweight as moderate and severe, moderate being below minus two standard deviations from median weight-for-age of reference population and severe below minus three standard deviations from median weight-for-age of reference population; (ii) wasting as moderate and severe, below minus two standard deviations from median weight-for-height of reference population; and (iii) stunting as moderate and severe, below minus two standard deviations from median height-for- age of reference population. See http://www.unicef.org/infobycountry/stats_popup2.html. Sources: Federal Republic of Nigeria, NDHS 2003, 2008, 2013; maternal mortality estimate for 2003 from UN Maternal Mortality Estimation Inter-Agency Group. three Nigeria Demographic and Health Surveys (NDHS)2 petro-state (Soares de Oliveria 2007), and its dependence demonstrate a 36 percent decline in the under-5 mortality on oil has diminished the need to re-enforce a social rate and a 31 percent decline in the infant mortality rate contract through public taxation in exchange for service during this period (Table 1). The country is still not on track delivery. This dependence has contributed to the rapid to achieve MDG4 on reducing child mortality, however. growth of centralized power through forms of political There has been almost no progress on MDG5 on reducing decentralization, fragmentation, and rivalry. maternal mortality, and fertility remains stubbornly high. Childhood malnutrition has actually worsened by some Despite compelling incentives and resilient structures measures (low weight-for-age has increased by 21 percent, that are deeply embedded in Nigeria’s history and culture, and wasting by 64 percent) and improved only modestly and that generally impede improved developmental by others (with stunting, or low height-for-age, dropping performance (Lewis and Watts 2015b), Nigeria has by 12 percent). nonetheless periodically experienced episodes of significant reform and pockets of effectiveness that Nigeria’s mixed performance—in the health sector defy this context. Outsiders who work on Nigeria know and beyond—has led to a deterioration of the social it to be a complex country with strong entrepreneurial contract between citizens and public authorities at all forces and capabilities that allow, under some conditions, levels. In many parts of the country, basic rights such as the emergence of reforms, institutional change, and, peace, order, and justice are not guaranteed. Nigerians’ ultimately, delivery. trust in decision makers and representatives is low in general, and trust levels decline along the delivery chain A series of case studies commissioned by the World from the federal-level government down to the local Bank to better understand why some reform initiatives government. LGAs, the frontline service providers, are move forward while others stall suggest that sequencing, perceived to be the least trustworthy and credible of establishing credibility early on, and creating a broader public agencies (Afrobarometer 2006, 2008). At the constituency for reform are critical features of any same time, Nigeria is often referred to as a centralized delivery process in Nigeria (Lewis and Watts 2015b). 2. The use of NDHS data, collected by the National Population Commission, allows for a consistent methodology over time and facilitates cross-country comparisons. The data are also recent. 7 Credibility problems loom large in the initial stages, given beneficiaries, and engaging popular groups in their embedded incentives and structures, making decisive agendas. Demand-side actors are rarely responsible for early actions essential for establishing new directions. initiating reforms in Nigeria but have played an important Shifting constituencies create both opportunities role in supporting them and keeping them on track. and difficulties for delivery, making communication, Building inclusive coalitions and using information and mobilization of support, and elaboration of strategies tactical skills to “crowd people in” is key to sustaining to deal with different audiences critical. support. The role of international technical assistance in supporting new forms of delivery or reform suggests Leadership is key in strong presidential systems like that solutions need to be well tailored to the local Nigeria, but it is not enough. It is important to form context and built on the basis of relationships of trust strong technical teams that can be isolated from political and local credibility. Many of these lessons from the interference, allowed to perform, and held to account broader literature on innovations and reform in Nigeria for results. Managers encounter strategic challenges are confirmed by this case study, as discussed in the in marginalizing or diluting opposition, mobilizing following sections. 8 Institutional Architecture   Institutional Architecture of Nigeria’s Ebola Response of Nigeria’s Ebola Response Organizational Structure The Senior Strategy Group, comprising several of the Response development partners and senior government officials from the Ministry of Health and NCDC, oversaw EEOC At the outset of the response, an Ebola Incident management. A Presidential Task Force comprising 18 Management Centre staffed by officials from the Lagos scientists, senior public officials (including the ministers State Primary Health Care Board (LSPHCB) and the NCDC of finance and health), and civil society leaders also played managed Nigeria’s Ebola response. This structure included an oversight role, particularly with regard to the allocation an incident manager, who is the technical head of primary and release of funds from the federal government for health care systems in Lagos State. This system relied the response. Several states established state-level task on traditional IDSR, streamlined into primary health forces as part of their preparedness efforts. care structures. The Ebola Incident Management Centre quickly morphed into an Ebola Emergency Operations Centre, with structures based on an incident management Information for Decision Making system (IMS) nomenclature. and Communication: Close The EEOC was led by a core management team that Supervision, Mid-Course Adaptations, reported to the NCDC, the minister of health, and and Bringing the Public Along the president, and comprised a 1,800-person team performing varying functions. The core management Data Flow team included both Nigerian and foreign-trained public Internally, the EEOC established clear reporting lines within health physicians and particularly epidemiologists, all teams as well as between team leaders and management serving in executive capacities within the federal and (Figure 2). The surveillance and contact tracing teams, Lagos State governments. comprising over 150 people, were responsible for field collection of primary data. The teams conducted over The EEOC formalized the involvement of federal, state, 18,500 household visits in two months, meticulously and local government actors, many of whom had in checking temperatures of primary and secondary some way attempted to initiate response activities at contacts. Contact tracing data were generated during various levels and scales—particularly Lagos State, with home visits using surveillance questionnaires and tablets initial support from the CDC and WHO. International with geolocation information and reported again during experts from partner organizations with the requisite supervision meetings. The surveillance team concurrently expertise (such as the CDC, WHO, UNICEF, and MSF) carried out rapid operational research to inform social were seeded within the response teams. For instance, mobilization strategies and the content of prevention the incident manager at the EEOC is part of the senior and control messages. Supervision meetings took place management of the Polio EOC. A senior official within every 12 hours, including managers’ review of operational the LSPHCB occupied the deputy incident manager data and teams’ “action trackers.” This allowed managers position and headed the Incident Management Centre to easily identify and address areas of underperformance prior to establishment of the EEOC. Operational teams or major implementation challenges. For instance, when included volunteers and civil servants from the Lagos a few members of the surveillance team misreported State Ministry of Health, LSPHCB, LGA Primary Health temperatures of contacts, owing perhaps to fatigue Care Authorities, Port Health Services, and NFELTP. given the sheer number of homes to visit, geolocation data were used to verify where they were at the time The EEOC follows a classic hierarchical organizational of reporting and to initiate corrective action for off- structure, with second-level functional organization site reporting. Data sharing took place among teams, (Figure 1). Specialist response teams were established, particularly those responsible for surveillance, contact each with a designated team leader. Team functions tracing, and case management. The teams worked included surveillance, case management, laboratory independently but in tandem to ensure cross-reporting service, social mobilization, coordination, and point-of- and transfer of contacts confirmed to be positive for entry response. Ebola. 9 Figure 1:  Organizational Structure of the EEOC Minister of Health Program Director NCDC Incident Deputy Incident Manager Media Manager Epidemiology/ Case Management/ Social Management/ Lab Services Point of Entry Surveillance Infection Control Mobilization Coordination Alert, Investigation, Evacuation House to House Diagnostics International Planning and and Response Team Social Mobilization Airports Budgeting Contact Tracking Rumors/Alert Sample Movement Land Borders Private Sector Social Media and Monitoring Investigation and Coordination (States) Engagement Logistics/Admin/ Infection and Training and Clinical Support Training Human Coordination Prevention Control Communication Resources Data Administration Clinical Care Advocacy Logistics Management Operational Decontamination Finance Research Psychosocial Secretariat Support Burial Team IT Support Source: Shuaib et al. 2014. Decision-making authority lay at various levels, depending Figure 2:  Data and Decision-making Cycle on the activity, and was guided by clear descriptions of jobs, tasks, and mandates. For example, the head of contact tracing was able to make many technical decisions Information on behalf of the contact tracing team at the EEOC and generated and make financial decisions regarding the organization’s shared logistical contributions to EEOC operations. Technical issues were reported at the end of the day, and issues requiring senior management approval were reviewed Action plans Real-time and approved at this meeting. Decision-making authority enacted monitoring of surveillance for implementation plans, resource requirements, staffing data generated acquisition, and training rested with team leaders, with oversight from the management team. Overall financial decisions regarding the use of federal government funds—including on procurement, disbursement, and Intense 12 hourly review of stipends or premiums paid to field workers—lay with Decisions taken surveillance data and team senior management, however. In certain situations, activities including ‘action- decisions were taken based on pre-existing information. tracker’ review with management For instance, when vehicles were required for surveillance activities, vendors with pre-existing relationships with the government were called upon to supply these, even in the absence of disbursements. This enabled the team to rapidly procure items that were critical to operations. 10 Figure 3:  Flow of Information to and from the EEOC   Internal/Formal: Team Leaders, EOC EOC Incident Manager, Social Mobilization HMH, NCDC Program Director, Task Force Management, Federal and State Government Team, Surveillance Team External/Formal and informal: Civil society including media/social media—situation reports, rumor management, stimulating stakeholders discussions e.g., Ebola Alert Tweet-a-thons Community/Informal: Support with contact tracing, stigma reduction, correction of myths The Senior Strategy Group was responsible for decisions alternative locations, this could be picked up. Team regarding the overall strategic direction of the response. members reported community and facility information to team leads. Team leads reported to the incident manager. International technical experts provided close support to The incident manager, deputy incident manager, and the head of each specialist unit. While there was country other members of senior management reviewed team ownership of the response execution, development reports jointly. partners were key players in determining the technical approaches employed by teams (see below for more External Communications: Creating on aid and technical assistance). Teams used terms of Awareness and Buy-in reference to guide their activities but had some degree of autonomy over microplanning and implementation. The Ebola Emergency Operations Centre used various Each team used the IDSR standard reporting forms at channels for external communications (Figure 3). The the outset. Instituting the IMS introduced a modified, EEOC communicated with the federal government, programmed set of reporting forms. Eight different tools including the minister of health and the presidency were used for reporting. (through the minister of health). The EEOC also communicated daily with the media through its media Although reporting was initially paper-based, the forms engagement team. The management of the EEOC were subsequently programmed into smartphones.3 engaged in daily press briefings to ensure adequate Personnel went through extensive training, going through information management and preclude widespread each of the forms and questions on the devices as a dissemination of rumors. Shortly after the confirmation group. Due to the urgent need to start collecting data, of the index case, there was a ramp-up of television and the information and communications technology and radio jingles, public shows of hand washing and use of data management support personnel modified and sanitizers by key societal figures such as the president reprogrammed the tools based on field reports, any and Lagos State governor, and circulation of a wide faulty questions, and review of reported data. Digitizing variety of information and educational materials. Civil the forms meant that there would be no missing variables society also played an important role in reshaping the in the data, allowing for 100 percent completeness in Ebola narrative. For instance, a civil society organization reporting. The GPS element of the phones not only worked with the government to staff the Ebola Alert facilitated real-time reporting, but also allowed the helpline and coordinate social media engagements with manager to maintain better control over inventory, health sector stakeholders and the public via its twitter since specific phones were linked to specific members handle @EbolaAlertNG. These social media platforms of the team. When phones were off or reporting from also provided an avenue for information from the public to reach the EEOC and the federal government. 3. The smartphones, SIM cards, and Internet data plans were donated by Etisalat telecommunications company as part of the private sector contribution to the response. 11 Building on and Complementing Services gained a new level of functionality through the Pre-existing Systems flow of resources, training, and experience gained from the Ebola response. For example, Port Health Services Harnessing Public Health Assets did not have functional ambulances, a health response desk, or clinics at the airport prior to the response and The Ebola response was not established tabula rasa, subsequently acquired five ambulances, a desk at each but was instead developed on the basis of pre-existing of Nigeria’s two largest airports, and costed plans for systems that were purposively, rather than systematically, the establishment of airport clinics. Also, the Federal identified (Figure 4). Although there was no clear Airports Authority of Nigeria’s longstanding request inventory or stocktaking prior to the response, ad hoc to recruit human resources as part of its reforms was identification of public health structures by government approved immediately during the response; over 400 officials enabled the EEOC to optimize existing physical environmental health officers were recruited to ensure and human resources. Shuaib et al. (2014) propose that to a critical mass of such expertise at the country’s borders. have rapidly established an operation as complex as this, the collective harnessing of all existing assets, combined with the establishment of an IMS, jointly take credit for Technology Can Greatly Enhance Processes the success of the response. Assets with different levels As noted above, EEOC systems moved quickly from of functionality, ranging from physical infrastructure, paper-based to digital forms of surveillance and reporting. such as the Infectious Diseases Hospital in Yaba, to The EEOC adopted the use of operational dashboards human resources in the NFELTP, all played key roles in that reported site data in real time. These dashboards the response. Most notably, the experience of the Polio took the form of large screens showing updated data, EOC management, from startup to project management reflecting new body temperatures of contacts during and surveillance using new technologies, was brought to monitoring periods. The system was preset to ring an bear in the Ebola response and was a critical driver of the “alarm” any time a contact being monitored was found operational efficiency that resulted in success. to have an elevated temperature. Use of pre-existing systems presented an opportunity to The use of technology helped to address two critical strengthen those that had previously been neglected or challenges. First, given the copious amount and depth of were poorly functional. For instance, referrals for Lassa data that needed to be reviewed on a regular basis, there Fever testing increased considerably during the Ebola was a significant possibility that errors would be made and crisis due to mix-ups in the symptoms. Similarly, LGA suspected cases missed. Some degree of data processing Epidemic Management Committees and Port Health Figure 4:  Public Health Assets Identified and Utilized during the Ebola Response World Health Organization (WHO), US Centers for Disease Control Nigeria Centre for Polio Emergency Primary Health Care (CDC), United Nation Disease Control Operations Centre system (Lagos State Port Health Children’s Fund (NCDC) (EOC) PHC Board) Services (UNICEF) • Previous • Incident Management • PHC Board • Human resources • Technical capacity experience with System that is involvement— provided TA and in: surveillance, lead poisoning action-based quick mobilization eventually case management, outbreak in 2010 • Adopted IMS of funds and constituted Point burial practices • Part of Polio nomenclature and human resources of Entry team and social Eradication structures • Epidemiological mobilization efforts since 2012 • Harnessed management sur veillance • Equipment, and technical systems—Disease technology personnel, NFELTP Sur veillance and • Human trainees Notification resources within • Existing working Officers (DSNOs) Ebola EOC relationship with CDC • LGA PHCA for and BMGF TA that was community easily transferable engagement • Technology (Monitoring, sur veillance systems) 12 and presentation on the operational dashboard allowed with previous Ebola outbreaks in the DRC and Uganda. for this analysis and review stage to be skipped, thereby Two WHO experts were solely responsible for case enhancing the rate and accuracy of reporting and decision management and were relieved by MSF experts until   making. Second, the accuracy of data and reliability of local health care workers were sufficiently mobilized data sources could have been questioned given the high and trained, having completed several dry runs of number of home visits expected of an initially short- facility entry and exit, patient management, and use of staffed team. The use of technology aided in this area personal protective equipment. Similarly, UNICEF’s years by ensuring that data sources (that is, the points where of experience in community mobilization were brought contacts’ temperatures were collected) were mapped to bear in social mobilization efforts. The European using GPS, thereby preventing misreporting. Union played a critical role in the early deployment of mobile laboratories for testing. This technical expertise Data collection forms were loaded onto mobile phones. was domiciled within the EEOC’s operational teams to The surveillance team’s quick adaptability to the use of advise and build the capacity of the local teams and these forms was aided by several factors. First, they concurrently carry out quality control (Shuaib et al. 2014). had already been using similar handheld devices for These organizations’ established presence and years of AFP (Polio) surveillance. Second, given the widespread implementing projects in-country precluded the need use of smartphones among Nigeria’s urban populace, for contextual learning, a process that often takes time technical facility for their use was readily available. Finally, in a country as complex as Nigeria. personnel recruited to the surveillance and contact tracing teams had been in contact with computers and National. Local teams brought with them varied types similar technologies on a day-to-day basis. It therefore and levels of skills and contextual knowledge. For example, only took a few hours for them to fully understand the certain foreign-trained members of the management forms and begin to use them efficiently. team offered a mix of deep local knowledge and first- class technical skills. Additionally, although its laboratory Aid and Technical Assistance: Contextual did not have the recommended biosafety levels, Lagos Knowledge, International Skills, and Applied University Teaching Hospital had the technical capacity to conduct laboratory diagnoses. Local teams whose Capacity Building expertise had been built over weeks of assisting the International. Despite the growing number of personnel response in Lagos were mobilized to support the being deployed from agencies such as the United response in Port Harcourt in Rivers State once cases States’ CDC, and increased funding to the tune of over were confirmed there. Some of these personnel are now US$400 million from the World Bank and € 14 million among the team of over 500 volunteers from Nigeria (US$18.7 million) from the European Union, global health supporting other West African countries hit by this crisis. agencies have been criticized for responding too slowly to the Ebola crisis in West Africa. The president of the The Nigerian private sector and business leaders United States has acknowledged that efforts made supported the response either directly—for example, the were insufficient if more infections and deaths are to provision of utility vehicles from Shell and MTN, a US$1 be averted in the region. million contribution through the Dangote Foundation, and 5N 100 million (US$621,000) from the Tony Elumelu In the Nigerian response, international development Foundation—or indirectly, including through Oando’s partners were at the battlefront well in time. Shortly contributions via coordinated platforms of the Ebola following the reported index case, the CDC offered its Containment Trust Fund and Etisalat’s support through technical support to the government of Nigeria for the the Private Sector Health Alliance of Nigeria. The latter, response. Other development partners, including the for example, lobbied telecommunications companies WHO, UNICEF, MSF, and the Red Cross, mobilized local to provide free post-paid SIM cards and mobile phones and international experts to support the response. The for surveillance and contact tracing operations and has United Nations Population Fund; the BMGF; Canadian continued engagements to coordinate private sector Department of Foreign Affairs, Trade, and Development; support for the post-crisis strategy. and the African Development Bank offered financial support. Mobilizing Human Resources: Development partner support was allocated strategically Crowding In and Motivating using the existing and functional Development Partners’ Group as a platform for coordination. In-kind support the Right Individuals came in the form of expertise, techniques, training, Nigeria’s response began with a team of less than materials, and commodities. For instance, WHO brought 20 people from the Lagos State Government and the to the response its international experience in dealing WHO, increasing to 100 people with the addition of the 13 federal government and other partners within a few days these funds remained unclear for several weeks, sparking of confirming the index case. Aside from government and controversy.5 N 200 million (US$1.24 million) was allocated partner secondees, most other team members working to the Lagos State Government and eventually disbursed during the first week of the response were primarily in the later weeks of the response. volunteers. The team eventually expanded to the full complement of 1,800 persons. These individuals were In the interim, and in the absence of federal funds in the recruited by invitation, including many high-performing early days, the Lagos State Government, international graduates and trainees of the Nigeria Field Epidemiology partners, and nongovernmental organizations funded Programme. Others responded to word circulating within initial activities. Within 48 hours of confirmation of the the health sector, as well as talk shops held by the NCDC. index case, the Lagos State health sector leadership These individuals had short-term contracts and were paid requested and received approval for 5 N 27 million a daily fee for the period of the response. Individuals (US$167,700) to renovate the Infectious Diseases Hospital. from the NFLETP or NCDC received per diem for feeding The fact that this early outbreak occurred in Lagos—the and accommodation. The NFELTP also handpicked several state with the highest internally generated revenue—has of its star graduates and trainees. The “per shift” fee been noted as an important factor by many observers. is largely credited for the success of the recruitment There were no reports of approval or disbursement exercise, as for some it served as a monetary match hitches within the EEOC, as team budgets were reviewed to the risk of exposure while taking care of infected and signed off by a management/coordination team patients. This highlights that—in a context where people responsible for budget approvals and financial processes. lack motivation, feel underpaid, or struggle financially— The intricacies of this remain unclear, however. financial incentives could offer significant impetus to ensure delivery of services. The bulk of external funding came preallocated and was channelled to the response team through the United Persons with clinical or public health expertise were Nations or CDC funds to specific activities. For example, employed in case management, contact tracing, and CAD$70,000 (US$54,700) was allocated specifically surveillance teams, while those with nonspecific through the International Federation of the Red Cross expertise were assigned to less technical services such as and Red Crescent Societies to support the Nigerian Red administration, finance, or data collection for operations Cross. The total value of cash and in-kind support to research. Incentives were based on job descriptions and/ Nigeria’s Ebola response has not been quantified, but or terms of reference adapted from the Polio EOC, and may be in the realm of US$10–20 million. were as large as 5 N 50,000 (US$310) per shift, in addition to other benefits. This incentive package seemed more The Federal Government of Nigeria also donated US$3.5 attractive to mid-level medical professionals such as million to other countries in the region. senior registrars, who now had the opportunity to earn an entire month’s salary in a week. It would appear that this package was not sufficient enough to attract Greater Together: Federal-State already established consultants, who earn approximately Collaboration N 1 million (US$6,200) per month in gross salary. 5 In a federal state such as Nigeria, coordination between Personnel were trained on case management and contact the various levels of political and technical leadership tracing by international experts and on surveillance by a could have proved challenging in delivering an emergency technical team from the Polio EOC. Due to the urgency response, especially as there was an urgent need for both of implementation, training focused heavily on practical technical leadership and quick allocation of resources. sessions, after which team members were deployed to Lagos State had mounted a response immediately specific tasks. Detailed job descriptions guided personnel after the first case of Ebola was confirmed and rapidly activities within teams. approved the release of funds for operations. Notably, the Lagos State Government’s approval of resources for the renovation of the Yaba Infectious Diseases Flow of Funds: Bridging Early Hospital—a federal government-owned facility—took place prior to the federal government’s announcement Hitches to Evolve into Coordinated that it would allocate funds for the response. Federal-State Action Shortly after the Federal Government of Nigeria had With the activation of federal actors, and after declaring declared a national emergency in the wake of the Ebola the outbreak a national threat, the federal government outbreak, it announced an intervention fund of 5 N 1.94 chose—rather than instituting a parallel response—to billion (US$12 million) to strengthen the emergency modify the existing state response. The result was a single, response. The exact status of disbursement and flow of strong national EEOC with shared fiscal responsibility. 14 This institutional setup avoided the overlaps in With regard to interstate collaboration, the president resource allocation that have occurred in other fiscally convened the Governors Forum to develop state-level decentralized areas of Nigeria’s health sector. EEOC staff emergency plans should the outbreak spread across   from federal and state governments worked under the states. This mechanism served as a strong foundation technical direction of a single management team, itself for cooperation between Lagos and Rivers states after comprised of managers from both federal and state the disease was identified in Rivers State. levels. 15 Lessons Learned: What Can Lessons Learned: What Can Nigeria’s Experience Tell Us about the Foundations of a Successful Emergency Response? Nigeria’s Experience Tell Us about the Foundations of a Successful Emergency Response? Fear as a Great Motivator for All richest states of the Nigerian Federation . . .” with large, highly mobile populations. Similar rhetoric was used in Many doubted that the Nigerian government would Nigeria, “thanking God” that Ebola came through Lagos mount an effective response, let alone contain the State borders and not any other, pointing to the fact Ebola outbreak in a complex, politically sensitive, and that the alertness and aggressiveness of the response only partially functional institutional environment. to Ebola were due in part to the fact that its arrival in International views of Nigerians and the Nigerian Lagos significantly raised the profile of the outbreak. This government had the potential to write off success before hypothesis is further validated by comparison to the it was even attempted (Nwuke 2014). Then, to everyone’s rural onset and spread of the outbreak in Guinea and the surprise, the response was not only quick and efficient, length of time (about four months) it took for Ebola to but also successful. This has raised the question: “how?” officially be declared a national emergency. Many observers have responded: “fear.” Second, Nigerians are prototypically labelled, by Ebola’s arrival in Nigeria incited fear and widespread themselves and others, as people who “love themselves” panic, as it presented threats unknown, unquantifiable, and are afraid to die. This refers both to a collective and unimaginable. Nwuke (2014) reports on a CNN death of the nation and to individual mortal death. commentator’s remark that the default belief was that Hence, some argue, we see the thriving of new religious Nigeria would become the “exporter” of Ebola to the denominations that preach prosperity and long life to rest of the world. This fear snowballed in response to its people, the growing commercialization of herbal the repetitive and dominant narrative in local and global remedies and supplements intended to support a longer media of a seemingly uncontrollable outbreak that was life span, and seemingly perpetual dislike across ethnic ravaging several countries in West Africa and would soon divides without secession of any from the others. In the hit the rest of the world. context of the Ebola outbreak, this deeply embedded fear of dying spurred the general public to put more First, there was a personal and individual fear due to pressure on the government, both informally and more the contagious nature of Ebola, particularly in light of formally through civil society and media, to respond the fact that it arrived after the devastating impact quickly. the disease had already had on the West African population, economy, and social fabric in other countries Third, Nigeria’s global reputation seems to have been a in the region. Moreover, the fact that the index case motivating factor. Global narratives began to quantify was a senior diplomat resulted in the “it could be me” the potential losses in billions of dollars. Spicer et al. syndrome, motivating the country’s elite to act. Nwuke (2014) posit that, in Nigeria and other similar contexts, (2014, 4) describes succinctly that symbols can be an quantitative information is invariably privileged over “instrument of civic pedagogy,” purporting that Ebola, a qualitative evidence. While many in leadership positions disease normally associated with poor regions, “entered may not have been able to foresee or forecast the Nigeria as a ‘middle class disease.’ It came in on an exact economic implications of such an outbreak, the airplane, was smuggled in by a middle-class American of approximation may have been somewhat like this: the Liberian descent . . . landed in Lagos, which has a literacy projected fiscal loss to the West African region, whose level of more than 87 percent [and] showed up in the two economies were much smaller than that of Lagos, was 16 Figure 5:  Translating Fear into Action   Pressure from general public and civil society Sense of urgency Shared purpose, clear focus to Political will, Establishment Perceived and contain the convergence of of responsive real threat spread of Ebola political leadership systems in Nigeria on the commitment Demands for response from Quick decision-making Nigerian public and international rapid execution community • Availability of funds in Lagos state • Mobilization of external human resources in the range of Nigeria’s foreign reserves and therefore trust and reassurance between the government and its akin to the unimaginable loss of the country’s entire people, even if only during the weeks of the outbreak “rainy day fund.” This concern may have been buttressed (Nwuke 2014). Following the government’s initial step, by visible changes in the investment climate, including all actors and stakeholders involved in the response— the withdrawal of expatriate mining company staff regardless of their motivations and levels of appreciation from countries where the outbreak had spiralled out of the threat—came together in pursuit of a common of control. This scenario resembles Nigeria’s experience purpose, with a shared focus and a clear expected with militancy in the Niger Delta, where it took the outcome (Figure 5). visible withdrawal of strategic oil company staff from flow stations and platforms, together with plummeting Adams (2000) proposes that social groups oppose oil production, to finally urge action on the part of potential reform because of a belief that it will harm their the government (Okonta 2014). Viewing the threat to economic interests. He adds that their political weight is the macroeconomic outlook and potential threat to a key determinant of whether the opposition can stall revenues vis-à-vis costs of containment fueled the fears such reform. Similarly, social groups support political of the political and business elite. actions that protect their economic and other interests. In the case of the Ebola outbreak, the aggregation of Within a few days of the outbreak, Nigeria’s president political weight, pivoted on shared purpose, is all the declared that the government would do anything leadership that was required. The result was a functional possible to contain the outbreak. The government and responsive system with limited bureaucracy and took immediate action following this announcement, competent and accountable technical leadership—a convening an emergency meeting of the National Council close ideal, if ever there was one. on Health. These actions re-established a relationship of 17 Technical Leadership Capacity Exists State Parliament recently voted to rename the Infectious in Nigeria and is effective when Diseases Hospital in Yaba after her, in memoriam. unleashed Even in the presence of dedicated political will and Incentives and Health Workers’ leadership to address the outbreak, the response Motivation: Bypassing Inertia while might still have been ineffective without the technical leadership demonstrated by key health sector actors Motivating Passionate Individuals from both the public and private sector. It is worth highlighting here that, despite the use of certain elements of a pre-existing system, including The Minister of Health, Dr. Onyebuchi Chukwu, served human resources, the Ebola response had to externalize as a “broker” between political and technical cadres. The those resources, institute alternative processes, and minister provided the president with daily updates on draw selectively from a pool of experts who were either the outbreak and advice on next steps. The deployment motivated or could be externalized. of Polio EOC personnel to the EEOC, for example, was an important government decision taken on the advice Paradoxically, the same fear that drove the response of the health minister and development partners, threatened to deter it on a micro level when health care based on their knowledge of the gains made in polio workers could not be mobilized to support the EEOC’s eradication. The minister was able to ensure that key case management, contact tracing, and surveillance federal and state government actors such as Dr. Faisal functions. News emerging from other West African Shuaib, Professor Abdulsalam Nasidi, and Dr. Kayode countries was revealing high infection rates among Oguntimehin, all of whom are infectious diseases health care workers, with over 240 infected at the end specialists and epidemiologists with decades of in- of August 2014 and only half of them having survived. country and international experience, were at the helm This identified and labelled health care workers as the of operations for the response. This sort of effective most vulnerable group in this response. Additionally, technical leadership had not been marshalled in response in the months preceding the Ebola outbreak, the to outbreaks of other diseases such as Lassa Fever or Nigerian Medical Association (NMA) had presented avian influenza. the government with a set of grievances concerning years of low wages, mismanagement, and rivalries with The health minister also served as an interlocutor allied health professionals. This friction had soured the between the government and the Nigerian public, relationship between the Nigerian government and the regularly giving updates on the status of the outbreak, NMA and resulted in strike action that was ongoing at on actions taken by the government, and on progress the time of the Ebola response. The NMA, in a bid to recorded. This deep understanding of the nature of stand firm in its position and reasoning for strike action, public health threats, particularly in the context of a initially decided not to be part of the response but rather broader underlying mistrust between Nigerians and their to “monitor” its progression. government, was pivotal to regaining the trust and buy-in of the public, as earlier asserted. Only a small group of less than 100 volunteers willingly, and without external motivating factors, joined the At the operational level, the index case in Nigeria’s Ebola EEOC’s response teams. A respondent from the EEOC outbreak could have been missed, given that it presented suggested that many of them did so because they felt a in a private facility that did not have clear channels of sense of duty or were responding to a call for help from communication with the public health sector. Dr. Ameyo humanity as part of their “purpose.” Similarly, a member Adadevoh, a consultant physician at First Consultants of the NFLETP staff said that she “just got up and went Medical Center in Lagos, demonstrated exceptional to Lagos” and stayed on a full two weeks before returning astuteness and professionalism in quickly considering home, even though she did not have clothes, while her a differential diagnosis for the patient and raising a red other colleagues declined to participate in the response. flag by informing relevant authorities that Ebola may Following heavy criticism from the Nigerian government have entered Nigeria. Dr. Adadevoh acquired personal and other sectors, the NMA leadership called on doctors protective equipment and Ebola information and to support the Ebola response while sustaining strike educational materials to distribute to her staff. Despite action. They heeded this call, although not without pressure from the patient’s employers to discharge incentivization. him, she enforced a quarantine that many attribute to preventing a wider outbreak. Although Dr. Adadevoh lost In her study on the motivation of primary health her life on August 19, 2014, her critical role in the response care workers in Nigeria, Bhatnagar (2014) reports self- has merited continued recognition by both the Nigerian efficacy, vocation, religion, and humanity as key intrinsic government and public as a “martyr” and hero. The Lagos motivators. She suggests that most Human Resources 18 for Health interventions in Nigeria currently focus on For example, the minister of health and the president extrinsic motivators, particularly financial incentives, with received daily briefings, but decisions on action items little integration of other organizational factors such as such as the procurement of vehicles for operations and   good working conditions. Knowledge and mistrust of approval for this within a 24-hour period were up to the existing organizational gaps in the health system might EEOC leadership. Each of the specialist units, which were have served as an initial disincentive for health workers. headed by expert epidemiologists and supported closely However, out of the pangs of these resource limitations, by international experts, used their terms of reference to creative solutions were borne when the EEOC devised guide their activities but had some degree of autonomy an incentive-based personnel mobilization strategy. over microplanning and implementation. Decisions on Health care workers’ reactions were twofold. Those implementation plans, resource requirements, staffing who participated in the response did so as individuals acquisition, and training rested with team leaders, with rather than as members of professional health bodies, oversight from the management team. compelled primarily by large shift premiums and other hazard allowances and benefits. For other health care Despite the likelihood of a directive management workers, especially some of the doctors on strike, approach, owing to the emergency nature of the neither financial incentives nor the provision of personal operation and the EEOC’s hierarchical organizational protective equipment was sufficient to incentivize their structure, the clarity of functions for each of the specialist participation in the response. The WHO’s Ebola response units fostered the autonomy that teams needed to roadmap, released later that month, advised that develop their own operations. Through this operational- “governments must rapidly establish a comprehensive level autonomy, the EEOC was able to override a system package that defines the salary, hazard pay and—where in which files could pass through multistage approvals, appropriate—insurance/death benefit available to each taking weeks or months. At the same time, the review category of worker required to implement the national and supervision process was coordinated and regular strategy” (WHO 2014a). enough to ensure the teams’ accountability to EEOC management and the flow of information across teams rather than just vertically. Operational Efficiencies: Clear Roles, Responsibilities, Autonomy, and Proactive Communication Technical Assistance: International Expertise Tailored to Local Reality Shuaib et al. (2014) state that contact tracing efforts are burdened by the complex nature of transit, commercial, Builds Trust and Results and public health notification and reporting mechanisms. The global threat presented by Ebola underlay the With a human resource capacity of 1,800, the EEOC’s international response in Nigeria, taking into account need to meticulously review all data generated frequently considerations such as Nigeria’s highly mobile population, with minimal error and to make and execute decisions with links to many countries abroad, as well as the quickly required more than just technical capacity. widespread local presence of international nonprofit Nigeria’s primary health care systems have struggled in organizations and businesses. Leach (2008) proposes that the past with coordination and the translation of policies the media-fueled narrative focuses on the threat to and into practice, owing to limited access to operational need to protect northern populations, rather than on the funds from higher levels as well as to bureaucracy fear of an emerging plague that could globally “infect us making implementation of basic decisions protracted all.” Irrespective of the genesis of motivations, Nigeria and unwieldy. Although the EEOC had initial funding had never had an Ebola outbreak, and the fear of both delays, operations were still executed efficiently. This is a localized and wider outbreak similar to that in Guinea, due in part to a bit of innovative thinking on procurement Liberia, and Sierra Leone was a crisis that no one was processes, as well as to stopgap funding from a state that willing to envision. There was also the risk that such a had the means and could leverage potential contributors scenario would undermine the state’s capacity to respond. from the private sector. Also important was the fact that Attention turned to the international community to decision making took place at the level of the response share its knowledge and expertise, resulting in a well- team/unit heads and at the senior management/strategy coordinated, complementary partnership. group level. International and local experts jointly used a “holding In its core structure, the EEOC exhibited autonomy room” approach in the management and execution of at two levels. At the management level, the EEOC the response. The level of cooperation and coordination management team could carry out operations quickly was greatly enhanced by the presence of technical and in a manner devoid of bureaucracy, yet remain assistance that had already been in place in Nigeria and accountable to health sector and national leadership. was therefore well positioned to broker international 19 expectations and expertise within available systems. All of but also across teams, and thus catalyzed operational the development partner representatives in the strategy efficiency. A notable example is the transfer of patients group had worked in Nigeria for five years or longer. from the surveillance team to the case management team Locally, a crop of experienced field epidemiologists with the onset of symptoms and upon confirmation and EEOC managers who had already established a of laboratory results. The two teams attained such an work rhythm with development partners through the efficient rhythm that team members colloquially termed NFELTP and polio eradication efforts created an enabling it the “SWAT” operation. environment for the receipt of partner support. A gap still remains in making data available to public health One form of assistance—perhaps unintended, but practitioners and researchers for retrospective analyses. present—was “silent arbitration,” through which the Use of these data could be invaluable to implementers presence of development partners focusing solely on of health programs in Nigeria, and to the ongoing regional outbreak response encouraged local leadership, despite response. A detailed documentation process led by the opposing political stances and different levels of federal government and supported by various consultant government, to focus on EEOC efforts and continue to teams is underway and may yet provide more evidence steer in the direction of success. A respondent mentioned from the country’s response. having to “put all aside and work together to fight this thing,” referring to initial friction over who should lead In addition, in the early days of its operations, the EEOC and own the response. Although there was no outward learned a lesson from an initial threat to containment contention, there was some tension following the CDC’s efforts. Within a few weeks of the Ebola outbreak, a request for a staff member from the NCDC to lead the rumor (initially circulated via social media and later via recruitment process for the case management team, SMS) convinced many people all over Nigeria that drinking when it seemed that the personnel initially instituted and bathing in salt water would protect them from Ebola by the state government were not getting results. This infection. Within 48 hours, at least two fatalities were arbitration helped smooth in-country and North-South recorded as a result of ensuing hypertensive crises. cooperation and create partnerships that yielded results. Although the EEOC had already structured daily media engagements, this was a frantic call for dissemination of The rapid capacity built among a significant number of accurate information and a reshaping of the narrative Nigerians positioned the country to provide regional of fear and panic into one of awareness and adherence. support by deploying—in a relatively rare example of South-South cooperation—over 250 personnel who Embedded in a communication channel that had initially were initially part of Nigeria’s Ebola response to assist the caused harm was an opportunity to disseminate accurate responses in Liberia, Sierra Leone, and Guinea. Traditional prevention information proactively. Prior to this, the cooperation between Nigeria and development partners media had led the Ebola narrative, often speculating is a metamorphosis of the old aid narrative, which Leach on areas where information was missing or not shared (2008) refers to as presenting a heroic west versus a weak by the government. For example, a great deal of media and needy developing world; Nigeria’s is rather a tale of speculation followed the government’s release of partial global concern, collaboration, and shared success among information about a family under surveillance who had local and international heroes alike. escaped, without disclosing who the individuals were or where they had been. Although the information management and public disclosure strategy was Data and Information Sharing informed by the medical ethics of confidentiality for Good Decision Making (including permission to disclose information if there is a public threat) and careful consideration of cultural and Adaptive Implementation sensitivities around stigma (better understood after years Nigeria’s Ebola response generated significant amounts of HIV programming in the country), the Ebola crisis of data at rapid rates, which were reviewed intensely on highlighted the ethical dilemma of balancing disclosure a frequent basis and used to modify implementation and confidentiality in the face of possible threats to the strategies and plans. This use of data highlights the public. importance of data-informed decision making to yield results. In addition, the fact that the data were of Ebola-related fatalities were a stark reminder that, in good quality (thanks, in part, to the use of handheld the absence of proactive dissemination of accurate devices), well organized, accessible, and analyzable information, the media will ultimately decide whether further enhanced the value of the information. A critical we will be afraid or aware, and people will make poor conjecture here is the catapulting effect of data-informed decisions on the basis of inaccurate information. In decisions on the pace and quality of implementation. countries such as Sierra Leone, myth and rumors Data from the response flowed not only vertically, circulated for such prolonged periods that a reversal of 20 the prevention message was not easy. Many refused to by individuals from outside the public system, and adhere to quarantine instructions, and some refused to instituting within it new processes and highly skilled and be treated. One Ebola facility was looted by hoodlums motivated individuals. In using existing infrastructure   who gave little thought to the risk of exposure. The ability and human resources, implementation could be quick, of key decision makers in Nigeria to recognize and quickly and considerable cost savings could be achieved. This reverse communication trends not only informed the approach contrasted with years of implementing vertical public on preventive measures but also helped build the programs that set up parallel structures, complicating trust that was needed to elicit widespread cooperation coordination and imposing significant costs. from such a large population. The use of pre-existing systems also presented an opportunity to strengthen those that had been neglected Building On—and Strengthening— or were poorly functional, as in the example of increased Pre-existing Systems referrals for Lassa Fever testing during the Ebola crisis due to mix-ups in the symptoms. The Ebola response system was established using pre- existing elements from the health system, complemented 21 Implications of Nigeria’s Ebola Implications of Nigeria’s Ebola Response for Service Delivery More Broadly Response for Service Delivery More Broadly This case study confirms the growing body of evidence Several important conclusions apply to health sector that pockets of effectiveness exist in Nigeria. Despite reform and service delivery more broadly: the country’s international reputation for governance challenges and ineffectiveness, the country is full of • Effective leadership. The unexpected policy response potential and is able to act when certain factors are to the Ebola outbreak reveals strong political and in place. In this case, the fact that Ebola was blind to technical leadership in the country, which can be economic class and threatened the elite was a primary spurred to move beyond political will and the will to motivator for the strong institutional response. It act toward firm commitment and execution if there is difficult to know, however, how replicable such an is a sufficient threat. In addition, despite systemic experience would be in other areas of service delivery. weaknesses such as fragmentation, bureaucracy, mismanagement, and transparency challenges, Nigeria Other critical factors that have been documented in can organize systems to be responsive and efficient. recent work on pockets of effectiveness are also borne Good motivation lies at the heart of any successful out it this case study. Strong, passionate leadership, action, and fear was a great motivator in this case. The coupled with first-class technical capacity—achieved in question remains how to elicit this strong leadership this case through a blend of contextualized international in the absence of an immediate public threat. The assistance and a highly capable Nigerian team—are answer may lie in the packaging of narratives and critical for effective delivery in Nigeria. Ensuring that such findings on global health issues. teams have clear roles and responsibilities, strong internal • Timely action. The earlier mini-case studies on the lead communication, and freedom from political interference poisoning outbreak response and the overwhelming is also important. A proactive communication strategy Ebola burden in neighboring countries demonstrate is required to build a broader coalition of support, the potential harm of delayed responses, whether due and demand-side actors such as nongovernmental to governance challenges or inadequate surveillance organizations play a helpful role in delivering reform and systems. In Nigeria’s Ebola’s response, timeliness was results in Nigeria. critical to the country’s ability to contain the spread of the disease. Federal government officials have said Delivery in this case was enhanced by the existence of that declaring a national public health emergency systems and practices, although in a hybrid arrangement upon confirmation of the first case of Ebola allowed in which passionate individuals were “hired in” to deliver for the required systems to be put in place (Shuaib the response when official health workers were on strike et al. 2014). Most response activities, such as planning or felt too threatened. Initial hiccups in fund flows were teams, contact tracing, and case management, had bridged because the outbreak was in relatively well- attained implementation synchronicity within a resourced Lagos State, and procurement practices were few days of index case confirmation as a result of streamlined to deliver goods when and where they were optimal combinations of political leadership, technical needed. Technology played a useful role as part of a competence, and good decision-making tools. A broader strategy, supporting evidence-based decision similar situation was reported with regard to Senegal’s making, close supervision of data collection, and quick response and containment of the virus. This points adaptations as necessary. The case shares these factors to the importance of ownership of processes and with a number of other case studies commissioned by suggests that projects can be extremely successful the World Bank on pockets of effectiveness (Lewis and if technical processes are intricately tied with Watts 2015b). government oversight, especially if such processes are owned by the government. 22 • Meaningful autonomy. Giving mid-level technical • Relevant technical assistance. Technical assistance managers control over the planning and management must be timely and provided within context by of their operations circumvents unwieldy bureaucracy people who have an understanding of local systems,   that can throttle a rapid response. It allows them organizational culture, and sectoral and political to find innovative solutions to challenges and can dynamics. This is best achieved in collaboration catalyze the efficient decentralization of functions. with competent and highly motivated local experts. This is consistent with the findings of performance- Acknowledging each partner’s strengths and expertise, based financing (PBF) interventions, which show as well as matching them in a manner that is that health care results are achieved not by policy complementary to the achievement of a certain goal, makers but by technical cadres at operational levels, are both necessary and critical for such partnerships particularly when they are granted autonomy. to be successful. It is also important to recognize the Moreover, autonomy and accountability are not value of technical assistance agencies, which goes mutually exclusive and can coexist in a manner that beyond financial and technical skills and could play optimizes the delivery of priority interventions. out in mediation or coordination. • Well-designed incentives. Incentives can help motivate health care workers, but they must be packaged and When Nigeria’s traditional primary health care system is offered in accordance with the broader economic, juxtaposed against its Ebola response (Table 2), it presents political, sectoral, and cultural context. Development a tale of two systems. This study shows that there are of incentive-based approaches should be considerate pockets of effectiveness within that traditional health care of intrinsic motivators and the premium placed upon system, although it may be premature to declare them those we seek to incentivize. Understanding situations entirely successful. The World Bank has made investments where financial incentives can work alone and at various levels of Nigeria’s primary health care system to those where they need to be integrated with other encourage improvements in health worker performance nonfinancial tangible or intangible incentives is central and accountability, as well as accountability among policy to the success of any such strategy. Adams (2000) makers at the local government and state levels using proposes that sector institutions and social groups are results-based financing (RBF) approaches, including PBF. pertinent to the political support base of policies and This approach aims to strengthen institutions and is interventions; therefore, their inclusion, recognition, showing promising early results. Results to date suggest and incentivization must be planned in the context of that targeted incentives, a flexible nonrecurrent budget, longer-term effects on their commitments. Bhatnagar and increased autonomy can strengthen coordination (2014) also prescribes exploring strategies that can and service delivery. A recent pilot of an information and potentially engender intrinsic motivation within the communications technology-based social accountability given context. system within the RBF project shows improvements in • Existing assets. Identifying existing assets and quality of care using data from operations and citizen resources—whether organizational, infrastructural, feedback. Table 2 compares the three systems to draw human, or fiscal—and quickly harnessing these some parallels in the lessons learned. techniques, technologies, and processes can yield rapid results while ensuring policy continuity. This Health systems and policy reformers will benefit was the case, for example, with the Ebola response’s from understanding not only what has worked in the adoption of techniques used in polio eradication contextual immediateness of the Ebola response, which and in the LSPHCP. Systemic reviews and extensive was vertical in nature, but also what may be sustained mappings of sectoral assets and their functionality and eventually institutionalized from within Nigeria’s could be informative in such a process. pockets of effectiveness and the challenges that persist • Data-driven decisions. Data should not merely be therein. Going forward, it will be important for the generated, but utilized. The availability of data for Nigerian government to remain vigilant, building on decision making affects not only the quality of the lessons learned during the Ebola response and the decisions but also their credibility. Making information effective platform provided by the EEOC to strengthen available, if properly generated and adequately its overall disease surveillance systems and continue utilized, fosters the potential for real-time learning efforts to ensure strong technical leadership and regular and application of lessons learned, which could communication with the public. prevent catastrophic mistakes and guide corrective actions. There is room for strengthening health sector leadership in this area in Nigeria. 23 Table 2:  Juxtaposing Nigeria’s Traditional Health Care System with the Country’s Ebola Response Primary Health Care in Performance- Traditional Primary Health Care Nigeria’s Ebola Response based Financing States • Fragmentation and poor • Coordination strengthened • Improving coordination of primary coordination between federal, very quickly and secondary health care, although state, and local government • Clear accountability in most referral systems could still be levels matters (especially technical) strengthened • Unclear accountability and • Certain degrees of autonomy • Accountability of health workers poor performance review to • Intense review of to LGA leadership and all levels of strengthen it performance/data to make leadership accountable to citizens • No incentives for good decisions as well as counterparts performance or disincentives • Motivation and incentives for • Copious amounts of data for poor performance “volunteers” generated and minimally utilized • No cash or autonomy at • Release of funds for for a while; various strategies health facilities operations introduced to foster use • Incentives for health workers resulting in changes in quality of care and improvements in organizational performance • Healthy health facility earnings from PBF available for operations independent of release of funds from government with liberty to allocate in alignment with broad guidelines Sources: World Bank, Nigeria State Investment Health Project, Project Appraisal Document (column 1); Nigeria State Health Investment Project operational and review reports (column 3). 24 Bibliography   Bibliography Abubakar, Aisha A., Mohammad N. 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