With only 5,000 of the over 120,000 backlog of VVF cases repaired annually in the country and 12,000 new cases occurring every year, Dr. Iyeme Efem, Project Manager of Engenderhealth, managers of USAID Fistula Care Project in Nigeria says community participation and prevention of new cases of Fistula are two major factors in the elimination of Fistula in the country. In this interview with AKPUS JOHN, he also speaks on the partnership between the project and the Cross River State Government on Fistula at the Ogoja General Hospital.
Your project extended its treatment programme to Ogoja in Cross River State, what has been the reaction of the people and how would you assess the quality of service?
First, it is a great success that we can clearly claim in partnership with the Cross River State Government. We have been able to site a centre here that responds to the challenging issue within the community. Before now, people in the community, the state and others did not know that fistula was a major challenge in this part of the state but we were able to identify, and in discussions with the state and so on, we got commitment to set up the centre and since we set it up, close to 250 women have been repaired of fistula in the centre.
We have always had more women coming in than the bed space. We only have 24 bed spaces, but we have 50 to 60 women registered so you have to ask them to go back and come within the next cycle of repair. It clearly shows that the need is great in this part of the world. There is need for a concerted effort. The state government cannot do everything. The development partners cannot do everything. Beside the project has a life span. It is going to end and move on. And so, there is a need to get all stakeholders to come on board and decide if this need is going to be addressed in a sustainable way. When we sat down and looked at it, we had to engage the communities in a sustainable way. The good thing about this is that when the community buys into it, it becomes self-propelling because the community would take it on. If the communities propel it on their own, the local government and state would become more involved because in the political dispensation, these are the people that would vote for the government.
How will the project get to the grassroots, because in remote places, people still need to know about the VVF Centre?
The good thing is that you have the National Healthcare Development Agency Strategy, (NHDAS) that goes right down to the grassroots through ward development and village development committees. So, if these systems are already set up and are there, there is no need to create another system through moving out and mobilizing the community. So, what we do is to tap into the existing system, support it to function more effectively and then you step back and allow it work. So, we are like catalysts. We come in and catalyze the Ward Development Committees (WDCs) so; they do what they have to do.
What we did was, first of all, was to bring all the members of the WDCs together in Ogoja and we talked to them about what the issues are. So, when they talk about it, it opens their eyes and they ask what they can do, and we say there is a lot they can do. We tell them to create awareness and help women to respond to all those things that would help prevent it. They don’t only serve as agents for identifying and repairing, but also as agents of prevention. So, that is one of the reasons we focus on them as our Community Engagement Strategy, (CES).
What is the level of enthusiasm of traditional rulers who are heads of the WDCs in terms of Fstula?
At community level, most times, women issues are left with the women to discuss. However, decision making is for the men. So, you find out that men make decisions without realizing the impact of those decisions on the women because women are not part of the decision making process. So, what we did was; bring all these traditional rulers, put each person in the primary health care centre as well as the primary health care coordinators together, and we sat down and talked about this issue of women.
By the time we talked about the challenges these women face; going through pregnancy, then being asked to go through unskilled hands in delivery, obstructed labour, and the suffer that follows, and when they do not die, the consequences, the injury as the result of that. These women are really in pain inside, and there is nothing as bad as the pain inside you that you cannot express. So, the men felt compelled to do something about it. In their responses they were surprised that those kinds of things existed and were surprised that the treatment is free.
And then the question is if the treatment is free and so on, all they needed was get these women to go to the facility and they would get healed. So they were really shocked to understand that there is really no cost implications in healing such a debilitating injury and so for most of them now said that whatever it is that they can do to ensure that our women who have this get treatment. Whatever we can do to ensure that our women do not get this injury in the first place, we would do. So that is the excitement that we have. They are energized, they are enthusiastic about it and they want to hit the ground running and what we do is to catalyse them to hit the ground running.
Ogoja Senatorial Zone is made up of several local governments, at the moment you are partnering with the state government on Fistula, do you envisage any kind of partnership between your project and the local governments within the zone?
Definitely, the local government administrations are directly involved in managing the ward development committees. That is why we have the primary healthcare coordinators in the local government who relates directly with the ward development committees as part of those leading. The primary healthcare coordinator would eventually bring the local government chairman, who would the act based on what they look at and see.
You see, sometimes, projects come but they come in the middle of the year, when local governments have already completed their budget and all that so it becomes difficult to find funding source to address that. However, what this does is that it gives them a head start, so in the next budget cycle, they would include all of these in their budget and then they would be able to execute effectively. Like Ogoja Local Government area is now feeding the women who come there, so even people from other local governments benefit from that feeding which is good. That is the great partnership we are talking about, they cannot afford it. And when you go to a hospital, you get free treatment but you don’t get food, you don’t heal properly.
What are some of these things that you look back to on this project and you would remember and say, I have done a good job?
Well, we are entering the 7th year of implementation and for me it has been a long road to travel. First, in spite of all the challenges that we have faced I can clearly say we have raised the profile of fistula in Nigeria. So people know fistula. We have also made it known and shown also that fistula is not just a problem of the North. It is a problem of Nigeria and it is a problem of the developing world. Wherever you have poor healthcare delivery system, you have Fistula.
Therefore Fistula is a marker to show that we have a poor healthcare delivery system whether in the north or in the south. Whether you are in Ghana or anywhere, you have Fistula there. So if it occurs, you need to do something to address it. So, I am glad that we have been able to do that. I am also glad that we have been able to bring in the religious people who have been able to clearly champion it. They are becoming champions of Fistula. When I met with His Eminence, the Sultan of Sokoto, he was very supportive and he told the religious leaders to support us and we educate the religious leaders who are now talking about it in North and western states.
Funding for Fistula at the federal and state levels have been a recurring problem, what can be done?
At national level, we have pushed and taken senators to all the fistula centres, so they were able to see first-hand and then we worked with them and we got budget line item into the Federal Ministry of Health budget for Fistula. So now we have a fistula budget line item. That is an achievement. We have also ensured that now you can count Fistula occurrence in any part of the country where we are working at the federal level. We are working in nine states now. So at federal level if you go to HMIS and you pull out data, you can see data for fistula. Two years ago it was not there. Nothing like that was existing, so you go to HMIS and they don’t have Fistula, and you know what they say, if you cannot count it, you cannot plan for it.
If you cannot plan for it, you cannot budget for it. Now you can count it, there is budget for it and then we have helped the Federal Ministry of Health to develop a national strategic framework that would look at the elimination of fistula in Nigeria. So that framework is currently in print. So by the time it gets ready, hopefully we would launch it in soon. The minister would launch it in by the end of the year and then people would start to implement it. We would have a coordinating system through the national obstetric Fistula working group which again, we in collaboration with UNICEF and other key stakeholders put together. So that is now some kind of a coordinating body for Fistula. So you see at the federal level and at the state level. In Ebonyi we have worked with them and we have been able to get that centre to become a federal establishment. Now a lot of states want federal presence.
Are we expecting to have a second National Fistula Hospital soon?
Well of course the budget is there but what we are now asking for is they should be a criteria or a set of criteria to follow within which to determine if a centre is right for this as a federal centre. So that is what we are working on now. You cannot just wake up and say we want this centre to be a federal centre. Let’s work on the criteria because once you have that criteria, it also helps you plan, knowing who is likely to come on board, what implications would that have on the budget and so in the next cycle you budget for it. In terms of surgeons we have increased the number of surgeons who now do fistula repair through our training programmes. You know we have helped to set up fistula centres in the south, Ebonyi of course a success story,Ogoja in Cross River State is another big success story.
And we have other states that are saying why don’t we come in, but again we say let’s step back and look at the criteria for setting up centres. Now that we have centres in several places that can be reached what is the existing backlog. Because the backlog of Fistula cases would tell you where they are more prevalent and then you can design a programme or plan or whatever to address that backlog. So those are the general things we are looking at. We did an assessment funded by USAID in partnership with UNFP Federal Ministry of Health, Federal Ministry of Women Affair. We went round some selected states did an assessment. We did an environmental scan from all over Nigeria wherever fistula is developed and what we found out was that the actual backlog for Nigeria is about 160, 000 to 200, 000 women living with fistula. Also the likely incident that is new yearly occurrence of new cases is about 12, 000 women coming up with fistula every year and the number of repairs that are been done on annual basis total in Nigeria is under 5, 000.
So in other words, you are having a little above 7, 000 women with fistula that cannot be treated and they keep entering the backlog every year. Our strategy is and I like to use examples to show, you already have a bucket that is full of water and the tap is still flowing into that bucket so the water is overflowing and you are given a spoon and asked to empty that bucket. With that tap running you would not succeed. That tap that is running is the new cases that are happening, the bucket that is full and overflowing is the current backlog that exists. What do we do? First of all as a nation we need to turn of the tap. When we work to turn off that tap, then we can take the spoon and when we see that the spoon is no longer enough to empty the bucket, we can then get people with a lot more spoons or even get cups. And who should drive that? the federal ministry of health.
In this strategy you just talked about, where does communication come in as one of the variables use to address the issue?
First of all the people have to hear of what it is you are talking about. What it is you are educating them about. So right there, you are communicating. So the question is what is the best way of communicating our messages to people? The best way depends on what your target group is. For us we stratified our targets. We looked at first of all those who are living with the condition. Those who are impacted by the condition, including the children of the women, the husbands, the family members, and then we look at those who make decisions that control the lives of these women and the traditions that control their lives.
And then we look at those who set policies for all of us and those who legislate. So what you stratify in targets like that would stratify what the best medium to reach out to these people and what messages we should put in those mediums. So you find out that in addressing the legislators and so on, we do a lot of radio and television activities, because the legislators want to listen and watch, so they learn from there. We also work with the government people. When you come down to the communities, then you look at what radio stations, which languages and so on.
But it is clearly very important to note that our work has a major platform that has helped it succeed and that major platform is the media,