Good Leaders Are Selfless and Always Question the Status Quo
Nigeria is sub-Saharan Africa's most populous country, with an estimated 130-140 million inhabitants according to the World Health Organization. Most people (52 percent) live in rural areas, although a substantial portion (27 percent) lives in cities with populations greater than 100,000.
Among the most daunting of Nigeria's public health issues is HIV & AIDS. Although Nigeria's HIV prevalence is lower than that of the adjacent southern Africa region, averaging 3.6 percent, an estimated 3.3 million people are living with HIV & AIDS, placing the country second only to South Africa in terms of the global infection burden. With funding from the United States Agency for International Development (USAID) and other donors, MSH is currently assisting the Nigerian government and private entities in Nigerian States to strengthen health systems, and improve access to quality health services.
MSH spoke with Dr. Paul Waibale, MSH’s Project Director and Senior Technical AIDS Advisor on the Prevention Organizational Systems AIDS Care and Treatment (ProACT) project, about the importance of good leadership, management, and governance in strengthening health systems.
What does the term “leadership” mean to you?
Leadership is an individual or team attribute that continuously stimulates fundamental changes to occur first in the values and beliefs of self and people followed by changes in the thought content, habits, and actions. As these are nurtured and reinforced, leadership then becomes a character of the individual or team, a way of doing business. Leadership is about being selfless and constantly questioning how the status quo could be improved for common good.
For example, 1,100 mothers per 100,000 live births are dying from preventable child birth-related conditions in some states of Northern Nigeria. The Ministry of Health (MOH) sets a target of reducing maternal mortality rates by 50% in the next 5 years because that is what is realistic within their level of thinking and resources. This is where those who will stand to be counted as leaders will say “NO” and declare this a cause that cannot wait. They will ask questions like, has the woman, husband, and community been informed about the dangers of this decision? Is there nothing that they can do for themselves to augment the government interventions? What are the “major root causes” of the status quo and by whom and when shall they be mitigated, if not now? Efforts to respond to these questions will generate new directions of action and empower individuals, teams, and society to commit to a change.
Good leadership sees the vision, galvanizes the energy of all actors towards a shared vision, and takes paths known and unknown to create the vision. Emergence of leadership at various levels then propagates the change even when the initial leader steps aside.
Why is good Leadership, Management, and Governance crucial to a strong health system?
I will use a metaphor to illustrate my point. In a health system, the infrastructure, the supplies and commodities, the health information system, and indeed all other remaining health system building blocks, including human resources, are the “hardware.” Left to themselves they are as useless as a 10 billion dollar sparkling hospital with only 30% of the staff needed. What moves the “hardware” is the “software” – the people or health workforce that has the right mix of leadership character. It is not just the quantity of health workers, but how the ministry of health or health facility uses the individual and collective skills of the workforce to achieve common shared goals is what makes the difference. People with the right leading and managing principles and practices move the rest of the health system.
MSH through its Leadership Development Program (LDP) is empowering individuals and teams to transform clinics, departments, and entire ministries of health. After three years without a response from His Excellency the Governor of Kogi State, the Kogi State Ministry of Health (SMOH) was able, after a MSH ProACT-organized LDP training to convince the Governor to establish three comprehensive HIV & AIDS care and treatment centers in three remote Local Government Areas.
The Nigeria SMOH has increased antenatal attendance from 40% to 60% following implementation of an action plan developed at MSH-supported LDP training. Therefore, leadership by the people (executive government, legislature, technocrats, health workforce, community leaders, families and individuals) is what puts life to otherwise mortal health systems.
How is the ProACT program improving health in Nigeria?
The Prevention Organizational Systems AIDS Care and Treatment (ProACT) is a USAID-funded MSH managed project in Nigeria. We do not directly provide HIV & AIDS and TB services, but we build the capacity of government, health facilities, and community based organizations to plan, manage, coordinate, monitor and evaluate HIV & AIDS service-delivery.
The ProACT approach right from the start has been to strengthen government, health facility, and community systems for service delivery. We have provided HIV counseling and testing services to at least 250,000 persons, guiding them to make informed decisions about their lives. ProACT has enrolled over 12,000 HIV positive persons into care and encourages them to live positively with HIV and take precautions to reduce re-infection and transmission to others. With ProACT support, 7,000 people were put on life-saving antiretroviral therapy (ART), 500 mothers were provided ART prophylaxis to reduce transmission of HIV to their babies, and over 2,000 orphans and vulnerable children were reached with basic care and support services.
In summary, ProACT is saving lives – for example we found one woman with full blown AIDS stigmatized and abandoned in a kraa (a livestock enclosure) in Kebbi State. We helped start her on ART and now she is well and a peer educator for new mothers initiating ART at the health facility. She has become a leader of change.
ProACT’s modest lessons are being packaged and shared locally and internationally. For example the project was invited by USAID to share our model of decentralizing facility-based HIV & AIDS support groups and their integration into communities at an implementing partners meeting in Abuja. The ProACT combined systems strengthening and service-delivery model is providing lessons to guide implementation of the Nigeria PEPFAR Country Partnership Framework, and the Global Health Initiative along the principles laid out in PEPFAR II.
How are gender-based approaches included into the programming?
ProACT has mainstreamed gender in its goal and interventions. The approach has been not to look at gender as just male/female disaggregation of data or the usual conventional stereotypes about gender. Instead, ProACT has trained project staff alongside partner state and health facility workers to continuously recognize gender disparities in all plans and activities they undertake and to make deliberate efforts to reduce them.
For example, when we found that women in Kebbi State were not returning for Preventing Mother-to-Child Transmission (PMTCT) of HIV prophylaxis because their husbands were stopping them, the project, through the Emir traditional leader, mobilized and sensitized over 700 men to support their wives. Paradoxically, more men began to fill the testing clinics in the following six months before we began to see a rise in number of women attending PMTCT services.
Service providers look for gender disparities in access to information and services and are taking remedial actions within their reasonable resources. For example, daily CD4 testing was introduced in Adamawa State after it was found that many mothers testing HIV positive and given appointments to return another day could not find time to return. The project is introducing men groups after realizing that most HIV positive support groups are being used predominantly by women.
What have been the biggest challenges the project has overcome?
The biggest challenge has been to change the staff mindset from “let the project provide everything since it is USAID money” to “it is partnership and the Government of Nigeria can and should meet its obligations.” It has been a paradigm shift for state governments that were used to an array of donor support to working in a trusted partnership with MSH in which they see their capacity to manage and own the HIV response. Also, it has been a challenge to get health workers enthusiastic and committed to providing HIV & AIDS services without extra pay from the project, even at sites with over 2,000 clients on ART.
What do you hope to accomplish in the remaining years of the project?
The project is working to continuously improve the HIV response in Nigeria and to get buy-in from the Government of Nigeria to improve HIV services at all levels throughout the country. This will include further capacity building of the government, health facility, and community teams to lead and manage the response. We want to apply of the LDP model to address other health challenges. ProACT is working to ensure that leadership is nurtured to grow and become a practice throughout the health systems. And, ProACT is supporting the Ministry of Health to integrate HIV & AIDS systems and services with other health conditions.