Q&A with Dr. Zipporah Kpamor: Nigerian Organization Leads AIDS Project

MSH: Tell us a little bit about yourself, your background, and how you decided to become a doctor.
I went to school here in Nigeria, at the University of Jos. After the basic medical degree, I did a residency in the Faculty of Community Health. I worked briefly teaching medical students [Dr. Zipporah Kpamor]Dr. Zipporah Kpamorand then began development work with the Centre for Development and Population Activities (CEDPA), starting with expanding access to reproductive health services in the north. Because the women there were in purdah, we went house-to-house, delivering services in their homes using innovative models.

After that I joined Family Health International and worked with the GHAIN (Global HIV/AIDS Initiative Nigeria) Project. Then I moved back to CEDPA, to the Positive Living Project, improving the quality of life of people who are living with AIDS by increasing their access to care and support services. From there I came to the Christian Health Association of Nigeria (CHAN) to continue increasing access by providing treatment services to people who are living with AIDS and their families in hard-to-reach areas. That’s actually the challenge: meeting people where nobody else has dared to go with HIV services. CHAN is able to provide services to those persons.

MSH: Are the people CHAN is trying to reach difficult to reach for a particular reason? Is it geography, is it their being rural, or is it a combination of reasons?
Yes, it is a combination of reasons, the first one being they’re very rural people, and in Nigeria about 70 percent of the population is rural. And infrastructure is very, very basic. So you don’t have roads to get you to those places, and you don’t have water, you don’t have electricity, and because of the lack of infrastructure, nobody wants to work in such places, you know. So access to health care is very limited.

Missionaries brought in health care and education, and that is why CHAN is able to get to those communities, because all of these missionary health facilities are owned by CHAN member institutions. These rural mission hospitals come together and form this very big umbrella which is CHAN.

MSH: Does the CHAN umbrella also do any large-scale purchasing of commodities or anything like that, or is it predominantly an organizational function?
Yes, CHAN actually has two main units. One unit provides primary health care services, and one component of primary health care is essential drugs. The second unit of CHAN, therefore, was formed so that they’re able to make these essential drugs available to the CHAN member institutions at prices they can afford. They can do bulk purchasing, and costs will be reduced because of the bulk purchase.

They also deal with principal partners like the International Dispensary Association and are sure of the source of the drugs they are purchasing. You know, Nigeria has had a big problem with fake drugs. And CHAN has warehouses so that they can adequately store these drugs.

MSH: How many member organizations and facilities are there, and how many people do they serve?
CHAN was established in 1973 by three organizations: the Catholics Bishops’ Conference of Nigeria, the Christian Council of Nigeria, and the Northern Christian Medical Advisory Council of Nigeria. It started with very few members but has grown: now CHAN has 358 member institutions.

These 358 institutions are running about 4,000 facilities—dispensaries, health posts, hospitals, and comprehensive health centers. A survey conducted by the World Health Organization, I think in 2004, showed that CHAN was second to the federal government of Nigeria in health care provision to the people of Nigeria and that CHAN actually is responsible for about 40 percent of health care service provision in the country.

MSH: It sounds like it has led the way. So how did CHAN come to have the Nigeria Capacity Building (NICaB) Project?
Several things have changed since CHAN started. Epidemics and outbreaks came up, and there was the problem of the six killer diseases; CHAN rose to the occasion by doing mass immunization and so on. CHAN is also concerned with diseases that affect the more vulnerable part of society—the women, the children. And when it comes to diseases like tuberculosis, like leprosy, the churches were the ones to take care of people. So when HIV became a pandemic and was then associated with tuberculosis, it was just a matter of time before mission hospitals began bearing the brunt of care, because they were already doing these things.

The member institutions started prodding CHAN to seek support because the drain on them was too much financially and even professionally. So CHAN, after implementing one or two projects, saw the civil society Annual Program Statement and felt that it was strategically placed to respond to it and sought out MSH as a technical partner, and USAID awarded the grant to them in 2007.

MSH: So what has that relationship with USAID been like?
USAID has been quite supportive and very, very patient with CHAN. CHAN as an indigenous organization had never worked directly receiving grants from the US Government. This was the first time that CHAN was receiving direct funding from USAID, and therefore there was lots of feedback CHAN needed to provide. Before the grant was awarded, USAID did a pre-award survey, looked at CHAN’s systems in order to be sure they could manage such a grant.

The first day we put a person on ART, that was the biggest day for me because this is the first time an indigenous Nigerian organization is receiving funding directly from the US Government and placing people on treatment.

MSH: To be sure they had the capacity?
Yes. Based on that, a plan was developed and included in the grant as it was being awarded, and MSH through the Leadership, Management, and Sustainability (LMS) Project was given the mandate to work with CHAN to meet those preconditions. It’s taken CHAN longer than the six months planned—over a year now—but tremendous progress has been made.

MSH: Could you describe that progress?
USAID found that CHAN had significant challenges in its systems, mainly its financial management systems. We needed specifically to get an accounting package, the staff needed to be trained on how to manage USAID funds, and so forth. Those things have been done. We also needed to recruit staff and strengthen communication among the CHAN secretariat, the project, the member institutions, and the zonal offices. We also set up an information technology system.

MSH: About your working relationship with MSH: What is that like, what is good about it, and what has been surprising to you about it?
MSH has helped make sure that CHAN is empowered to carry out the activities and deliver the targets in the proposal. Apart from placing an MSH staff person right here in Nigeria, they have employed technical staff who mentor CHAN and staff from CHAN member institutions on service delivery and also on putting systems in place. For example, they came out to help us with our site assessments with getting those sites up and running, ensuring that quality is maintained, that standards are put in place, and that those standards are upheld.

One of the things that surprised me pleasantly about this relationship is the way MSH works as a body. When we started out, it was the LMS Project that was here, and the way they just took off and supported us, you would think that they were part of the NICaB Project, but LMS is quite a different project. I’m looking forward to even more support from MSH, and I know being the big brother, so to speak, they’re able to oblige us and provide whatever support that they can.

MSH: What are your hopes for the future, for next year, and for the end of the project?
NICaB is mandated to deliver in three broad areas. The first one is building the institutional capacity of CHAN as an organization. Now the secretariat is able to function to such an extent because we have put systems in place—financial systems, program management systems—and we’re looking forward to putting an M&E system in place so that it can capture all of these numbers that are flying around.

The ultimate goal is for us to be able to support the CHAN secretariat to compete in a grant proposal and win. That would go a long way in sustaining some of these activities and the systems that we have put in place, ensuring that they’re continuously funded.

Apart from supporting the secretariat, we’re working directly with member institutions to create model centers. Once those models are up and running efficiently, we can get them to “sell” this idea to the other member institutions.

MSH: Could you give an example of a model institution you’ve selected?
NICaB is going to work with 12 member institutions and has already started working with 6: St. Francis Hospital, the Seventh Day Adventist Hospital, St. Anne’s Hospital, NKST Hospital, and Holy Family Catholic Hospital. And then we’re working with the United Methodist Church of Nigeria, their comprehensive center in Zing. In year two we’ll add another 6 sites. Once we’re able to get these sites providing quality HIV & AIDS services, then we’ll use them as models for the other 300-plus sites so that they can learn from what these sites are doing. The model centers will mentor the other sites and train members within the community to support services at the centers.

Members within the community will tell other members, “You know, these services are provided in this place, and this is what you will need to access those services.” So they will serve as advocates for these sites within the community. This will increase coverage and increase access to sites. We also train them to provide some services to clients in their homes so that not all patients end up in the hospital.

MSH: That’s wonderful. So if you look across those six sites, what’s your rough estimate of how many workers might have been trained?
We have trained over 50 workers on topics that include comprehensive ART, laboratory services, and HIV counseling and testing. We have been able to reach about 200 people with ART. We have also counseled close to 4,000 people now.

MSH: What do you think is the most important lesson that you’ve learned in this work so far in leading the project? What has surprised you?
I have always known that there is a dire need to be met within our community, but what surprised me was how much there is within the community that we can tap into to meet this need. Help does not always have to come from the outside, and I discovered that very pleasantly. When we went to one community, Saint Anne’s, to activate that site, there was so much that needed to be done. We needed to turn around the maternity and the lab, do renovation work, paint, lay tile, put in cupboards, and so on. We looked at our budget, and we didn’t have half of the money that we expected would go into that project. And lucky for us our visit coincided with a Sunday service, so we went into the church and we told them about the NICaB Project that is building good-quality services for people living with AIDS. We said, “We have come and assessed Saint Anne’s Hospital and found that we need to do a lot, and we’re counting on your support to do that because we have seen that we just can’t do it all.”

Right in the church a member stood up and said, “Okay, I am interested in this project. It’s a lot of good things that you’re going to bring to the people. I’d like to identify with this project, and therefore please come and collect half a million as my own contribution to the project.”

Half a million Nigerian naira! That’s half our budget. And once we collected the money, we were able to prepare that hospital to be activated.

MSH: Talk about community ownership! Looking back on your whole career as a physician, what’s the accomplishment you’re most proud of?
The first day we put a person on ART, that was the biggest day for me because this is the first time an indigenous Nigerian organization is receiving funding directly from the US Government and placing people on treatment. All the other organizations that have done this have been international NGOs. They’ve been the ones to access PEPFAR funding and then support local organizations to do it.

We’ve been making lots and lots of progress ever since. The slogan of this project is like Obama’s campaign slogan: “Nigerian organizations have the capacity to do it.”

Visit the All Africa site to learn more about the NICaB Project.