Bridget Akudo Nwagbara, FHI 360
Immaculata Amadi, FHI 360
Benmun Damul, FHI 360
Andrea Surette, FHI 360

The COVID-19 pandemic highlighted the importance of improved case management and critical care, and the Government of Nigeria responded with increased investments. The United States Government (USG), through the U.S. Agency for International Development-funded Meeting Targets and Maintaining Epidemic Control (EpiC) project, complemented these efforts by enhancing the capacity of the Federal Ministry of Health (FMOH) to provide COVID-19 case management and critical care — including the capacity to receive, install, and use 200 USG-donated ventilators.

This technical assistance began in August 2020 with a facility-level assessment of the readiness to provide critical care — including ventilator use for severely ill COVID-19 patients — at 88 isolation and treatment centers in all 36 states and the Federal Capitol Territory. The results of the assessment guided EpiC’s capacity strengthening efforts.

By November 2021, EpiC had trained 24 master trainers, who then provided “stepdown” training to 210 health care workers on the use of the donated ventilators; had provided training and clinical mentoring on COVID-19 case management to 950 health workers; and had trained and mentored 120 health workers in critical care, including COVID-19 critical care. To support continued improvement, EpiC established a community of practice for COVID-19 critical care and assisted the FMOH in coordinating case management and critical care for COVID-19.

EpiC also convened a series of three webinars and a national policy dialogue to translate the lessons learned from this strategic technical assistance to sustainable policy decisions that will enhance the government’s capacity to provide case management and critical care during the COVID-19 pandemic and future public health emergencies. The webinar series was held September 14–16, 2021, and the national policy dialogue took place on November 30.

These events featured panelists from the FMOH, USAID, the World Health Organization, FHI 360, General Electric Healthcare, and the Society for Critical Care Medicine, as well as public and private health care providers, patients, and international health experts. The dialogues resulted in the following key recommendations:

Strengthen infrastructure for critical care through the private sector.

Efforts to scale up case management and critical care after the emergence of COVID-19 were led by the Government of Nigeria through public sector secondary and tertiary health facilities. The 88 COVID-19 isolation and treatment centers that received technical assistance in critical care and case management were public facilities. However, scaling up and sustaining access to the infrastructure needed for case management and critical care (including equipment, commodities, consumables, power supply, and medical oxygen) require strategic collaboration between the public and private sectors. The following features of a public-private infrastructure partnership are therefore recommended:

  • Sustainable impact investing approaches from the private sector (beyond the reach of philanthropy)
  • Total market approaches that prioritize affordability and equitable access to critical care
  • Flexible procurement and leasing agreements that include long-term preventive maintenance of critical care equipment
  • Reductions in regulatory and policy barriers that prevent the private sector from investing in critical care
  • Decentralized critical care units that are within geographic and socioeconomic reach of the Nigerian populace
  • Equitable health financing mechanisms that are pro-poor and reduce the high out-of-pocket payments for critical care
  • Use of “green bonds” to improve power and medical oxygen supply (Green bonds are fixed-income instruments that are designed to support climate or environmental projects.)

“The value chain for critical care is diverse. We need a diverse range of investors to deploy sustainable business strategies like lease arrangements, after-sales maintenance, and longer warranty periods to strengthen critical care delivery in Nigeria.” — Modupe Shittu, General Electric Healthcare, West Central Africa

“We need a total market approach for critical care service delivery that is pro-poor and equitable.” — Moses Katbi, USAID

“Collaboration between health care providers and technology providers is key. Health care providers should focus on providing high quality care, while technology providers will make their work easier.” — Kabiru Mohammed Aliyu, Information and Communication Technology (ICT) Expert

Scale up virtual approaches for health care worker capacity strengthening.

Before the COVID-19 pandemic, the public health sector in Nigeria relied heavily on in-person delivery of both didactic and practical training for health care workers. Adapting to COVID-19 required a shift to virtual training to curb the spread of the virus while building health care workers’ knowledge and skills to provide clinical care to COVID-19 patients. EpiC used virtual distance learning methods to train more than a thousand health care workers. The project adapted training courses from the Society of Critical Care Medicine (SCMM), which allowed the FMOH to quickly and efficiently strengthen the capacity of health care workers to respond to COVID-19. Those health care workers attested that the training empowered them with skills that enabled them to save the lives of critically ill COVID-19 patients in often challenging settings. Virtual training in COVID-19 case management and critical care should be scaled up through a strategic collaboration between the Society for Critical Care Medicine, educational technology providers, the FMOH, and communities of practice in the health sector.

“More people will be trained if we move from classroom/in-person trainings to online trainings.” — Emmanuel Affa, University of Calabar Teaching Hospital

“The Fundamentals of Critical Care Course helped non-intensivists to make better clinical decisions” — Job Otokwala, University of Port Harcourt Teaching Hospital

Use digital tools to enhance patient engagement.

Myths and misinformation about COVID-19 are commonplace, and many people do not know when and where to seek care for severe forms of COVID-19. This challenge is compounded by the complex new workflow that health care workers must navigate to provide quality case management and clinical care to COVID-19 patients. Digital tools should be leveraged to rapidly disseminate facts about COVID-19, help patients find and navigate the multiple service delivery points required for COVID-19 care, and enhance the capacity of health care providers to improve the quality of care. For example, the SCCM course was deployed through an online training platform. The Online Reservation Application (ORA) tool (which EpiC developed and deployed to help people living with HIV gain access to and navigate HIV care and treatment services) can be adapted and used as a powerful engagement tool for COVID-19 patients and care providers. The adaptation of the ORA tool should consider literacy levels, local contexts, and the need to facilitate referrals between different levels of health care.

“Navigating the various services for COVID-19 prevention and management is cumbersome. The ORA app can help patients navigate services.” — Dr. Osaheni, University of Benin Teaching Hospital

“Automating COVID-19 case management and critical care processes will reduce the frustration that patients experience. ORA is a key step towards this automation.” — Kabiru Mohammed Aliyu, ICT Expert

Photo Credit: Stakeholders meet during the national policy dialogue to discuss lessons learned from the critical care technical assistance (Prince Agala/FHI 360).