Impact of a Newly Established Revolving Outbreak Investigation Fund on Timeliness of Response to Public Health Emergencies in Nigeria

Abstract

Timely access to emergency funding has been identified as a bottleneck for outbreak response in Nigeria. In February 2019, a new revolving outbreak investigation fund (ROIF) was established by the Nigeria Centre for Disease Control (NCDC). We abstracted the date of NCDC notification, date of verification, and date of response for 25 events that occurred prior to establishing the fund (April 2017 to August 2019) and for 8 events that occurred after establishing the fund (February to October 2019). The median time to notification (1 day) and to verification (0 days) did not change after establishing the ROIF, but the median time to response significantly decreased, from 6 days to 2 days (P = .003). Response to disease outbreaks was accelerated by access to emergency funding with a clear approval process. We recommend that the ROIF should be financed by the national government through budget allocation. Finally, development partners can provide financial support for the existing fund and technical assistance for protocol development toward financial accountability and sustainability.

Introduction

NIGERIA has been affected by outbreaks of infectious diseases that strain the public health sector and cause significant economic and social disruption.¹ The country's population density, tropical climate, poor socioeconomic indicators, and other factors increase its risk of infectious disease outbreaks caused by endemic diseases such as Lassa fever, measles, yellow fever, cholera,² and emerging zoonotic pathogens such as monkeypox and Ebola viruses.¹ In 2017, a study by the Nigeria Centre for Disease Control (NCDC) and Dalberg estimated that the aggregated economic impact of 4 disease outbreaks—Lassa fever, cholera, cerebrospinal meningitis,³ and measles—cost 3.8 billion naira (approximately US$9.12 million).⁴

NCDC is the country's national public health institute with the mandate to prevent, detect, and respond to infectious disease threats and other public health emergencies.⁵ As part of its legal obligations, NCDC has a responsibility to support states in response to outbreaks.

Nigeria implements the World Health Organization (WHO) Integrated Disease Surveillance and Response Strategy. Disease surveillance and response to disease outbreaks begins in health facilities, with reports aggregated and transmitted to state authorities from the local government area level. Each facility has a focal person who gathers patient records and submits data to the local government area disease surveillance and notification officers. These officers provide technical support to health facility focal persons on disease detection, verification, reporting, sample collection, packaging and transportation, and response to outbreaks. The state surveillance and notification officers and state epidemiologists work together to collate reports from all local government areas into a state summary form, which they submit to NCDC at the national level.⁶ While the sequence of events required for reporting can result in delays in timeliness to notification and response, Nigeria recently implemented an electronic surveillance system that enables immediate transmission of data from local government areas to state and national levels.

Investigation and response to infectious disease outbreaks or other public health emergencies requires a timely approach to prevent further spread and minimize the health consequences of the event.⁷ Critical timeliness metrics have been proposed to measure the impact of a country's ability to detect, notify, verify, and respond to outbreaks.⁸ A consensus statement by leading global public health agencies was developed in Salzburg in 2018, with definitions for outbreak milestones to be measured.⁹ These metrics were integrated into the monitoring framework for the WHO Thirteenth General Programme of Work 2019-2023.¹⁰ Implementation of the monitoring framework requires countries to standardize data elements for serious public health emergencies and measure the timeliness of event detection, notification, and response.⁹ A study of 296 outbreaks in the WHO Africa region found that between 2017 and 2019, the time from event onset to detection and end of the outbreak decreased, whereas the time from event onset to notification increased.¹¹ A study of the 2016-2017 outbreak of meningococcal meningitis in 3 states in Nigeria revealed that time delays in initiating outbreak investigation and response activities by state and federal governments contributed to the severity of the outbreak and led to an increase in the number of cases and deaths from the disease.¹²

As a federal government institution, NCDC is primarily funded through the government's budgetary allocation.¹¹ In 2017, the agency was allocated 1.5 billion naira (US$3.9 million), but only 49% or 700 million naira (US$1.8 million, or 0.9 cents per capita) was released to the agency for its activities. The allocation amount increased in 2018 to 1.6 billion naira (US$4.1 million), but only 38% (US$1.6 million, or 0.8 cents per capita) was released. The increase in funding to NCDC resulted from sustained awareness and advocacy efforts toward policymakers on the importance of health security financing and the passage of the NCDC Act in 2018, which created an annual budget line for the agency.⁵ Funding for NCDC support human resources, operations, and capital projects, with a limited reservoir available for outbreak response activities. In 2019, the budgetary allocation for NCDC decreased to 1 billion naira (US$2.6 million). In comparison, the United Kingdom's Public Health England had a budget of US$369 million in 2018 ($6.60 per capita),¹³ and the fiscal year budget for the US Centers for Disease Control and Prevention was US$11.1 billion ($3.38 per capita) in 2018, a decrease of US$1.0 billion since 2017.¹⁴ Given the limited financial resources available to the NCDC, it depends on support from various partners to augment its budget to implement emergency preparedness and response activities.

To accelerate outbreak response efforts, NCDC, with support from partners, established a revolving outbreak investigation fund, which has the ability to release funds rapidly and enable the deployment of multidisciplinary teams to investigate, verify, and contain outbreaks before they become larger events. In this article, we describe the establishment of the fund and its impact on timely verification and response to outbreaks in Nigeria.

Methods

Establishing the Revolving Outbreak Investigation Fund

The ROIF was established through a partnership between NCDC, the African Field Epidemiology Network (AFENET), and Resolve to Save Lives, an initiative of Vital Strategies. Through a request from the director general of NCDC, the organizations developed a standard operating procedure to determine qualifying events, expenditures, approval chains, and reporting on performance metrics. The standard operating procedures were developed collaboratively, formalized, and approved through a tripartite agreement between the partners. Initial seed funding and replenishment was provided by Resolve to Save Lives, with the objective of creating a pooled and rapidly accessible funding source for qualifying outbreak investigations, for use by multiple donors. In addition, Resolve to Save Lives provided stable overhead support to AFENET for financial management and reporting to ensure judicious and externally audited use of the funds. The director general of NCDC authorizes an outbreak investigation and approves the release of funds as quickly as required. Once the request is approved by AFENET's authorized signatories, the requested amount of funds is disbursed from the ROIF bank account within 24 to 48 hours of receipt of request. Where possible, AFENET pays the investigating team directly for costs related to travel and procurement of emergency supplies. Funds for other team logistics are advanced to the team lead and/or team members to cover a deployment period for up to a maximum of 2 weeks unless an extension is approved by the NCDC director general. All funds are paid by electronic funds transfer and rates are aligned with NCDC approved rates as specified in its best practices manual.¹⁵ The AFENET administrative officer then notifies the team lead when funds are disbursed. Team leads are responsible for ensuring complete accountability documentation, including submitting an investigation report to AFENET within 5 days of completing deployment. Reconciliation is done after each deployment to ensure balancing of accounts. The ROIF is maintained in a dedicated bank account and reconciliation is done monthly. AFENET provides a monthly financial report to NCDC and donors supporting the ROIF. The monthly report includes a bank statement, a list of expenditures, and variance analysis.

Data Sources and Analysis

We obtained data on disease outbreaks between 2017 and 2019 from NCDC. Major variables included in our analysis were the date of detection (when the outbreak or disease-related event was first recorded by any source or in any system), date of outbreak notification (when the outbreak was first reported to a public health authority), date of outbreak verification (earliest date of outbreak verification through a reliable verification mechanism), and date of outbreak response (earliest date of any public health intervention to control the outbreak).⁹ The data were abstracted from outbreak situation reports, rapid response team final reports, SITAware (NCDC's incident management system), and technical working group reports. They were analyzed using Microsoft Excel and SPSS Statistics for Windows version 21 (IBM Corp., Armonk, NY).

To perform a statistical comparison of timeliness to detection, verification, and response to outbreaks before and after the ROIF was established, we tested for assumptions using a parametric test. For the 2 sets of continuous data, we tested for the normality of the data using a histogram and Shapiro-Wilk test. The data did not meet the assumption of normality and thus we opted to use the Mann-Whitney U test to compare measures of central tendency. The analysis assumed that the groups are independent, and the data are not normally distributed.

This study was not considered human subjects research and was granted an ethical review waiver by the Nigerian National Health Research Ethics Committee.

Outbreak Milestone Definitions

We used outbreak milestones to establish the timeliness metrics for country-level studies as described by Smolinski et al.⁸ The definitions for each milestone are:

Outbreak start – date of the symptom's onset of the first reported case; if it is not available, the first date of hospitalization or medical visit may be used

Date of detection – date when the outbreak threshold case presents to a hospital, clinic, laboratory, community health worker, or public health agency

Date of notification – date when the outbreak threshold case is reported to public health authorities at the local, regional, national, or international level

Date of laboratory confirmation – date of the first laboratory report of the causative pathogen from an epidemiologically linked case

Date of response – earliest date when the local public health professionals took actions to stop or control the outbreak in the community

Results

The ROIF was established on February 1, 2019. Between February 2019 and September 2020, the fund supported responses to 14 outbreaks, including the deployment of 66 teams.

Prior to establishing the ROIF, the median time from notification to detection was 1 day, notification to verification was 0 days, and verification to response was 6 days (Table 1), indicating that the time to respond to verified events was a bottleneck to outbreak control. Five events took longer than 30 days from verification to response, including an outbreak of cerebrospinal meningitis in Zamfara State that took 108 days to respond to. After establishing the ROIF, the median time from notification to detection was 1 day, notification to verification was 0 days, and verification to response was 2 days (Table 2). The establishment of the fund did not decrease the timeliness of notification (median 1 day) or verification (median 0 days), but it significantly reduced the time from verification to response, from 6 days to 2 days (P = .003) (Table 3).

Table 1.

Timeliness Intervals for Events Prior to Establishing the Revolving Outbreak Investigation Fund in Nigeria, April 2017 to August 2019

Event	State	Date of Deployment	Detection to Notification (days)	Notification to Verification (days)	Verification to Response (days)
CSM	Zamfara	September 4, 2017	1	1	108
Yellow fever	Kebbi	October 3, 2017	1	0	66
CSM	Katsina	December 23, 2017	1	1	7
Lassa fever	Ebonyi	December 28, 2017	3	0	1
Botulism	FCT Abuja	January 6, 2018	3	0	0
Lassa fever	Edo	January 8, 2018	0	0	4
Lassa fever	Ondo	January 16, 2018	0	0	8
Lassa fever	Ondo	February 14, 2018	1	0	6
Lassa fever	Edo	February 19, 2018	1	0	5
Lassa fever	Ebonyi	February 22, 2018	1	0	5
Lassa fever	Kogi	February 27, 2018	2	0	6
Lassa fever	Plateau	March 4, 2018	1	0	7
Lassa fever	Adamawa	March 5, 2018	2	0	5
Yellow fever	Katsina	April 27, 2018	0	0	5
Yellow fever	Ekiti	May 2, 2018	2	0	45
CSM	Adamawa	May 9, 2018	0	0	10
Cholera	Zamfara	May 28, 2018	0	0	5
Cholera	Bauchi	June 3, 2018	2	0	7
Yellow fever	Anambra	August 19, 2018	6	0	36
Yellow fever	Benue	August 20, 2018	6	0	36
Lassa fever	Ondo	September 30, 2018	1	0	1
Lassa fever	Ondo	December 31, 2018	1	0	6
Lassa Fever	Edo State	January 3, 2019	0	0	5
Yellow Fever	Nasarawa	January 7, 2019	2	0	7
Lassa Fever	Plateau	January 8, 2019	0	0	5

Abbreviation: CSM, cerebrospinal meningitis.

Table 2.

Timeliness Intervals for Events After Establishing the Revolving Outbreak Investigation Fund in Nigeria, February to October 2019

Event	State	Date of Deployment	Detection to Notification (days)	Notification to Verification (days)	Verification to Response (days)
CSM	Katsina	February 26, 2019	1	0	6
Cholera	Bayelsa	March 6, 2019	5	0	2
CSM	Niger	March 9, 2019	1	0	2
Monkeypox	Oyo	May 2, 2019	3	1	3
Cholera	Adamawa	June 13, 2019	1	0	2
Monkeypox	Lagos	July 2, 2019	1	0	2
Measles	Kaduna	July 23, 2019	41	0	1
Lassa fever	Benue	October 16, 2019	0	0	2

Abbreviation: CSM, cerebrospinal meningitis.

Table 3.

Analysis of Event Timeliness Intervals Before and After Establishing the Outbreak Revolving Fund in Nigeria, 2017 to 2019

Outbreak Intervals	Median Time Before Fund (Days)	Median Time After Fund (Days)	Mean Rank Before Fund	Mean Rank After Fund	Mann-Whitney (z Score)	Mann-Whitney (P Value)
Detection to notification	1	1	16.22	19.44	-0.854	.393
Notification to verification	0	0	16.82	17.56	-0.379	.704
Verification to response	6	2	19.70	8.56	-2.860	.003

The ROIF mechanism was leveraged to prepare for and respond to COVID-19 beginning in February 2020. The fund was used to deploy NCDC personnel to 34 of 36 states (94%) in Nigeria. The median time to deploy NCDC teams to states was 3 days (interquartile range, 1.75 to 4 days) from the time of the first verified cases in those states.

Discussion

In this article, we describe the process of establishing a flexible outbreak investigation fund and used the timeliness framework^9-11 to measure its impact on the rapid response to outbreaks. We found that establishing the ROIF led to a substantial and significant decrease in the time to respond to outbreaks, from 6 days to 2 days, a 67% improvement.

The revolving fund mechanism was not hypothesized to accelerate notification or verification of outbreaks, as the existing surveillance system in Nigeria, based on the integrated disease surveillance and response strategy, was able to rapidly notify and verify events both before and after the ROIF was implemented.⁹ Prior to establishing the fund, however,⁸ substantial delays in responding to verified events were a crucial bottleneck for disease control; 20% of events during this period took longer than 1 month to respond to. For example, 108 days passed before a response was initiated in the meningitis outbreak that occurred in 2017 in Zamfara State.¹² The majority of responses to outbreak events took more than 1 week. NCDC historically relied on its inadequate budgetary allocation and ad hoc requests to partners for funds to deploy rapid response teams for outbreak/field investigations. The revolving fund mechanism, however, has enabled NCDC to release funds using a predefined approval process through a financially accountable external partner who disburses the funds rapidly. In June 2019, for example, the ROIF enabled a response team to be deployed within 24 hours to investigate an Ebola scare in Lagos. Other factors contributing to improvements in timeliness of reporting include the availability of rapidly mobilized funds from Lagos State and development partners, political will and leadership, and trained epidemiologists.¹

Funding has long been recognized as central to mounting an effective response to public health emergencies. Funding for emergency response, however, remains inadequate, and where available it is usually associated with administrative and technical delays. Common barriers to the allocation, release, and effective utilization of emergency response funds are related to regulatory, contracting, purchasing, legislative, staffing, and other issues involved in transferring funds.¹⁶

During health emergencies, public health institutes are challenged to provide various services to the public. In Nigeria, NCDC is the primary institute responsible for providing these services. During emergencies such as the COVID-19 pandemic, NCDC uses the incident management system to coordinate its response. Responding to public health emergencies requires the timely movement of personnel, supplies, and equipment, which requires sufficient funding. With adequate planning, coordination, and rapidly accessible funding such as the ROIF, personnel and supplies can be moved quickly to mitigate emergencies.^9,17

Nigeria's prompt response to COVID-19 can be attributed to operational readiness due to its experience responding to past outbreaks and institutionalized processes including the ROIF. Until May 2020, no other dedicated funding support was available for NCDC to rapidly implement flexible programming to respond to COVID-19. At the start of the COVID-19 pandemic in Nigeria, the fund was already established as a rapid, flexible funding mechanism with financial and technical protocols in place, guidelines for regular reporting, and a history of using funds effectively in previous outbreaks. Efforts to replenish the ROIF by NCDC and AFENET have targeted the government through statutory allocated funds, multilateral donor agencies, private-public partnerships, and corporate business social responsibility initiatives. During the COVID-19 pandemic, donors were assured of substantial accountability mechanisms in place for the fund, and an additional donor organization provided funding to support NCDC's COVID-19 response. Regardless of the amount contributed, all donors who contributed to the ROIF received the same quarterly technical and financial reports to build trust and ensure transparency.

Suboptimal documentation practices resulted in challenges during the data analysis process when comparing timeliness intervals before and after the ROIF was established. However, we relied on institutional memory of the researchers using deployment reports, as well as records retrieved from some administrative processes, to help overcome this challenge. The deficiency in recordkeeping was a major weakness of our study. To address this deficiency for future efforts, timeliness metrics are being systematically added to the NCDC's event management system, called SITAware. Including timeliness metrics, such as the outbreak milestones described earlier, in national event management systems can facilitate routine reporting for impact metrics and performance management metrics.¹⁷

The Nigeria ROIF is accessible only at the national level and is the first step toward identifying funding mechanisms that can be scaled down to state levels. Our research findings provide evidence that a functional outbreak investigation fund at the national level in Nigeria can accelerate the initial response to outbreaks and overcome previous bottlenecks. Additional research should be conducted at subnational levels and in other limited-resource settings. The findings from our research can inform advocacy efforts, given that setting up such a funding mechanism requires high political will and commitment, including legislative action.¹⁸ Investments in infrastructure, strategies, innovations, and technologies reduce vulnerabilities to outbreaks and improve resource mobilization. Unfortunately, low- and middle-income countries with higher prehazard vulnerabilities and fewer resources to respond to outbreaks¹⁹ make disproportionately lower investments in these areas, hence the need for scaling up initiatives such as the revolving fund mechanism.

The ROIF is an example of how building partnerships can support emergency response planning and response activities during public health events like the COVID-19 pandemic, ultimately leading to better outcomes.²⁰ However, it is important that Nigeria begins to work toward strong, stable, and sustainable financing for emergency response with less dependence on its partners. A critical step was made in 2018 with the launch of the Basic Health Care Provision Fund. This is a provision for 1% of the government of Nigeria's consolidated revenue fund to be dedicated to improving universal health coverage and response to health emergencies. NCDC was allocated 2.5% of the provision fund for public health emergency preparedness and response, with the National Health Insurance Scheme receiving 50%, the National Primary Healthcare Development Agency receiving 45%, and the Department of Hospital Services receiving the remainder (2.5%).⁵ Unfortunately, in 2020, the revised Basic Health Care Provision Fund guidelines excluded NCDC, thereby reducing government funding for response to public health emergencies. While the ROIF is a critical strategy that has contributed to improved response turnaround time in Nigeria, the mechanism lacks sustainability. Thus, Nigeria should provide specific budgetary allocations such as the Basic Health Care Provision Fund to ensure sustainable national funding of health emergencies.

Despite the availability of funding for outbreak response, other factors could hinder the effective use of funds and outbreak response in general. Such factors include inadequate human resources, inadequate infrastructure critical to outbreak response, and difficulty implementing policy changes.²⁰ Funds such as the ROIF, can be institutionalized and potentially serve to strengthen the system for outbreak response vis-à-vis human resource and infrastructure requirements.²¹

Conclusion

Our research shows that the ROIF is an effective mechanism to initiate early outbreak responses in Nigeria and create a bridge to more sustainable domestic financing. Until more domestic funding is made available, this mechanism enables diversified sources of funds from development partners and private-sector foundations—with clear technical and financial accountability mechanisms—to ensure that threats are verified and responded to quickly.²² Increased domestic funding could be accomplished by earmarking budgeted funds for response activities, in addition to establishing continency emergency financing for national public health emergencies or allocating an adequate budget for NCDC response activities.²³ This model, financed by domestic budgets where available or by development partners in the interim, can strengthen emergency responses and the use of timeliness metrics can aid in technical reporting, performance management, and impact assessment.

Footnotes

Acknowledgments

The authors wish to acknowledge Resolve to Save Lives for providing the seed funds for piloting the revolving fund in Nigeria. We are grateful to the leadership of the African Field Epidemiology Network for providing administrative support for rapid disbursement of the revolving funds.

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