LANDSCAPE ANALYSIS OF ROUTINE IMMUNISATION IN NIGERIA

One in four deaths of children are preventable through routine immunisation

Given the size and complexity of Nigeria, knowing the landscape, understanding the problems and possible solutions, and who makes decisions at what levels of government has been a critical piece of developing an effective advocacy strategy for immunisation in this often challenging country.

Mapping the existing immunisation landscape

Nigeria has the 12th highest under-five mortality rate in the world. As many as one in four of these deaths are caused by diseases preventable through routine immunisation. However, being the most populous African nation, Nigeria has the highest number of unvaccinated children on the continent.

Routine immunisation in Nigeria is delivered through a complex network of players at the federal, state, and local levels. Nigeria has 36 states and the Federal Capital Territory, which are further divided into 774 Local Government Areas (LGAs).

While the federal government pays for traditional vaccines as well as the Hepatitis B vaccine (and co-pays for newer Gavi-supported vaccines), the state and local governments manage the funding and implementation of routine immunisation programmes. The National Primary Health Care Development Agency (NPHCDA), an arm of the Federal Ministry of Health, develops immunisation policy and supports states and LGAs to carry out these guidelines and serves as a bridge between all three government levels.

Despite this comprehensive framework for immunisation, several gaps continue to prevent vaccines from reaching everyone. For example, programme managers and frontline health workers have much knowledge about reasons for the poor performance of the system, but this knowledge was scattered and not well-documented, and a systematic approach to prioritising and addressing the bottlenecks was lacking.

Conducting a landscape analysis

As a first step, the Johns Hopkins School of Public Health’s International Vaccine Access Center (IVAC) set out to identify and catalogue barriers to routine immunisation. This understanding helped determine interventions to increase routine immunisation coverage rates, as well as inform immunisation advocacy efforts in the country.

IVAC partnered with NPHCDA and consulting firm Solina Health to launch the Landscape Analysis of Routine Immunisation (LARI) in Nigeria. Funded by the Bill & Melinda Gates Foundation, the project explored barriers to and opportunities for improving routine immunisation coverage in eight states:
Bayelsa, Ebonyi, Gombe, Kano, Osun, Taraba, Zamfara, and the Federal Capital Territory.

During a four-month period, the LARI team conducted one-on-one interviews with key informants at the national, state, local, and community levels as well as focus group discussions in primary health care facilities and within local communities. These conversations with a breadth of stakeholders ranging from health staff to community outreach personnel to policymakers were geared towards uncovering issues surrounding routine immunisation demand and supply.

Identifying the gaps

Three major themes emerged: 1) inadequate transportation, 2) inadequate cold chain capacity and functionality, and 3) financial barriers. These challenges gravely affected the ability of public health facilities to adequately deliver routine immunisation to children.

Taken together, these multi-faceted barriers were hindering universal routine immunisation coverage. For example, the lack of consistent and reliable transportation meant that hard-to-reach communities were often receiving few vaccines, if any. Most states had insufficient amounts of cold chain equipment and none had established a routine maintenance system; without such a system in place it risked vaccine availability and, potentially, their potency. Funding was a major issue at the two lowest levels, the LGAs and health facilities, which bear the burden of immunisation delivery. LGAs for example, struggled with lack of sufficient funds; though funds were budgeted for routine immunisation, there were frequent delays in the release of these funds.

Finding feasible solutions

Having identified the key problems, the LARI team forged ahead to the next phase: determining possible solutions around which to build a targeted advocacy strategy. This required looking for successful strategies within a similar context and reviewing the literature for evidence of effective interventions.

Given that multiple solutions were possible but resources were constrained, the LARI team assigned priorities to each potential solution. An impact-and-feasibility matrix was used to categorise interventions. The goal was that interventions deemed high impact and highly feasible would be given the highest priority, while those assessed to be low impact with low feasibility would be deprioritised—keeping in mind the timeframe necessary for implementation. Once the high-impact, high-feasibility strategies were identified, the team was ready to develop communications strategies that would best target key stakeholders in Nigeria’s routine immunisation system.

Advocating for sustainable financing

Basket funds are an example of a local solution to financial barriers determined by the LARI team and now being advocated for by the IVAC and other partners. The approach was based on the experience from Zamfara state, which developed the fund in 2009 to assure the availability of financing for Primary Health Care (PHC), including routine immunisation, at the local government level where funding had been weak and unreliable. The basket fund pooled monies from the state government, LGAs, and development partners to finance dedicated programme priorities. By 2010, the increased availability of funds to carry out routine immunisation activities contributed to overall improvement in childhood immunisation coverage levels in the state.

Noting the potential of this approach to improving financial flow, the LARI team championed the basket fund and now a few states have begun steps to put such a fund in place. To expedite adoption and support advocacy efforts for basket funds, IVAC has comprehensively documented the mechanisms of establishing a basket fund and captured lessons learned that can be disseminated among states interested in operationalising the fund.

Another example is the establishment of State Primary Health Care Development Agencies (SPHCDA) to integrate all their functions and management under one roof. These state-level agencies have been identified as important strategies to strengthen PHC financial accountability and governance. The policy and guidelines mandating every state to establish an SPHCDA have been adopted, but roll-out has been slow. As part of advocacy efforts to accelerate their adoption, IVAC has supported the government and partners to develop a scorecard that tracks the state’s performance on key elements of the reform. Use of this scorecard has created political visibility for the establishment of SPHCDA and is helping to drive further action.

The impact of advocacy for immunisation in Nigeria

Besides the two examples above, several high-impact, high-feasibility strategies are now underway— thanks in part to the LARI effort. For example, two states have established contracts with the private sector to deliver vaccines to the health facilities, and a vaccine management dashboard has now been scaled up nationally.

Overall, LARI has helped shape the policy and advocacy environment for routine immunisation in Nigeria. Through this work, LARI has not only informed key actors on the various mechanisms to tackle routine immunisation challenges, but has also opened communication channels to actively advocate and engage important stakeholders for strengthening the quality and delivery of routine immunisation in the country.