By Dr. Chizoba Wonodi

Last month, I had the privilege of sharing the findings from a newly released International Vaccine Access Center study – the Landscape Analysis of Routine Immunization in Nigeria (LARI) – with a group of experts at the Center for Global Development (CGD) in Washington, DC. The talk, which focused on overcoming barriers to routine immunization (RI) in Nigeria, was hosted by IVAC’s Executive Director, Dr. Orin Levine.

I didn’t quite expect the level of interest the talk generated. Kudos to CGD’s Amanda Glassman for convening an impressive “sold out crowd” of donors and implementers including veterans and new entrants in the immunization field. The audience gave my colleagues and I plenty to chew on after we presented our findings. Below are some of the key points from the discussion.

Why Nigeria?

Nigeria is an important country in the immunization world. It’s a large country with high child mortality and low immunization coverage rates. Of the 6 million Nigerian children born every year, more than 1 million fail to get fully vaccinated by their first birthday. But despite systemic weaknesses, Nigeria has taken impressive steps to improve vaccine access in recent years. Over the 2000 to 2010 decade, DTP3 coverage increased from 29% to 69%. And in 2012, Nigeria began a three-year rollout of the pentavalent vaccine.

Polio is still a problem for Nigeria. After nearly finishing the job of elimination in 2010, the country slipped, and in the last two years, the virus has made an unnerving comeback. International condemnation of Nigeria over the polio crisis put the government on notice. Everyone wants to know how to crack the polio nut in Nigeria, and raising routine immunization (RI) rates is part of the answer.

“We want to know the bottlenecks and barriers in routine immunization, to help us prioritize our interventions”.

Nigeria's Minister of State for Health - Dr. Muhammad Pate

Nigeria's Minister of State for Health, Dr. Muhammad Pate, speaking at Nigeria's National Vaccine Summit.

This was the charge that Dr. Muhammad Pate gave to us at the outset of the LARI study. At the time, he was the Executive Director of Nigeria’s National Primary Health Care Development Agency. He’s now Nigeria’s Minister of State for Health.

We anticipated that solutions for routine immunization in Nigeria would need to be local ones. Our role as researchers was to listen, organize, synthesize and disseminate. Over the course of four months in 2011, we spoke to Nigerians working on RI at all levels of government from a sample of seven states and the federal capital territory.

Where are the bottlenecks?

We found that both supply and demand barriers are important impediments to RI performance. In many places, supply is not robust enough to meet existing demand; therefore focusing on addressing supply constraints was a pragmatic first step. Among the plethora of problems identified, three main interlinked barriers emerged: funding constraints, logistical challenges and lack of leadership. Put another way; no money to run programs when needed; inability to deliver vaccines for immunization sessions and lack of cold chain equipment; and political leaders who don’t prioritize RI.

This short list will come as no surprise to most people – they are typical symptoms of weak systems and fledging institutions. And in Nigeria, responsibility for tertiary, secondary and primary health is devolved across the three levels of government – federal, state and local respectively, but the capacity to handle responsibilities varies considerably, and is much lower at lower levels. Primary Health Care, and by extension, immunization services, which is the responsibility of the Local Government Areas (LGAs), bears the brunt of this capacity/responsibility gap.

Interestingly, funding constraints identified resulted more from the failure to expend than failure to budget. There are federal and state budget line items for routine immunization, but the release of such funds is neither guaranteed nor timely. The same thing happens at the LGAs, and to an even greater extent here, provisions are made but funding disbursements are not.

As such, RI programs struggle to conduct basic operational tasks needed to vaccinate children. For example, in the LARI study, program managers and health workers complained about the lack of funds to fuel vehicles or take public transport to collect vaccines from state or LGA cold stores.

With the country’s unreliable power supply, generators are a necessity. Where generators exist, there is often no money to fuel them to maintain the cold chain. Solar fridges and freezers lay fallow due to lack of maintenance. Partners like GAVI, Gates Foundation, WHO, UNICEF, DFID, EU, NORAD and USAID have helped make strides in some areas, but problems still remain.

The federal government plays an important role in procuring and supplying vaccines to states and providing technical oversight, but because of the structure of Nigeria’s government, the federal government does not have authority to drive change at lower levels. Solutions must be implemented at the state and LGA level, because most barriers are occurring in these areas. 

Identifying solutions

The people we spoke to had many ideas for solutions to the problems of Nigeria’s RI system. In selecting solutions, we emphasized the need for in-country stakeholders to consider both impact & feasibility in order to maximize results with limited resources.

Health Clinic in Nigeria

A health clinic in Nigeria.

High impact, simple to implement innovations may include:

Mechanisms to make financing more predictable and flexible to reduce barriers at national and sub-national levels. Ebbs in financial flows can be addressed through the use of basket/pooled funds (these have proven successful in some states). Financial guarantees and flexible funding may improve the likelihood that funds designated for RI are spent on RI—in a timely, efficient manner.

The delivery and supply networks also require urgent improvements, which could be implemented using transportation and cold chain maintenance contracts. These contracts could be designed to boost local economies and/or disadvantaged groups. Leadership and ownership at state and local levels are also critical to success. In the absence of the political will to act, holding governments accountable for their responsibilities can drive improvement. But the question is: how do you make political leaders accountable for delivery of immunization services when public awareness of benefits is low and local authorities don’t view immunization as a priority? These are questions for another day.

Nigeria - Breaking Down Barriers to Immunization Coverage (Infographic)

The Landscape Analysis of Routine Immunization in Nigeria was conducted at the request of Nigerian authorities with support from the Bill & Melinda Gates Foundation and the GAVI Alliance. Chizoba Wonodi, MBBS, MPH, DrPH is Lead of Nigeria Projects at IVAC. Cross-posted at National Vaccine Summit.