This article was originally published in Open Magazine and is cross-posted here with permission.
This post is part of the #ProtectingKids blog series. Read the whole series here.
Niya Zameen with her two boys outside their home in Ramsar
Niya Zameen, 33, lives with her two sons in Ramsar, in Barmer district of Rajasthan. Her village has a population of just 1,078 and is close to the India-Pakistan border. Niya has always tried to ensure that her children receive the necessary healthcare services, including vaccines, to give them a healthy start in life. Getting her children vaccinated hasn’t always been easy because of shortages of government recommended vaccines. But Niya has never given up. With the help of the local health worker, Rampatti, she made sure that her children received the necessary vaccines against measles, polio, and three doses of diphtheria-tetanus-pertussis.
Of the 1.3 million Indian children under-5 that died in 2013, pneumonia claimed more than 175,000 lives and diarrhoea caused more than 130,000 deaths. Even in cases of survival, the severe burden of illness from diarrhoea and pneumonia adversely impacts children’s growth and development. But many of these severe illnesses can be easily prevented through immunisation. The pentavalent vaccine, that prevents a deadly form of pneumonia and meningitis, is now available through government immunisation programmes in some states and the vaccine to tackle diarrhoea caused by rotavirus, will soon be rolled out.
Niya Zameen acknowledges the crucial role that Rampatti, the local health worker, plays in her life. She has provided guidance on important health decisions, including the role of vaccines in giving all children protection against preventable diseases.
Vaccine delivery is a challenge in this region, due to extremely hot weather and the difficult desert terrain. If the vaccines don’t arrive on the designated day of immunisation, Rampatti travels to the vaccine cold chain point to collect them for her village. On her return, she vaccinates children.
Every child has the right to a healthy start, and it is the responsibility of not just the government, but also of the community to ensure that all our children are timely and fully immunised.
Photos by Shikha Nayyar
Matt Coles serves as the Senior Program & Contract Analyst for IVAC. Prior to IVAC, he worked for the National Foundation for the Centers for Disease Control & Prevention and served as a US Peace Corps Volunteer in West Africa from 2000-2003.
This post is part of the #ProtectingKids blog series. Read the whole series here.
By: Matt Coles
This is not a not a sports article, I promise. On Sunday, February 1st, millions of people tuned into the Super Bowl to watch the New England Patriots and Seattle Seahawks duke it out, including an incredible 4th quarter catch by Jermaine Kearse of the Seahawks and a goal line interception by Malcolm Butler to clinch the Patriots win. One of my passions is football, but I was unable to watch the last quarter of that game. Our three month old son was having trouble breathing.
As a parent, there are two situations in which you always take your child to the hospital – when their fever is over 100°or they are having trouble breathing. The cough started small on Friday and only worsened over the weekend. Finally, on Sunday night, we made the decision to head to the hospital. My wife hurriedly made her way to the hospital, trying to beat the snow that was coming down, while I stayed back to call the neighbors to watch our daughter, who was fast asleep.
Matt's baby in the hospital
Later at the hospital, we discovered our son had Respiratory Syncytial Virus, or RSV. This is a virus that affects breathing and, in infants, secondary infections such as bronchiolitis and pneumonia can make it more serious. According to the Centers for Disease Control and Prevention (CDC), almost all children will have an RSV infection by their 2nd birthday. Here in the United States, approximately 100,000 - 126,000 infants and children under the age of two are hospitalized from RSV.
RSV was new to us and, aside from short-acting prophylaxis for at-risk children, there is no vaccine on the market to prevent RSV.
I am well-informed about respiratory infections in children such as pneumonia, whooping cough, influenza, croup, and Hib. I’m very fortunate to work at the Johns Hopkins Bloomberg School of Public Health and its International Vaccine Access Center (IVAC) – a place where I can ask my colleagues questions on childhood diseases, both from an academic and parental standpoint. Not all parents are this lucky.
As parents, we sometimes question our decisions for our children, especially when they get sick. Should we have called the pediatrician earlier? Will the medicine work? Will the fever break? It goes with the territory.
One thing we do not question is the benefits of vaccines. I have seen firsthand the benefits of vaccines in The Gambia, where I served as a Health Volunteer with the Peace Corps from 2000-2003. During my Peace Corp service, I worked with the Ministry of Health National Immunization Days for Polio. We went house to house helping to vaccinate children with the oral polio vaccine (OPV) and providing Vitamin A supplementation for infants during week-long vaccine campaigns. More than a decade later, our son’s brief battle with RSV only helped to reinforce the value I place on vaccines and the need for more, effective vaccines.
When we came home from the hospital, we also had to do breathing treatments four to five times a day to continue to loosen the mucus. There were some sleepless nights that week, but we got through it. The cough dissipated and like the Patriots victory, my family was also able to celebrate duking it out with RSV. The victory photo says it all...
Huma Khawar is a freelance journalist and IVAC advocacy and communications consultant working in close coordination with the Expanded Programme on Immunization (EPI) in Pakistan.
By: Huma Khawar
“I don’t have any children of my own, but after 12 years as a lady health worker (LHW) all the children here in my village are my own children,” she explains as we sit together in a small village 150 kilometers outside Pakistan’s capitol of Islamabad. Rukhsana is a young woman in her early thirties with a distinct mission and a packed schedule. She is one of over 100,000 LHWs that go door-to-door every day to educate families – particularly women of child-bearing age – on health topics such as pregnancy, nutrition, hygiene, family planning, and immunization.
In Pakistan, LHWs play an integral role in providing essential health services to communities, especially in rural areas that are difficult to reach. According to local medical experts, the households visited by LHW have 15% more fully-immunized children than households that are outside the LHW catchment area. This is an important outcome as Pakistan is one of three countries that contributes nearly half of the 21.8 million children worldwide that did not receive routine immunization services and where outbreaks of childhood vaccine-preventable diseases, such as measles, are common.
Rukhsana recently earned her official certification as a LHW. She regularly leads immunization sessions, where she vaccinates children and provides basic health care. “When the vaccinator announces their arrival in an area every month, I go door-to-door to bring out children that are due for their shots. I encourage the remaining children to go to the nearest health center so they do not delay their immunization,” Rukhsana reports. “But still, some families hide their children or say that they are visiting relatives in adjoining villages,” she shares openly. These ploys do not deter Rukhsana, who accepts the challenge and is determined to improve the well-being of women and children in her own village.
She does admit, however, that misconceptions about vaccines are pervasive. “Some parents argue that the injection gives their children fever. I tell them these are common side effects that can be treated with 1-2 doses of pain killers. I give them paracetamol,” Rukhsana shares. She feels that arguments, refusals, and misconceptions can be countered with education and appropriate interventions.
Rukhsana distinguishes herself as a LHW because she establishes excellent rapport with community members. She often pleads with elders who are reluctant to vaccinate their children. “I make sure that all children in my villages are vaccinated,” she states proudly.
Rukhsana reaches 15-20 households each day. This year, Pakistan will provide specialized training for 14,000 LHWs on vaccine administration. It is no doubt that LHWs form the backbone of basic health care for this country and will be instrumental in administering vaccines that are a foundation for protection throughout a child’s life. Vaccines help children grow to reach their full potential.
With her shawl covering her gentle frame, leaving only her eyes to be seen by those she encounters, and a black bag of basic medicines resting comfortably on her shoulder, Rokhsana walks out of her home today, ready to tackle her first visit for the day, feeling ever confident to meet with all the families on her list.
Huma Khawar is based in Pakistan and works for the International Vaccine Access Center (IVAC) at the Johns Hopkins Bloomberg School of Public Health. Support for this project was provided by Gavi, The Vaccine Alliance, for the Vaccine Implementation Technical Assistance Consortium (VITAC). The views expressed by the author does not necessarily reflect the views of Gavi and/or VITAC partners.
By Ahmad Abdulwahab
Where do you go when you need medication? Treatment for a minor injury? Vaccination for your child? Education about preventing or managing disease? In Nigeria, the answer should be your primary health care (PHC) facility. PHCs are required to provide these services and more, including clean water and basic sanitation. But the truth is many can only manage to provide a subset. Due to a lack of skilled health workers and adequate supplies, these PHCs leave communities underserved and vulnerable to disease.
Indeed, while Nigeria’s PHC system has made great strides over the years—with a shift from narrow disease-specific vertical programs to a horizontal health system focus of the new “Primary Health Care Under One Roof” reform—there remain many challenges in the health sector, mostly concentrated at the primary health care level. Rather than enumerating these, it is perhaps better to focus on one root problem and a remedy - financing and basket funds, respectively. Initially implemented in Zamfara State to improve routine immunization, the successful basket fund model has since expanded to other states, with the goal of further enhancing overall PHC service delivery.
While working as the Director of Primary Health Care in Yobe State, and later as the National Programme Manager of the Partnership for Reviving Routine Immunization in Northern Nigeria- Maternal Newborn and Child Health (PRRINN-MNCH), I learned that financing lies at the core of Nigeria’s PHC delivery challenges. It is difficult to access the necessary funds to finance basic needs in the health sector. At the state level, federal and state allocations are occasionally misapplied, resulting in incomplete disbursement of local budgets. On the local level, budgets are not earmarked, leading to delays in the release (or at times non-release) of PHC funds—often hinging upon the political will and administrative priorities of those in power.
Dr. Ahmad Abdulwahab in a group photograph with LGA Chairmen of Zamfara State, the Honorable Commissioners of the State Ministry of Health and State Ministry for Local Governments and senior officials of the PRRINN-MNCH program after a meeting on the Basket fund.
A basket fund is a promising mechanism of addressing many of these financing problems. In 2009, Zamfara State with PRRINN-MNCH established the first basket fund in the country to improve routine immunization program and delivery. A basket fund pools resources from state, local, and federal governments as well as from donors and even the private sector. These resources are then directly disbursed to responsible officers for specific PHC activities such as immunization outreach and vaccine distribution to health facilities. Zamfara’s basket fund consists of government contributions (80%) and support from developmental partners (20%) for improving routine immunization.
Over the past five years, the Zamfara basket fund has been tremendously useful in addressing the issue of financial resources. By creating a strong set of checks and balances, the basket fund has increased accountability and transparency in how, when, and where the funds are disbursed. It has helped guarantee funding for basic PHC services and also ensure coordination so that duplication of resources does not exist. As a result of the basket fund, the number of political wards with regular disbursements to finance routine immunization rose from 14% to 100%. Similarly, the DPT3 immunization coverage significantly increased in these political wards over a period of six months.
Due to this success, Zamfara’s basket fund has now expanded to finance maternal health (in particular, the Midwives Service Scheme that mobilizes midwives to rural areas), polio supplemental immunization campaign, and nutrition programs and activities. In the near future, we hope to see the basket fund encompass all PHC services.
Many states with the support of partners are now replicating the Zamfara basket fund model in hopes of achieving similar success. For example, in 2013, Kano State established a basket fund, with an agreement to gradually reduce the significant contribution of international donors until 2016, when the basket should be completely funded by the government. Even the National Primary Health Care Development Agency (NPHCDA) has recognized the efficacy of basket funding and has incorporated it into the National Routine Immunization Strategic Plan as one of the interventions that the federal government recommends all states to implement.
However, basket funds are not without their own challenges. Namely, political will is critical. The Kano basket fund was established quickly with the strong endorsement of the Deputy Governor, but achieving such commitment has been slow in other states. Additionally, coordination and alignment of priorities among partners and the government is essential, and a liaison is often needed to spearhead this process.
Dr. Abdulwahab photographed along with the Zamfara State Public Health Officials and IVAC members.
On a scale of 1-10, I would rate Nigeria’s overall PHC system at three or four. This is an improvement from scores in the negative that it would have garnered several years ago when there was little effort in strengthening health systems. There is now greater awareness among policymakers and partners that primary health care is fundamental to improving the health of the nation.
I believe the basket fund is a high impact, easy, and replicable model that can help Nigeria achieve its goals of increased accountability, effective service delivery, and improved health outcomes. IVAC’s White Paper on Basket Funds provides a timely and useful resource for states wishing to establish and implement basket funds. If basket funds continue to grow beyond specific program priorities, they will cover all PHC services. This would be the ultimate realization of our vision of “primary health care under one roof.” Because of basket funds, the issue of lack of funding for basic PHC services may become an issue of the past.
Support from states and partners during this process will be essential for the success of basket funds. To reach its full potential and move the needle on PHC in the country, there must be strong political will and clear leadership. The time has come for Nigerian officials and partners to work together to usher in a new era in which the financing, resource allocation, and implementation of primary health care activities are designed in a way that is streamlined and accountable, and serves the true functions they were intended for. That is the vision many of us working in the PHC field have for this country.
Dr. Ahmad Abdulwahab, [MBBS, MPH], is a Nigerian medical doctor and public health/health systems specialist with over 18 years of experience in the Nigerian health sector. He has worked with both Government and International organizations at state and national levels. He was at a time the Director of PHC and Disease Control in the Yobe State Ministry of Health and served as the National Programme Manager for the 7-year 65 million pounds DFID/Norwegian Government funded Partnership for Reviving Routine Immunization in Northern Nigeria - Maternal Newborn and Child Health (PRRINN-MNCH) programme. He has also provided technical services to several International agencies such WHO, UNICEF, USAID, Netherland Leprosy Relief and Global Fund and has shared his extensive experience and knowledge of public health, policy development and health systems reform, through presentations at several national and international fora.
This post originally appeared on the Nigeria Health Watch and is cross-posted here with permission.
By Chizoba Wonodi
Nigeria launched the introduction of the pneumococcal conjugate vaccine (PCV)into its childhood immunization schedule in Lokoja, on December 22nd 2014. PCV prevents one of the deadliest bacterial causes of pneumonia, meningitis, blood infections and middle ear infections in children. Before now, only parents with the means could afford to vaccinate their children for thousands of naira in private clinics. But now, government is offering it for free to all kids. This is a big deal, so get excited!
Launch of PCV Vaccination in Lokoja
A journey that began 6 years ago has finally come to a successful end. But it was not an easy ride. As I think about the road to this introduction, I remember all the twists and turns along the way and marvel at the tenacity and perseverance of the chief actors in this story.
In 2008, I was working for a Johns Hopkins project called PneumoAdip, which was set up to accelerate the introduction of PCV into African and Asian countries. You may wonder why anyone needs a project to do that, right? Well, it turns out that having a vaccine that works is not enough to get countries to use it, unless the vaccine is for Ebola. I bet countries will scramble for an Ebola vaccine, if it comes. But then most diseases are not like Ebola. For more silent diseases like pneumonia, it takes concerted effort to make the decision makers recognize the burden of the disease, the value of the vaccine and the actions to take on it. For example, it took Nigeria 21 years to adopt the Haemophilus Influenza b (Hib) vaccine into our routine system. The first country to use Hib vaccine in their national program started in 1991, we started 2012.
I remember sitting in the Premier Hotel Ibadan during the 39th Annual General and Scientific Conference of the Paediatric Association of Nigeria (PANCONF) in January 2008. The halls were packed, the place was buzzing, the energy was infectious, pediatricians were milling around discussing how to save babies. I had come from Baltimore to field test a pneumonia diagnostic tool and discuss the prospect of Nigeria introducing PCV into the national immunization program.
At one of the session breaks, I cornered Dr. Abanida, then Director of Immunization at NPHCDA and asked him, “Doc, when are we going to introduce penta and PCV?” “Very soon” he replied, “We will apply for both vaccines this year”. This was an unexpected and pleasant surprise. I had predicted he would commit to only penta, but PCV as well? That was great. You see, it was no coincidence that we were coming late to the penta party when countries like Kenya had introduced the vaccine 8 year before. As a country, we had been preoccupied with battling polio, especially after the major polio vaccine rejection of 2004. In addition, our systems were weak. Indeed, before 2005, we would not have been able to apply for Gavi support for new vaccines even our immunization coverage was less than 50%, less than the required threshold. To get Gavi’s help, countries have to meet certain eligibility criteria and they have to formally apply and be approved for support.
Just as Dr. Abanida had declared, in April 2008, Nigeria tendered their first Gavi application for penta and PCV introduction support. In June 2008, the reviewers granted the application a conditional approval.
Disappointed but not deterred, in September 2008, the new vaccine application team led by Dr. Oteri, then Gavi desk officer at NPHCDA, responded to the conditions and queries from Gavi. But the second submission was rejected and the country was asked to re-apply.
Three things then happened that delayed the process for the next two and half years. First, Gavi suspended all new vaccine applications due to internal processes and funding constraints. No country could apply for new vaccine support in 2009. Second, Gavi revised their new vaccine application policy, now requiring an immunization coverage rate of at least 70% instead of 50%. Third, Nigeria’s vaccine coverage dropped below 50% to 42% according to WHO-UNICEF estimate released in June 2010. This new drop caused Dr. Dorothy Esangbedo, then the President of the Pediatric Association of Nigeria, to lament bitterly and call for stronger action to shore up routine immunization.
Under the new policy and with the lower coverage, Nigeria could not re-apply in 2010. In fact, a workshop in August 2010 convened by NPHCDA to develop the third submission was truncated by the twin news that our coverage rate had dropped and Gavi coverage requirement had increased.
When Gavi began revising their policy, there had been talk and expectation in some quarters that countries such as Nigeria, who were already in the application process before the policy change, would be “grandfathered in”. That did not pan out. To help matters, Gavi delayed the implementation of the new coverage requirement by one year, which left Nigeria with one window of opportunity to apply in May 2011.
But there was one more hurdle to scale. Coverage estimates for 2010 had to be 50% or better. The National Immunization Coverage Survey (NICS), showed coverage to be 71% for 2010, but Gavi only recognizes the WHO/UNICEF estimates, which was still 42% and would only be updated in July. Nigeria needed the updated estimates to apply in May. The update would be two months late. What to do?
The emails and phone calls started going back and forth advocating for a solution. At IVAC we pushed for different options: allow Nigeria use the NICS to apply, allow a phased introduction, so that states that meet the coverage criteria can be supported to introduce the vaccine, while effort be made to raise coverage in the other states. Dr. Mohammad Ali Pate, then Minister of State for Health, was very vocal in his advocacy to find a solution. Eventually and exceptionally, Gavi allowed Nigeria to apply for penta and PCV in May 2011. Then in July 2011, penta was approved and PCV was conditionally approved. All decisions were subject to the 2010 WHO/UNICEF DTP3 coverage estimates being >50%.
After the July 2011 conditional approval for PCV, Nigeria worked on responding to the conditions attached to the approval by strengthening the cold chain system. Then, 15 months later, in October 2012, Gavi gave the final approval for a phased roll out of PCV to begin in 2013. However, due to global supply constraints and other operational issues such as strikes in the Nigerian health sector, the first child could not be vaccinated till December 2014.
I didn’t go for the launch, but my colleagues went, and it was gratifying to see the culmination of everyone’s effort. Big thanks should go to the NPHCDA, Gavi, UNICEF, WHO, Pediatric Association of Nigeria, CHAI and all other groups who have pushed hard to see this happen.
First Nigerian Child to receive the Free Pneumococcal Conjugate Vaccine
As I look at the grainy picture of baby Collins, who is the first child to be vaccinated, cry out in pain from the shots of the first PCV vaccination, I wish I could tell him,
“Baby, don’t cry, laugh instead, even though that injection is painful. You are getting a shot a life. Something that babies before you did not get, but thankfully those after you will receive. If we are able to immunize 87% of your fellow babies every year with this vaccine, we can save about 200,000 lives by 2020. Isn’t that something to laugh or even rejoice about? Yes indeed, it is cause for celebration. I only wish it didn’t take six long years for this to happen. Think of all the babies we could have saved in that time. Anyway, you are too young to understand all this. After all, what do you know? You are just a baby. You probably just want to suck you mother’s breast right now, forget all this noise and go to sleep. So I’ll let you be.”
Dr. Chizoba Wonodi (MBBS, MPH, DrPH),
Nigeria Country Programs Lead, Johns Hopkins International Vaccine Access Centre,
Advisor, Saving One Million Lives Initiative,
Advisor, Gavi’s Strategic Demand Forecast for vaccines.