Nigeria is home to one out of every eight child deaths worldwide. Routine vaccinations save lives and money. The Decade of Vaccines Economics projects 90 percent vaccine coverage against Hib, pneumococcal disease, rotavirus, measles and pertussis can save 600,000 lives and $17 billion in Nigeria over the next 10 years.
A new report by the International Vaccine Access Center (IVAC) at Johns Hopkins University identifies the challenges and solutions to increasing routine vaccinations in Nigeria. "Nigeria's advantages are its resources. It has a strong concentration of human resources with its middle class and economy," said Dr. Orin Levine, IAVC Executive Director and study co-author.
The study, "Landscape Analysis of Routine Immunization in Nigeria," was a collaborative effort between the IVAC, the government of Nigeria and Solina Health. The researchers interviewed stakeholders in eight Nigerian states. All involved in the vaccine process, from individual mothers to national government officials, were interviewed. "The results are Nigerian solutions for challenges to routine immunizations in Nigeria," said Dr. Levine.
Based on the interviews, the report identifies supply, human resource and demand solutions to increasing vaccination access. For example, transportation presents a challenge at nearly every level. Distance from health services is a documented challenge in Nigeria. A 2008 survey found that 36 percent of Nigerian women said the distance from a health facility was an impediment to accessing medical care.
From the report:
The authors recommend the use of transportation contracts and distributing vehicles to smooth out the supply chain issues and bring vaccines closer to individuals. Though transportation will present its own challenges and costs, it presents a way to reach people in remote parts of the country who are often populations with low vaccination coverage.
Simple changes like the way money is disbursed will also smooth out coverage. The highly visible national vaccine campaigns tend to provide more equitable coverage, explained Levine. At the present, money disbursed by the Nigerian government for the purchase vaccines is an annual process. Levine says, "By changing the funding mechanism to occur throughout the year, the vaccine supply can remain consistent."
The other side of the coin is the demand side. If all the logistical problems are solved there is still the issue of parents wanting to vaccinate their children. Further, there are those who want to vaccinate their children but the schedule of vaccinations is spread out and they may miss or forget about appointments.
Levine took the time to point out that addressing the problems of demand is paramount. He saw incentives and reminders as ways to ensure that the care is delivered by providers and accessed by patients. That could look like pay for performance for individual health workers and results based financing at the state, local, and institutional levels.
Money is disbursed when specific targets are met. If a hospital wants money to fund other programs it will need to meet given targets to access further funding; an incentive to ensure more coverage of patients.
The patients can be incentivized through conditional or unconditional cash transfers. Distance between the parents and the vaccination distribution point can be a challenge, but incentives can help reduce that barrier. "You can bet people from villages that are not reached by vaccines are traveling to do commerce and other things. If you incentive parents, you will find them innovating their own transportation schemes," Levine said.
SMS reminders have been used in the past for big campaigns. The hope is that the technology and its successes can be harnessed into routine vaccination campaigns. There is a gap in the immunization schedule between 14 weeks and nine months. Reminders may overcome the attendance attrition.
An important component to the success of the campaign will be linking up the various actors. Nigerian Minister of State for Health Dr. Muhammad Pate says awareness is an important target for the government. "In recent years we have made tremendous progress in promoting the awareness among our population, but there are still areas where the awareness is inadequate. These areas are both geographic as well as socioeconomic. For example, the upper 20th wealth quintile in the population has 13-fold higher full immunization coverage among its children than the poorest 20th wealth quintile according to the 2008 demographic and health survey," he said.
"This may be a reflection of inequities in access to the vaccines or disproportionate awareness among the richer more educated populace or both. Whatever the case, we are committed to ensuring that every child has an equal chance of getting protected with life-saving vaccines."
Collaboration will lead to a successful campaign, said Dr. Pate. "If federal, state and local governments align their efforts towards basic services, and are supported by civil society and private sector, the impact will naturally expand beyond vaccine delivery," he said.
Doing so will reach beyond just routine vaccinations. "It will have impact on other important services such as maternal health, prevention of parent to child transmission of HIV, treatment of other ailments like anti-malarials, zinc/ORS for diarrhea, antibiotics for pneumonia, etc.," continued Dr. Pate.
The government actors indicate willingness to take action. However, Levine points out, "The challenge going forward is translating political will into action and change at the local level."
Follow Tom Murphy on Twitter: www.twitter.com/viewfromthecave