Vaccinating a Complex Country
Nigeria is known in the development community for being a complicated country, especially when it comes to health interventions like vaccines. With the responsibility for the health sector split between the national, state, and local governments, there can be confusion, overlap, and just plain gaps in how moms get their kids vaccinated. In a country with 36 states and 774 local governments areas, having buy-in from each level of policy-makers and health providers has proven tricky, at best, or non-existent, at worst.
But, with child survival statistics like Nigeria has, these players have to find some sort of common strategy to combat the leading child killers. According to UNICEF, Nigeria loses about 2,300 under five children every day. The Countdown to 2015: Maternal, Newborn and Child Survival reports that in 2010 out of every 1000 children born in Nigeria, 143 did not reach their fifth birthday. Almost 30 percent of those deaths are caused by pneumonia and diarrhea, yet only 23 percent of children suspected of pneumonia are receiving antibiotics and only 26 percent of children with severe diarrhea are receiving oral rehydration therapy — the life-saving salt and sugar blend that can prevent a child from dying of dehydration.
Access to the new rotavirus (leading cause of diarrhea) and pneumococcal vaccines could prevent many of these deaths, however Nigeria has not yet reached the standard set by the GAVI Alliance that says in order to receive funding for new vaccines, a country must first reach 80 percent immunization coverage rates with routine immunization (coverage rates are measured by how many children receive the basic DTP3 vaccine which prevents diphtheria, tetanus and pertussis).
Nigeria is not just behind on basic vaccines. It is one of only three countries (other non-winners here are Afghanistan and Pakistan) where polio is still endemic, while elsewhere in the world, immunization has enabled the eradication of the often crippling, if not deadly, disease. On basic vaccines, there has been progress, albeit slow. The country reached its highest routine immunization rate yet of 69 percent coverage in 2010, which is a huge improvement from 10 years ago.
So, what other barriers are limiting access to immunization in Nigeria? Why is it still playing catch up to get its routine immunizations up to 80 percent coverage for children?
The International Vaccine Access Center (IVAC) team at Johns Hopkins University researched key barriers and put together a brief that lists “potential high-impact solutions” that they presented to advocates and development experts in Washington, DC last week. By talking to key players, government health officials at national, state and local government, local health providers, and NGOs across 8 different states, they found that many of the barriers bubbled up across the country. Some examples:
- Delays in the release of funds from national and then state level governments create stock outs of the vaccines and, in turn, low access in hard to reach communities.
- Not having regular, reliable transportation for the vaccines from one location to another prevent getting them to local clinics in a timely way.
- Like milk or other live items, vaccines have to maintain a certain cool temperature through refrigeration to keep their efficacy. Keeping a vaccine cold from one location to another is called the “cold chain” and breaks in the cold chain can spoil a vaccine. Not having any or large enough refrigeration systems in rural areas makes it difficult to access the vaccines.
- Staff shortages and poor incentives for health care workers create an issue for getting the vaccines delivered. Without a solid way to monitor and evaluate the delivery system, there is often poor accountability and even not reliable or valid data for how well the vaccines are delivered.
- Lack of country level advocacy within the local, state, and national level leads to poor oversight, and a lack in quality monitoring and evaluation. Without strong advocacy and public awareness about the benefits of vaccines the community engagement is lower and demand for the vaccines is lower.
Rural and hard to reach villages face many of these same barriers in other country contexts. So what are some of the solutions? IVAC offers suggested interventions for how to address the top barriers.
- One approach under way to fix funding delays is getting the national government to treat vaccines as a recurring expense, instead of an item that has to be re-appropriated annually (sounds familiar to the US appropriations process). Having financial guarantees from donor groups to ensure that funding is continuous could also prevent stock outs and provide regular financing.
- Nigeria could create more reliable transport and delivery of the vaccines by securing a contract with a transportation company to regularly deliver the vaccines. Having working vehicles and refrigeration systems are also necessary to ensure vaccine safety. Contracts with maintenance groups that repair refrigerators and auto mechanics to repair the automobiles when they break down could preemptively ensure reliable transport for the vaccines from point A to point B.
- Use available technology like SMS texting for cell phones to more accurately record data and send out reminders to parents to get them to come to a clinic for vaccines that require more than one dose.
- Collaborate with traditional leaders and the faith communities to build a ground swell of demand from parents that can complement advocacy efforts and create more of a demand locally for immunizations.
As IVAC rolls out its recommendations, donors and implementers alike should look at how they can build partnerships to better address the barriers to accessing immunization in Nigeria. What they learn about what works in Nigeria can help inform other countries about best practices and provide solutions to similar barriers.
By increasing access to basic and new vaccines at an accelerated rate, countries are able to save more young lives. Our work as advocates is to push for good policies and the resources to help make that happen.