Landscape Analysis of Routine Immunization in Nigeria: Identifying Barriers and Prioritizing Interventions

"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....Everyone wants to know how to crack the polio nut in Nigeria, and raising routine immunization (RI) rates is part of the answer." - Chizoba Wonodi

This analysis of supply-side constraints and demand-side determinants of RI coverage in Nigeria was carried out in this context: "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." Nigeria has the twelfth highest under-five mortality rate in the world; approximately one in four of those deaths are preventable through RI, but coverage of routine childhood vaccines remains lower than global benchmarks and, in many parts of Nigeria, is among the lowest in the world. Noting the potential to piggy-back on polio eradication efforts, the study identifies high-impact solutions to RI coverage in Nigeria in the areas of financing and vaccine security, transportation, cold chain technology, performance management, advocacy, leadership, and demand creation.

The International Vaccine Access Center (IVAC) undertook a landscape analysis of routine immunisation in Nigeria, with funding from the Bill & Melinda Gates Foundation and the GAVI Alliance and in partnership with the National Primary Health Care Development Agency and Solina Health. Collaborators conducted field interviews between April and August 2011 throughout 8 Nigerian states with a wide variety of stakeholders, including state and local government representatives, clinics, parents, and other key gatekeepers of vaccine demand, such as market women and antenatal clinic (ANC) attendees as well as male group representatives such as commercial drivers and mechanics. This white paper draws on responses from these 126 key informant interviews and 11 focus groups.

Combining information from respondents with survey data and a review of the available literature, the study identifies various barriers to RI coverage (most of which were operating across states and local areas). For example, barriers for health information systems exist in terms of accurate data collection and lack of data use; each problem exacerbates the other. According to the study, governance barriers that exist could be overcome through sustained engagement with leaders in and out of government.

Communication-related findings and recommendations included in the report are related to:

• Performance: Human capital is as important, or perhaps even more so, than any other resource, and the report found that Nigeria's health personnel are often overstretched and under-supervised. Making sure that personnel are adequately trained and rewarded for their part in making sure vaccines reach the people that need them is a suggested strategy for keeping health workers motivated to succeed. The use of information and communication technology (ICT) as a tool is highlighted by several studies cited in this report; for example, the widespread use of text messaging to send SMS reminders to staff has been found to strengthen communication and improve health service delivery in countries such as Kenya and South Africa.
• Demand: Explaining that not enough parents know about vaccines' benefits and availability, the authors again point to Nigeria's more than 90 million cellphones, which can be a direct line to vital health information. Another is rewarding parents for vaccinating their children - an idea called conditional cash transfers (CCT) - that has been used successfully to improve health-seeking behaviours in other areas, particularly in Latin America (research is cited to support this claim) and is rapidly being rolled out across Africa.
• Leadership: "In Nigeria, state and LGA [local government area] leaders have significant influence, and improving their understanding and ability to support immunization could have far-reaching impacts across all other domains." Civil society organisations can also play an advocacy role here, keeping up the pressure and letting leaders know the price of inaction. The study supports the importance of advocacy from traditional leaders focused on paternal support of vaccines. Researchers cited here highlight that indigenous health practices embedded in different cultures should be used to complement, rather than compete with, vaccine uptake.

It is noted that, within and across intervention packages, the appropriate priorities must be set by on-the-ground decision-makers. To that end, the researchers analysed interventions (e.g. SMS reminders to parents) through a series of lenses: feasibility vs. impact, impact on underserved populations, time to implementation and impact, implementing stakeholder, and zero-cost interventions. One overarching finding is that, due to lack of information, it is difficult to say whether lack of support or outright resistance to RI, when it occurs, is a function of poor information, personal beliefs, or competing political concerns. IVAC is in the preliminary stages of a knowledge, attitudes, and practices (KAP) analysis focused on the Nigerian Parliament and other key high-level decision-makers. It is hoped that this analysis will "help understand the factors that will lead to sustained and stable political support for RI across parties and regions."