During his recent visit to Nigeria, Bill Gates urged leaders in government, traditional and the private sectors to commit to helping children be healthy. Gates and Nigerian billionaire Aliko Dangote met with various stakeholders and visited health facilities to see firsthand how services are being delivered and interacted with service providers and clients.
For Nigeria to improve its health outcomes, particularly to end vaccine-preventable child deaths, the highest level of commitment and accountability from Nigerian leaders is imperative. While Gates told CNN during a recent interview that he wanted to spark action and debate during his visit, Nigeria leaders are the ones who need to respond with actual action of investing in health far beyond the current levels, starting with investing in immunization.
Nigeria currently has the highest numbers of unimmunized children globally at over 3 million. In the past year alone, Nigeria has suffered outbreaks and tragic deaths from Meningitis, Measles, Lassa fever, Monkey Pox and Yellow Fever. The Nigerian Center for Disease Control has been playing a critical role in ensuring an increasingly rapid response to these outbreaks, but preventing them in the first place should be the goal.
The reasons for the low immunization rates are varied and include underlying factors like low awareness of the need for immunization, low parental education and conflict and fragile environments. Low socioeconomic status and poverty also play a big role, particularly in urban slums while health systems factors contribute to an inequitable distribution of health workers, poor quality services and poor community linkages.
Unit costs for vaccination may vary with hard to reach or remote areas often costing more than more accessible and high volume urban areas. Sadly, in Nigeria those not immunized are mostly the poorest people with only 13.6 percent of the poorest children between ages 12 to 23 months receiving pentavalent 3 vaccinations compared to 74.5 percent of the richest children.
Routine immunization offers one of the highest returns on investments in health, saving up to 44 dollars in additional benefits for every dollar spent on routine immunization, and allows children the chance to grow to be healthy and productive adults. Benefits exceeds costs. It’s no wonder Gates and Dangote, who know a lot about investments, support it. They also know that billions of dollars are lost from hospital visits, hospitalization and indirect costs due to premature deaths, long term morbidity and associated loss of productivity. Prevention of diseases makes economic sense.
Gavi: The Vaccine Alliance was set up as an international funding entity to improve access to new and underutilized vaccines. It rapidly became the single largest source for external financing for immunization for the poorest countries and currently supports Nigeria. As countries’ economies grow and graduate out of Gavi support, one decision that must be made is how to increase domestic funding for immunization and invest in a healthy future. This is a decision Nigeria needs to make now.
There is no magic bullet for fixing the problem in Nigeria, but more government funding toward immunization can help. More funding is something that Nigeria, along with other countries, committed to doing in the Addis Declaration on Immunization and Abuja declaration, but right now, Nigeria’s health budgets are among the lowest globally.
In 2017, Nigeria’s health budget was merely 4.1 percent of its total budget, while immunization allocation was 22.5 percent of the total capital health budget, however most of that was not released. Nigeria spends just 1 percent of its GDP on public health from its own revenues and has an under 5 mortality rate of 108 per 1000 live births. In neighboring Ghana, the government spends 2 percent of its GDP on its public health. Here, both poor and rich alike receive immunization as a basic service at almost the same rates with overall high coverage of over 90 percent and under 5 mortality rates at 61 per 1000 live births.
While India used to have the highest numbers of unimmunized children they have made significant additional investment since 2014 and have reduced this number and reached immunization rates of 88 percent Pentavalent 3 coverage in 2016. Drivers of India’s success in reaching the unimmunized, as shared recently by one of my colleagues from the Ministry of Health and Family Welfare in India, includes its use of detailed microplanning, community structures, multidimensional approaches, midcourse corrections, smart technology, accountability, strong domestic funding and unrelenting political will.
Funding for immunization can also come in the form of innovative financing. Public funding options could include general revenue, health and social insurance, trust funds and earmarks. Earmarks can come from many sources such as general budget, taxes on goods and services, lottery revenues and domestic trust funds. A few country examples include Senegal and their development of a trust fund for immunization and Moldovia where immunization funds are made available through social health insurance linked to an earmarked tax.
While Gates did his part during his advocacy mission to promote immunization and primary health care, Nigeria now must make the decisions and commitment to provide sufficient resources to ensure no Nigerian child is left behind as it aims to reach the Universal Health Coverage goals. It's not only a smart investment worth making but also the right path to take.
Dr. Folake Olayinka works with JSI in Arlington, Virginia and is public health specialist with particular interest in immunization, maternal and child health and infectious diseases. She is an Aspen Fellow. Follow her on Twitter @joflakes.