Nigeria: Next Steps Necessary for Improving Nigeria's Low Immunization Rates

Binta, a Volunteer Community Mobilizer, has convinced Sabiu to get his children immunized against polio.

The World Health Organization (WHO) recently announced a donation of equipment to Nigeria’s National Emergency Routine Immunization Coordination Centre. The Centre was set up after Nigeria declared a state of emergency on the routine immunization crisis in June.

Of course, this state of emergency wasn’t all that surprising. The extent of the situation has been masked by poor data quality in the past. The worsening situation came to the fore through the results  of the recent National Immunization Coverage survey (2016/2017) showing 77% of children aged 12-23 months had not received all their immunizations and up to 40% had not received any vaccinations. Nigeria has as many as five million unimmunized children, accounting for one of every four unimmunized child globally.

Nigeria also has one of the largest gaps in immunization coverage between the poor and the rich, varying as much as 73 percentage points. There also is wide variation among the geopolitical zones and states with full vaccination coverage. Fifty-two percent of children in the South East and South South zones are fully immunized, compared with just 10% in the North West, according to the NDHS 2013. The 2013 survey also found that a mother’s educational status played a critical role in whether her child would be immunized or not with immunization rates of infants of mothers who had at least a secondary education or more being 57 percentage points higher than that those those born to mothers with no education.

Adding to the problem are serious concerns about data quality: several coverage surveys report much lower figures than the government’s administrative data. This really calls into question the underlying issues of population figures for planning as well as the accuracy of reporting. Improving data transparency and reliability will go a long way to help with decision making. Certainly the government is making efforts to ensure quality data at all levels, but it will involve an extensive behavioral change to reverse.

The decision of the National Primary Health Care Development Agency to establish an Emergency Center in July for routine immunization is a step in the right direction, though caution must be exercised. Routine immunization will not be sustainably strengthened through short-term quick measures. To be sure, short-term responses can certainly reach more children immediately but they come at very high costs and will have only a limited effect on sustaining high coverage and reductions in vaccine preventable diseases.

Here are a few other steps that Nigeria could take in order to strengthen its routine immunization system for the long term.

Better understanding of the root causes. This is crucial for being able to identify problems not only in the health sector but also from the perspective of the communities and caregivers. The process for coming up with solutions should involve the stakeholders to help in tailoring solutions. WHO provides resources on best practices for immunization strategizes and practices.

Political leadership and governance at all levels. This can be demonstrated with adequate domestic resources from government as well as collaboration with the private sector. To foster accountability, government leadership needs to be responsible for ensuring quality services everywhere and for everyone. They can engage communities and civil society in monitoring, generating demand for immunization and making government accountable.

Fundamental elements of the health systems need to be in place. There is an urgent need for adequate and equitably distributed health workers across the country, including in rural areas. Nigeria must place community health workers in the communities to provide a package of essential primary health care including immunization.    Realistic comprehensive operational microplanning. This is needed annually to complement multiyear planning and it must start from the lowest implementation levels and should involve not only health officers and communities, but also bring in other non-health stakeholders such as the education sector to help improve women’s education status. The latter could play a role in addressing issues routine immunization issues that are also linked with the broader health and development.

Equitable access to quality service by trained providers. This can be achieved through regularly-scheduled and predictable services through facility based, outreach, mobile or periodic intensification of immunization for special circumstances like conflict zones or seasonal hard to reach areas. Stronger partnership and engagement of Civil society, NGOs, private sector in specifically tailored service delivery can be helpful particularly in reaching the urban poor. The report State of Inequality Childhood Immunization shows that Nigeria could improve immunization rates by up to 40% if it ensured the poor have access to immunization and are immunized.

Institute a daily immunization policy so that no child is turned away. This should also be integrated with other primary health care services or available on the same day to ensure there are no missed opportunities for vaccination to both give messages on immunization and provide immunization services.

It makes good sense to invest in routine immunizations. It gives one of the highest returns on investment, of up to 44 dollars for every one dollar spent. So ensuring adequate funding for immunization operations as well as vaccines is certainly a wise decision and saves money. Innovative financing with private sector, trust funds, special taxes, are options that can be explored. Here are some tools and resources to ensure sustained funding.

Ultimately, while the donation of equipment from WHO is a welcome step, we must also take a closer look at the underlying issues and work alongside each other to find solutions that achieve lasting results for the long term.

Dr. Folake Olayinka works with JSI 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

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