As 2019 wound down to its close and holiday plans were being made, arrangements were also being made for a high-level visit of Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance and his team to Nigeria. This was a much-welcomed visit- as it comes after a dark period that saw Nigeria closed out of Gavi support because misuse of fundsintended for vaccine procurement and health systems strengthening was detected between 2011- 2013.The Nigerian government had to repay Gavi the funds that were misappropriated as the country was in danger of losing funding support for its routine immunisation programmes.
Gavi’s support was also at risk for another reason; the improvement of the Nigerian economy in the mid 2000s took Nigeria into the “middle income country” category above Gavi’s eligibility threshold of a Gross National Income (GNI) per capita of less than US$ 1,580, and therefore no longer eligible for Gavi support. In 2017, Nigeria was scheduled to start transitioning from Gavi funding over a 5-year period, with the government taking over funding of routine immunisation programmes. As the country requested and negotiated for an extension of its support, Gavi insisted that any discussions on the requested transition extension was contingent on the misappropriated funds being repaid, in line with agreed timelines. After extensive negotiations, Nigeria’s transition out of Gavi funding has now been extended by 10 years. Since then accountability policies have been put in place that enable greater transparency and closer grant monitoring and management.
Pushing up routine immunisation coverage
In the recent past, Nigeria has faced many challenges implementing immunisation programmes and pushing up routine immunisation coverage rates. The many challenges included poor health literacy, weak demand for vaccinations, parent’s hesitancy to bring their children to be immunised, inefficient supply chains hampering vaccine delivery, funding challenges for vaccine programmes as well as inadequate human resources to carry out vaccination programmes. From all indications, the National Primary Healthcare Development Agency (NPHCDA) has been working hard to improve this situation, for the first time, using verifiable survey data to monitor progress rather than unreliable administrative data.
Why was the Gavi visit so important?
Gavi, the Vaccine Alliance created in 2000 has been supporting Nigeria’s immunisation programme, providing vaccines, cash support and technical assistance through its partners the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF). So, this visit was timely and showed the restored confidence that Gavi has in the leadership of the Nigerian health sector. Behind the photos, smiles and handshakes were the important meetings that took place, reviewing progress and setting new targets. The Gavi team also used their visit to Nigeria to review the implementation of the Nigeria Strategy for Immunisation and Primary Health Care System Strengthening (NSIPSS) and other initiatives under NPHCDA and the Ministry of Health.
There is little doubt that over the past three years, Nigeria has recorded significant improvement in routine immunisation coverage rates, helped by efforts made by the
NPHCDA and partners. According to the National Demographic and Health Survey (NDHS), in 2008 DPT3/Penta3 vaccine coverage was 35%, increasing to 38% in 2013 and 50.1% in 2018.
The increased vaccine coverage rates were helped by the many initiatives put in place by the NPHCDA. In 2017, a state of emergency was declared on the poor rates of routine immunisaton in the country and the National Emergency Routine Immunisation Coordination Centre (NERICC) was inaugurated by the Executive Director, Dr Faisal Shuaib. These coordination centres have played a critical role in strengthening routine immunisation coordination across the country with the State Emergency Routine Immunisation Coordination Centre (SERICC) coordinating efforts at the state level and Local Emergency Routine Immunisation Coordination Centre (LERICC) operating down to the Local Government Area (LGA) level. There is still a lot of work to be done, since despite the improvement from a low base, Nigeria cannot be happy with an average DPT3/Penta3 vaccine coverage of 50.1% in 2018.
Transitioning out of Gavi funding
Between 2000–2019, Gavi disbursed $954,315,294 (as of September 2019), to Nigeria which is approximately 93% of total funds committed to support the country’s routine immunisation programme, cold chain equipment, and health systems strengthening. The goal of NSIPSS is to improve vaccine coverage rates and ensure that sustainable financing is in place to support the countries vaccine efforts after 2028. Renewed Gavi funding was only agreed upon with stringent conditions which includes the country meeting counterpart funding commitments, being subject to annual reviews from a high-level Gavi delegation, as well as mid-term reviews. Accountability frameworks for routine immunisation were put in place to track progress over the extended transition period. The clock is now ticking in earnest till Gavi funding comes to an end in 2028 and the country will have to self-fund immunisation programmes and also achieve the NSIPSS goal of 84% average national immunisation coverage.
A critical requirement in ensuring sustained government funding for immunisation programmes, and pushing up immunisation coverage is “political will and prioritisation.” The Nigerian population is growing at approximately 2.6% annually and by 2050, the country is projected to have the third largest population in the world. A commitment to sustained funding for immunisation programmes will protect the lives of new-borns and children, so they don’t die from vaccine-preventable diseases. It is for this reason that the visit to see President Muhammadu Buhari and the subsequent courtesy visit to the Senate President Dr. Ahmed Lawn by the Gavi team was critical in the Nigerian context. Political commitment from the highest level has the potential to lead to a shift in the way health is prioritised, as well as driving sustainable immunisation financing.
Most routine immunisation data has shown that Nigeria made significant progress in improving vaccine coverage rates, but the 2018 NDHS has showed that progress is not uniformly distributed, and that Kebbi and Sokoto State showed less improvement in vaccine coverage rates, than the national average. While the federal government has some influence over the health status of its citizens, the state government has greater direct influence over their health outcomes of its citizens. The efforts made by state governments are critical in the Nigerian context. This made the meeting of the Gavi team with His Excellency Abubakar Bagudu, the Governor of Kebbi state to discuss areas of additional support for Kebbi state, even more critical.
Out on field visits
In addition to the long meetings with government leaders, the Gavi team also had two field visits — one to Aleyita Primary Healthcare Centre (PHC) in Abuja where they witnessed an immunisation session and to the Nigeria Centre for Disease Control’s National Reference Laboratory. At both sites, the team had an opportunity to engage colleagues working at the frontlines of delivering vaccines and detecting vaccine preventable diseases.
The visit to the National Reference Laboratory, enabled the Gavi team to see first-hand the progress the country has made to improve its ability to carry out surveillance for vaccine preventable diseases. At Aleyita PHC, in line with Gavi’s health systems strengthening objective, Dr Seth Berkley launched cold chain equipment. This will help improve vaccine storage.
Nigeria on the road to vaccine self-financing
Finally, as Nigeria continues on the journey, transiting out of Gavi funding, the performance of the economy will be critical in order to increase the countries national self–reliance, using its domestic resources for routine immunisation programmes. The enactment of the National Health Act now guarantees the statutory payment of the Basic Health Care Provision fund. These much-needed resources with support in strengthening PHCs, through which all immunisation programmes will be delivered. Domestic resource mobilisation will also require the involvement of the private sector to support in bringing much needed capacity and expertise.
A current example exists of a state self-financing its immunisation programme. Kano State implemented reforms with support from partners that enabled the state to modernise its vaccine delivery and gradually transition their vaccine financing to self-reliance, over a 5-year period. Routine immunisation coverage in the state increased from 19%, according to NDHS 2013, to 46% in 2018. Much work still needs to be done, but with continued technical support from partners, could this be a model for other states in Nigeria to emulate?