In Nigeria, a child is considered fully vaccinated if he or she has received the full course of vaccinations essential for protecting them from preventable and potentially life-threatening infectious diseases, by the second year of life, throughout six visits, including the required birth doses. This regimen is essential for reducing disability and mortality rates and improving public health.
In 2020, 2.6 million children in Nigeria were reported as zero-dose, meaning they had not received a single dose of any vaccine in the immunisation schedule. The 2021 Multiple Indicator Cluster Survey/National Immunisation Coverage Survey (MICS/NICS) revealed that in Northern Nigeria, an estimated 65% of children are categorised as zero-dose, with the North East and North West regions accounting for 27% each. Bauchi State in the Northeast is the second-highest state with a zero-dose rate of 35%, following Sokoto State in the Northwest with 51%. These statistics indicate that Nigeria faces significant challenges in achieving the Immunisation Agenda (IA2030) target of fully vaccinating 90% of eligible children by 2030.
Bridging the zero-dose gap
The Community Reorientation Women Network (CRoWN) initiative is one of the several initiatives being implemented to improve the uptake of routine immunisation (RI) and decrease the number of zero-dose children in Nigeria. Co-created by the Solina Centre for International Development and Research (SCIDaR) and Aliko Dangote Foundation (ADF) and implemented in collaboration with the Bauchi State Primary Health Care Development Agency (BSPHCDA), "the programme aims to determine the accurate numbers, physically identify and locate the zero dose children; and then reach them in their locations, thereby increasing uptake and reducing the zero-dose burden," said CRoWN Programme Director, Raihanah Ibrahim. CRoWN leverages existing female community resources such as trained polio vaccination teams to track and identify priority groups, defaulters and zero-dose children and refer them to health facilities for immunisation.
According to Pharmacist Rabiu Muhammad Fagge, state representative of the ADF, the project was piloted in Bauchi State because 13 of the state's 20 Local Government Areas (LGAs) are among the 100 LGAs with a high zero-dose burden in Nigeria. This means that 13% of the zero-dose LGAs in the country are in Bauchi State. He added that the initiative was piloted in Konkiyel ward of Darazo LGA in Bauchi State due to its history of recurring outbreaks of circulating vaccine-derived poliovirus (cVDPV) and measles, as well as its persistent challenges in achieving optimal immunisation levels.
Stakeholder engagement and community sensitisation
To secure community support, the CRoWN team (ADF, SCIDaR, and BSPHCDA) conducted consultative meetings with stakeholders at various levels, including state, LGA, ward, and community. These collaborative sessions aimed to collectively design and tailor the initiative to suit the specific needs and context of Konkiyel Ward.
Alhaji Garba Magaji Abdulkadir, the Village Head of Konkiyel Ward, a former chairman of Darazo LGA, who doubles as the ward development committee (WDC) chairman, said that he was not surprised to learn that his district was among the highest zero-dose communities in Darazo "because we know from experience that some mothers here don't take their children for immunisation."
A mini-census
To effectively execute the project, a mini-census was conducted to gather accurate information on the target population for immunisation in the community. The door-to-door data-capturing exercise was carried out by CRoWN women, leveraging their familiarity with the terrain to ensure that no household was left out. The Mai Unguwas" (ward heads), and "Jauros" (heads of Fulani settlements) played a crucial role in securing community support during the engagement.
Yusuf Maigari Pate, the Community Engagement Focal Person at the BSPHCDA, stated that the census helped identify the number of zero-dose children, defaulters, women of childbearing age, and pregnant women in the settlements. Results indicated that 66% of the eligible under-2 children in the ward were appropriately immunised for age, 21% were partially immunised (defaulters), and 13% had not received any vaccines.
CRoWN agent selection
To identify the areas where zero-dose children were located and ensure their access to immunisation services, CRoWN leveraged the polio supervisors and vaccinators in the Ward, enlisting 45 agents to enumerate and list zero-dose children. They also visit households to encourage parents and caregivers in Konkiyel to take their children for vaccination. Fagge revealed that the agents volunteer their services as no funding was available for their remuneration.
The volunteers received a comprehensive one-day training at the Konkiyel Primary Health Centre (PHC) from the LGA team and the RI service providers from the four health facilities in the ward. According to Ibrahim, one of the challenges encountered during this stage of the project was finding literate volunteers who could effectively identify priority groups. To mitigate this challenge, as implementation progressed, the 45 already engaged volunteers were required to identify and refer additional volunteers.
Agent deployment, tracking and referral
Furera Aliyu, a supervisor and community volunteer with more than seven years of experience, was assigned to Konkiyel Primary Health Centre (PHC) as her designated catchment facility. During her tracking activities, she gives red-coded cards to mothers with zero-dose children and yellow-coded cards to defaulters and refers them to the facility. At the facility, the RI service provider validates the immunisation status of the referred children, retrieves the referral card, and proceeds to administer vaccines and document the service in the immunisation register and CROWN summary sheet.
Mansur Bala, the RI service provider at Konkiyel PHC, said the referral cards are reusable. Therefore, when caregivers present the cards at the facility, he stores them in a referral box for weekly validation by the CRoWN agents, who then reuse them for another referral.
The agents revisit the households once a week to remind caregivers of the next visit and ensure the visit is conducted until the child completes the full complement of the expected vaccines. Bala said that caregivers appreciate these follow-ups adding that at Konkiyel PHC, he now immunises between 35-46 children per session, a significant increase from the previous range of 15-21.
"Unfortunately, we still have some women defaulting," Aliyu said. "For example, Hafsat Muhammad, an 18-year-old mother of two, doesn't miss out on antenatal care (ANC), but as soon as she gives birth, it becomes difficult for her to leave the house because she is also taking care of her husband's siblings," she added, emphasising that unless a team of vaccinators conduct outreach programmes in that community, many women like Hafsat will default on immunisation appointments.
Caregivers taking ownership
Halima Bako from Unguwan Yandure is committed to mobilising caregivers for immunisation in her neighbourhood. She has five children and has only immunised two of them. "It now pains me to see a woman who doesn't take her child for immunisation because I have seen its importance," she said, adding that she was waiting to be officially recognised as a volunteer before mobilising women in her neighbourhood for immunisation.
Sab̔u Maternity located five kilometres east of Konkiyel, initially experienced low immunisation rates of only 3-6 children per session and 5-6 women attending ANC per week, said Adamu Muhammad, the facility's Officer in Charge (OIC). He partly attributed this to the absence of a facility volunteer at the time. However, Ladi Yahaya, a resident and mother of six, stated that her husband prohibited her from visiting the facility due to its inadequate infrastructure and the lack of privacy for women waiting to be attended to. Muhammed reported that with the active involvement of Bilkisu Sulaiman, a CRoWN volunteer, immunisation and ANC attendance has significantly improved, with 11-16 attendees for immunisation and 10-15 attendees for ANC. Sulaiman diligently visits households, especially on immunisation days, to mobilise women and their children.
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Scaling up the CRoWN initiative
According to Raihanah Ibrahim, three months into the pilot phase, which began in September 2022, the CRoWN agents reached 99% of the zero-dose children identified during the enumeration process. After six months of implementing the enumeration and facilitated referral components of the CRoWN initiative, 87% and 76% of the initially identified zero-dose and partially immunised children have been successfully reached and immunised according to their age.
Aliyu and Suleiman credited the initiative's success to the strategic community entry process. It empowered traditional leaders and ensured their involvement in decision making. It also empowered women to contribute meaningfully to community development, breaking traditional gender barriers.
Acknowledging the lessons learned from the challenges encountered, Ibrahim mentioned some modifications being considered to ensure the programme's long-term success. These include replacing the paper-based enumeration tool with an electronic system to ensure faster data entry and analysis.
Additionally, as an incentive scheme for the initiative, the initiation of adult literacy and vocational skills training classes in targeted communities would be highly valuable, considering that the agents currently do not receive any financial compensation for their work.
Building on the learnings and success of the pilot project in Konkiyel, the CRoWN programme was extended to Warji LGA in Bauchi State in February 2023, according to Pate. "In Warji, the mobilisers were trained to use Open Data Kit (ODK) to collect data for the mini census," he said.
The CRoWN Initiative has been expanded to Kano State and currently plans to expand to other high zero-dose locations in Northern Nigeria. This demonstrates the team's commitment to ensuring that more communities benefit from this initiative, particularly as it aligns with the IA2030 target of fully vaccinating 90% of eligible children by 2030.
