USAID/TSHIP Routine Immunization Review in Bauchi and Sokoto States

"If we are to protect our children, born and yet unborn, against vaccine-preventable diseases, we must reconnect with the community to improve and hold their trust in immunization through better government ownership and self-reliance. This must involve working with the private sector and community-based organizations and working in collaboration within the context of a complete health system, using a step-by-step methodical process."

The United States Agency for International Development (USAID)'s Targeted States High Impact Project (TSHIP) is a 5-year Nigerian project that aims to strengthen healthcare delivery in in all 20 Local Government Areas (LGA) in Bauchi State and all 23 LGAs in Sokoto State. With the project entering its 5th year, a team was asked to review the routine immunisation (RI) component and advise on strengthening USAID/TSHIP's plans for enhancing engagement at all levels in RI, in line with the Reaching Every Ward (REW) strategy. This report shares the details of that review, which involved record reviews, observations and interviews structured along major components of the REW approach: (i) planning and management of resources, including issues relating to governance, (ii) increasing access to immunisation services, (iii) monitoring for action, (iv) supportive supervision, (v) linking services with community, and (vi) building building. The review team visited 6 LGAs and 12 health facilities (HFs) across Bauchi and Sokoto States and interviewed national partners in Abuja.

Selected findings include:

• "At the national level, all partners interviewed were aware of the presence of USAID/TSHIP and its activities in both states. State officials were particularly appreciative of the role of USAID/TSHIP support for planning, improvement of infrastructure (buildings, cold chain equipment), strengthening provision of services, supportive supervision, reactivation of Ward Development Committees (WDCs) and Community Based Health Volunteers (CBHVs), and capacity building efforts. However, national partners noted concern over the two states being too small for a system strengthening project in a country as large as Nigeria, and also highlighted the lack of visibility of USAID/TSHIP at the national level - especially with the current increased focus on RI with the newly endorsed strategy."
• "In terms of findings in the two states with governance, there are varying degrees of political will and financial commitment, the latter being more evident in Bauchi. State task forces on immunization exist in both states, with terms of reference that include RI, although by far the focus of discussions remains on campaign-related activities. Importantly, accountability in terms of use of RI-related funds released remains an issue in both states."
• "In the area of planning and management of resources, all 6 LGAs and 12 HFs visited across both states demonstrated some planning as seen in either catchment area maps, immunization session plans, etc. But consolidated plans in the form of micro plans, and commensurate follow up on plans using data to guide decision making was found to be weak."
• "As part of efforts at increasing access to immunization services, Bauchi has shown a recent increase in the number of HFs providing RI services, while Sokoto has not shown an increase. Although administrative reports show RI coverage increasing, all partners at national level acknowledged data quality concerns, and lot quality assurance sampling done by USAID/TSHIP in the two states points to the likely coverage in both being less than 10% DPT3."
• "Supportive supervision visits are being carried out in both states, as sometimes evidenced by written feedback at the level of the supervisees, and at the HF level in Bauchi. However, supportive supervision is reported to be conducted infrequently by state-level officers unless partners are leading the process."
• Monitoring and use of data is done, as seen by monitoring charts on display in all LGAs and all HFs visited during the review. However, the quality of the data was not only questionable, but there was also little evidence that the data was being used to solve local problems (e.g. examples include combining of DTP1 and DPT3 into one line on the chart, erroneous dropout rate calculations, many charts not fully updated)."
• "Community structures such as WDCs, CBHVs and sub-grantees who are potentially key for community linkages with HFs were found in the two states, but the review team did not find evidence of strong community demand for RI services - as evidenced by chronically low numbers of children vaccinated and sub optimal attendance at existing sessions. Currently, financial incentives for engaging these structures is wholly supported by partners, with no evidence of a costing handover plan to the Ministry of Local Government (e.g. to align with financial incentive scheme as outlined in the WDC/VDC strategy)."

The reviewers conclude that the RI system in Bauchi and Sokoto States is weak (for instance, from 2009-2012, the number of children being vaccinated by DPT3 [diphtheria, pertussis (whooping cough), and tetanus] declined or stagnated, with Bauchi showing an increase in 2013 but Sokoto showing a decline. In the context of these issues, the review team asserts that USAID/TSHIP, with only a short implementation time remaining, should focus attention during the next 20-24 months on how to address persistent system operational gaps in close collaboration with the states and partners in the areas of governance, advocacy, supporting community structures, supportive supervision, and capacity building. For example, USAID/TSHIP and partners should specifically be involved in high-level advocacy:

• working to strengthen ownership and sustainability of the RI programme
• supporting the government to establish a mechanism to ensure release and accountability for the use of RI funds
• supporting community structures with emphasis on working with the community on creating demand
• training and capacity building at all levels using appropriate and updated training modules
• making updated data tools available, working through regular and supportive supervision on improving data quality at all levels and building the capacity of health workers to analyse, interpret and use data they are generating for timely local action.

In short: "Both states require continued system-strengthening support from partners, but need to provide support in ways that foster increased ownership and maturation of processes, so that every eligible woman and child are reached by timely vaccination services with all required antigens."

Click here for the 37-page report in PDF format.