IMMUNIZATIONbasics Nigeria

From its beginning, this project was based on an approach that could be characterised as: bottom-up; affordable, for future nationwide roll-out by the government; low-tech, needing neither costly equipment requiring maintenance systems, nor capacity beyond that of the average health facility personnel; and focused on building a foundation for sustained and effective RI coverage, rather than a rapid unsustainable rise in reported "results". To that end, IMMbasics worked to ensure that staff of the Ministries of Health or its agencies, such as the Primary Health Care Development Agency (PHCDA) and local governments, played leading roles in all it was doing. By so doing, the project sought to not only build their capacity but to also put them on a path to success with the hope that they would learn to follow it regularly. In addition, the project tried to ensure active participation of all concerned, thereby building a sense of ownership in the staff.

Specifically, IMMbasics, in partnership with the Governments of Bauchi and Sokoto States and their LGAs, worked to strengthen the RI system in the two states using the Reaching Every Ward (REW) strategy, adopted from the World Health Organization (WHO)'s Reaching Every District (RED) approach. This approach takes into consideration the complexity of an RI system, as well as the importance of not only attaining high immunisation coverage but also of sustaining that coverage over the long term. To put the REW operational components in place, IMMbasics worked with both states to undertake a systematic start-up effort at State and LGA administrative levels using the National Primary Health Care Development Agency (NPHCDA)'s "Basic Guide for Immunization Service Providers" as a key reference material (whose development was led by USAID's BASICS project). Using a step-by-step process, IMMbasics worked with State and LGA personnel to create a sustainable system, which was to serve as a low-cost model for rebuilding the RI system. From early 2007 to mid-2009, a series of 7 steps were conducted with the state and LGA health teams focusing on how to make all of the 5 REW components operational:

1. Participatory state-wide assessment to collectively review how RI was being managed, implemented, and monitored - this included examination of existing documents, such as monthly summaries of RI data, health worker personnel lists and qualifications, and data on immunisation coverage and access to services. Based on findings, each state updated their RI work plans - a process that continued through regular meetings.
2. LGA planning and management through sensitisation meetings with groups of 3-5 LGAs together, a mini-review to establish baseline information in each LGA and to expose everyone in a participatory manner to the complete situation of the RI system in their LGA, and RI work planning (microplanning).
3. Systems strengthening with a focus on supervision and monitoring (e.g., out of task identification and standard setting exercises, two checklists were jointly developed taking into consideration national standards. The status of State-to-LGA and LGA-to-health facility performance was documented using these checklists during supervision visits for quantitative measurement, comparison, feedback and decision making. Data were reviewed during supervisory visits and at monthly meetings - encouraging use of data in making management and service delivery improvements. LGA and health facility teams were also encouraged to share key immunisation information with community and political leaders).
4. Formal RI training with on-the-job mentoring for LGA management and health facility staff, mainly held in small clusters (bringing together health staff numbering between 15-20 persons with 3 facilitators promoting participatory and practical on–the-job training techniques).
5. Efforts to increase access to services, such as through updating of health facility catchment area maps - a process that was done in a participatory way (with traditional and religious leaders involved), with the purpose of regularising health facility engagement with their communities.
6. Linking of services with communities, which involved promoting routine contact between community leadership and health facility staff by: exchanging feedback and reviewing progress with community leaders to keep each other abreast of issues; listening to the concerns and suggestions of each; planning ways to overcome local obstacles to health service utilisation; and seeking mutual support. (The key was to look for any opportunity which would involve community members in the community's health care by, for examples, delivering public announcements on immunisation, including days when fixed or outreach services are available).
7. Maintenance and expansion through continuous on-the-job reinforcement (e.g., support supervision and periodic refresher training from established in-service training) and efforts to keep monitoring and supervision systems effective through long-term state structure and support for reviewing and updating methods and tools.

A note on communication strategy from an end-of-project report (see Related Summaries, below): "Quality of data has been a recurring problem identified through various assessments in Nigeria and its use to guide action has also been sub-optimal. The use of data is a powerful tool for advocacy, decision making, mobilization of resources, planning, and activating and sustaining engagement of communities, health facilities, LGAs and states. The project spent much effort on this important aspect of the REW approach, and worked with the states, LGAs, health facilities and partners to track and review immunization data by service delivery strategy. This was done so that particular coverage gap concerns from routine immunization versus other delivery strategies could be pinpointed and solutions to address the gaps put into place."

Immunisation and Vaccines

According to the IMMbasics website: "With a population of approximately 140 million, Nigeria remains Africa’s most populous nation. Vaccine preventable diseases account for approximately 22% of child deaths in the country; amounting to over 200,000 deaths per year. The Expanded Program on Immunization (EPI), responsible for routinely delivering immunization, started in the late 1970s. In 1990, reported DPT3 [diphtheria, pertussis (whooping cough) and tetanus] coverage in infants (<12 months of age) reached an estimated 56%. During the years following the global Universal Childhood Immunization efforts that culminated in 1990, immunization coverage rates in Nigeria declined significantly. Preliminary results of a 2006 national coverage survey reported 36% DPT3 coverage and only 18% of children fully immunized (aged 12-23 months at survey time, using card + recall). The survey results reveal significant differences across zones ranging from 0%-40% fully immunized children."