Commemorating World Immunization Week, 2021: The RI experience of the PAS Project

TABLE OF CONTENTS

TABLE OF TABLES —————- 2

1.0 World Immunization Week 2021 —————- 3

2.0 PACFaH@Scale (PAS) and the National Immunization Strategy (NSIPSS) —————- 3

3.0 FINANCING OF ROUTINE IMMUNIZATION AT NATIONAL LEVEL & IN PAS FOCAL STATES – KANO KADUNA, NIGER, AND LAGOS —– 5

3.1 Routine Immunization Financing Mechanism in PAS focal states —————- 5

3.2 Routine Immunization Funding at The National and PAS States from 2018-2021 —————- 5

3.2.1 Federal Government Routine Immunization Funding —————- 5

3.2.2 Subnational Level Routine Immunization Funding —————- 6

3.3 States Routine Immunization Budgetary Allocation 2018-2021 —————- 7

3.3.1 KADUNA STATE —————- 7

3.3.2 KANO STATE —————- 8

3.3.3 NIGER STATE —————- 9

3.3.4 LAGOS STATE —————- 10

4.0 COMPARATIVE ANALYSIS OF THE NATIONAL AND SUBNATIONAL ROUTINE IMMUNIZATION FUNDING 2018-2021 —————- 11

4.1 Over dependency on donor/partners —————- 12

4.1 Risk in Underfunding Routine Immunization at the National and Subnational States —————- 13

5.0 PROGRESS ON ROUTINE IMMUNIZATION COMMITMENTS BY PAS FOCAL STATES —————- 13

5.1 Bureaucratic Challenges of Routine Immunisation implementation in the PAS focal states —————- 15

6.0 THE ROLE OF PAS MONITORING THE ROUTINE IMMUNIZATION COMMITMENTS IN PAS FOCAL STATES —————- 16

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7.0 CONCLUSION —————- 16

8.0 REFERENCES —————- 17

TABLE OF TABLES

TABLE 1: FEDERAL GOVERNMENT ROUTINE IMMUNIZATION FUNDING IN MILLIONS OF NAIRA —————- 6

TABLE 2: KADUNA STATE ROUTINE IMMUNIZATION BUDGET ESTIMATES IN MILLIONS OF NAIRA 2018-2021 —————- 8

TABLE 3: KADUNA STATE FG SUPPORTED RELATED ROUTINE IMMUNIZATION IN MILLIONS OF NAIRA —————- 8

TABLE 4: KANO STATE ROUTINE IMMUNIZATION BUDGET ESTIMATES IN MILLIONS OF NAIRA 2018-2021 —————- 9

TABLE 5: KANO STATE FG AND DONOR SUPPORTED RELATED ROUTINE IMMUNIZATION IN MILLIONS OF NAIRA —————- 9

TABLE 6: NIGER STATE FG AND DONOR SUPPORTED RELATED ROUTINE IMMUNIZATION IN MILLIONS OF NAIRA —————- 10

TABLE 7: NIGER STATE CONTRIBUTION TO FG/DONOR SUPPORTED PROGRAMMES IN MILLIONS OF NAIRA 2018-2021 —————- 10

TABLE 8: LAGOS ROUTINE IMMUNIZATION BUDGET ESTIMATES IN MILLIONS OF NAIRA 2018-2021 —————- 11

1.0 World Immunization Week 2021

As Nigeria marks World Immunization Week for 2021 celebrated from April 24th – 30th every year, it is important to highlight the use of vaccines in mitigating vaccine preventable diseases (VPDs) and to measure the progress of Nigeria’s journey for self-reliance. According to the World Health Organisation (WHO), the primary objective of the week is to emphasise the value of vaccines in preventing diseases that were hitherto perceived as life-threatening. This World Immunization Week seeks to highlight the importance of vaccines as a “public good that saves lives and protects health” whilst also allowing development. The theme of 2021 is “Vaccines bring us closer”. This theme seeks to illustrate how vaccines, by preventing disease, can bring us closer to global health goals of eradicating vaccine preventable diseases as well as furthering health equity through universal immunisation coverage.

In Nigeria, the positive impact of vaccines is evidenced in Nigeria’s polio-free status. Nigeria was officially free of polio recently after a longstanding battle with the serious infectious disease. Disease control measures and principally, the emphasis on the polio vaccine led to this new status.

Evidence shows that each year, immunisation prevents 2- 3 million deaths globally.

However, child mortality (under-five mortality rate), a relevant marker with respect to vaccines persists in Nigeria. Nigeria ranks the highest in the number of under-five deaths as a direct result of VPDs. This is according to the United Nations Children’s Fund (UNICEF) figures which indicate that in 2019, 858,000 under-five deaths occurred in Nigeria. The 2018 Nigeria Demographic Health Survey (NDHS) also estimated that the under-five mortality rate in Nigeria is 132 per 1,000 live births; which is about 1 in 8 Nigerian children.

It is estimated that the 1 in 4 deaths that occur in children under-five in Nigeria are entirely preventable with recommended vaccines. Overall, immunisation coverage in Nigeria varies amongst Nigerian states but is still below average. In particular, Nigeria committed to the goals of the Global Vaccine Action Plan (GVAP) which aims to ensure that individuals, regardless of where they are or live, can equitably access vaccines. Nigeria’s coverage is below the GVAP goal. The 2016/17 National Survey of routine immunization coverage shows that 2 in 3 children in Nigeria do not receive three doses of pentavalent vaccine.

Annually, World Immunisation Week, is an opportunity for International Organisations, to highlight the significance of immunization by creating campaigns and building awareness on universal immunisation coverage. In 2020, the United Nations Children’s Fund (UNICEF) and European Union for the Ministry of Public Health saw to the expansion of programmes on Immunisation that resulted in 597,000 routine vaccines procured for a particularly vulnerable – children under-five. In 2021, UNICEF, in a press release committed to pledge $1 for every like, share or comment in a social media campaign till April 30th. The rationale being to create online advocates and disseminate the information on vaccine effectiveness. The United Nations Foundation’s Shot@Life campaign and the Bill & Melinda Gates Foundation intends to also donate US$5 million to ensure all children get access to life-saving vaccines. In addition to this, UNICEF ambassadors alongside healthcare workers, vaccine experts and supporters are scheduled to have a series of online discussions which aim to address this important subject matter.

2.0 PACFaH@Scale (PAS) and the National Immunization Strategy (NSIPSS)

The guiding framework for Immunization in Nigeria is the National Strategy for Immunization and PHC system Strengthening (NSIPSS), a document developed by the National Primary Health Care Development Agency (NPHCDA) in 2018 with inputs from multiple development partners and Nigerian CSOs including PAS partner – the National Association for Primary Health Practitioners of Nigeria (NACHPN) whose representatives participated in all NSIPSS development meetings.

In addition to supporting the NSIPSS development, NACHPN also convened a high-level stakeholder’s dissemination of the Strategy in collaboration with the NPHCDA in 18th August 2018. At the meeting, the ED/CEO, NPHCDA, Dr Faisal Shuaib NPHCDA, represented by Dr. Abdullahi Garba, Director of Planning Research and Statistics in the NPHCDA stated that – the NPHCDA has entered a new era of accountability and openness exemplified by collaboration with partners and other groups. Using the recent MICS results, he noted that available data do not match the increased funding for immunization. Consequently, civil society groups were in a unique position due to their independence from government to advocate for increased allocation and judicious use of resources. This, he stated is especially important since plans to directly fund health facilities using the Nigerian State Health Investment Project (NSHIP) model are being developed. He confirmed that partners like GAVI are willing to support the implementation of the NSIPSS strategy, which he acknowledged, had significant input from stakeholders. The willingness by partners to support the strategy was due to its clear framework for accountability.

Link to meeting report: Report Of The High-level Strategic Dialogue Of PAS CSOS, States And Vital Voices On NSIPSS (2018-2028): CSO Engagement, Accountability, Roles & Expectations – dRPC (drpcngr.org)

The Strategy (2018 – 2028) aims to achieve sustainable immunisation outcomes within a strengthening the primary healthcare system and presents the country’s plan for transitioning to financial ownership of the immunisation and primary health care health system over a ten-year period. This is in line with Nigeria’s proposed timeline for graduating from Gavi support.

Although Nigeria is one of the largest recipients of GAVI grants in Africa, having received US$770 million and US$707 million in approvals and disbursements respectively from 2001 to June 2017, the relationship between the Nigeria and Gavi continues to be an important and valuable for reaching millions of children whose lives can be saved by immunisation.

Nigeria has pledged ownership of the immunisation programme and has outlined programmatic strategies and innovations and sustainable financing solutions, to address inequities in access to vaccines and ensure every eligible child are reached with vaccination.

Sustaining immunisation coverage and equity, the NSIPSS builds on progress that has already been made in recent times and also on strategies that have the best potentials to achieve sustainable immunisation coverage.

Supporting the NSIPSS in recent times are high-level policy pronouncements of the Presidency, Ministries, National Assembly, State Governors, Development Agencies and Civil Society. At the national level, the Federal Government, has shown concrete commitment to RI through an official Letter of Commitment that outlined its planned funding mechanisms including increased annual budgetary allocation for immunisation, Service Wide Votes, First-Line Charge, and the Basic Health Care Provision Fund (BHCPF). Overall, the federal government committed to spending $3 billion to scale up immunization in the country through ‘Nigeria’s Strategy on Immunization and PHC Systems Strengthening (NSIPSS)’. Additional funding sources include World Bank loans and donor funding. The country has also committed to a schedule of payments to full responsibility for its co-financing of routine vaccines on a vaccine-by vaccine basis.

At the level of the National Primary Health Care Development Agency (NPHCDA) there have been significant changes in financial management. In June 2017, the agency declared a state of National Emergency on Routine Immunisation, elevating the political importance of the programme and putting in place a tightly managed structure dedicated to driving measurable change in the 18 lowest performing states and sustaining the gains in the better performing states. In January 2017, the President officially launched the government’s Primary Healthcare Revitalization programme. In February 2018, the President also launched the Community Health Influencers, Promoters and Services (CHIPS) programme to strengthen PHC demand generation and service delivery. In 2020,

3.0 FINANCING OF ROUTINE IMMUNIZATION AT NATIONAL LEVEL & IN PAS FOCAL STATES – KANO KADUNA, NIGER, AND LAGOS

The policy of the Federal Government of Nigeria provides immunization services and potent vaccines, free to all populations at risk of vaccine-preventable diseases.

At national and sub-national levels, routine immunization financing is typically used for vaccination costs such as procurement of vaccines & storage of vaccines, transportation of vaccines to state Central Medical Stores (CMS), maintenance of cold chain, immunization outreach to hard-to-reach areas, program management for immunization, advocacy, communications and social mobilization.

3.1 Routine Immunization Financing Mechanism in PAS focal states

The Nigerian health system is generally funded from the federation’s account. Funding of immunization services is the collective responsibility of all tiers of government through statutory budgetary allocation from the Federal, State and Local Government Areas.

Other sources include external donors, development partners, private sector and the community.

State Governments finance RI through their annual health budgets and Basic HealthCare Provision Fund (BHCPF). Co-funding for the immunization by state governments, donor agencies and the private sector may exist for example, mechanism such as Tripartite MoU signed in 2017 in Kaduna and Kano states with the Bill and Melinda Gates Foundation and Dangote Foundation, in Niger with the Bill and Melinda Gates Foundation bilateral funding.

3.2 Routine Immunization Funding at The National and PAS States from 2018-2021

3.2.1 Federal Government Routine Immunization Funding

The Federal government has increased the routine immunization fund over the years. It was increased significantly from N17 billion in 2018 to N57 billion in the Approved 2021 budget. This shows an increase of 234.95%. The Gavi/Immunization alone was raised from N21 billion in 2018 to N45 billion in 2021 (112%). This is a huge commitment on the part of the government. Similarly, the overall routine immunization allocation to the Federal Ministry of Health (FMoH) budget increased from 4.18% in 2018 to 10.50% in 2021; to overall health, it increased from 4.12% in 2018 to 9.55% in 2021. As per the budget size, it increased to from 0.18% in 2018 to 0.42% in 2021. The increase in immunization funding over the years indicates some level of commitment on the part of the government.

BUDGET LINES 2018 2019 2020 2021
Procurement of RI Vaccines, Devices & Operational Cost 8895.46 7630.95 533.58 2678.33
Polio Eradication 1204.19 100 4800 2204.95
Procurement of Nonpolio SIA Vaccine, Device and Operational Cost 540 1263.72 615.21 639.23
procurement of Outbreak (Emergency)response Vaccine, Devices and Operational Cost 1500 292.97 0 643.16
Procurement of Travelers and Pilgrims Vaccines 174.57 201.19 0 286.95
Vaccines Distribution and Transport (National to States & Health Facilities) 301.06 319.66 393.72
Vaccines Supply Chain Governance 1428.52 70.68 76.94 81.45
Immunization Supply Chain Strengthening at NSCS and Zonal Cost Stores 0 72.54 81.18 106.18
Development of the National Vaccines Policy (NVP) Document Validation of the NYP Draft, Printing and dissemination of Policy Across the 6 Geopolitical Zones of Country 0 28.01 21 29.71
Gavi Immunization 0 21250.42 26843.06 45191.85
Counterpart Funding for Donor Supported Programmes including Global Health/Refund to Gavi 3500 3500 5500 5500
Total 17242.74 34711.54 38790.63 57755.53
% to total FMoH budget 0.0418 0.0818 0.0935 0.105
% to Overall Health Budget 0.0412 0.0768 6.74 0.0955
% to Budget size 0.0018 0.0038 0.0035 0.0042

3.2.2 Subnational Level Routine Immunization Funding

At the Subnational level routine immunization funding is being supported by both the National and donors, apart from the dedicated programs in the annual state health budget.

Basic Health Care Provision Fund (BHCPF)

The Basic Health Care Provision Fund (BHCPF) was created under section 11 paragraph (2) of the National Health Act, 2014 . Basic minimum package of health services to be provided free of charge at the PHC through BHCPF include:

maternal health intervention for pregnant women (ANC, labor delivery, emergency obstetric and neonatal care and family planning); intervention for under 5 (curative and immunizations); malaria treatment for the general population; and non-communicable diseases screening (high blood pressure and diabetes).

Saving One Million lives for Result Programme (SOML)

Launched in 2012, in response to the poor health outcomes in the country. It is an ambitious and comprehensive initiative to scale up access to essential primary health services and commodities for Nigeria’s women and children. The pillars of SOML are – improving maternal, newborn and child health; improving routine immunization coverage and achieving polio eradication; elimination of mother to child transmission of HIV; scaling up access to essential medicines and commodities; malaria control; and improving child nutrition.

Bill & Melinda Gates Foundation Support for PHC System Strengthening & the CHIPS program in Niger State

This is part of sub-national level funding from donors (BMGF). This funding mechanism was legitimized by the MoU signed between the Bill and Melinda Gates Foundation and the Niger state government in 2017 to span for four years.

Building on the Federal level PHC revitalization agenda, this support aimed to bolster the NPHCDA-promoted transformation agenda at the sub-national level organized around a health systems approach focused on seven thematic areas including governance and accountability, human resources for health, infrastructure, drugs and commodities, financing and sustainability, data management and use, service integration, community service and demand creation including the introduction of Community Health Influencers, Promoters and Services (CHIPS) program to Niger state to bring health services to the community.

This MoU represents funding support for program areas such as routine immunization, family planning, nutrition and maternal, neonatal and child health in Niger state.

UNICEF Hard to Reach

According to UNICEF, most children are denied their fair chance at a healthy life because they are not immunized. 17 teams, with 85 well-trained health workers were deployed in Niger State to deliver integrated, mobile outreach services to targeted communities . This is to ensure that children receive vaccinations against measles, meningitis, and other diseases. They also provide basic health services, including medications to fight infections, and health promotion activities.

3.3 States Routine Immunization Budgetary Allocation 2018-2021

3.3.1 KADUNA STATE

The Kaduna state government entered into an MOU in 2018 where it committed the sum of N199,812 million to routine immunization and system strengthening as counterpart funding between 2019 and 2021 and the sum of N285 million between 2022 and 2023. The state government kept this promise in 2019 and 2020 with the allocation of the N200 million to the budget line.

In 2018 and 2019, there was a clear provision for the RI and system strengthening with N200 million allocated in each year under the State Primary Health Care Development Agency (SPHCDA) recurrent budget. The sum of N41 million and N26 million was also allocated for Immunization Plus Days in 2018 and 2019. In the same period, there was a provision of Counterpart Funding with the sum of N720 million in 2018 and N550 in 2019 million under the SPHCDA capital budget. The purpose was not clearly stated but a further inquiry shows that the sum of N570 million and N199 million was released for RI under the fund respectively. It is believed that the N199 million released in 2019 is for the RI and system strengthening which fell under the recurrent budget as part of the N199 million committed in the 2018 MOU.

Lack of clarity has created some confusion in making sense of the state government’s commitment to RI funding. For instance, having removed all dedicated RI budget under the recurrent expenditure in the approved 2021 budget, the counterpart funding for the RI committed by the state government under 2018 MOU would be funded under the N817 million for the Provision of Counterpart Funding (PHC MOU, RSSH MOU, IMPACT Project, CHAI, BHCPF {25%} etc.) as part of the State new PHC integrative funding mechanism . This scenario indicates an end to the Kaduna state government routine immunization funding through recurrent expenditures. The question remains that, was the RI funded under the same budget in 2020, if yes, how much fund goes to RI under N1,946 billion budgeted for the same budget line in the 2020 fiscal year, and how much will go to it in the 2021 fiscal year from N817 million? The response to the question will remove all suspicions.

YEARS COUNTERPART FUNDING UNDER THE SPHCDA CAPITAL BUDGET AMOUNT BUDGETED ACTUAL RELEASED OTHER RI ALLOCATION UNDER RECURRENT SPHCDA BUDGET AMOUNT ACTUAL RELEASED
BUDGETED
2018 Provision of Counterpart Funding 720 570.23 Immunization Plus Days 41.46 N.A
RI & System Strengthening 200 N.A
2019 Provision of Counterpart Funding 550 N.A Immunization Plus Days 26.95 N.A
RI & System Strengthening 200 199
2020 Provision of Counterpart Funding (PHC MOU, TCF MOU, RSSH MOU etc) 1946.19 N.A Immunization Plus Days 10.5 N.A
RI & System Strengthening 200 199
2021 Provision of Counterpart Funding (PHC MOU, RSSH MOU, IMPACT Project, CHAI, BHCPF {25%} etc) 817.8 N.A Nil

It is important to note that other funding mechanisms for the RI in the state include the Saving One Million Lives program for result (SOML) and Basic Health Care Provision Fund, although the actual amount allocated and released for RI from the programs over the years cannot be ascertained.

Budget Lines 2018 2019 2020 2021
Saving One Million Lives program for result (SOML) 552 552 50 N.A
Basic Health Care Provision Fund. Nil 200 Nil N.A

3.3.2 KANO STATE

Similar to Kaduna State, the Kano State government has also been consistent in routine immunization funding. In 2018, the sum of N370 million was allocated for both the routine immunization and the Global Polio Eradication Initiative. Out of this amount, N256 million was released and utilized. Similarly, N500 million was allocated for the two budget lines in 2019: N230 million in 2020 and N330 million in 2021. However, while N342 million was released in 2019, the sum of N276 was released in the 2020 fiscal year and nothing is yet to be released for the year 2021 fiscal year as of the time of writing the report.

BUDGET LINES 2018 RELEASED 2019 RELEASED 2020 RELEASED 2021 RELEASED
ALLOCATION ALLOCATION ALLOCATION ALLOCATION
Routine Immunization 300.8 256 430 313.85 230 276.58 330 Nil
Global Polio Eradication 70 70 70 28.47 50 Nil 50 Nil
Initiative
Total RI 370.8 326 500 342.32 280 276.58 380
Total RI Budget as % 0.0234 0.0328 0.0233 0.0231
of Health Capital Budget
Total RI Budget as % 0.0115 0.0149 0.0104 0.0123
of Health Budget
Total RI Budget as % 0.0015 0.0022 0.002 0.0021
of Budget size

In addition to the state government’s commitment, RI was also funded through the Saving One Million Lives Program for Result (SOML) and the Basic Health Care Provision Fund. The state government released the sum of N304 million in 2018, N664 million in 2019, and N180 million in 2020 for the various programmes and activities under the SOML including routine immunization. The share of the RI from the fund cannot be ascertained. Similarly, N946 million was released as Basic Health Care Provision Fund in 2019, it is believed that aspects of the fund were spent on the routine immunization activities. This is because RI is one of the basic minimum packages to be provided at the PHC from the fund.

BUDGET LINES 2018 ACTUAL 2019 ACTUAL 2020 ACTUAL RELEASED 2021 ACTUAL
ALLOCATION RELEASED ALLOCATION RELEASED ALLOCATION ALLOCATION RELEASED
Saving One Million Lives Program for Result 500 304.97 500 664.37 1314 180.23 1314 Nil
(SOML)
Basic Health Care Provision Fund. Nil 948 950 Nil Nil Nil

3.3.3 NIGER STATE

In Niger State there is no dedicated line item for routine immunization strengthening. However, in 2019 and 2020, the State allocated the sum of N200 and N100 million, respectively, in lumpsums for Nutrition, Safe Motherhood, Family Planning, Adolescent Health, Women in Health, Immunization, MNCH Week, DRF, Environmental Health, IMCI, and Health Promotion. With no specific state’s funded immunization programs, there are budget lines for donors’ funded programs/activities immunizations as could be seen in table below.

TABLE 6: NIGER STATE FG AND DONOR SUPPORTED RELATED ROUTINE IMMUNIZATION IN MILLIONS OF NAIRA        
BUDGET LINES 2018 2019 2020 2021
Saving One Million Lives program for result (SOML) 28.25 306 230.25 1,500,
Bill & Melinda Gates Foundation Support to CHIPs & PHC system strengthening 50 157.06 238.37 238.37
UNICEF Hard to Reach. UNICEF: UNICEF Support to Immunization/ Health Promotion Activities 250 178.6 470.07 118
Basic Health Care Provision Fund. 1300 1500 750

Therefore, out of the N250 million pledged by UNICEF to support the RI in 2018, the sum of N96.18 million was released. The state also released N16.80 million out of the N17.86 million as counterpart funding. For the BHCPF, the state released the sum of N964 million in 2020 even though only N750 was allocated for the budget line in the year.

On the other hand, the Niger state government also contributed N20 million as part of the counterpart funding to the Saving one million live FG fund in 2018; N40 million and N39 million were paid in the 2018 and 2019 respectively as the state contribution to the Bill & Melinda Gates Foundation Support to CHIPs & PHC system strengthening; N50 million and N17 million were contributed in 2018 and 2019 respectively to UNICEF Hard to Reach. UNICEF: UNICEF Support to Immunization/ Health Promotion Activities; N45 million and N100 were contributed in 2018 and 2019 respectively to Basic Health Care Provision Fund. Thus, no contribution was made in this regard in the year 2020 and that of 2021 cannot be ascertained 2021 in the year budget document.

STATE CONTRIBUTIONS 2018 2019 2020 2021
Saving One Million Lives program for result (SOML) 20.1 Nil Nil N.A
Bill & Melinda Gates Foundation Support to CHIPs & PHC system strengthening 40 39.26. Nil N.A
UNICEF Hard to Reach. UNICEF: UNICEF Support to Immunization/ Health Promotion Activities 50.5 17.86 Nil N.A
Basic Health Care Provision Fund. 45 100 Nil N.A

3.3.4 LAGOS STATE

Given the tradition in Lago state of only making budget summaries available to the public the amount allocated to the routine immunization program in 2018 cannot be ascertained. However, the states allocated the sum of N100 million and N234 million for the RI in the year 2019 and 2020 respectively. Out of this N38 million and N126 million were released. The 2021 routine immunization budget in Lagos State includes the counterpart fund-support for the first and the seconds round of the National Immunization Plus Days (NIPDs) with N14 million each; N39 million counterpart funding for the national integrated measles campaign; and N20 million counterpart fund for the supply chain performance impact in public health

YEAR BUDGET LINE ITEMS AMOUNT ALLOCATION ACTUAL
RELEASED
2018 Routine immunization N.A N.A
2019 Routine immunization 100 38
2020 Routine immunization 234.81 126.73
Counterpart fund-support for first round National Immunization Plus Days (NIPDs) 14000 N.A
Counterpart fund-supports for 2nd round National Immunization Plus Days (NIPDs) 14000 N.A
Counterpart fund-national integrated measles campaign 39000 N.A
2021 Counterpart fund-supply chain performance impact in public health facilities in Lagos state 20000 N.A
Subtotal 87000 N.A

4.0 COMPARATIVE ANALYSIS OF THE NATIONAL AND SUBNATIONAL ROUTINE IMMUNIZATION FUNDING 2018-2021

The Federal government routine immunization budget has seen the increase over the years; this is not the situation at subnational level. At subnational level – Kano, Kaduna, Niger, and Lagos States have seen allocations fluctuate. In Kano state, the RI funding was reduced from N500 million to N276 million in 2020 and subsequently increased to N380 million in 2021. In Niger state, the state contribution to RI Immunization/ Health Promotion Activities reduced from N50 million in 2018 to N17.8 million in 2019, and there was no such dedicated budget line for such contribution in the year 2020 and 2021 fiscal years. The 2021 Lagos state budget revealed N87 million allocated for various RI activities. This amount was less than the N100 and N234 million allocated for RI in the 2019 and 2020 fiscal years. In Kaduna State, Immunization Plus Day was reduced from N26 million in 2019 to N10 million in 2020. This budget funding and the “RI & System Strengthening” were subsequently removed in the 2021 budget.

Unlike the Federal government and Kano State where the RI budget has consistently appeared in the budget document between 2018 and 2021, this was not the case with Kaduna, Niger and Lagos state. In Kaduna State in 2018 to 2020 the government initially made good efforts to capture the RI budget in a clear term using performance budgeting based on functions, actives, however, in 2021 this was not the case. This was because the allocation for the routine immunization was lumped under the N817 million provision of Counterpart Funding. The amount allocated for the RI under this budget line cannot be ascertained. In Niger state, apart from the UNICEF donor-funded hard-to-reach programme, the state has no dedicated budget line for the RI between 2018 and 2021. The 2018 and 2019 allocation for RI was lumped with other programmes which include family planning, nutrition, women’s health among others. Also, the summary nature of the Lagos state government often creates problem of ascertaining budget allocation to the routine immunization.

Aside from the Federal government and the Lagos State 2021 RI budget where the specific activities to be funded under the routine immunization are stated, the RI budgetary allocation in Kaduna, Kano, and Niger States did not states in a clear term, the relative programmes, and activities under which the allocated fund for RI will be used for. For instance, FG tied the N639 million to the Procurement of Nonpolio SIA Vaccine, Device and Operational Cost, N81 million to Vaccines Supply Chain Governance which are activities under the routine immunization, etc. Likewise, Lagos State 2021 budget, the N14 million is tied to the Counterpart fund-support for first round National Immunization Plus Days (NIPDs), and another N14 million to the second round. This was not the case in the Kano State where a significant amount of money was allocated to routine immunization without a breakdown. Kaduna and Niger States are also not exception.

4.1 Over dependency on donor/partners

A cursory look at Federal and states government’s budgets shows that they all receive donor funds to implement the immunization programmes and activities. While the FG received strong financial support for immunization from donors such as Gavi, the states also have received financial supports from donors such as UNICEF, Bill and Melinda Gate Foundation (BMGF), Dangote Foundation, etc. Through the National Primary Health Care Development Agency (PHCDA), the federal government also provides vaccines, immunization Guidelines, and technical support to the states and LGAs. State and local governments are responsible for funding and implementing immunization programs at the subnational level.

There is consistency in the PAS States with funding their RI from external supports (e.g., like the Bill & Melinda Gates Foundation Support to CHIPs & PHC System Strengthening) and Federal government-supported interventions (e.g., BHCPF, SOML among others). States like Niger State depend largely on the donors/partners to implement routine immunization programmes. This was evidenced in Tables 6 and 7 above. The state has no independent identifiable programs on the related issues in its annual health budget.

Thus, From the external RI supports, one thing that is observable in all the states is the non-disclosure of the actual amount that goes to the RI from the external/partners’ supports in the annual budget. For instance, the SOML has several pillars which include HIV, essential medicines and commodities, malaria control, child nutrition, routine immunization coverage, polio eradication, etc. None of the States explain in clear terms, how much will go to routine immunization from the external supports/FG intervention in their annual budget. The same applies to all others that are not programme specific.

Accountability of RI funding

Still on accountability, Kano and Niger States to some extent publish their respective RI budget releases in their budget document, whereas Kaduna, Lagos and Federal government do not publish the releases for the routine immunization allocation in their budget document. Also, none of the states including the Federal government published the routine immunization releases in their quarterly budget implementation report or annual financial statement. This raised the issue of accountability as there was no information whatsoever on the issue.

Timely releases of RI funding

There is also evidence of untimely releases of funds for the RI at the national and subnational levels. It is one thing to allocate funding for RI, it is another thing to ensure that the allocated funds are released for effective utilization. Most times, the fund allocated are not released and those released are not in full or delayed. This is evidenced in the Kano, Niger, Kaduna, and Lagos State RI funding releases in the previous years. At the Federal level, the FG has been allocating fund to the budget line entitled “Development of the National Vaccines Policy (NVP); Document Validation of the NYP Draft, Printing and dissemination of Policy Across the 6 Geopolitical Zones of Country” since 2019. What happens to the fund, was it released, has the document been produced, when, was it been disseminated? These are some of the burning questions that come to mind. Delay and none release of fund to RI could have a greater implication on the RI programs and activities.

Irregularity in the RI funding in some states may suggest three things; poor government revenue generation and unrealistic projection, dependency on external funds, and relaxation of the funding under a notion that the war against wild poliovirus and other related diseases have been won, hence, no need for huge funding. The latter point could only be justified if the government at either the national and subnational levels have not entered into any contractual agreement with anybody or that such agreement has been reviewed in line with the current budget line. When these are not in affirmative, the state still has the responsibility to fulfill her side of the agreement.

4.1 Risk in Underfunding Routine Immunization at the National and Subnational States

Inadequate and untimely releases of funding to immunization related activities could lead to non or under-vaccination of the under-5 children in the 2021 fiscal year. This could in turn create a potential risk for the outbreak of some other preventable diseases in the state.

With no dedicated budget lines for RI in 2021 especially in the Niger State approved budget, whatever the intention of the state government, this will not only send a wrong signal to donors or other potential parties interested in supporting the government on the issue of child health, but it could also lead to underfunding of the RI activities including training of Human of Resources for Health (HRH), transportation of logistic to health facilities, maintenance of cold chain, etc.

A poor priority on health-related issues especially on child health is a risk to a nation’s socio-economic development. This is given the fact that the country is now the home of the under-five children in the world having overtaken India (UNICEF).

There is also an issue of sustainability of the donor-funded or supported immunization programmes. In every part of the world, donor supported or funded programmes have a lifespan. When they end, the beneficiary government is expected to take ownership with adequate funding commitment and releases. Kaduna State PHC MOU will end by 2023, the state is expected to take full financing with N285 million for RI starting 2022. The question that comes to mind, whether or not state will fund the programme with optimal level, not only with allocation but releases given its current revenue challenges which have resulted in the sack 4000 workers. The Niger and Kano State government also have related MOUs in this regard to expire by 2021 and 2023 respectively.

Thus, sustaining such efforts through adequate funding will sustain the gains already made by polio resources and help ensure a safer environment for the children given the current public health crisis. Hence, the national and subnational level government must understand that this is not the time to take its foot off the accelerator rather it’s a period to give routine immunization a vital boost through dedicated budget lines and adequate funding.

5.0 PROGRESS ON ROUTINE IMMUNIZATION COMMITMENTS BY PAS FOCAL STATES

A comparative analysis of routine immunization commitments and performance in the four PAS states (Lagos, Kaduna, Niger and Kano) was conducted by the PAS project with a focus on 11 indicators. The MoU commitments amongst three PAS states (Kaduna, Kano and Niger) and adapted for Lagos state were tracked by key indicators using a checklist adapted from the tripartite agreement and VTC MoU signed by various states. PAS CSOs held key personnel interviews with top RI government officials for data collection in Kano, Kaduna, Niger and Lagos states. The findings below provide significant insights on the progress in the states in the context of Covid-19.

PAS lead assessor with the Kaduna state

PAS lead assessor with the Kano ES SPHCMB

PAS lead assessor with the PM-SERICC Niger state

PAS lead assessor with Lagos Immunization

1. Conduct intensified catch up campaigns to reach all the children missed during the COVID-19 surge with RI and PHC

This activity is meant to close the gaps of missed vaccination that occurred during the covid 19 pandemic period in order to reach the missed children in the states. Lagos conducted the RI intensification catch-up campaigns from October to December 2020 to reach underserved communities, Kaduna had same activities in the last two quarters of last year (2020) in three LGAs (Kachia, Kaura and Jama’a), while facilities in Kano state are presently conducting daily sessions in high volume PHCs and has also embarked on monthly oral vaccinations (MOVs) which is ongoing in 248 facilities in the state. Niger state has also set out a plan to intensify the RI campaign to reach underserved communities in 5 identified LGAs (Bida, Lavun, Magama, Mashegu and Paikoro) from May to December, 2021.

2. Deploy and monitor performance of phase 1 CHIPS agents at HF, LGA and State levels

Community health influencers promoters and services (CHIPS) agents are important personalities in the communities who can drive behavioural and attitudinal changes in their various communities to improve acceptability and uptake of routine immunization. The Kano and Kaduna state Government have launched and deployed the CHIPS agents to all local government in the state. Kano has even reached the stage of assessing the performance of the phase 1 of CHIPs Agent which was conducted in March 2021. Niger state has launched the program but its yet to commence full-service delivery at community level while Lagos state is yet to launch the program.

3. Number of Outreaches and fixed session conducted (Oct 2020-Mar 2021)

To improve the RI coverage, it is necessary to conduct outreach and fixed session campaigns to reach many children who will not come to the facilities for vaccination in the states. Kano state conducted the highest number of outreaches with 19153 fixed sessions and 19153 outreach sessions in Q3 and 7828 fixed sessions and 7828 outreach sessions in Q4 of 2020, Lagos state conducted about 39,198 outreaches and fixed sessions exercise between Oct 2020 and Mar 2021, Kaduna state also conducted four outreach per month in all the facilities while the number of outreaches and fixed sessions could not be ascertained for Niger state.

4. Development and implementation of polio ramp down strategy which leverages polio structures to drive PHC services

Niger state has developed and implemented the polio ramp down strategy designed by WHO and in Kano, the EOC has leveraged on the polio structure to conduct surveillance on Covid19, and the strange aliment that was killing people in the State. Kaduna and Lagos states have also leveraged on polio legacies to strengthen RI, AFP surveillance and community engagement strategies.

5. Development and implementation of state-wide human resource for health plan

All the PAS states have fulfilled this commitment through different strategies. In Niger state, the department of planning research and statistics of the SPHCB carry out this exercise every year while Lagos has an exit-replacement strategy in line with the public service rules in the State. Kaduna state also have this done yearly.

6. Timely funds release and allocation for SIAs

Fund release is important to carry out the SIA activities. This continues to be a challenge for states. Supporting partners and State counterpart funds are usually eventually released for the SIA in the states, Lagos state claims its releases fund are usually timely but acknowledges the challenge of not getting adequate notice about changes in programme from the NPHCDA which affects budgeting and subsequent release of required funds.

7. Numbers of SIAs conducted

The frequency of the SIAs varied across the four states due to availability of funds. Lagos conducted 2 in Q4 of 2020 and 1 in Q1 of 2021, Kaduna conducted 2 in the last two Quarters of 2020, Niger conducted 2 in Q1 of 2021 while that of Kano is unknown.

8. The RI antigen coverage in the state

The RI coverage for the states varies and it’s recorded on Quarterly basis. The latest record shows that Lagos state is at 70% overall coverage, Kano at 93.3% and 87.7% for penta 1, penta 3 respectively. Niger state is at 91% for Penta 3 coverage while Kaduna state data was not available.

9. Timely release of State and LGA counterpart funds and continue providing oversight on PEI activities in LGAs through Task Force meetings and monitoring of SIAs

All states release the counterpart funds but not all LGAs fulfil this commitment. In Lagos state, funds are released as soon as received and monthly RIWG meetings are held to monitor PEI activities to resolve challenges. Also, some LGAs in Niger state have support for the rounds and task force meetings held at LGAs and reactivation process at state level. Kano state released money about 8 months before the exercise. Kaduna also releases counterpart funds as at when due.

10. Leveraging on polio legacies to strengthen RI, AFP surveillance and community engagement strategies

All the PAS states fulfilled this part of the commitment with their various forms of collaborations and leveraging on polio legacies in the states. For example; the Kano SPHCMB used the polio strategy to conduct MI-MOP which targeted the low RI LGAs. Lagos, Niger and Kaduna also use all polio structure at the wards/community levels to reach all the community with RI services and surveillance approaches.

11. Supportive supervision using the revised optimized RISS Standard Operating Procedure (SOP) for conducting supportive supervision at state and sub-levels

Routine supportive supervision is one of the important indicators of the commitment. It is structured to provide onsite mentoring and assessment of RI activities at various facilities and posts using the RISS SOP in the states. In Lagos; each team member and partner are assigned to specific LGAs and prioritise HFs with unresolved challenges. Supervisors use logbooks at the health facility to document feedback and to-dos. The RISS is done fortnightly in Kano with other PHC services also leveraging on the exercise. Niger state conduct it on weekly basis where the state team visit the LGA/Facilities and LGA team visit Health facilities. This also happens routinely in Kaduna state.

5.1 Bureaucratic Challenges of Routine Immunisation implementation in the PAS focal states

Each state has its own peculiar challenges and bottlenecks affecting the RI activities in the state.

In Kaduna state; tracking of defaulters, lack of support from LGA and poor attitude of the health care workers are the major challenges. Niger faces challenges ranging from inadequate funding for routine immunization activities particularly at the lower levels to irregular conduct of fixed and outreach sessions and inadequate human resources for health. Others include poor motivation of health workers due to irregular payment of salaries, insecurity in compromised communities and lack of regular social mobilization and demand generation activities. The challenges in Lagos state are minimal and has to do with poor data on population and increasing migrant population. The main bureaucratic challenge in Lagos is inadequate financing of the RI program while that of Kano is the delay in approving the RI work plan as the 2021 RI work plan is still undergoing bureaucratic processes.

6.0 THE ROLE OF PAS MONITORING THE ROUTINE IMMUNIZATION COMMITMENTS IN PAS FOCAL STATES

Tracking of the commitments

PAS CSO partners in all the four states monitors the efforts of each government towards meeting the commitment as agreed. Routine data on activities carried out in line with the agreed indicators are collected. These evidences inform their advocacies to the stakeholders to ensure fulfilment of the commitments.

Active on SERICC platforms across the states

PAS CSO partners in priority states are active stakeholders and supporters of SERICC. PAS regularly contributes to solving issues on this platform and other routine immunization technical working groups and sub-committees.

Routine Immunization Supportive supervision

PAS partners are supporting the states and participating in the routine immunization supportive supervision targeting low performing LGAs. In Kano state, PAS partners conduct RISS in partnership with SERICC. This supports the states effort to expand vaccine coverage.

Trainings and Capacity Building

PAS is supporting Kano state to conduct capacity building activities targeted at traditional and religious leaders in fulfilment of commitment to include them as vaccine promoters in their constituencies. Most recent was the capacity building for the Bichi Emirate committee members supporting them to be more effective, producing an operational work plan. Members of the Bichi Emirate council, KSMOH and Bichi LGA officials were in attendance. The Emir of Bichi chaired this event. The event was held between 15th – 16th April 2021 at FCE(Technical), Bichi.

Group picture of the participants after the training on 16th April 2021

7.0 CONCLUSION

As Nigeria approaches the mid-point of the 10-year Immunization Strategy, government at all levels should ensure that they fulfil their funding obligations in adequate and timely terms. Despite the gains so far, Nigeria must work to improve upon the shortcomings for routine immunization strengthening through the PHCs. There is a role for civil society organizations to catalyse transparency and accountability at all levels to ensure Nigeria stays on track to meeting her targets.

8.0 REFERENCES

• 2018 Appropriation Act, Https://Www.Budgetoffice.Gov.Ng/Index.Php/2018-Appropriation-Act/2018-Appropriation-Act/Download

• 2019 Appropriation Act, Https://Www.Budgetoffice.Gov.Ng/Index.Php/2019-Appropriation-Bill-V2/2019-Appropriation-Bill/Download

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• Using collective voices to create state-level accountability. Case Study No. 11 | March 2018, https://www.mnch2.com/wp-content/uploads/2018/04/TSC-MNCH2-CS_11_SLAMs_single-1.pdf

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