Landscape Analysis
of Routine Immunization
in Nigeria: Identifying Barriers
and Prioritizing Interventions
By: Cecily Stokes-Prindle, Chizoba Wonodi, Muyi Aina, Gbolahan Oni,
Tope Olukowi, Muhammad Ali Pate, Lois Privor-Dumm & Orin Levine
)NTERNATIONAL6ACCINE!CCESS#ENTER)6!#s*OHNS(OPKINS"LOOMBERG3CHOOLOF0UBLIC(EALTH\1
International Vaccine
Access Center (IVAC)
Johns Hopkins Bloomberg
School of Public Health
Rangos Bldg, Suite 600
855 N. Wolfe Street
Baltimore, MD 21205
www.jhsph.edu/ivac
This study was made possible by funding from the Bill & Melinda Gates Foundation
The Desk Review was supported by a grant from the GAVI Alliance
2\2OUTINE)MMUNIZATIONIN.IGERIAs2012
EXECUTIVE SUMMARY
Nigeria has the twelfth highest under-five mortality rate in the world, with 143 child deaths per 1,000 live births
in 2010. Approximately one in four of those deaths are preventable through routine immunization (RI), but
coverage of routine childhood vaccines remains lower than global benchmarks and, in many parts of Nigeria,
is among the lowest in the world. Nonetheless, the Nigerian government and her partners have succeeded in
acheiving major improvements in coverage rates over the past three years. National DPT3 coverage rates have
improved steadily, reaching approximately 69% in 2010 according to WHO best estimates. However, this overall
progress occurs in the context of significant heterogeneity at the state level and an overall coverage rate below the
regional average; the need for improved systems remains apparent.
In order to identify key strengths, weaknesses, opportunities, and threats facing the Nigerian RI system, the
International Vaccine Access Center undertook a Landscape Analysis of Routine Immunization (LARI) in Nigeria,
with funding from the Bill & Melinda Gates Foundation and the GAVI Alliance. The study was conducted between
between April and August 2011 in collaboration with the National Primary Health Care Development Agency and
Solina Health. This white paper draws on responses from 126 key informant interviews and 11 focus groups in 7
Nigerian states and the Federal Capital Territory (FCT), hereafter referred to as 8 states. The analysis combines
information from respondents with survey data and a review of the available literature; the final product is an
analysis of supply-side constraints and demand-side determinants of RI coverage in Nigeria, along with an
evaluation of potential interventions for the Nigerian context.
Key strengths in the RI system include strong support by high-level policy makers and technocrats at the federal
level, specifically from the NPHCDA and the Ministry of Health. Other strengths include a federal budget line for
immunizations and a record of success with polio eradication in most states of the federation. The RI program has
also demonstrated the ability to disseminate pro-immunization messages and increase demand for vaccines.
Weaknesses in the RI system are both structural and logistical. Recurring themes include a lack of accountability
stemming from poor governance, weak monitoring and evaluation systems, and the perception of low political
benefit of RI support, especially at the sub-national level. Inadequate cold chain and transportation were
mentioned as near-universal barriers; Nigeria’s large area presents a logistical difficulty in and of itself.
Disbursement of designated funds has also been problematic, and fiscal decentralization has resulted in
inconsistent funding levels across states and LGAs.
The external context for RI is generally positive. Although the system is facing potential threats from a shrinking
program landscape, an unstable global economy, and the prioritization of polio eradication efforts over routine
immunization, there are important opportunities as well. These include strong global support for RI, a favorable
political climate in-country, moderate to high vaccine demand, and the potential to piggy-back on polio
eradication efforts.
Recommendations to address these barriers relate to the structural as well as logistical. Examples include
technical support of newly formed State Primary Health Care Development Agencies, increased provision of cold
chain equipment and vehicles, and demand-side interventions where appropriate. All potential interventions are
categorized by likely impact and feasibility of implementation, with a suggestion that diversifying intervention
investments provides a good balance between definite, but incremental improvements and riskier but potentially
high-impact innovations.
)NTERNATIONAL6ACCINE!CCESS#ENTER)6!#s*OHNS(OPKINS"LOOMBERG3CHOOLOF0UBLIC(EALTH\1
&ACILITYOBSERVATIONSWERECONDUCTEDINFACILITIESINSTATES
1 INTRODUCTION
1.1 BACKGROUND
FOCUSGROUPDISCUSSIONSWERECONDUCTEDINSTATESKEY
INFORMANTINTERVIEWSWERECONDUCTEDWITHKEYINFORMANTSFROM
STATES2ESPONSESWERECOLLECTEDANDANALYZEDBYTHE,!2)TEAMTO
IDENTIFYRECURRINGTHEMESBYSTATEANDATTHENATIONALLEVELS
7ORLD(EALTH/RGANIZATIONESTIMATESFORTHEYEARRANK.IGERIAAS
HAVINGTHETHHIGHESTUNDERlVEMORTALITYRATEINTHEWORLDAT
4HISSTUDYCANBECONSIDEREDANEXPLORATORYANALYSISOF2)GAPSATTHE
DEATHSPERLIVEBIRTHS%VERYYEARMORETHAN.IGERIAN
STATELEVEL'IVENTHENATUREOFQUALITATIVERESEARCHANDTHEVARIATIONS
CHILDRENINTHISAGEGROUPDIE$UETOTHEHIGHUNDERlVEMORTALITY
WITHINACOUNTRYASLARGEAS.IGERIAITWOULDBEOVERREACHINGTO
RATEANDALARGEANNUALBIRTHCOHORTOFOVERMILLIONCHILDREN.IGERIA
PRESENTTHESERESULTSASFULLYREPRESENTATIVEOFTHECOUNTRY(OWEVER
CONTRIBUTESDISPROPORTIONATELYTOTHEGLOBALBURDENOFUNDERlVEDEATHS
THESELECTIONOFSTATESFROMALLSIXGEOPOLITICALZONESANDOFRESPONDENTS
FROMALLTHREELEVELSOFGOVERNMENTSPOSITIONEDTHISANALYSISTOELICIT
6ACCINEPREVENTABLEDEATHSCONSTITUTEASIGNIlCANTPROPORTIONOFMORTALITY
ADIVERSITYOFISSUESATDIFFERENTLEVELS4HERECURRENCEOFKEYTHEMES
AMONGCHILDRENUNDERTHEAGEOFlVEYEARSIN.IGERIA&OREXAMPLE
ACROSSGEOPOLITICALZONESANDGOVERNMENTALLEVELSPROVIDESFURTHER
VACCINEPREVENTABLEDISEASESSUCHASPERTUSSISTETANUSANDMEASLES
VERIlCATIONOFTHERELEVANCEANDUSEFULNESSOFTHISAPPROACH
CAUSEDANESTIMATEDANNUALDEATHSINTHESECHILDRENIN
2ECENTESTIMATESFROMTHE#HILD(EALTH%PIDEMIOLOGY2EFERENCE'ROUP
2.1 FIELD SURVEY
FOUNDTHATPNEUMONIADIARRHEAANDMENINGITISPREVENTABLEINPARTWITH
2.1.1 STATE SELECTION
NEWERVACCINESLEDTONEARLYANNUALCHILDDEATHSIN.IGERIAIN
"ASEDON$04COVERAGERATESREPORTEDINTHE.$(3ANDTHE
—APPROXIMATELYATHIRDOFTHECOUNTRYSUNDERlVEMORTALITY
.)#3SURVEYTHETEAMCATEGORIZEDALLSTATESIN.IGERIAINTOONE
OFFOURPERFORMANCETYPOLOGIES4YPOLOGIESWEREBASEDONTHEHISTORIC
!LTHOUGHTHEREHAVEBEENRECENTIMPROVEMENTSINIMMUNIZATION
ANDCURRENT'!6)COVERAGElLTERSFORNEWVACCINESUPPORTAND
COVERAGERATESINMANYPARTSOF.IGERIACOVERAGEOFROUTINEVACCINES
$04COVERAGE
REMAINSAMONGTHELOWESTINTHEWORLD)NNEARLYMILLION
.IGERIANCHILDRENWEREUNVACCINATEDTHEHIGHESTNUMBEROF
UNVACCINATEDCHILDRENINANY!FRICANCOUNTRY'IVENTHESIGNIlCANT
BURDENOFVACCINEPREVENTABLEDISEASEIN.IGERIAIMPROVINGACCESSTO
ANDUTILIZATIONOFROUTINEIMMUNIZATIONSERVICESWILLCONTRIBUTETOREDUCED
CHILDMORTALITYANDACCELERATEDPROGRESSTOWARDSTHE-$'TARGET
1.2 OBJECTIVES
4HIS,ANDSCAPE!NALYSISWASUNDERTAKENWITHTWOMAINOBJECTIVESTO
IDENTIFYBARRIERSTOUNIVERSAL2)COVERAGEANDTODETERMINEEVIDENCE
3TATESWITHpersistently low coverageDElNEDASTHOSEWITH$04
COVERAGEOFPERCENTORLESSINBOTHSURVEYS
3TATESWITHpersistently high coverageDElNEDASTHOSEWITH
$04COVERAGEOFPERCENTORMOREINBOTHSURVEYS
/FTHEREMAININGSTATES
3TATESWITH large increases in DPT3 coverage
PERCENTAGEPOINTSORMOREBETWEENAND
3TATESWITHsmall to moderate increases in DPT3 coverage
LESSTHANPERCENTAGEPOINTSBETWEENAND
BASEDSOLUTIONSTHATWOULDADDRESSTHESEBARRIERSANDIMPROVE2)
2 METHODOLOGY
4HEPROJECTWASIMPLEMENTEDASAMULTICOMPONENTQUALITATIVE
Zamfara
Kano
ASSESSMENTTHATINCLUDEDTHEFOLLOWING
&ACILITYBASEDPARTICIPANTOBSERVATIONANDEXITINTERVIEWSTO
Gombe
DETERMINECOREISSUESFACING2)UTILIZATIONUPTAKEANDDEMAND
&ACILITYANDCOMMUNITYBASEDFOCUSGROUPDISCUSSIONSWITH
FCT
KEYGATEKEEPERSOFVACCINEDEMAND$ISCUSSANTSINCLUDED
REPRESENTATIONFROMFEMALEGROUPSSUCHASMARKETWOMENAND
!.#ATTENDEESASWELLASREPRESENTATIONFROMMALEGROUPSSUCH
Taraba
Osun
ASCOMMERCIALDRIVERSANDMECHANICS
Ebonyi
+EYINFORMANTINTERVIEWSWITHOPINIONLEADERSATTHENATIONAL
STATE,OCAL'OVERNMENT!REA,'!ANDCOMMUNITYLEVELS
1UALITATIVEANALYSISTOIDENTIFYPERCEIVEDBARRIERSANDCROSS
CUTTINGTHEMES
)DENTIlCATIONANDASSESSMENTOFPOTENTIALSOLUTIONS
2\2OUTINE)MMUNIZATIONIN.IGERIAs2012
Bayelsa
!TOTALOFEIGHTSTATESANDTHE&#4WEREINCLUDEDINTHISSTUDY
Community-based interviews.4HECOMMUNITYBASEDPORTIONSOF
4HOSESTATESWERE"AYELSA%BONYI'OMBE+ANO/SUN4ARABA
THESTUDYINCLUDEDPARTICIPANTSFROMCOMMUNITIESSERVEDBYTHE
:AMFARAALONGWITHTHE&#44HISGROUPOFSTATESWASSELECTEDTO
0(#SSELECTEDACCORDINGTOTHEMETHODDETAILEDABOVE)NEACH
REPRESENTARANGEOFPERFORMANCETYPOLOGIESGEOPOLITICALZONES
COMMUNITYKEYINFORMANTSWEREIDENTIlEDWITHINPUTFROMTHE0(#
TOPOGRAPHYUPLANDVSRIVERINEANDLEVELOFCURRENTPARTNERSUPPORT
WORKERSANDTHE7ARD6ILLAGE(EALTH#OMMITTEEMEMBERS
FORIMMUNIZATIONSTRENGTHENING
Exclusion criteria. 0OTENTIALCOMMUNITYPARTICIPANTSWEREEXCLUDEDFROM
2.1.2 PARTICIPANT SELECTION
THISSTUDYIFTHEYDIDNOTHAVECHILDRENORWERELESSTHANYEARSOLD
0ARTICIPANTSELECTIONWASCONDUCTEDASFOLLOWS
Key informant selection.+EYINFORMANTSWERESELECTEDFORINCLUSION
2.1.3 INTERVIEW METHODS
4HE,!2)TEAMUSEDASETOFSTANDARDIZEDTOOLSFOREACHCOMPONENT
IN,!2)USINGTHECOMBINATIONOFPURPOSEFULSELECTIONANDSNOWBALL
OFTHESTUDYANEXITINTERVIEWQUESTIONNAIREANDPARTICIPANT
SAMPLING"ASEDONTHE,!2)TEAMSKNOWLEDGEOFSTAKEHOLDERS
OBSERVATIONCHECKLISTFORFACILITYBASEDPARTICIPANTSANDASEMI
ALISTOFCATEGORIESOFKEYINFORMANTSFROMGOVERNMENTANDPARTNER
STRUCTUREDINTERVIEWGUIDEFORKEYINFORMANTINTERVIEWS!LLTOOLSWERE
AGENCIESATTHENATIONALSTATE,'!ANDCOMMUNITYLEVELSWAS
JOINTLYDEVELOPEDBY)6!#AND3OLINA(EALTHSTAFFANDPRETESTED
DEVELOPED#ATEGORIESOFSTAKEHOLDERSINCLUDEDTECHNOCRATS
PRIORTOBEINGUSEDFORDATACOLLECTION%ACHINTERVIEWWASCONDUCTED
POLITICIANSANDPOLICYMAKERSIMMUNIZATIONPROGRAMMANAGERS
BYAMINIMUMOFTWORESEARCHERSANDRESPONSESWERECAPTURED
ANDSTAFF!STHEINTERVIEWSPROGRESSEDTHEINTIALSETOFRESPONDENTS
ELECTRONICALLYONAUDIORECORDERSASWELLASININTERVIEWERNOTES
HELPEDIDENTIFYOTHERNATIONALSTATEAND,'!LEVELINFORMANTSWHO
2.2 DATA ANALYSIS
WERETHENINCLUDEDINTHESTUDYSAMPLE
4HERESEARCHTEAMANALYZEDTHEQUALITATIVEDATAACCORDINGTO
Facility-based participant observation.0RIMARY(EALTH#AREFACILITIES
ASTANDARDFRAMEWORKAPPROACH0OPEAND-AYSUSING
0(#SWITHINSELECTEDSTATESWEREPURPOSIVELYSAMPLEDFORTHE
THEDOMAINCLASSIlCATIONSOUTLINEDBELOW!SAlRSTSTEPTRAINED
lELDOBSERVATIONSANDEXITINTERVIEWS)NEACHSTATETWO,'!SWERE
PERSONNELCOMPLETEDTRANSCRIPTIONOFINTERVIEWSAND&'$SFROM
VISITEDONEURBANANDONERURAL!CTUAL,'!SELECTIONWASINFORMED
THEAUDIORECORDINGSANDINTERVIEWERNOTES&OLLOWINGTHATTHE
BYSTATE-INISTRYOF(EALTHOFlCIALSWHOWEREMOREFAMILIARWITHTHE
RESEARCHERSCATEGORIZEDANDINDEXEDALLPOINTSMADEBYEACH
LOCALLANDSCAPE/NE0(#WASTHENSELECTEDWITHINEACH,'!THIS
RESPONDENTINTOAPPROPRIATEDOMAINS2ESEARCHERSTHENCREATEDA
TIMEBASEDONTHEADVICEOFTHE,'!OFlCIALS0(##OORDINATORSAND
DATABASEOFKEYISSUESBARRIERSOPPORTUNITIESANDRECOMMENDATIONS
,OCAL)MMUNIZATION/FlCERS7HILETHISMETHODISAPOTENTIALSOURCE
FOREACHSTATEANDTHENATIONALLEVEL4HElNALSTEPWASACOMPARISON
FORBIASITALSOFACILITATEDWILLINGNESSTOPARTICIPATEANDALLOWED
ANDINTEGRATIONOFINSIGHTSFROMEACHSTATEANDNATIONALLEVEL
RESEARCHERSTOINCLUDEALARGESAMPLEINASHORTTIMEFRAME
INTERVIEWINTOACOMPOSITESETOFlNDINGSANDRECOMMENDATIONS
PERFORMANCE TYPOLOGY
(DTP3)
Persistently Low coverage:
,ESSTHANINAND
Persistently High coverage:
ORABOVEINAND
Large coverage gains:
)NCREASEOFPERCENTAGEPOINTSORMORE
BETWEENAND
Moderate to low or no coverage gains:
)NCREASEOFLESSTHANPERCENTAGEPOINTS
BETWEENAND
STATES
+ANO+EBBI+ATSINA
"AUCHI9OBE
"ORNO4ARABA
%KITI/SUN
!NAMBRA)MO
&#4,AGOS
3OKOTO:AMFARA*IGAWA
!DAMAWA%NUGU
"AYELSA
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+ADUNA'OMBE"ENUE
+OGI+WARA0LATEAU
%DO2IVERS!KWA)BOM
$ELTA#ROSS2IVERS
!BIA%BONYI/YO/NDO
/GUN
)NTERNATIONAL6ACCINE!CCESS#ENTER)6!#s*OHNS(OPKINS"LOOMBERG3CHOOLOF0UBLIC(EALTH\3
2.2.1 FRAMEWORK
5SINGTHESTUDYOBJECTIVESAREVIEWOFTHELITERATUREAND
CONVERSATIONSWITHDIVERSESTAKEHOLDERSTHE,!2)TEAMIDENTIlED
CHAINCAPACITYPOORCOLDCHAINEQUIPMENTMAINTENANCEVACCINESTOCK
OUTSINADEQUATESUPPLYANDINCONSISTENTPOWERSUPPLY
SIXKEYTHEMATICDOMAINSTOFRAMETHECONCEPTUALANALYSIS&OUR
Financial barriersARECROSSCUTTING4HEYCANAFFECTTHEENTIRE
DOMAINSADDRESSSPECIlCCOMPONENTSOFTHESYSTEMWHILETWOARE
PROCESSOFVACCINEPROCUREMENTANDDELIVERYFROMTHENATIONALTOTHE
CROSSCUTTINGCONTEXTUALDOMAINS4HEDOMAINSAREASFOLLOWS
HEALTHFACILITYLEVEL4HEPRACTICALFEASIBILITYOFADDRESSINGlNANCIAL
BARRIERSISOFTENHIGHBUTISSUESSUCHASSUSTAINABILITYANDPOLITICAL
#ONTEXTUALDOMAINS
Leadership and Governance.4HEDEMONSTRATEDANDREPORTED
COMMITMENTOFLEADERSATTHENATIONALSTATEANDLOCALLEVELTHE
FEASIBILITYMAYACTASROADBLOCKSTOEFFECTIVEACTION4HEIMPACTOF
ADDRESSINGlNANCIALBARRIERSISVARIABLEIFTHEADDITIONALMONIESARE
NOTUSEDEFlCIENTLYTHEIMPACTWILLBELOWERED
EXTENTTOWHICHPROGRAMSAREACTUALLYIMPLEMENTEDATEACHLEVEL
Financing and Resource Management.)SSUESRELATEDTOTHE
DESIGNATIONPROCUREMENTANDUSAGEOF2)FUNDING
#OMPONENTFOCUSEDDOMAINS
Logistics, Planning and Management.4HEDEVELOPMENTAND
/NEIMPORTANTOBSERVATIONISTHATlNANCIALBARRIERSAREOFTENTHElRSTTO
BECITEDBYRESPONDENTS(OWEVERTHEYARENOTALWAYSTHEMOSTDIRECT
LEVERSFORCHANGE)NMANYCASESIMPROVINGOTHERASPECTSOFTHESYSTEM
CANRESULTININCREASEDAVAILABILITYOFFUNDS!SWITHLOGISTICALISSUES
DISTANCEFROMPOINTOFSERVICEISIMPORTANT7HILETHEREMAYBESUFlCIENT
MAINTENANCEOFNECESSARYSUPPLYCHAINSTORAGEANDDELIVERY
FUNDINGWITHINTHEGREATERSYSTEMIFITSNOTAVAILABLEATTHEPOINTOF
RESOURCESFOR2)
SERVICETHEOUTCOMEWILLBETHESAMEASTHATOFINSUFlCIENTFUNDSOVERALL
Human Resources for Health.4HEQUANTITYANDCAPACITYOF2)
STAFF
Health Management and Information Systems.$ATACOLLECTIONAND
FEEDBACKTOIMPROVESERVICE
)NADDITIONTHECAPACITYTOCOMPENSATEFORLACKOFFUNDINGDECREASES
ATEACHSYSTEMLEVELCLOSERTOPOINTOFSERVICEATTHE0(#ORINDIVIDUAL
LEVELFEWPARTICIPANTSHAVETHEDECISIONMAKINGPOWERORRESOURCESTO
MAKECHANGESTHATWOULDCOMPENSATEFORLACKOFFUNDS
Service Delivery and Demand Creation. 4HEDEMANDSIDE
DOMAININCLUDESCLIENTLEVELBARRIERSTO2)
)DENTIlEDlNANCIALBARRIERSINCLUDEDELAYSINRELEASEOFDESIGNATED
FUNDSATALLLEVELSINADEQUATEFUNDINGESPECIALLYATTHELOCALLEVEL
7ITHINEACHDOMAINWEHAVEANALYZEDKEYINFORMANTINTERVIEWSTO
INEFlCIENTUSEOFFUNDSAPPROPRIATIONOF2)DESIGNATEDFUNDSFORNON
IDENTIFYRECURRINGTHEMES"ARRIERSAREPRESENTEDBYDOMAINWITHAN
2)PROJECTSANDNONSUSTAINABLElNANCINGOFDONORPROJECTS
ADDITIONALSECTIONFORSTATELEVELHIGHLIGHTS7ETHENPRESENTPOTENTIAL
INTERVENTIONPACKAGESDEVELOPEDTOADDRESSTHOSEIDENTIlEDBARRIERS
Human resource barriersCANBEINTHEFORMOFINADEQUATESUPPLY
INADEQUATECAPACITYORBOTH4HESEBARRIERSARERELEVANTATTHE
3 RESULTS: IDENTIFIED BARRIERS
3.1 OVERVIEW
MANAGERIALLEVELASWELLASTHEHEALTHWORKERLEVEL!DDRESSING
THESEBARRIERSCANBEPRACTICALLYFEASIBLEPARTICULARLYINAREAS
WHEREINADEQUATESUPPLYISTHEMAINISSUE(OWEVERTHEIMPACTOF
ADDRESSINGHUMANRESOURCESBARRIERSWILLBELIMITEDINTHEABSENCE
"ARRIERSAREPRESENTEDBYDOMAINSECTIONSFORSTATESPECIlC
OFOTHERSYSTEMIMPROVEMENTS)DENTIlEDHUMANRESOURCESBARRIERS
HIGHLIGHTSANDTHESPECIALCASEOFPOLIOERADICATIONFOLLOW4HIS
INCLUDECAPACITYGAPSPOORPERFORMANCEMANAGEMENTSTAFF
APPROACHISAPPROPRIATEGIVENSURPRISINGHOMOGENEITYOFTHElNDINGS
SHORTAGESINEFlCIENTSTAFFALLOCATIONORALLOCATIONOFSTAFFTIMECULTURE
MOSTBARRIERSIDENTIlEDWEREOPERATINGACROSSSTATESANDLOCALAREAS
OFMONETIZATIONOFTASKSANDPOORATTITUDEWORKETHICANDMOTIVATION
3UBNATIONALDIFFERENCESARENOTEDWHEREAPPARENT
Service delivery barriersDECREASETHESTANDARDOFCARETHISDOMAIN
Logistical barriersRELATETOSUPPLYANDTRANSPORTATIONOFVACCINESCOLD
ISTHEREFORETHEMOSTCLOSELYLINKEDTOTHEDEMANDSIDEOF2)WITH
STORAGEPOWERSUPPLYANDOTHEREQUIPMENTRELATEDISSUES4HESE
POTENTIALFEEDBACKINTOTHEGOVERNANCEDOMAINIFPERCEIVEDDEMAND
BARRIERSGENERALLYBECOMEMORERELEVANTASTHEPOINTOFSERVICEBECOMES
AFFECTSTHEPOLITICALBENElTOFTACKLINGIMMUNIZATIONISSUES
MOREREMOTE4HEPRACTICALDIFlCULTIESINADDRESSINGTHESEBARRIERSCAN
BESIGNIlCANTDUETOHARDTOREACHTARGETPOPULATIONSDIFlCULTIESWITH
!DDRESSINGTHESEBARRIERSISPRACTICALLYFEASIBLEFORINTERVENTIONS
MAINTENANCEOFPROVIDEDEQUIPMENTANDTHENECESSITYOFENSURING
REQUIRINGIMPROVEDCONDITIONSBUTMOREDIFlCULTWHENBEHAVIOR
THATVEHICLESAREUSEDASINTENDED(OWEVERTHEIMPACTOFSUCCESSFULLY
CHANGEISTHEGOAL!DDRESSINGSERVICEDELIVERYBARRIERSHASTHE
ADDRESSINGLOGISTICALBARRIERSWOULDBEVERYHIGHTHESEBARRIERSWERECITED
GREATESTIMPACTINAREASWHERETHEREAREOTHERWISEADEQUATERESOURCES
REPEATEDLYBYSURVEYPARTICIPANTSATALLLEVELS)DENTIlEDLOGISTICALBARRIERS
TOMEETANYINCREASESINDEMANDITISNOTLIKELYTOBEASTANDALONE
INCLUDETRANSPORTATIONCHALLENGESATPERIPHERALPOINTSINADEQUATECOLD
INTERVENTIONINAREASWITHOTHERSIGNIlCANTPROBLEMS)DENTIlEDSERVICE
4\2OUTINE)MMUNIZATIONIN.IGERIAs2012
DELIVERYBARRIERSINCLUDEPOORINTEGRATIONOF2)SERVICESWITHBROADER
BUDGETEDFORVACCINELOGISTICSTHEYMAYNOTBERELEASEDONTIMEAND
PRIMARYHEALTHSERVICESINADEQUATEQUANTITYOFHEALTHFACILITIESLOW
TOTHEAPPROPRIATEPERSONNEL
ORNONEXISTENTCOMMUNITYENGAGEMENTPOORACCESSTOHARDTOREACH
COMMUNITIESANDPOORCONDITIONSATHEALTHFACILITIES
3PECIlCISSUESCITEDBYRESPONDENTSINCLUDETHEFOLLOWING
Barriers for health information systemsEXISTINTERMSOFINACCURATE
Supply chain management.!LLBUTONEOFTHEHEALTHFACILITIES
DATACOLLECTIONANDLACKOFDATAUSE%ACHPROBLEMEXACERBATESTHE
SURVEYEDREPORTEDRECENTSTOCKOUTSOFVACCINEANTIGENSANDOR
OTHERWITHNOCONSEQUENCESFEEDINGBACKTOTHEFACILITYLEVELTHERE
ACCOMPANYINGMATERIALSSUCHASSPECIALIZEDSYRINGESANDDILUENTS
ISLITTLEREASONTOWORKFORACCURATEREPORTINGWHILEWITHOUTACCURATE
0(#PERSONNELMOSTOFTENCITEINADEQUATESUPPLYATTHESTATE
DATATHEREISLITTLEREASONTOINCORPORATEDATABASEDDECISIONMAKING
LEVELASTHEREASONFORTHESHORTAGE0OORINVENTORYMANAGEMENT
INTOMANAGEMENTPROTOCOLS4HEPRACTICALFEASIBILITYOFIMPROVINGDATA
PRACTICESATSTATEAND,'!LEVELSCOMBINEWITHDELAYEDUPWARD
COLLECTIONISRELATIVELYHIGHBUTTHEREMAYBESOMEPOLITICALDIFlCULTY
FEEDBACKOFDATAWHENSTOCKSAPPROACHAMINIMUMTHRESHOLD
INIMPLEMENTINGSYSTEMSOFDATABASEDDECISIONMAKING4HEIMPACT
RESULTINGINSLOWRESPONSIVENESSANDRESTOCKINGFROMTHENATIONAL
OFIMPROVEDDATACOLLECTIONCOULDBEHIGHIFITISACCOMPANIED
LEVELS)TISCOMMONTOHAVEEXCESSSTOCKATONE,'!WHILEANOTHER
BYIMPLEMENTATIONOFPROTOCOLSFORDATABASEDDECISIONMAKING
HASASTOCKOUTEVENWITHINTHESAMESTATE!LSOBECAUSEOFA
)NTHOSECIRCUMSTANCESIMPROVEDDATACOLLECTIONCOULDINCREASE
FAILURETO@BUNDLEVACCINESITISCOMMONPLACETOlNDSTATESAND
ACCOUNTABILITYATMULTIPLELEVELS)TCOULDALSOAFFECTPROCUREMENTBY
OR,'!SWITHVACCINESTHATARENOTUSABLEBECAUSEOFASHORTAGEOF
IMPROVINGTHEACCURACYOFDEMANDFORECASTS
REQUIREDACCOMPANYINGSUPPLIES
)DENTIlEDBARRIERSTOFUNCTIONALANDACCURATE(-)3INCLUDEUNRELIABLE
!CCORDINGTO.0(#$!OFlCIALSTHESESUPPLYSHORTFALLSOCCUR
ORINVALIDADMINISTRATIVEDATAUNCLEARPROTOCOLSANDINADEQUATE
BECAUSETHEFEDERALGOVERNMENTDISTRIBUTESVACCINESBASEDON
TRAININGOFSTAFFFORAPPROPRIATEDATACOLLECTIONANDUTILIZATIONDATANOT
FORECASTESTIMATESTHATAREBASEDONTARGETPOPULATIONSINEACH
USEDFORDECISIONMAKINGSOME0(#SLACKINGBASICDATACOLLECTION
,'!ANDSTATES2ESPONDENTSNOTEDTHATPOPULATIONESTIMATESARE
TOOLSSUCHASPAPERANDPENREGISTERSPOORFORECASTINGANDLACKOF
SOMETIMESNOTACCURATEORNOTADJUSTEDFORRECENTINCREASESIN
FEEDBACKTOTHECOMMUNITYREDUCINGACCOUNTABILITY
COVERAGERESULTINGINSHORTFALLS
Governance barriersLIKElNANCIALBARRIERSARECROSSCUTTING"ECAUSE
Inadequate transport for vaccines and health workers.0ARTICULARLY
THEYAFFECTSYSTEMWIDEISSUESSUCHASACCOUNTABILITYANDFUNDING
INREMOTELYLOCATED0(#FACILITIESTRANSPORTOFSUPPLIESAND
AVAILABILITYTHESEBARRIERSCANHAVEEFFECTSATEVERYLEVEL!SLAST
SERVICESISCHALLENGING&ACILITIESMAYBEFARFROM,'!COLDSTORES
MILEPROVISIONISTHEMOSTSENSITIVETODISRUPTIONTHEEFFECTSOFPOOR
ORLOCATEDONACCESSROADSWHICHAREIMPASSABLETHROUGHOUTTHE
GOVERNANCEAREOFTENCOMPOUNDEDALONGTHE2)SUPPLYCHAIN'IVEN
YEARORDURINGTHERAINYSEASON#ONSEQUENTLYTHEYAREUNABLETO
THEWIDERANGINGCONSEQUENCESOFPOORGOVERNANCETHEIMPACT
COLLECTVACCINESFOR2)DAYSREGULARLY7HENCOLLECTIONDOESTAKE
OFADDRESSINGTHESEBARRIERSWOULDBEVERYHIGH4HEPRACTICALAND
PLACETHEJOURNEYTOANDFROMTHECOLDSTOREMAYTAKEMOSTOFTHE
POLITICALFEASIBILITYOFAGOVERNANCEFOCUSEDINTERVENTIONISLOWINTHE
DAYRESULTINGINADELAYEDCLINICSTARTTIMETHATREDUCESTHE
SHORTTERMTHELEVERSFORCHANGEARENOTCLEARNORISITOBVIOUSWHO
NUMBEROFCLIENTSSERVED!CCORDINGTOONENATIONALLEVEL
MIGHTIMPLEMENTSUCHANINTERVENTION(OWEVEROVERTHELONGTERM
INTERVIEWEE.0(#$!CURRENTLYENGAGESSMALLSCALEINDEPENDENT
SUSTAINEDENGAGEMENTWITHLEADERSINANDOUTOFGOVERNMENTCAN
CONTRACTORSFORTRANSPORTATIONOFVACCINESBUTSOMEOFTHESE
ADDRESSUNDERLYINGISSUESINTHESYSTEMCREATINGLASTINGIMPROVEMENT
CONTRACTORSHAVENOTUSEDAPPROPRIATEANDRELIABLEEQUIPMENT
)DENTIlEDGOVERNANCEBARRIERSINCLUDEDEPENDENCEONINDIVIDUAL
4RANSPORTATIONFORHEALTHWORKERSTHEMSELVESISALSOLACKING)N
INTERESTSTOPRIORITIZE2)ATTHESTATELEVELDECENTRALIZATIONLEADING
LOWCOVERAGEAREASWHEREVACCINATIONISACCOMPLISHEDATLEAST
TOLOWACCOUNTABILITYANDELECTEDOFlCIALSRELUCTANCETOINVESTIN2)
PARTLYBYOUTREACHEFFORTSRATHERTHANSOLELYAT0(#SHEALTH
RATHERTHANMOREIMMEDIATELYVISIBLEPROJECTS
WORKERSMUSTHAVEADEQUATEANDRELIABLETRANSPORTATIONINORDER
TOREACHFAMILIESINTHEIRHOMES
3.2 LOGISTICS
-ANYSTATESAND,'!SDONOTCOMMITADEQUATERESOURCESTOVACCINE
4HESETRANSPORTATIONPROBLEMSWERENOTEDBYLOCALANDFACILITY
LOGISTICSANDTRANSPORTATION4HISRESULTSINCOMPROMISEOFTHE
LEVELINFORMANTSINMULTIPLESTATES0ERHAPSSURPRISINGLYEVENTHE
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SUGGESTINGTHATWHILETHEIMPACTISMAGNIlEDINRURALAREASITIS
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NOTSOLELYARURALPROBLEM
)NTERNATIONAL6ACCINE!CCESS#ENTER)6!#s*OHNS(OPKINS"LOOMBERG3CHOOLOF0UBLIC(EALTH\5
Inadequate cold chain capacity.!CROSSTHECOUNTRYLACKOF
THENORTHERNSTATES!SIMILARSITUATIONEXISTSEVENFORMANAGERIAL
ESTABLISHEDMECHANISMSFORREPAIRANDMAINTENANCEOFCOLDCHAIN
FUNCTIONS&OREXAMPLEINTHENORTHERNSTATES0(#DEPARTMENTS
EQUIPMENTCANLEADTOFREQUENTBREAKDOWNSANDDISRUPTIONOFTHE
AT,'!SARERUNBY0(#COORDINATORSWHOAREMOSTCOMMONLY
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#OMMUNITY(EALTH7ORKERSCOMPAREDTOTHESOUTHERNSTATES
/NLYONESTATE+ANOHADASYSTEMFORMAINTAININGCOLDCHAIN
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EQUIPMENTPUTINPLACEBYADONORFUNDEDPROJECT%VENIN+ANO
(EALTHWHOAREGENERALLYPUBLICHEALTHPHYSICIANS
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3.3 HUMAN RESOURCES
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Poor staff motivation and work ethic.4HREENATIONALLEVEL
RESPONDENTSANDTHIRTEENSTATEAND0(#LEVELRESPONDENTSIN
'OMBE&#4+ANOAND4ARABASTATESCITEDALACKOFMOTIVATION
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-ANY0(#DEPARTMENTSPARTICULARLYAT,'!SAREHEADEDBYSTAFFWITH
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PERCEPTIONTHATTHElNANCIALINCENTIVESMOTIVATE0(#WORKERS
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Mis-aligned accountability structures.7ITHINTHESTATESTWO
DIFFERENTLINEMINISTRIESAREINVOLVEDINTHEEXECUTIONAND
4HESTAFlNGANDSUPERVISORYSTRUCTUREWITHINGOVERNMENTHEALTH
SUPERVISIONOF0(#SERVICES4HE,OCAL'OVERNMENT3ERVICE
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#OMMISSIONORINSOMESTATES-INISTRYOF,OCAL'OVERNMENT
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SYSTEMLEADERSLIKETHE0(##OORDINATORS4HE3TATE-INISTRYOF
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PROBLEMS
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,'!PERSONNELANDTHEREFORECANNOTHOLDTHEMACCOUNTABLE
Inadequate numbers of health workers in many PHCs.3TATESAND
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0(#FACILITIESBUTDONOTFOLLOWTHROUGHWITHSTAFlNGUPGRADES
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ATTHE,'!LEVEL4HISDISCONNECTWASCITEDBYRESPONDENTSAS
STATEDTHATWHILETHEHUMANRESOURCEGAPSOCCURINPARTFROM
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INADEQUATEHIRINGBY,'!STHEREISALSOANOVERALLSHORTAGE
PARTICULARLYTHOSEWORKINGINTHE0(#SYSTEM
OFQUALIlEDSTAFFTHATCANBEHIRED)NADDITIONTWOSTATELEVEL
INTERVIEWEESMENTIONEDTHATTHEFEWSTAFFAVAILABLEAREINEQUITABLY
3.4 SERVICE DELIVERY
DISTRIBUTEDMANYSTAFFMEMBERSARELOCATEDINURBANAREAS
,'!SBEARTHEPRIMARYRESPONSIBILITYFORDELIVERYOF2)ANDOTHER0(#
LEAVINGRURALAREASUNDERSERVED
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FACILITIESOFTENHAVELIMITEDBASICTRAININGWITHMOSTBEING
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Some PHCs are not providing a high standard of care.!COMMON
lNDINGACROSSALLSTATESISTHATDEMANDFOR2)ISDIMINISHED
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Poor integration of immunization services into routine PHC services.
ISGENERALLYBETTERINTHESOUTHERNSTATESTHANINTHENORTHERN
2ESPONDENTSSUGGESTEDTHATOTHERHEALTHSERVICESANDTREATMENTS
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WITHINSTATES,'!SDIFFERINTHEIRPERFORMANCEURBAN0(#STEND
PERCEIVEALACKOFFOCUSONOTHERIMPORTANTISSUESSUCHAS
TODOBETTERTHANTHOSEINREMOTELOCATIONS
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!NUMBEROFMOTHERSWHOPARTICIPATEDINTHEFOCUSGROUP
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AGAINHEREASITIMPACTSDEMANDFOR0(#BASEDSERVICES
0(#SISNOTMATCHEDBYTHATOFOTHERBASICSERVICESWHICH
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)NADDITIONSOMEREMOTECOMMUNITIESFACEUNIQUECHALLENGES
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FOCUSGROUPPARTICIPANTRAISEDTHEISSUEOFNOMADICCOMMUNITIES
MOTHERSATTENDINGANTENATALCAREWITHTHEIRlRSTPREGNANCIES
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WEREOFTENNOTAWAREOFREQUIREDCHILDHOODIMMUNIZATIONSWHICH
#OMMUNITYINTERVIEWRESPONDENTSIDENTIlEDALACKOFSYSTEMATIC
SUGGESTSBOTHASERVICEGAPANDANOPPORTUNITYFORIMMUNIZATION
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EDUCATIONASPARTOFANTENATALSERVICES
COMMUNITIESASACAUSEOFDECREASEDOWNERSHIP$ILAPIDATED
CLINICSTRUCTURESANDOBSOLETEEQUIPMENTWEREALSOMENTIONEDAS
3.5 HEALTH INFORMATION SYSTEMS
DETERRENTSTOSEEKING0(#CARE
0(#FACILITIESARETASKEDWITHCOLLECTINGDATAONVACCINEUTILIZATION
NUMBEROFCHILDRENIMMUNIZEDWASTAGERATES4HESEDATA
Low demand in some areas.-ANYRESPONDENTSBELIEVETHATDEMAND
ARETHEORETICALLYCOLLECTEDWITHANATIONALLYSTANDARDIZEDPAPER
FOR2)ISSTILLNOTASHIGHASTHEIDEALPARTICULARLYINTHENORTHERN
INSTRUMENT4HEDATAAREREPORTEDTOTHE,'!SWHERETHEYARE
PARTOFTHECOUNTRY4HEREISAHIGHDEGREEOFVARIABILITYINDEMAND
AGGREGATEDANDSENTTOTHESTATESFORCOLLATIONANDTRANSMISSIONTOTHE
FOR2)SERVICESBETWEENSTATESANDEVENAMONG,'!SINTHESAME
.0(#$!4HISSYSTEMHOWEVERHASNOTBEENHIGHLYFUNCTIONALAND
STATE)NSTATESWITHRELATIVELYHIGHCOVERAGEPARTICULARLYSTATESIN
SEVERALLAPSESINDATAMANAGEMENTWEREIDENTIlED
SOUTHERN.IGERIAAWARENESSANDDEMANDFOR2)SERVICESISHIGH
AMONGTHEPOPULATIONSOMEFOCUSGROUPRESPONDENTSINTHESE
AREASEVENEXPRESSEDWILLINGNESSTOPAYFORSERVICES
Unclear and/or inconsistently implemented data collection protocols.
,'!STAFFANDFRONTLINE0(#STAFFARENOTCONSISTENTLYTRAINEDIN
METHODSFORACCURATEDATACOLLECTIONANDREPORTINGANDAPPROPRIATE
)NTHOSESTATESWITHLOWERCOVERAGERATESHOWEVERTHEREISSTILL
MATERIALSARENOTALWAYSPROVIDED4HISCAPACITYGAPCANRESULTIN
GROUNDTOBECOVEREDINCREATINGPOPULATIONAWARENESSAND
INCOMPLETEANDINACCURATEDATACOLLECTION)NADDITION,'!OFlCIALS
GENERATINGDEMAND2ESPONDENTSREPORTPOCKETSOFVACCINE
MENTIONEDTHATMANY0(#SROUTINELYLACKREQUIREDREGISTERSAND
REJECTIONINAFEWSTATESINTHENORTHDUETOPERSISTENCEOF
OTHERDATACAPTUREFORMS,'!SOFTENDONOTHAVEFUNDSAVAILABLE
TRADITIONALORRELIGIOUSANTIVACCINEBELIEFS
TOPRINTORPROVIDETHEFORMSFOR0(#SANDTHESTATESDONOTALWAYS
PROVIDEADEQUATEQUANTITIES)NADDITIONWITHOUTCONSISTENTLY
Focus on Immunization Plus Days (IPDs).2ESPONDENTSREPORTTHAT
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PARTICIPATIONOFCLINICSTAFFINFREQUENTPOLIOFOCUSED)0$SHASHAD
TOIDENTIFYINCIDENTSOFFALSIlCATIONWHILEITISDIFlCULTTODETERMINETHE
ANEGATIVEIMPACTONSERVICEDELIVERYAT0(#S4HESECAMPAIGNS
EXISTENCEOREXTENTOFDELIBERATEFALSIlCATIONITWASCITEDASANISSUE
PULLHEALTHWORKERSFROMTHEIRREGULARACTIVITIESINORDERTO
BYASMALLNUMBEROFRESPONDENTSATTHESTATEANDNATIONALLEVEL
)NTERNATIONAL6ACCINE!CCESS#ENTER)6!#s*OHNS(OPKINS"LOOMBERG3CHOOLOF0UBLIC(EALTH\7
Administrative data are unreliable.4HEABOVEMENTIONEDISSUES
WITHDATACOLLECTIONATTHELOCALANDFACILITYLEVELCARRYTHROUGHAS
3.6 FINANCIAL
4HEMAJORITYOFFUNDINGFOR2)COMESFROMTHEFEDERALGOVERNMENT
DATAAREAGGREGATEDATTHESTATEANDNATIONALLEVEL!SARESULTIT
THROUGHDIRECTBUDGETSANDFROMDESIGNATED-$'FUNDS3TATES
ISGENERALLYACCEPTEDTHATADMINISTRATIVEDATADONOTACCURATELY
AND,'!SAREREQUIREDTHROUGHSTATUTORYPROVISIONSOFTHE.ATIONAL
REPRESENT2)COVERAGELEVELSTHEYTENDTOBEINmATEDRELATIVETO
(EALTH"ILLTOPROVIDEFUNDSFORVACCINELOGISTICSANDTRANSPORTATION
ACTUALCOVERAGE4HELACKOFACCURATECOVERAGEDATAMAKESIT
WITHINTHESTATESAND,'!S(OWEVERTHEREAREQUESTIONSABOUTTHE
DIFlCULTTOACCURATELYTARGETANDEVALUATEPROGRAMSWITHINTHE2)
CONSISTENCYSUFlCIENCYANDENFORCEMENTOFTHESECONTRIBUTIONS)N
SYSTEMASWELLAS2)IN.IGERIAASAWHOLE
ALLSTATESVISITEDSTATESCONTRIBUTESOMEFUNDSFORVACCINELOGISTICS
Lack of implemented protocols for decision-making based on
collected data.2ESPONDENTSATALLLEVELSIDENTIlEDAGENERAL
!LSOBECAUSETHESTATESDIRECTLYCONTROLFUNDINGTO,'!STHEYARE
ABLETOINmUENCECONTRIBUTIONSBYTHE,'!SBYWITHDRAWING,'!
FUNDS@ATSOURCETOFUNDAVACCINELOGISTICSPOOLASIN:AMFARASTATE
DISREGARDOFDATAANDITSUSE#OLLECTEDDATAARENOTUSEDFOR
PLANNINGHEALTHACTIVITIESORDECISIONMAKINGANDTHEREIS
)NTERNATIONALDONORSPROVIDESIGNIlCANTRESOURCESFORIMMUNIZATION
THEREFORELITTLEINCENTIVEATANYLEVELTODEVOTETIMEANDRESOURCES
SERVICES!FEWLIKE'!6)FUNDNATIONWIDEACTIVITIESWHILEMANY
TOENSURINGDATAACCURACY)NTURNTHEINACCURACYOFCOLLECTED
OTHERSSUPPORTTARGETEDINTERVENTIONSINSPECIlCSTATESEG32)+
DATAMAKESITDIFlCULTTOJUSTIFYDECISIONMAKINGBASEDONTHOSE
SUPPORTSCAPACITYBUILDINGANDLOGISTICSIN+ANOSTATE%XCLUDING
DATATHEPROBLEMSOFCOLLECTIONANDUSEAMPLIFYEACHOTHER
'!6)DONORSMOSTOFTENFUNDVACCINECOLDCHAINANDTRANSPORTATION
3EVERAL,'!AND0(#PERSONNELEXPRESSEDDISSATISFACTIONTHAT2)
Budgeted funds are not released regularly and promptly, disrupting
DATAISCOLLECTEDSOLELYFORREPORTINGPURPOSESATSUBNATIONALLEVELS
vaccine supply.4HE'OVERNMENTOF.IGERIAPROCURESVACCINES
ANDTHEYDONOTRECEIVEANYFEEDBACKONTHEIRDATA4HISISSUEWAS
THROUGH5.)#%&BUTSTRICTLYONACASHBASIS4HISVACCINE
ALSOIDENTIlEDBYTWONATIONALLEVELINTERVIEWEESWHOSUGGESTED
PROCUREMENTISRELATIVELYWELLFUNDEDINTHEFEDERALBUDGET
THATBECAUSEOFTHELACKOFFEEDBACKTHEREISNOOWNERSHIPORUSE
(OWEVERFEDERALBUDGETCYCLESANDBUREAUCRATICPROCESSESOFTEN
OFTHEDATAFORDECISIONMAKINGAT0(#,'!OREVENSTATELEVELS
MEANTHATFUNDSARENOTAVAILABLEFORDRAWDOWNUNTILLATEINTHE
)NADDITIONCOMMUNITIESAND0(#SARERARELYPROVIDEDFEEDBACK
YEAR3INCEVACCINEPROCUREMENTISSCHEDULEDTOBEQUARTERLY
REGARDINGTHEIRPERFORMANCEDATAWHICHCREATESASIGNIlCANT
SUPPLIESFORTHESTANDNDQUARTERSAREOFTENNOTORDEREDON
MISSEDOPPORTUNITYTOSTIMULATEPERFORMANCEIMPROVEMENT
TIMEANDVACCINEPROVISIONISDISRUPTED
Lack of accountability."ECAUSEDATAAREUNRELIABLENOTDISSEMINATED
States and LGAs do not provide sufficient funding for logistical
TOTHEPUBLICANDNOTUSEDFORFEEDBACKPROGRAMDESIGNORFUNDING
support.$ESPITESTATUTORYOBLIGATIONSMANYRESPONDENTSFELTSTATES
DECISIONSTHEREISAWIDESPREADLACKOFACCOUNTABILITY7HEN
AND,'!SDONOTPROVIDESUFlCIENTFUNDINGSUPPORTFORLOGISTICSAND
COMBINEDWITHTHEMISMATCHEDSUPERVISORYSTRUCTUREDISCUSSEDIN
TRANSPORTATIONEVENINCASESWHEREFUNDSAREBUDGETEDTHEYMAY
THEHUMANRESOURCESSECTIONTHERESULTISASYSTEMINWHICHITIS
NOTBEDISBURSEDORTHEYMAYBEUSEDFORNON2)PURPOSES4HESE
VERYDIFlCULTTOREWARDANDSCALEUPHIGHPERFORMINGPROGRAMSAND
FUNDINGGAPSCREATEGAPSINVACCINEDISTRIBUTIONTHATWORSENATEACH
TOPINPOINTANDADDRESSISSUESINLOWPERFORMINGSETTINGS
LEVELCLOSERTOPOINTOFSERVICE7HILEDONORPROGRAMSSOMETIMES
STEPINTOBRIDGETHESEGAPSINIMPLEMENTATIONMOSTOFTHESE
!LONGTHESELINESONEDIRECTOBSERVATIONBYTHESTUDYTEAMWAS
ACTIVITIESTERMINATEONCEDONORFUNDINGCEASES
THATTHEUSEOFADMINISTRATIVEDATARESULTSINAFALSESENSEOFHIGH
PERFORMANCE!LLSTATESAND,'!SVISITEDWEREWELLBELOWTHE
NATIONALTARGETCOVERAGERATESFOR2)BASEDON.)#3DATA
3.7 GOVERNANCE
3TAKEHOLDERSINTERVIEWEDWERECONSISTENTINTHEIRUNDERSTANDING
(OWEVERINTHETHREESTATESWHERE3-/(OFlCIALSKNEWTHEIR
OFTHEDELINEATIONOFRESPONSIBILITIESBETWEENTHENATIONALSTATE
PERFORMANCENUMBERSATALLTHEYREFERENCEDTHEADMINISTRATIVE
AND,'!2ESPONDENTSCITEDTHEREGULARPROVISIONOFFUNDSFOR
COVERAGERATESWHICHTENDTOBEHIGHERTHANACTUALCOVERAGE
VACCINEPROCUREMENTINTHENATIONALBUDGETASEVIDENCETHAT2)IS
LEVELS,OWCOVERAGE,'!SANDSTATESWERETHEREFOREEXPRESSING
AHIGHPRIORITYATTHENATIONALLEVEL4HREEOUTOFSEVENNATIONALLEVEL
SATISFACTIONTHATTHEYHADMETPERFORMANCETARGETSOFOR
RESPONDENTSSTATEDTHATTHE&EDERALGOVERNMENTTHROUGH.0(#$!
HIGHERCOVERAGERATES4HISFALSESENSEOFHIGHPERFORMANCE
PROVIDESSTRONGLEADERSHIPFOR2)IN.IGERIA(OWEVERACCORDINGTO
CONTRASTSSHARPLYWITHTHEPERFORMANCEREmECTEDINMORERIGOROUS
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SURVEYDATA
LIMITEDBECAUSECOMMITMENTISLACKINGATTHESTATEAND,'!LEVELS
8\2OUTINE)MMUNIZATIONIN.IGERIAs2012
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GOVERNANCEISDUETOMULTIPLEFACTORS
State and local RI efforts are inconsistent and dependent on
personal interests.2ESPONDENTSCONSISTENTLYINDICATEDTHAT
3.8 NOTE ON POLIO ERADICATION
EFFORTS
4HEONGOING0OLIO%RADICATION)NITIATIVE0%)PROVIDESBOTHANOBSTACLE
ANDANOPPORTUNITYFORTHE2)SYSTEM7HILERESPONDENTSHAVECITED
SOMENEGATIVEIMPACTSDISCUSSEDBELOWTHEREAREALSOOPENINGS
STATESAND,'!SWERELACKINGINTERMSOFLEADERSHIP!TTHESUB
FOR2)TOBUILDON0%)INVESTMENTSANDACCOMPLISHMENTS)NMANY
NATIONALLEVELSTHEDEGREEOFGOVERNMENTCOMMITMENTVARIES
STATES2)ACTIVITIESPIGGYBACKON0%)RESOURCESANDACTIVITIESANDHAVE
CONSIDERABLYWITHMANYSTATESAND,'!SSHOWINGLITTLEEVIDENCE
BENElTEDSIGNIlCANTLYFROMTHEM)NALLSTATESSURVEYEDRESPONDENTS
OFLOCALOWNERSHIPOF2)4HEDEGREETOWHICHASTATEPRIORITIZES
REPORTEDTHATTHEINCREASEDAWARENESSCREATEDBY0%)HASRESULTED
ANDCOMMITSRESOURCESTO2)DEPENDSVERYHEAVILYONTHE
ININCREASEDOVERALLDEMANDANDUTILIZATIONOFIMMUNIZATIONSERVICES
PERSONALINTERESTSOFTHESTATEGOVERNORANDHISADVISERS)N+ANO
!LSOPARTICULARLYINTHENORTHERNSTATES0%)ISOFTENTHEMAINDRIVEROF
FOREXAMPLETHESTATEEXECUTIVESARESUPPORTIVEOF2)ANDHAVE
IMMUNIZATIONACTIVITIESANDTHEONLYSOURCEOFGUARANTEEDCOMMITTED
USEDTHEIRINmUENCEON,'!FUNDINGALLOCATIONSTOINCREASETHE
FUNDSFORIMMUNIZATIONATTHE,'!AND0(#FACILITYLEVELS
ENGAGEMENTOF,'!CHAIRMEN)TISWORTHNOTINGHOWEVERTHAT
THISAPPARENTINCREASEDLEVELOFCOMMITMENTHASNOTTRANSLATEDTO
(OWEVERTHE0%)HASHADAFEWSIGNIlCANTNEGATIVEEFFECTSON2)AND
SIGNIlCANTLYIMPROVED2)PERFORMANCEIN+ANO
MOREBROADLY0(#SYSTEMFUNCTIONING4HEFOCUSONPOLIOINMANY
Decentralization hampers accountability.!SNOTEDEARLIER.IGERIAS
LOWRESOURCESTATESAND,'!SAGAINOFTENINTHENORTHHASMEANT
THATTHELIMITEDHUMANANDMATERIALRESOURCESAVAILABLEARECHANNELED
0(#SYSTEMISlSCALLYDECENTRALIZED4HEFEDERALGOVERNMENTSETS
ALMOSTEXCLUSIVELYTOWARDSPOLIOERADICATIONACTIVITIESTOTHEDETRIMENT
THEOVERALLAGENDABUTEACHSTATEAND,'!FUNDSCOMPONENTS
OFOTHER0(#SERVICES!PARTICULARCONCERNHASBEENTHATHEALTHCARE
OFSERVICEDELIVERYATITSDISCRETION4HEREARETHEREFORENO
WORKERSANDOTHERSTAKEHOLDERSMAYHAVElNANCIALINCENTIVESFOR
ACCOUNTABILITYMECHANISMSALLOWINGTHEFEDERALGOVERNMENTTO
PARTICIPATIONIN0%)CAMPAIGNSRESULTINGINA@MONETIZATIONOFSTAFF
ENSURETHATSTATESDELIVERONKEYHEALTHPROGRAMS4HEREISALSO
COMMITMENT0OLICYMAKERSAND0(#SYSTEMLEADERSHAVESOFAR
LITTLEINCENTIVEOROPPORTUNITYFORFEEDBACKTOMOVEBACKUPTHE
DEMONSTRATEDAPREFERENCETOENGAGEIN0%)ACTIVITIESRATHERTHAN2)
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ACTIVITIESTHATDONOTHAVEANYATTACHEDlNANCIALINCENTIVES3OME0(#
WORKERSSURVEYEDALSOEXPRESSEDAPREFERENCEFOR0%)ACTIVITIESOVER
4HEPROBLEMISEXACERBATEDBYTHEDUALAGENCYSTRUCTURENOTED
THEIRROUTINERESPONSIBILITIESDUETOTHElNANCIALINCENTIVE
INTHEHUMANRESOURCESDISCUSSION4WODIFFERENTMINISTRIESARE
INVOLVEDINTHEEXECUTIONANDSUPERVISIONOF0(#SERVICESTHE
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,OCAL'OVERNMENT3ERVICE#OMMISSION,'3#OR-INISTRYOF
ONTHEBASELINEPERFORMANCEOFTHE2)SYSTEM)NTHENORTHERNSTATES
,OCAL'OVERNMENT!FFAIRSBEARSTHERESPONSIBILITYFORRECRUITING
WHERE2)PERFORMANCEWASLOWPOLIOERADICATIONHASHADANETPOSITIVE
TRAININGDEPLOYINGANDPAYINGSALARIESOFSENIOR,'!PERSONNEL
IMPACTON2)(OWEVERINSTATESWHEREPERFORMANCEWASHIGHTOBEGIN
AND0(#SYSTEMLEADERS4HE3TATE-INISTRYOF(EALTH3-O(
WITHTHE0%)MAYHAVEHADANETNEGATIVEIMPACTON2)PERFORMANCE
ONTHEOTHERHANDSETSTHE0(#AGENDADElNESPOLICYAND
PROGRAMOBJECTIVESANDMONITORSPERFORMANCEAGAINSTSETGOALS
ANDTARGETSˆBUTDOESNOTHAVESUPERVISORYAUTHORITYOVER,'!
AND0(#PERSONNEL4HEOPTIONSFORFEEDBACKANDACCOUNTABILITY
BASEDONFEDERALLYDElNEDPRIORITIESARETHEREFORELIMITED
Leaders do not perceive an immediate political benefit from
investments in immunization7ITHOUTCLEARMECHANISMSFOR
3.9 STATE-SPECIFIC STRENGTHS
& WEAKNESSES
$UETOTHECROSSCUTTINGNATUREOFMOSTFACTORSNOTEDINTHISANALYSIS
WEFOUNDTHATNATIONALISSUESWEREAMONGTHEMOSTIMPORTANT
FACTORSINmUENCING2)PERFORMANCEATTHESTATELEVEL(OWEVERTHE
HETEROGENEITYOF2)COVERAGEBYSTATEISEVIDENCETHATSTATELEVEL
FACTORSAREALSOIMPORTANT)NTHISSECTIONWEPRESENTIDENTIlED
ACCOUNTABILITYTOCOMMUNITIESTHEPOLITICALVALUEOFINVESTMENTS
FACTORSPARTICULARTOEACHSTATEINCLUDEDTHESEFACTORSAREOPERATING
IN2)ISLOW0OLITICIANSMAYSEEMOREIMMEDIATEBENElTSTO
INTHEBROADERCONTEXTDISCUSSEDEARLIERBUTMAYPROVIDESOME
INVESTMENTSINHIGHLYVISIBLETANGIBLEPROJECTSTHATCANSERVEAS
INSIGHTINTOSTATEBYSTATEDIFFERENCES
THEIR@LEGACIES!CCORDINGTOINTERVIEWEESINTWOSTATESPHYSICAL
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4.2 INTERVENTION PACKAGES
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THETRANSPORTANDCOLDCHAINPACKAGESADDRESSLOGISTICALBARRIERS
4.1 SUMMARY
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THANTHEDIFFERENCES4HESMALLSAMPLESIZEANDTHEQUALITATIVE
NATUREOFTHISSTUDYMADEITDIFlCULTTOCHARACTERIZEPRIORITIESOFA
Implementing stakeholder.$IFFERENTSTAKEHOLDERSWILLHAVEDIFFERENT
PARTICULARSTATEASRESPONDENTSOFTENHADDIFFERINGVIEWSBASEDON
RESOURCESANDMOTIVATIONSANDSOMEINTERVENTIONSREQUIREINPUT
THEIRFUNCTION
ANDBUYINFROMARANGEOFSTAKEHOLDERS)TISUSEFULTOCONSIDER
THELIKELYIMPLEMENTERSOFANINTERVENTIONARTICULATINGWHERETHE
4HESIMILARITIESACROSSSTATESMAYBEDUEINPARTTOTHEFACTTHAT
BURDENOFIMPLEMENTATIONANDEVALUATIONWILLFALLASWELLASNOTING
RESPONDENTSTHEMSELVESHAVEDIFlCULTYINPINPOINTINGTHEMOST
OPPORTUNITIESFORCROSSSECTORALINVOLVEMENT
RELEVANTBARRIERSATANYPARTICULARLEVEL)TISLIKELYALSODUETOTHE
NEEDFORARICHERCONTEXTUALANALYSIS#URRENTDATAATTHESTATE
-OSTCOMPONENTSOFOURINTERVENTIONPACKAGESCOULDBE
AND,'!LEVELAREGENERALLYLACKINGANDMEDIATINGFACTORSSUCH
IMPLEMENTEDBYMORETHANONESTAKEHOLDER$ONORSAND.'/S
ASMARKETACCESSPOVERTYLEVELCOMPETINGHEALTHCONCERNSAND
AREOFTENTHEIMMEDIATECHOICEBUTMANYINTERVENTIONSCOULDALSO
COMMUNITYANDHOUSEHOLDDYNAMICSMAYHAVEAGREATEREFFECTON
BEHOUSEDINGOVERNMENTAGENCIESORCOULDBETRANSITIONEDTO
2)COVERAGETHANHASBEENCAPTUREDHERE#ONTINUEDRESEARCHMAY
GOVERNMENTAGENCIESAFTERANINITIALPERIODOFDONOR.'/OWNERSHIP
PROVIDEINSIGHTINTOTHESEFACTORS
5 CONCLUSIONS
!TTHESTRUCTURALLEVELTHEREISALACKOFINFORMATIONABOUTTHE
/URANALYSISDREWFROMSEVENSTATESANDTHE&#4INORDERTO
PARLIAMENTARIANS)TISDIFlCULTTOSAYWHETHERLACKOFSUPPORTOR
REPRESENTARANGEOFGEOPOLITICALCONTEXTS)NEACHSTATEWEFOUNDTHE
OUTRIGHTRESISTANCETO2)WHENITOCCURSISAFUNCTIONOFPOOR
SAMEISSUESHIGHLIGHTEDREPEATEDLYGOVERNANCETRANSPORTATIONAND
INFORMATIONPERSONALBELIEFSORCOMPETINGPOLITICALCONCERNS)6!#IS
COLDCHAIN4HROUGHRESPONDENTSUGGESTIONSEXPERTFEEDBACKAND
INTHEPRELIMINARYSTAGESOFA+!0ANALYSISFOCUSEDONTHE.IGERIAN
AREVIEWOFTHELITERATUREWEWEREABLETOIDENTIFYARANGEOFPOSSIBLE
0ARLIAMENTANDOTHERKEYHIGHLEVELDECISIONMAKERS4HISANALYSIS
INTERVENTIONSTOADDRESSTHESERECURRINGISSUESACROSSSETTINGSAND
WHENCOMPLETEWILLIMPROVEOURUNDERSTANDINGOFHIGHLEVELLEVERSFOR
CONTEXTS$UETOTHEHOMOGENEITYOFBARRIERSREPORTEDACROSSSTATES
ACTIONTHEULTIMATEGOALISTOUNDERSTANDTHEFACTORSTHATTHATWILLLEADTO
THISANALYSISTOOKANATIONALPERSPECTIVE(OWEVERWEHOPEAND
SUSTAINEDANDSTABLEPOLITICALSUPPORTFOR2)ACROSSPARTIESANDREGIONS
24\2OUTINE)MMUNIZATIONIN.IGERIAs2012
KNOWLEDGEATTITUDESANDPRACTICESOFGOVERNMENTOFlCIALSAND
REFERENCES
!NAND3"ARNIGHAUSEN4(EALTHWORKERSANDVACCINATIONCOVERAGEINDEVELOPINGCOUNTRIES!NECONOMETRICANALYSIS,ANCET
DOI3
!TTANASIO/#ARLOS'ØMEZ,(EREDIA06ERA(ERNÈNDEZ-4HESHORTTERMIMPACTOFACONDITIONALCASHSUBSIDYONCHILD
HEALTHANDNUTRITIONIN#OLOMBIA#ENTREFORTHE%VALUATIONOF$EVELOPMENT0OLICIES
!YAYA3/,IECHTY%#ONWAY*(+AMAU4%SAMAI&/4RAININGNEEDSFORMIDLEVELMANAGERSANDIMMUNISATION
COVERAGEINWESTERN+ENYA%AST!FRICAN-EDICAL*OURNAL
"ABALOLA3$ETERMINANTSOFTHEUPTAKEOFTHEFULLDOSEOFDIPHTHERIAPERTUSSISTETANUSVACCINES$04INNORTHERN.IGERIA!
MULTILEVELANALYSIS-ATERNALAND#HILD(EALTH*OURNALDOIS
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(EALTHDOIJXJX
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SPECTIVE*OURNALOF#HILD(EALTH#ARE&OR0ROFESSIONALS7ORKINGWITH#HILDRENINTHE(OSPITALAND#OMMUNITY
DOI
"ANERJEE!6$UmO%'LENNERSTER2+OTHARI$)MPROVINGIMMUNISATIONCOVERAGEINRURAL)NDIA#LUSTEREDRANDOMISED
CONTROLLEDEVALUATIONOFIMMUNISATIONCAMPAIGNSWITHANDWITHOUTINCENTIVES"-*#LINICAL2ESEARCH%DCDOIBMJ
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"ARHAM4-ALUCCIO*!%RADICATINGDISEASES4HEEFFECTOFCONDITIONALCASHTRANSFERSONVACCINATIONCOVERAGEINRURAL
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*EGEDE!37HATLEDTOTHE.IGERIANBOYCOTTOFTHEPOLIOVACCINATIONCAMPAIGN0,O3-EDICINEEDOIJOURNAL
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+AMARA,-ILSTIEN*"0ATYNA-,YDON0,EVIN!"RENZEL,3TRATEGIESFORlNANCIALSUSTAINABILITYOFIMMUNIZATION
PROGRAMS!REVIEWOFTHESTRATEGIESFROMNATIONALIMMUNIZATIONPROGRAMlNANCIALSUSTAINABILITYPLANS6ACCINE
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DOI3
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International Vaccine Access Center (IVAC)
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www.jhsph.edu/ivac
4\2OUTINE)MMUNIZATIONIN.IGERIAs2012