“It was a hectic day, we had a fixed immunisation session in Gachi village,” says Umar Alhassan, a Routine Immunisation (RI) provider as he arrives in Wudil town on his motorbike with two coolers he uses to carry vaccines from the Wudil Primary Health Centre (PHC). Gachi is a settlement in Wudil Local Government Area (LGA). The settlement’s health facility does not have a fridge to store vaccines, so Alhassan transports the vaccines from the solar-powered refrigerator in Wudil PHC to the village on immunisation days. Alhassan is happy doing this he says, but one thing he is most happy about is that vaccines are always available in his facility. “We don’t run out of vaccines. We always have enough for our use and that of settlements under us. Every month we receive enough supply from the zonal cold store”, he says, as Musa Shehu, an immunisation supervisor, helps him offload the coolers.
Back in the town of Wudil, inside a rehabilitated building, Zonal Cold Chain Officer Yahaya Garba and his deputy are busy entering data of vaccines supplied to health facilities into their computer. The building has many rooms, including a cold store with large freezers, a room housing consumables, a standby generator and two vans used in conveying vaccines from the store to 71 health facilities in seven LGAs in Kano State. The zonal cold chain store is one of six in Kano State, established to ensure proper storage as well as direct and seamless delivery of vaccines to the last mile as part of Kano State’s RI reforms.
“We used to record very low coverage, as low as less than five percent” says Mr. Bashir Sunusi, the program manager for the State Emergency Routine Immunisation Coordination Centre (SERICC). He is just done chairing a quarterly review meeting on the 2019 RI workplan with officials of the State Primary Healthcare Management Board (SPHCMB) and representatives of the World Health Organisation, Aliko Dangote Foundation (ADF), Bill & Melinda Gates Foundation, UNICEF and others. The 2013 National Demographic and Health Survey showed that Kano State had a RI coverage of 19%, only better than Sokoto (3%), Zamfara (6%), Katsina (15%), Kebbi (3%) and Jigawa (7%) states. The state has been implementing various reforms across its immunisation activities, thanks to the support and partnership of the Bill & Melinda Gates Foundation and Aliko Dangote Foundation (ADF). These reforms have seen the modernisation and revolutionisation of immunisation financing and vaccine delivery through deliberate, targeted actions.
Careful planning and execution
The journey started in November 2012 with a Memorandum of Understanding (MoU) between the Kano State Government, ADF and Bill & Melinda Gates Foundation to strengthen key aspects of immunisation, in the context of ongoing polio cases. “The goal was to achieve at least 80% coverage in every ward of the state over time, but to mainly focus on how to do this in a way that could be sustained,’’ says Jenny Sequeira, Senior Program Officer at the Bill & Melinda Gates Foundation. The two foundations collaborated with the NPHCDA and the state government to design a detailed and costed work plan that captures every step in the delivery of RI all year round, from the point where vaccines arrive at the state cold chain store till they are administered. This led to the creation of a basket fund, where Kano State Government was to contribute 30% of the overall cost in 2013 while ADF and the Bill & Melinda Gates Foundation make up the balance. In 2014, the state’s contribution increased to 50% and 65% in 2015 and 2016 respectively. From 2017 onwards, Kano State government transitioned to 100% funding of RI activities amounting to N420 million, while ADF and Bill & Melinda Goal continued providing technical support — while at the same time starting a PHC MOU using the same concept of the “graduating” basket fund.
Improving quality of service and engagement
“The whole objective was to build systems that function sustainably,” says Yusuf Yusufari, Senior Program Officer at the Bill & Melindates Foundation. “People’s confidence will always improve when they see the quality in the services they are provided with,” he added. Critical in ensuring the provision of quality immunisation services is making vaccines always available at the last mile. Using money from the basket fund, solar-powered refrigerators were provided in health facilities across the state while some health facilities received minor rehabilitation. Six zonal cold stores were strengthened, and 12 vans fitted with refrigerating systems were bought for the direct delivery of vaccines from the zonal cold stores to the health facilities. Also, health workers were trained on developing, delivering and transmitting monthly vaccination workplans to the SPHCMB. Traditional ward heads popularly known as “Mai Anguwas” were engaged as volunteers to record names of children under two years old, including new-borns, in their domains. They are also responsible for ensuring that every child is taken for immunisation on their scheduled date, and to meet with the health worker every month to review progress.
Uncompromising political will
According to Dr Shamsuddeen Sani, Consultant for ADF and Bill & Melinda Gates Foundations in Kano State, since the basket fund started in 2012, there has never been a year that the State government defaulted in the payment of their counterpart fund. This has contributed greatly to building confidence among the parties and has enabled timely review and prompt release of needed funds to the SPHCMB for implementation of RI activities. The state government also built two cold rooms in the state central cold store in 2018 to improve vaccine storage. Prior to that, there was only one cold room in the store, which meant that vaccines had to be transported in batches from the National Primary Healthcare Development Agency’s (NPHCDA) north-west zonal cold store to the state cold chain store.
Ensuring vaccine availability all day, everyday
The timely supply of vaccines to health facilities goes a long way in ensuring that the vaccination of children is continuously carried out. From 2013–2016, vaccines were delivered to health facilities through a third-party logistics system, funded by the MOU basket — with a few areas covered by the SPHCDA. But in January 2017, Kano State began the full implementation of direct vaccine delivery to health facilities including PHCs, health posts and general hospitals. According to the Executive Secretary of Kano SPHCMB, Dr Tijjani Hussaini, 95% of 484 wards in Kano State have at least one health facility with a solar-powered refrigerating system for vaccine storage. The health facilities are also equipped with coolers that are used to supply vaccines to smaller health posts under their wards.
Between the 25th and 30th day of every month, vaccines are supplied from the state cold chain store to the six zonal cold chain stores in the state. The zonal cold chain stores in turn supply to health facilities during the first week of every month. The system is designed in such a way that every health facility has a particular date on which it receives its vaccines, Pharmacist Isah Bala, the state logistics officer, explains. To avoid unexpected stock-outs, 25% of the vaccines of every LGA are stored at the local cold chain store in the LGA headquarters, so that any facility that runs out of vaccines before its supply date can restock from the store.
Building on and sustaining gains
To sustain the gains, another MOU between the parties was signed in 2017 to improve the capacity of the state’s primary health centers to provide comprehensive quality services especially as it relates to maternal and child health. The activities in the workplan were tailored to further operationalise the Primary Health Care Under One Roof (PHCUOR) programme of the NPHCDA. The basket fund for the PHC MOU has Kano State contributing 20% of the required money in 2017 and 2018, 40% in 2019, 60% in 2020, 80% in 2021 and transition to 100% from 2022 according to Sequeira. The funds from ADF and BMGF are contingent upon the Kano State Government paying its counterpart funding, as well as sustaining its 100% funding for RI activities.
A model for other states
Immunisation financing, like any aspect of healthcare delivery, is capital intensive. With Nigeria receiving support from GAVI and other partners in vaccine procurement, it is only rational for governments to take up other areas of the vaccine delivery value chain. From 2001 to date, GAVI has spent close to $700 million on vaccine support to Nigeria. With GAVI’s support expected to end in 2028, state governments must begin to build systems that will ensure vaccination of children does not face any obstacle at that time. Kano State’s model of starting small and building gradually is one to leverage.
Nigeria’s dependence on donors for immunisation is not sustainable and collaboration that builds systems and capacities of our governments such as the one being done by the Bill & Melinda Gates Foundation and ADF is definitely the ideal solution in the long term. Buoyed by the successes being recorded in Kano, the two foundations entered into similar MOUs with five other states Bauchi, Borno, Kaduna, Sokoto, and Yobe. And in 2019, NPHCDA and GAVI are working to take some of the lessons learned from the MOUs to 8 additional states — Bayelsa, Gombe, Jigawa, Katsina, Kebbi, Niger, Taraba, and Zamfara. ADF and the Bill & Melinda Gates Foundation are also working to take the MOU approach to sub-national areas of other African countries that are at risk of polio, and where the RI coverage has remained low (e.g. districts in Cameroon, Central African Republic, Chad, DRC, Guinea, and Niger).
Kano State must be given credit for showing great commitments towards routine immunisation financing in the state by strictly following through the agreements reached with the Bill & Melinda Gates Foundation and ADF in 2012. The state recorded RI coverage of 46% in the 2018 National Demographic Health Survey, signalling gradual improvement. The state must, however, digitize its vaccine stocking system. As it stands, health workers at facilities and officials of the State zonal cold stores take stock of vaccines and records of supplies. Zonal cold chain officers spend several days every month transferring the data into their computers which will obviously affect their efficiency. The data is also prone to damage as a result of any unforeseen accident. The work of these officers will be greatly enhanced if they are trained and supplied with mobile tablets for stock taking and record entry.
The zonal cold stores could also do with an increase in workforce. Two staff aren’t enough to run the stores as tasks such as cleaning, vaccine arrangement, data management, taking delivery of vaccines and supply of vaccines to health facilities definitely requires more hands. In addition, what happens if any of the two vans attached to each store breaks down? The SPHCMB has a plan to procure six more vans in 2019 according to Pharm. Bala. Expediting the procurement should be a priority to avert any obstacle in vaccine delivery to health facilities. Umar Alhassan had to leave his duty post to transport vaccines to Gachi settlement all alone and still provide vaccination, which could be physically and mentally draining. A second hand will surely optimize his work and ultimately improve immunisation coverage in Kano State.
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