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Immunisation Thought Leadership Series

When Gavi came to visit Nigeria

A welcome visit from Gavi
 As 2019 wound down to its close and holiday plans were being made, arrangements were also being made for a high-level visit of Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance and his team to Nigeria. This was a much-welcomed visit- as it comes after a dark period that saw Nigeria closed out of Gavi support because misuse of funds intended for vaccine procurement and health systems strengthening was detected between 2011- 2013.The Nigerian government had to repay Gavi the funds that were misappropriated as the country was in danger of losing funding support for its routine immunisation programmes.
 
Gavi’s support was also at risk for another reason; the improvement of the Nigerian economy in the mid 2000s took Nigeria into the “middle income country” category above Gavi’s eligibility threshold of a Gross National Income (GNI) per capita of less than US$ 1,580, and therefore no longer eligible for Gavi support. In 2017, Nigeria was scheduled to start transitioning from Gavi funding over a 5-year period, with the government taking over funding of routine immunisation programmes. As the country requested and negotiated for an extension of its support, Gavi insisted that any discussions on the requested transition extension was contingent on the misappropriated funds being repaid, in line with agreed timelines. After extensive negotiations, Nigeria’s transition out of Gavi funding has now been extended by 10 years. Since then accountability policies have been put in place that enable greater transparency and closer grant monitoring and management.

Pushing up routine immunisation coverage
In the recent past, Nigeria has faced many challenges implementing immunisation programmes and pushing up routine immunisation coverage rates. The many challenges included poor health literacy, weak demand for vaccinations, parent’s hesitancy to bring their children to be immunised, inefficient supply chains hampering vaccine delivery, funding challenges for vaccine programmes as well as inadequate human resources to carry out vaccination programmes. From all indications, the National Primary Healthcare Development Agency (NPHCDA) has been working hard to improve this situation, for the first time, using verifiable survey data to monitor progress rather than unreliable administrative data.
 
Why was the Gavi visit so important?
Gavi, the Vaccine Alliance created in 2000 has been supporting Nigeria’s immunisation programme, providing vaccines, cash support and technical assistance through its partners the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF). So, this visit was timely and showed the restored confidence that Gavi has in the leadership of the Nigerian health sector. Behind the photos, smiles and handshakes were the important meetings that took place, reviewing progress and setting new targets. The Gavi team also used their visit to Nigeria to review the implementation of the Nigeria Strategy for Immunisation and Primary Health Care System Strengthening (NSIPSS) and other initiatives under NPHCDA and the Ministry of Health.

Gavi delegation meets with Dr. Faisal Shuaib, Executive Director, NPHCDA, to discuss the Nigeria Strategy for Immunisation and Primary Health Care System Strengthening (NSIPSS). Photo source: NPHCDA

There is little doubt that over the past three years, Nigeria has recorded significant improvement in routine immunisation coverage rates, helped by efforts made by the
NPHCDA and partners. According to the National Demographic and Health Survey (NDHS), in 2008 DPT3/Penta3 vaccine coverage was 35%, increasing to 38% in 2013 and 50.1% in 2018.

Image credit: Nigeria Health Watch

The increased vaccine coverage rates were helped by the many initiatives put in place by the NPHCDA. In 2017, a state of emergency was declared on the poor rates of routine immunisaton in the country and the National Emergency Routine Immunisation Coordination Centre (NERICC) was inaugurated by the Executive Director, Dr Faisal Shuaib. These coordination centres have played a critical role in strengthening routine immunisation coordination across the country with the State Emergency Routine Immunisation Coordination Centre (SERICC) coordinating efforts at the state level and Local Emergency Routine Immunisation Coordination Centre (LERICC) operating down to the Local Government Area (LGA) level. There is still a lot of work to be done, since despite the improvement from a low base, Nigeria cannot be happy with an average DPT3/Penta3 vaccine coverage of 50.1% in 2018.

Transitioning out of Gavi funding

Image credit: Nigeria Health Watch

Between 2000–2019, Gavi disbursed $954,315,294 (as of September 2019), to Nigeria which is approximately 93% of total funds committed to support the country’s routine immunisation programme, cold chain equipment, and health systems strengthening. The goal of NSIPSS is to improve vaccine coverage rates and ensure that sustainable financing is in place to support the countries vaccine efforts after 2028. Renewed Gavi funding was only agreed upon with stringent conditions which includes the country meeting counterpart funding commitments, being subject to annual reviews from a high-level Gavi delegation, as well as mid-term reviews. Accountability frameworks for routine immunisation were put in place to track progress over the extended transition period. The clock is now ticking in earnest till Gavi funding comes to an end in 2028 and the country will have to self-fund immunisation programmes and also achieve the NSIPSS goal of 84% average national immunisation coverage.
 
A critical requirement in ensuring sustained government funding for immunisation programmes, and pushing up immunisation coverage is “political will and prioritisation.” The Nigerian population is growing at approximately 2.6% annually and by 2050, the country is projected to have the third largest population in the world. A commitment to sustained funding for immunisation programmes will protect the lives of new-borns and children, so they don’t die from vaccine-preventable diseases. It is for this reason that the visit to see President Muhammadu Buhari and the subsequent courtesy visit to the Senate President Dr. Ahmed Lawn by the Gavi team was critical in the Nigerian context. Political commitment from the highest level has the potential to lead to a shift in the way health is prioritised, as well as driving sustainable immunisation financing.

Gavi, the Vaccine Alliance high-level delegation meets with His Excellency Senator Abubakar Bagudu, Governor of Kebbi State. Photo source: Kebbi State Government

Most routine immunisation data has shown that Nigeria made significant progress in improving vaccine coverage rates, but the 2018 NDHS has showed that progress is not uniformly distributed, and that Kebbi and Sokoto State showed less improvement in vaccine coverage rates, than the national average. While the federal government has some influence over the health status of its citizens, the state government has greater direct influence over their health outcomes of its citizens. The efforts made by state governments are critical in the Nigerian context. This made the meeting of the Gavi team with His Excellency Abubakar Bagudu, the Governor of Kebbi state to discuss areas of additional support for Kebbi state, even more critical.
 
 Out on field visits
 In addition to the long meetings with government leaders, the Gavi team also had two field visits — one to Aleyita Primary Healthcare Centre (PHC) in Abuja where they witnessed an immunisation session and to the Nigeria Centre for Disease Control’s National Reference Laboratory. At both sites, the team had an opportunity to engage colleagues working at the frontlines of delivering vaccines and detecting vaccine preventable diseases. 
 
The visit to the National Reference Laboratory, enabled the Gavi team to see first-hand the progress the country has made to improve its ability to carry out surveillance for vaccine preventable diseases. At Aleyita PHC, in line with Gavi’s health systems strengthening objective, Dr Seth Berkley launched cold chain equipment. This will help improve vaccine storage.

Gavi’s visit to the National Reference Laboratory with NCDC Director General, Dr Chikwe Ihekweazu. Photo source: Nigeria Centre for Disease Control

Nigeria on the road to vaccine self-financing
Finally, as Nigeria continues on the journey, transiting out of Gavi funding, the performance of the economy will be critical in order to increase the countries national self–reliance, using its domestic resources for routine immunisation programmes. The enactment of the National Health Act now guarantees the statutory payment of the Basic Health Care Provision fund. These much-needed resources with support in strengthening PHCs, through which all immunisation programmes will be delivered. Domestic resource mobilisation will also require the involvement of the private sector to support in bringing much needed capacity and expertise.
 
A current example exists of a state self-financing its immunisation programme. Kano State implemented reforms with support from partners that enabled the state to modernise its vaccine delivery and gradually transition their vaccine financing to self-reliance, over a 5-year period. Routine immunisation coverage in the state increased from 19%, according to NDHS 2013, to 46% in 2018. Much work still needs to be done, but with continued technical support from partners, could this be a model for other states in Nigeria to emulate?

2 replies on “When Gavi came to visit Nigeria”

Thank you very much for the splash over the visit of the Gavi delegation to Nigeria, this December 2019. Given her population, especially the childhood population, success in and of Nigeria on protecting her population from vaccine preventable diseases will be a gold medal achievement for Gavi. So, the need for the high “powerfulness” of the Gavi delegation and desire to meet with the highest level of governance are both understandable. Perhaps what I find most “galling” is what led to the Gavi visit in the first place. Your opening comments pointedly describe the antecedents to this Gavi visit; ” ….this (visit}….comes after a dark period that saw Nigeria closed out of Gavi support because (of the detection between 2001-2013, of the) misuse of funds intended for vaccine procurement and health systems strengthening. The Nigerian government had to repay Gavi the funds that were misappropriated as the country was in danger of losing funding support for its routine immunisation programmes…..
The second point you raised for the unabashed euphoria over this Gavi visit was again well articulated in your article- “……Gavi’s support was also at risk for another reason; the improvement of the Nigerian economy in the mid-2000s took Nigeria into the “middle income country” category above Gavi’s eligibility threshold of a Gross National Income (GNI) per capita of less than US$ 1,580, and therefore no longer eligible for Gavi support….”).
Country ownership of, and independence from foreign aid for health care delivery should be important targets and goals for any country with national pride and self-respect. The two reasons given above – misuse of foreign aid, and non-eligibility of Nigeria for Gavi aid because of improved economy, rather call for a ceRebration, than a ceLebration. First, it is as unacceptable for a country to misuse donor fund, and second it is a shame for a country whose economy has so improved to the level of achieving aid independence to beg for continued dependency in order to provide basic and essential health care to her childhood population. The issue of Nigeria’s current predicament of Gavi dependency is more about Nigeria than about Gavi. Two of the six pillars on which Nigeria’s Optimized Integrated Routine Immunization Sessions (OIRIS) rests are ownership and accountability. The first pillar is wobbling, while we are in the process of excavating the soil on which to build the second pillar. While the issue is not about Gavi, Nigeria must realise that according to Gavi 2018 annual report, only 56% of 16 Gavi independent countries are on track to full self-financing of their immunization programme. It would seem that transitioning out of Gavi support leads to some sort of Gavi dependency. As we hit the year 2020, Nigeria must be fully aware that 2028 is just around the corner. It is hoped that by that time, Nigeria will be so empowered as to take ownership of her vaccination programmes as, from now, she allocates annually, an increasing amount of resources to vaccination, eventually achieving financial sustainability on or before 2028. The only good outcome of the 2019 end year and future annual Gavi visits to Nigeria will be Nigeria’s successful transition from Gavi dependency to full self-financing, not just of the immunization programme, but also, of her entire health care delivery. Let no one tell you that we do not have the resources to meet this obligation. We have all it takes, but we have not taken all we have, because a few have taken most of what we have for themselves and family members.

Thank you Professor Tomori as always for your very poignant comments.

We appreciate the immense work you have done to bring improvements to the Nigerian health sector, as well as your sustained advocacy for Nigeria to fund its own health budget. Health does not make headlines (unless there is an outbreak/”unexplained illness”!!! Our elections are not won based on the health policies of individual political parties, health is not a vote winner. There is not enough political will to deliver healthcare to Nigerians.

The question is, If you have never had something, how can you ever appreciate the benefits of that thing you have never had? The average Nigerian (population circa 200 million) has never had access to quality healthcare, so where is the drive to demand it or understand that health is a right? Gavi’s visit (and future visits) will be very important and the stakes are very high for our country. That is why the article mentioned “Behind the photos, smiles, and handshakes” because the clock is ticking and these visits ensure there is continuous monitoring and accountability and for the country to fulfill its mandate/promise to fund routine immunisation programmes (and increase immunisation coverage rates). In the meantime, we have to keep up the pressure for states to take ownership of their immunisation budgets and programmes, Kano State has made the transition after much support from development partners.

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