An Evaluation of a Multi-partner Approach to Increase Routine Immunization Coverage in Six Northern Nigerian States

"Over the last twenty years, global health partnerships have emerged as an important resource for health system strengthening and addressing public health challenges..."

In northern Nigeria, the routine immunisation (RI) programme and polio eradication campaign have faced historical boycotts at the local level driven by rumours (e.g., vaccinations causes HIV or sterility in young Muslim girls) and amplified by the political context. In response to such challenges, the Bill & Melinda Gates Foundation (BMGF) and Aliko Dangote Foundation (ADF) forged a partnership with six northern state governments in a multi-year Memorandum of Understanding (MoU) partnership that aimed to strengthen RI systems and sustainably increase its immunisation coverage. This mixed-methods evaluation describes the MoU's contribution to improving programme performance, strengthening capacity and government financial commitment, and increasing immunisation coverage.

The MoU approach was implemented at the state, local government area (LGA) and health facility levels in six northern states. Population size across the six states ranges from approximately 13 million in Kano to three million in Yobe. Several states (i.e., Borno, Kaduna, and Sokoto) experienced insecurity during implementation. The MoU approach involved the creation of a basket fund, establishment of meetings with key stakeholders and government officials to ensure high level government engagement, and provision of technical assistance to support implementation of the programme. The inputs aimed to facilitate processes related to governance, financial management, vaccine supply chain, service delivery, monitoring and evaluation, and community engagement. For example, the RI MoU aimed to improve community demand for RI services by implementing a name-based community engagement strategy, including identification and tracking of all eligible children led by a traditional system. All states adopted the use of line listing for newborn, as well as defaulter tracking, to improve community use of vaccination services. States worked with community actors (Mai Unguwas) and created defined roles and plans to support the work.

For the mixed-methods study, the study team reviewed existing programme documents through a desk review and conducted key informant (KI) interviews with stakeholders and state programme implementers. They also conducted a quantitative health facility assessment and client exit interview and qualitative interviews with service providers, community leaders, and programme participants. Finally, to assess the overall impact of the MoU in achieving programme outcomes, they assessed data from household surveys and the District Health Information System 2 (DHIS2).

This process revealed the RI MoUs across the six states as mostly successful in strengthening health systems, improving accountability and coordination, and increasing the utilisation of services and financing for RI. For example, the RI MoU aimed to improve the equitable access to quality immunisation services for all eligible children; client exit interviews assessed the quality of provider-client interactions by asking if providers provided information on four important RI counseling points. In three states (Bauchi, Kaduna, and Sokoto), the percentage of clients who said providers shared information on the four counseling points was over 85%.

However, the evaluation found that addressing cultural norms received minimal consideration throughout the MoU design. For instance, based on client exit interviews, mothers are not the primary decision maker regarding the child's vaccination status in a number of states. In Kano, 62% of fathers are the primary decision makers regarding whether the child goes for vaccinations. This challenge was reflected in the qualitative interviews, where a programme participant noted that women cannot access services without the husband's approval. Spousal refusal from poor sensitisation on adverse events following immunisation was found to contribute to vaccine hesitancy and refusal. "If interventions to address socio-cultural norms are not incorporated into the program, service uptake may remain low."

Across all six states, pentavalent 3 vaccine coverage increased from 2011 to 2021, and, in some states, the gains were substantial. For example, in Yobe, vaccination coverage increased from 10% in 2011 to nearly 60% in 2021. However, in Sokoto, the change was minimal, increasing from only 4% in 2011 to nearly 8% in 2021.

Evaluation findings indicate that issues pertaining to human resources for health, insecurity that inhibits supportive supervision, and vaccine logistics, as well as harmful socio-cultural norms remain a persistent challenge in the states. For example, while the use of community leaders is important in addressing community-level barriers, the MoU approach did not focus on the individual behavioural barriers that may require efforts to address knowledge, attitudes, beliefs, social norms, and self-efficacy. Training health providers on how to address vaccine hesitancy and concerns related to adverse events following immunization may be required. Efforts to engage directly with fathers, who were often the primary decision maker of whether a child was vaccinated, through traditional channels such as Wanzams may help address barriers to vaccination coverage. There is also a need for a rigorous monitoring and evaluation plan with well-defined measures collected prior to and throughout implementation.

In conclusion: "Introducing a multi-partner approach grounded in a MoU agreement provides a promising approach to addressing health system challenges that confront RI programs."