Integrating Gender Considerations into Nigeria's Immunization Strategy: Lessons from the Full Portfolio Planning (FPP) Process

"Gender barriers, including sociocultural norms, economic constraints, and limited decision-making power, often prevent women and girls from accessing essential vaccination services. The Immunization Agenda 2030 (IA2030) emphasizes the need to overcome these barriers to achieve equitable immunization coverage."

This case study highlights the importance of addressing gender-related barriers to immunisation in Nigeria, a country with the world's highest number of zero-dose children, and the measures undertaken to address these barriers through national immunisation strategic planning. Published by the United Nations Children's Fund (UNICEF) in partnership with the Government of Canada and Gavi, the Vaccine Alliance, it focuses on the experience of integrating gender considerations into national immunisation strategic planning, using Nigeria's application for Gavi support through Gavi's Full Portfolio Planning (FPP) process as an example.

As outlined in the report, the FPP process is an approach used by Gavi to support countries in developing robust, evidence-based national immunisation strategies. The FPP process involves assessment of a country's immunisation needs, resources, and challenges, followed by the formulation of a detailed plan that outlines the strategies and interventions required to achieve immunisation goals. This process includes stakeholder engagement, data analysis, and the alignment of immunisation strategies with broader health and development objectives.

In Nigeria, the FPP process began in March 2023; the final submission of the application package to Gavi occurred in July 2024.

This case study employed qualitative methods, utilising analysis of documents related to the FPP application and key informant interviews with stakeholders from UNICEF, Gavi, the National Primary Health Care Development Agency (NPHCDA), and civil society.

Having provided an overview of the 3-pronged approach that was employed for gender integration in the FPP, the report shares findings from the analysis of the FPP application. It describes key gender barriers to immunisation in Nigeria in terms of demand, governance, vaccine supply chains, human resources, surveillance, financing, health information management systems, coverage, equity, and service delivery. For example, a gender barrier analysis (GBA) for immunisation, which was conducted by the Ladysmith Collective (contracted by UNICEF New York on behalf of the NPHCDA) found these barriers:

• Grassroots level:
  • Gendered health decision-making that was influenced by patriarchal cultural beliefs, lack of financial independence, social stigma, education barriers, lack of awareness, resistance from religious groups, rumours and false information, women's daily responsibilities, mobility constraints, and disparities in resource access limited women's willingness or ability to vaccinate their children.
  • Adolescent mothers also face gender and age-specific barriers to immunisation, including cultural norms around needing permission, social stigma from healthcare workers, lack of awareness, and education barriers.
• Health facility level: There were disparities in gender equality training for healthcare workers, general mistrust of the health system, dissatisfaction with services, and gendered challenges faced by female health workers, including marital responsibilities and financial barriers.
• Policy level: The analysis found a lack of policy framework to address gender concerns within immunisation initiatives, varying degrees of institutional commitment to gender integration, limited awareness, disparities in gender analysis capacities, and inconsistencies in gender responsibilities, training, and inclusivity practices.

The results of the GBA were presented to a diverse group of FPP stakeholders at the February 2024 national kickoff workshop. Stakeholders requested additional information on areas such as identifying positive drivers of immunisation coverage, regional differences, and gender barriers affecting adolescents. This feedback necessitated revisions and further research by the consultants to address these specific areas. Respondents also suggested several ways to improve the conduct of a GBA, making it more participatory and action-oriented (e.g., engage national stakeholders in GBA design and conduct).

Per the report: "The results of the GBA were crucial for advocacy efforts, as they provided compelling evidence of the impact of gender inequities on immunization coverage. This concrete evidence made it difficult to dispute the need to address gender barriers to immunization and significantly increased stakeholders' understanding of the issue." The report examines what worked well in terms of advocacy, what challenges were encountered, and what opportunities for improvement exist (e.g., engage men as advocates).

A critical aspect of the strategy was ensuring that gender experts were integrated at every stage of the FPP process. UNICEF played a pivotal role in identifying and engaging these experts. The report describes who these experts were, how they productively worked together, what challenges were encountered, and what opportunities for improvement exist (e.g., enhance gender integration capacity building).

Alongside the barriers, the report summarises the tailored solutions developed to tackle them. Below are outlined just a few examples in one of the areas: demand. Previous interventions were deemed to have been inefficient partly because of complex mass media messaging that failed to reach caregivers, especially those with low awareness of immunisation. The FPP documents emphasised the need for gender-specific approaches to mitigate sociocultural norms and beliefs that limit women's abilities to make informed decisions on their children's health. The FPP laid out plans to address these norms and beliefs by:
 

• Integrating existing campaigns and employing communication strategies tailored to men and women to convey the real risks of vaccine-preventable diseases to motivate vaccination;
• Complementing the recruitment of formally trained personnel by the recruitment of less skilled, predominantly female community-based health workers who will be involved in raising awareness about the importance of immunisation among women;
• Establishing or upscaling women collectives, who will participate in community outreach and health talks; and
• Implementing community-driven interventions to engage men and boys through education initiatives for men emphasising the broader societal benefits of vaccination, identifying and empowering male vaccination champions at the community level to serve as advocates for immunisation, and regularly engaging men at venues where they congregate for discussions, such as community gatherings, religious institutions, and social events.

To mitigate the gender-specific barriers to immunisation adolescent mothers, it was highlighted in the FPP workplan that adolescent mothers-focused clubs will be established, supported by civil society organisations (CSOs) trained in supporting adolescent mothers, including raising awareness about immunisation and helping them learn about childcare and life skills. Also, involving parents, guardians, and partners in workshops that challenge harmful beliefs about gender roles can help change attitudes and behaviours that restrict adolescent girls' agency and empowerment. 

Negative experiences with disrespectful or aggressive healthcare workers also discourage women from attending healthcare facilities. To address this, the budget and work plan specifically earmark funds to support behavioural change among frontline health workers. This goal will be achieved by building capacity through an upskilling programme including gender concepts, behaviour change communication, and counseling techniques.

Additional recommendations for enhancing gender integration in future strategic planning processes in the areas of governance, supply chain, human resources for health, surveillance, finance, health information management systems, and coverage, equity, and service delivery are provided in the report as a foundation for enhancing vaccine equity and improving health outcomes.

A few key lessons emerge that can inform gender integration efforts in other country contexts:

1. Prioritise evidence-based gender analysis: Conducting an in-depth GBA provided crucial data and insights that drove the integration of gender throughout the FPP process. Leveraging local and international expertise ensured the analysis captured nuanced regional dynamics.
2. Institutionalise gender advocacy and expertise: Consistent advocacy from Gavi, UNICEF, and other stakeholders raised awareness and buy-in for gender integration. Embedding dedicated gender experts within the FPP technical committees helped ensure gender perspectives were continuously reflected.
3. Prioritise stakeholder engagement and ownership: Bringing together stakeholders from the government, international community, and civil society to develop the FPP ensured that a multitude of perspectives, including those of caregivers and community workers, were reflected in the final analysis and workplan. This inclusive approach not only promotes local ownership but also fosters locally driven solutions that are more likely to be effective and sustainable.
4. Ensure accountability for implementation: Establishing gender-focused indicators, targets, and a dedicated gender unit will be critical to monitor progress and drive the effective implementation of gender-responsive interventions.

In conclusion: "By adopting this multi-faceted approach, Nigeria has laid a strong foundation to address gender barriers and achieve more equitable immunization outcomes. Other countries can learn from Nigeria's experience to enhance the gender responsiveness of their immunization strategies and programming. Ultimately, integrating gender is essential to reaching zero-dose children and realizing the vision of the Immunization Agenda 2030."