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“Expanding Access: Reaching the Hard to Reach”

Towards Saving One Million Lives in Nigeria

Dr Muhammad Ali Pate Former Minister of State for Health, Nigeria

MSF Vaccines Seminar

Oslo, Norway – 14th October 2013

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Contents

▪ Background on Nigeria

▪ Saving One Million Lives Initiative

▪ Case study on Routine Immunization

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Nigeria is a Federal Republic that operates a fully fiscally decentralized government structure

Administratively, Nigeria is divided into:

36 states

A Federal Capital Territory (FCT)

774 Local Government Areas (LGAs)

9,565 wards

Six geopolitical zones

With a population of 167 million and:

31 million women of child bearing age

28 million children under the age of five

An estimated 6 million births annually

Context Regional Map of Nigeria (Population in mn)

SOURCE: Nigeria Population Census 2006

Sokoto

Kebbi (3.08)

Zamfara Borno Yobe

Gombe Bauchi

Kano Jigawa

Oyo Kwara

Osun Ogun Ondo

Ekiti

Lagos

Kaduna

Niger

Nassarawa Taraba

Adamawa

Akwa lbom

FCT Abuja

Kogi Benue

Cross river

Delta

(5.1) Bayels

a

Plateau

Edo Enugu

Ebonyi

Imo

Anam- bra

Abia

Katsina (3.6)

(3.2)

(5.7)

9.3 4.3

(4.6) 6.0

(3.9)

(2.3) (1.8)

(3.2) (4.2)

(3.1)

(2.3)

(2.3) (4.1)

(2.3)

(3.1)

(5.5)

(3.7)

(9.0)

(3.4) (3.4)

(2.3)

(3.22)

(4.0) (2.8)

Rivers (1.7)

(1.4)

(3.9) (2.8)

(3.2) (2.1) (4.1)

(3.9)

North west (35.8) North east (18.9) North central (18.8) South east (21) South South (16.4) South west (27.5) Total population

( )

National capital

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Country’s landscape as diverse as its population of 160 million people, with over 125 ethnic groups, and 250 languages

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Poor health outcomes, exacerbated by inadequate supply and low demand for services, including vaccines

4 4 SOURCE: Nigeria Demographic and Health Survey, 2008

▪ Maternal mortality rate is 545/100,000 live births = 33,000 women each year

▪ 1 in 9 maternal deaths worldwide

▪ Contraceptive prevalence rate = 14.6

▪ Infant mortality rate is 75/1,000

▪ 8% of the global total ▪ An estimated 70% of these

deaths are preventable

▪ Child mortality rate is 157/1,000 = ~1 million deaths per year

▪ ~10% of the global total

▪ ~23,000 health facilities (estimated 14,000 PHCs) but with different levels of functionality

▪ Poor quality of care ▪ Shortage of critical human

resources

▪ Supply challenges – Inadequate power or

water supply – Commodity stock-outs – Equipment inadequacy – Inadequate number of

trained service providers

▪ Demand for critical services very low, largely driven by a loss of confidence in the system e.g. – Only 38% of women

have skilled births – Only 58% attend ANC

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Significant inequity in access to basic services exists, poor significantly worse off

0

10

20

30

40

50

60

70

80

90

100

Med. Treatment ofFever

Med. Treatment ofAc. Res. Inf.

Oral RehydrationThereapy

Antenatal Care Att. Delivery Full Immunization

Lowest 20% of Population Highest 20% of Population

Source: 2008 Nigerian Demographic and Health Survey

Use of primary maternal and child health care services among lowest and highest population quintiles %

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20

40

60

80

100

120

Lowest Second Third Fourth Highest

Perc

enta

ges

Wealth Quintile

Nigeria

Ghana

Kenya

Cameroon

Morocco

Mozambique

Source: Gwatkin et al, 2007, based on 2003 DHS country data and Nigeria DHS 2008.

Same inequities seen in access to routine immunization services

Children U5 fully immunized by socioeconomic quintile in Nigeria %

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Contents

▪ Background on Nigeria

▪ Saving One Million Lives Initiative

▪ Case study on Routine Immunization

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Successful delivery is the key to bridging the gap between great plans and tangible impact

“Perhaps the greatest challenge for any government is successfully implementing its policies…. ... Many a government has come unstuck from failing to deliver, even when its ideas and policies were potentially sound… ….As one former prime minister lamented on leaving office, 'We tried to do better but everything turned out as usual”

Sir Michael Barber1

1 Previous head of the Prime Minister’s Delivery Unit in the UK

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Set out a vision to save one million lives and improve the quality of care by 2015, focusing on four priority pillars

…We will encourage healthy living and good quality of life by emphasising prevention of disease…

…We will expand basic services through strengthening primary health care and providing integrated care at the frontlines…

…We will improve the quality of care provided to Nigerians in health facilities through improved clinical governance…

1 2

3

…We will revive the private health sector through unlocking its market potential and encouraging additional investment from the private sector…

“Our vision is to save one million lives and improve the quality of

care” 4

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In line with the basic services pillar, Mr. President launched the “saving one million lives” initiative, to accelerate access to basic services with a focus on results

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1 million lives saved by 2015

Logistics and supply chain

Innovation and technology (ICT & Private Sector engagement)

Essential medicine Malaria eMTCT MCH

Routine immunization

Nutrition

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Contents

▪ Background on Nigeria

▪ Saving One Million Lives Initiative

▪ Case study on Routine Immunization

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In the second component, Nigeria lags peer countries in several indicators for routine immunization coverage…

SOURCE: WHO

Ghana 99 Gambia 95 Eritrea 99 Côte d’Ivoire 91 Chad 40

Average= 82

BCG

Somalia 36 82 Sierra Leone

Guinea

Senegal 98 Nigeria 69 Niger 64 Mauritania 89 Mali 77

84 80

Burundi 99 Burkina Faso

Liberia

Botswana 99 Benin 88

92

31 60

88 54

66 74

68 64 66

87 96 97

74 20

92 79

96 67

Ø 71

DTP3

68

HepB3

60 88

41

74 68 64 71

87 99 97

74 10

92 79

93 67

75

63 23

84

95

69

MCV

60 77

62 80

65 68 64 64

86 91

94 61

Coverage of Routine Immunization by country (2007) %

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Governance and Stewardship

Planning and Supply Chain Management

Health Management Information

Systems

Immunization Program

Financing and Resource

Mobilization Service Delivery

Human Resources

Conducted an assessment of the Immunization program, focusing on 6 aspects of the program

SOURCE: PDU/LARI team—JHUSPH-IVAC/SolinaHealth, NPHCDA

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EXAMPLE Assessment – Governance and Stewardship

Text

▪ Varying degrees of commitment from states, with some State governors generally more engaged than others

▪ Execution by LGAs believed to be weakest link in the program

▪ Less resources available to support RI

▪ Executives less engaged in RI

▪ Politicians prefer to invest in ‘tangible’ legacy projects – e.g., building PHCs

Weaknesses Implications

▪ Need for focused advocacy targeting states and LGA executives

▪ Make the benefits of RI investments more ‘tangible’ for politician e.g. determine and disseminate lives saved, illnesses averted

▪ Establishment of SPHCDAs with responsibility for coordination of state- and LGA- level RI activities

▪ Provide technical assistance support to develop an SPHCDA

▪ Clear delineation of roles

▪ Federal government does overall planning, procurement and supportive field supervision

▪ States support logistics and distribution within states, and supervision of LGAs

▪ LGAs responsible for frontline service delivery

▪ Evidence of strong leadership and commitment by Federal government and some states

▪ Conducive policy environment at national level, and to a lesser degree, state level

Strengths

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EXAMPLE Assessment – Planning and Supply Chain Management

Text

▪ Stock-outs of vaccine antigens and/or supplies common, particularly at LGA levels

▪ Inadequate supply of bundled vaccines to states, hence states ‘allocate’ supplies to LGAs

▪ Poorly maintained cold chain equipment results in frequent breakdown / malfunction

▪ Logistical challenges due to poor access, remoteness, of some locations

▪ Inadequate field supervision of RI activities results in variable performance

Weaknesses Implications

▪ Re-evaluate population data that forms basis for vaccine needs forecasting

▪ Adjust vaccine needs for increases due to improved coverage rates and ensure bundling of vaccine supplies

▪ Establish sustainable maintenance mechanisms for cold chain and logistics/ transport equipment e.g. with private sector involvement

▪ Establish satellite cold stores for large LGAs (being done in Kano)

▪ Advocate for adequate budgetary provisions for field supervision, at states/LGAs

▪ Leverage existing supervisory structures of government and partners for supervision (e.g., WHO resident facilitators)

▪ Federal government is committed to funding routine vaccine procurement

▪ Guarantees quality of products

▪ Fairly regular investments in procurement of cold chain equipment by the governments and partners

Strengths

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EXAMPLE Assessment – Financing and Resource Mobilization

Text

▪ Release of funds for vaccine procurement sometimes delayed

▪ Overall distribution of funding for RI does not reflect target population or birth cohort sizes at state level

▪ Inadequate financial commitment to RI programs by states and, especially, LGAs, causing gaps in SCM, HR

▪ Donor funded RI program activities not often sustained beyond donor support due to lack of funds

Weaknesses Implications

▪ Develop mechanisms to smoothen financial flows

▪ Treat RI funding as recurrent expenditure

▪ Make provision for next year’s vaccines in current year budget

▪ Explore systematic and integrated private sector participation in vaccine collection, distribution, inventory and cold chain management

▪ Build transition plans into donor programs from inception to ensure ownership of the program by government(s) from the start through counterpart funding which is gradually transitioned to Government funding

▪ Procurement of vaccines is relatively well funded

▪ Federal government is committed to providing funding for vaccines through annual budgetary allocations

▪ National Health Bill at the brink of being signed into law

Strengths

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Despite these challenges, modest improvement may have been realized..

DPT3 NDHS2003 (%)

NICS 2003 (%)

NICS2006 (%)

NDHS2008 (%)

NICS2010 (%)

South West 67.8 47.8 63.5 66.5 76.37

South East 58.5 65.5 53.7 66.9 91.18

South South 32.5 36.5 57.9 54.2 72.15

North Central 23.8 31.9 25.4 43.4 67.10

North East 9.1 17.6 46.8 12.4 46.16

North West 5.8 19.6 19.6 9.1 59.86

National 21.4 24.8 36.3 35.4 67.73

17 Source: NDHS 2003 and 2008; NICS 2003, 2006, 2010

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To accelerate progress we needed break through introduction of new vaccines in a difficult context...

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LOWER HIGHER

Conditioned low demand for vaccination

Weak administrative data collection, reporting and management capacity

Inadequate functional cold chain and logistics management system, in setting of unstable electricity supply

Unreliable funding allocation and releases by sub-national levels of government

Fragile PHC delivery platform with human resources capacity gaps

Fiscal burden on limited public health sector budget...

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Cost profile projection for routine vaccines, 2011-2015

Source: NPHCDA Team/NDC ICC Core Group

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Projected co-financing amounts between Government and GAVI

Source: NPHCDA Team/NDC ICC Core Group

Year 2011 2012 2013 2014 2015

Co-financing level $0.20 $0.23 $0.26 $0.30 $0.35Government co-financing amount $1,348,763.00 $1,712,194.00 $2,099,211.00 $2,625,542.00 $3,312,819.00

Co-financing level $0.00 $0.45 $0.52 $0.60 $0.68Government co-financing amount $3,969,716.00 $8,328,282.00 $15,508,668.00 $18,148,487.00

Co-financing level $0.00 $0.00 $0.52 $0.60 $0.68Government co-financing amount $0.00 $0.00 $4,096,747.00 $8,601,713.00 $16,397,899.00Total Government co-financing $1,348,763.00 $5,681,910.00 $14,524,240.00 $26,735,923.00 $37,859,205.00Total GAVI co-financing $6,055,000.00 $17,891,934.00 $58,780,564.00 $109,592,781.00 $170,756,810.00

Total cost of vaccines $7,403,763.00 $23,573,844.00 $73,304,804.00 $136,328,704.00 $208,616,015.00Ratio of Govt to GAVI co-financing 22% 32% 25% 24% 22%

Yellow Fever vaccine

Penta-valent vaccine

Pneumococcal conjugate vaccine

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Sample priority interventions for improvement

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LOWER HIGHER

Impact vs. Feasibility

FEASIBILITY

▪ Budget line for vaccine procurement & fiscal space expansion in outer years

▪ MDTF/Pooled funds

▪ RBF & Conditional cash transfer

▪ Logistics and supply chain management

▪ Thermo-stable vaccines

▪ CCE Maintenance and Technologically adapted CCE

▪ Flexible funding at SNL ▪ Strengthened PHC

Delivery (HRH/Infra.)

▪ Performance dashboard (performance tracking data system) and accountability framework

▪ Structured transition of donor funded project

▪ Mid-level management training for Immunization and PHC managers

▪ Satellite cold chain storage

▪ Continued advocacy ▪ SPHCDA management

support

▪ Health care vouchers ▪ Data checks

▪ Mobile RI units ▪ SMS reminders

(parents)

▪ SMS reminders (staff)

LOW

ER

H

IGH

ER

IMPA

CT

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How global partners can further support Nigeria’s immunization programme...

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LOWER HIGHER

Address urgently vaccine pricing and affordability post-GAVI and implications of GDP rebasing in Nigeria

Support a common financing framework for routine immunization while leveraging domestic financing, e.g. Pooled funding through an MDTF for RI & RBF

Expand LSCM Pilots (supported by Dangote, BMGF, GAVI, DfID, Federal and States)

Strengthen PHC Delivery platform -- HSS

Retrain Mid-level Managers and cascade to frontlines

Promote technology and innovations in Cold Chain management

Assist Government in mobilizing demand for immunization, expanding CCT, etc.

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And finally....

Continue to speak-up on utility of vaccines to save lives in Nigeria, and

Entrench open and mutual accountability in financing and delivery by all sides

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THANK YOU