HMSH
“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
HMSH
Contents
▪ Background on Nigeria
▪ Saving One Million Lives Initiative
▪ Case study on Routine Immunization
| HMSH 2
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
| HMSH
Country’s landscape as diverse as its population of 160 million people, with over 125 ethnic groups, and 250 languages
| HMSH
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
HMSH
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 %
| HMSH
0
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 %
HMSH
Contents
▪ Background on Nigeria
▪ Saving One Million Lives Initiative
▪ Case study on Routine Immunization
HMSH
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
HMSH
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
9
| HMSH
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
10
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
HMSH
Contents
▪ Background on Nigeria
▪ Saving One Million Lives Initiative
▪ Case study on Routine Immunization
| HMSH 12
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) %
| HMSH
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
| HMSH
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
| HMSH
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
| HMSH
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
| HMSH
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
| HMSH
To accelerate progress we needed break through introduction of new vaccines in a difficult context...
18
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...
| 19
Cost profile projection for routine vaccines, 2011-2015
Source: NPHCDA Team/NDC ICC Core Group
| 20
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
|
Sample priority interventions for improvement
21
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
| HMSH
How global partners can further support Nigeria’s immunization programme...
22
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.
| HMSH
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
23
| HMSH
THANK YOU
Top Related