“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
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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 Context
Regional Map of Nigeria (Population in mn)
Administratively, Nigeria is divided into:
Sokoto (3.6)
36 states
A Federal Capital Territory (FCT)
Kebbi (3.08)
Zamfara (3.2)
774 Local Government Areas (LGAs)
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
Jigawa 4.3 Kano 9.3
Kaduna 6.0
9,565 wards Six geopolitical zones
Katsina (5.7)
Bauchi (4.6)
Niger (3.9)
Oyo (5.5)
Kwara (2.3)
Yobe (2.3)
Plateau FCT (3.1) Abuja (1.4)Nassarawa (1.8)
Kogi Ekiti Osun (2.3) (3.2) Benue (3.4) (4.2) Ogun Ondo (3.4) Edo Enugu (3.7) (3.2) Lagos (3.22) Anam- Ebonyi (9.0) bra (2.1) Cross (4.1) river ImoAbia (2.8) Delta (3.9) (4.0) (2.8) Akwa Bayels Rivers lbom a (1.7) (5.1) (3.9)
Borno (4.1)
Gombe (2.3) Adamawa (3.1)
Taraba (2.3)
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
SOURCE: Nigeria Population Census 2006
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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 ▪ 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
▪ ~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
▪ Child mortality rate is ▪
157/1,000 = ~1 million deaths per year ~10% of the global total
SOURCE: Nigeria Demographic and Health Survey, 2008
▪ 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 Use of primary maternal and child health care services among lowest and highest population quintiles % 100 90 80 70 60 50 40 30 20 10 0 M ed. Treatment of M ed. Treatment of Oral Rehydration Fever Ac. Res. Inf. Thereapy
Lowest 20% of Population
Source: 2008 Nigerian Demographic and Health Survey
Antenatal Care
Att. Delivery
Full Immunization
Highest 20% of Population
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Same inequities seen in access to routine immunization services Children U5 fully immunized by socioeconomic quintile in Nigeria %
120 100
Percentages
80
Nigeria Ghana
60
Kenya Cameroon
40
Morocco Mozambique
20 0 Lowest
Second
Third
Fourth
Highest
Wealth Quintile Source: Gwatkin et al, 2007, based on 2003 DHS country data and Nigeria DHS 2008.
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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
1
2 …We will expand basic services through strengthening primary health care and providing integrated care at the frontlines…
3
…We will encourage healthy living and good quality of life by emphasising prevention of disease…
“Our vision is to save one million lives and improve the quality of care” …We will improve the quality of care provided to Nigerians in health facilities through improved clinical governance…
4
…We will revive the private health sector through unlocking its market potential and encouraging additional investment from the private sector…
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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
1 million lives saved by 2015
Routine immunization MCH
eMTCT
Nutrition
Malaria
Essential medicine
Logistics and supply chain Innovation and technology (ICT & Private Sector engagement)
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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… Coverage of Routine Immunization by country (2007) % BCG Benin
88
Botswana
75
79 23
10
63
74
74
91
84
92
92 20
Côte d’Ivoire
94
93
79
99 40
61
67 96
92
Burundi
MCV
67
99
Burkina Faso Chad
HepB3
DTP3
Eritrea
99
97
97
95
Gambia
95
96
99
91
Ghana
99
87
87
71
86
Guinea
84
66
Liberia
80
64
64
64
Mali
77
68
68
68
Mauritania Niger
Somalia
36
62 88
77
60
60
60
Ø 71
68
69
82
Average= 82 SOURCE: WHO
41 88
98
Sierra Leone
80
54
69
Senegal
65
66
64
Nigeria
74
74
89
64
31
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Conducted an assessment of the Immunization program, focusing on 6 aspects of the program
Governance and Stewardship Health Management Information Systems
Planning and Supply Chain Management Immunization Program Financing and Resource Mobilization
Service Delivery
Human Resources
SOURCE: PDU/LARI team—JHUSPH-IVAC/SolinaHealth, NPHCDA
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EXAMPLE Assessment – Governance and Stewardship Strengths Text
▪ ▪
▪ ▪ ▪
▪
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
Weaknesses
▪
▪ ▪ ▪ ▪
Varying degrees of commitment from states, with some State governors generally more engaged than others
Implications
▪ ▪
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
▪
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
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EXAMPLE Assessment – Planning and Supply Chain Management Strengths Text
Weaknesses
▪ Federal government is
▪ Stock-outs of vaccine
committed to funding routine vaccine procurement
▪ Guarantees quality of products
▪ Fairly regular investments in procurement of cold chain equipment by the governments and partners
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
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)
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EXAMPLE Assessment – Financing and Resource Mobilization Strengths Text
Weaknesses
▪ Procurement of vaccines
▪ Release of funds for
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
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
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
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Despite these challenges, modest improvement may have been realized.. DPT3
NDHS2003 (%)
NICS 2003 (%)
NICS2006 (%)
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
Source: NDHS 2003 and 2008; NICS 2003, 2006, 2010
NDHS2008 (%)
NICS2010 (%)
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To accelerate progress we needed break through introduction of new vaccines in a difficult context...
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 subnational levels of government
Fragile PHC delivery platform with human resources capacity gaps HIGHER LOWER Fiscal burden on limited public health sector budget... HMSH
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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 Year
2011
2012
2013
2014
2015
$0.20
$0.23
$0.26
$0.30
$0.35
$1,348,763.00 $1,712,194.00
$2,099,211.00
$2,625,542.00
$3,312,819.00
$0.52
$0.60
$0.68
Yellow Fever vaccine Co-financing level Government cofinancing amount Penta-valent vaccine Co-financing level Government cofinancing amount
$0.00
$0.45 $3,969,716.00
$8,328,282.00 $15,508,668.00 $18,148,487.00
Pneumococcal conjugate vaccine Co-financing level $0.00 $0.00 $0.52 $0.60 $0.68 Government cofinancing amount $0.00 $0.00 $4,096,747.00 $8,601,713.00 $16,397,899.00 Total Government cofinancing $1,348,763.00 $5,681,910.00 $14,524,240.00 $26,735,923.00 $37,859,205.00 Total GAVI cofinancing $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 $208,616,015.00 Ratio of Govt to GAVI co-financing 22% 32% 25% 24% 22%
Source: NPHCDA Team/NDC ICC Core Group
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Sample priority interventions for improvement
HIGHER
Impact vs. Feasibility
▪
▪
LOWER
IMPACT
▪
▪ ▪
Budget line for vaccine procurement & fiscal space expansion in outer years MDTF/Pooled funds Performance dashboard (performance tracking data system) and accountability framework Health care vouchers Data checks
▪ ▪ ▪ ▪ ▪
▪ ▪
RBF & Conditional cash transfer Logistics and supply chain management Thermo-stable vaccines Structured transition of donor funded project Mid-level management training for Immunization and PHC managers Mobile RI units
▪ ▪ ▪ ▪ ▪ ▪ ▪
CCE Maintenance and Technologically adapted CCE Flexible funding at SNL Strengthened PHC Delivery (HRH/Infra.) Satellite cold chain storage Continued advocacy SPHCDA management support SMS reminders (staff)
SMS reminders (parents)
LOWER
HIGHER
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How global partners can further support Nigeria’s immunization programme...
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, LOWER expanding CCT, etc.
HIGHER
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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
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