1_Dr Pate_Expanding Access_Reaching the Hard to Reach_Towards Saving One Million Lives in Nigeria

“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

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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...

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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

FEASIBILITY | 21

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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