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Scaling up routine immunisation coverage in Nigeria

Critical months ahead

Vaccine-preventable diseases like tuberculosis, measles and pneumonia continue to rank among the top killers of children under age five in developing countries. Each year, nearly 31 million children under five suffer from these diseases every year and many end up dying from them. Pneumonia alone claims the lives of more than 800,000 children every year. Deaths that could be prevented with adequate vaccine coverage.

Despite these alarming figures, nearly 10 million children in low-income countries still do not receive essential vaccines like diphtheria, tetanus and pertussis-containing vaccine. These zero-dose children account for nearly half of all vaccine-preventable deaths globally. Reaching them is critical if we are to come anywhere close to the global Sustainable Development Goal 3 (SDG3) of ending preventable deaths of children under five by 2030.

Nigeria is one of the five countries that account for two-thirds of all zero-dose children worldwide, along with India, the Democratic Republic of the Congo, Pakistan and Ethiopia.

A bleak picture for Nigerian children

On its own, Nigeria contributes 30% of the global number of unimmunised children under five. Government efforts to strengthen routine immunisation coverage and reduce under-five mortality have had limited success over the last decade. In 2019, the country was at the top in the WHO list of the countries with the highest numbers of under-five deaths. The most recent National Demographic and Health Survey also reported a very high under-five mortality rate of 132 per 1,000 live births – far higher than the target of 25 per 1,000 live births goal set out in SDG 3.2.1.

Recent news is not reassuring. The World Health Organization and UNICEF have warned that COVID-19 related disruptions may have reversed any hard-won progress in immunisation rates worldwide. In the northern part of the country this is compounded by persistent conflict and insecurities, especially for the poorest households and most vulnerable children, by making the delivery of essential services and life-saving immunisation even more difficult.

The rural–urban divide continues to widen in the country, sustained by various barriers preventing access to health services, such as the limited number of available or accessible facilities in remote areas and high out-of-pocket payments for health service. As a result, uptake of basic essential services like antenatal and post-natal care remains low especially among women and children in rural communities.

To make matters worse, the country is entering a new election period, adding threats of further political and economic instability even in more stable parts of the country. During this period resource allocation to priority health interventions such as primary healthcare (PHC) services or immunisation programmes may be heavily disrupted. The post-election period can prove equally challenging. Administration changes have been known to stall the continuity and stability of previous progress.

Critical priorities

The coming years are going to be critical for Nigeria if the country is to change the current trend.

With the current health resource allocation at only 4% of annual budgetary allocation, more than ever, authorities will need strong political will and intentional efforts if we are to reach the 15% minimum commitment. In the meantime, rigorous governance and transparency in how money is allocated, released and spent are necessary to ensure that the limited resources available are used effectively where it is needed most.

A strong PHC system is vital to deliver vaccines to all children, especially those with least access to health services, who are the most vulnerable. Across all public health policies, there needs to be a deliberate emphasis on strengthening maternal, newborn and child health services. Efforts to empower, train and retain health workers will need to be scaled up and extended to community health workers (CHWs), the back bone of PHC.

To make these changes sustainable, public health authorities will need to continuously evaluate and consolidate relevant policies to create an enabling environment. Efforts to support CHWs, remove user fees, reduce non-financing barriers to accessing care and prioritise PHC services need to be cemented in appropriate legislation.

Finally, women’s and children’s voice must be at the centre of all decisions. Initiatives such as developing and adopting community engagement charters are essential to enhance demand creation and promote community involvement and trust.

High stakes

Scaling up immunisation coverage and uptake in Nigeria is not just a goal, it is an imperative. With stakes this high, it is incumbent on us to reimagine how we can make immunisation work in Nigeria despite the challenges and complex dynamics.

This will require stronger national ownership as well as continued collaboration across health actors, international agencies and civil society to ensure that immunisation remains a political priority in the months and years to come.

Photo: 22-day-old Rukayya is given a vaccine outside his home in Jigawa State, Nigeria. “Early immunisation helps children, that is why we give it to them,” says his mother, Sahura (Yagazie Emezi / Save the Children).

Immunisation in Nigeria