Vaccine access: A tall dream?

Vaccines are one of the most cost-effective public health interventions. With about one million children dying annually from vaccine preventable diseases in Nigeria, the country has the second largest number of child mortality deaths globally.

The Expanded Programme on Immunisation (EPI) was launched by the World Health Organisation (WHO) in 1974 to improve universal access of children to vaccines against six killer diseases: tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, and measles. Three decades since its inception the programme has made huge impact in safeguarding the lives of children globally.

Renewed effort to interrupt polio virus transmission and increase in routine immunisation (RI) coverage between 2000 and 2010 in Nigeria witnessed progress in RI coverage, achieving a Diphtheria-Pertussis-Tetanus (DTP3) coverage rate of 69 percent in 2010.

The measles vaccination programmes witnessed an estimated 71 percent of target population vaccinated by 2011 as compared to 33 percent in 2000.

Despite these successes, RI is yet to reach 90 percent coverage target as a large gap in coverage rates exists between the six geopolitical zones, ranging from 46 percent in North-East zone to 91 percent in the South-East zone, according to National Vaccine Summit 2012 report.

Vaccine coverage

The report stated that vaccine access in Nigeria is affected by lack of performance management, ineffective accountability framework, poor infrastructural support, inadequate cold chain management and a poor transportation network.

According to the report, “Interruption of wild poliovirus transmission in some Northern states continues to defy elimination strategies for several reasons, including lack of awareness of the benefits of vaccination and weak health systems in remote areas.

“There is relative paucity of locally generated data from clinical and health system research to guide efficient implementation of vaccine programmes. Other barriers to vaccine uptake stem from insufficient numbers of skilled healthcare workers, cultural and religious misperceptions of vaccination, and very recently, the growing insecurity in certain communities.”

In 2010, a record 19.3 million infants were not immunised with DTP3 vaccine, of which 85 percent were in Global Alliance for Vaccines and Immunisation (GAVI) eligible countries and 1.8 million in Nigeria.

Funding

In a bid to address these issues, Nigeria developed the Immunisation Comprehensive Multiyear Plan (cMYP) for 2011-2015, which indicates a funding gap of 63 percent with secured funding but 21 percent when probable funding is included.

Nigeria currently spends $15 per surviving infant. The introduction of new vaccines-Pneumococcal conjugate and Rotavirus Vaccines-is expected to increase the cost of fully vaccinating a child from $45 to $80 per surviving infant, according to Emmanuel Abanida, director, Disease Control and Immunisation, National Health Care Development Agency (NPHCDA).

The demand of rising costs leaves Nigeria with the need to develop a national sustainability strategy for vaccine financing. Following growth of the country’s Gross Domestic Product (GDP), it may soon become GAVI-ineligible, experts believe.

There is presently zero duty on vaccine importation in Nigeria and procurement of vaccines is outsourced to United Nations Children’s Fund (UNICEF) to ensure timeliness and price competitiveness in vaccine delivery.

With PCV expected to be introduced this year, experts have called for the need to explore internal funding for vaccines as Nigeria cannot continue to depend on funds coming from donor agencies as costs increase.

“Nigeria must look into the local manufacturing of vaccines as Government has provided sufficient funds this year to cover procurement of vaccines,” Ado Mohammad, executive director, NPHCDA explained.

Addressing shortfall

Dorothy Esangbedo, president, Paediatric Association of Nigeria (PAN), noted that the provision of vaccines should target prevailing major vaccine preventable diseases (VPDs), emphasising that addressing the gaps will have huge impact on child mortality.

“There is need to learn from our past mistakes and ensure that massive awareness creation campaigns are held before the introduction of new vaccines,” Esangbedo maintained.

The international community is worried about the situation of polio in Nigeria, a virus preventable disease that has remained endemic in Nigeria and has now become a global public health issue.

Chizoba Wonodi, lead of Nigeria Projects, International Vaccine Access Center (IVAC) identified systemic barriers to routine immunisation to include vaccine stock outs, inadequate funding and delayed release of funds for RI programs, logistics and supply chain constraints including cold chain

Wonodi highlighted the need to create basket funds for primary healthcare (PHC) or for routine immunisation to improve funds flow for RI operations at the state and local government levels.

“There is need to explore private sector participation in vaccine logistics and transportation. Other solution that are harder to implement but potentially high impact includes establishing accountability for routine immunisation at all levels, instituting results-based financing for providers or health facilities and incentives to parents for vaccinating their children,” Wonodi added.

The National Vaccine Summit 2012 report called for the establishment of Nigerian Alliance for Vaccines and Immunisation (NAVI), a public private partnership that will raise funds to bridge financing gaps in vaccination programme delivery, surveillance and monitoring.

“There is the need for a National Immunisation Technical Advisory Groups (NITAG), as an independent body to provide unbiased and expert advice on vaccination programmes. Pharmaco-vigilance should be integral to vaccine delivery to track adverse events. Local research into vaccines should be promoted. Technologies should be deployed in tracking the integrity of supply chain.

“Everyone deserves to benefit from immunisation services. Government must mobilise the community through advocacy and communication to make full use of available services. Multi-sector involvement in planning and execution is important to success of immunisation efforts. There is need to explore private sector solutions for improving access to immunisation services and nurture positive attitudes of key players in immunisation programmes,” the report concluded.