Herd Immunity: Jigawa’s community-driven approach boosts immunisation coverage

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Jigawa State has been largely characterised by its poor development indices. The latest States Domestic Product report from the Nigeran National Bureau of Statistics identifies it as being one of Nigeria’s poorest states. In addition, its literacy rates are among the lowest in Nigeria and the number of out of school children is among the highest in Nigeria according to the 2016 – 2017 Multiple Indicator Cluster Survey (MICS). On the child nutrition front, the state has a stunting rate  of 54%, one of the highest in the country, according to the 2018 National Nutrition and Health Survey. The state has the highest total fertility rate, 8.4%, in the country, perhaps unsurprisingly as contraceptive use is only 1.3%, the lowest in the country. In one critical area, Jigawa State seems to be making strides in the right direction; immunisation coverage. In the 2016- 2017 MICS Survey the state’s immunisation coverage was at 2%. In the recently released NDHS 2018 it was recorded at 23.8%. However at the end of the first quarter of 2019, the NPHCDA conducted a Lot Quality Assurance Sampling (LQAS), an internal survey meant to assess how immunisation strategies and initiatives being implemented by the Agency were faring, and by those estimates Jigawa seems to be faring quite well, recording a 92% coverage rate.

This seemingly unattainable feat appears to be rooted in the actions of the Jigawa State Primary Healthcare Development Agency (JSPHCDA), created in 2016, in response to the low immunisation coverage rate in the 2016-2017 MICS. Dr Shehu Sambo, Director of Primary Healthcare at the Agency, said the state had never recorded double-digit immunisation coverage, and that the low coverage stemmed from issues such as inadequate healthcare facilities, lack of transport fare and the poor attitude of health workers towards patients. These issues prevented Jigawa State residents from taking their children to health facilities for immunisation; and even during routine immunisation campaigns when health workers conducted house-to-house campaigns, many parents were still reluctant to present their children due to their cultural beliefs.

Image source: NPHCDA 

In collaboration with development partners like the Bill & Melinda Gates Foundation (BMGF) and the Maternal New-born and Child Health (MNCH2) Program funded by the United Kingdom Department For International Development (DFID), the Agency designed and implemented strategies to remove barriers to immunisation uptake in the state.  The implementation of these strategies which began in September 2017 appears to have yielded impressive results.

Taking immunisation to doorsteps
Delivering healthcare interventions successfully, immunisation included, largely depends on the twin factors of demand and supply. As the government, partners and other providers supply essential resources such as drugs, vaccines, health workers and equipment, the targeted individuals or populations also have to go to the points of delivery and make use of the resources provided.  The introduction of state outreach days in September 2017, by the Jigawa Primary Healthcare Development Agency and its partners, was one of the strategies to tackle the incredibly low demand for immunisation in the state. Unlike routine immunisation campaigns which took place quarterly or sometimes only twice a year, the new state outreach days took place on the first five working days of every month.  

In each of the state’s 288 wards, six immunisation teams were set up, comprising of a trained health worker to administer the vaccines; a trained recorder to document every child vaccinated; and a community leader who serves as a link to the community, helping to establish and reinforce trust in the state outreach days programme. Each team is deployed to specific settlements, and on outreach days, they go house-to-house to vaccinate children. Where they meet resistance, the community leader steps in to counsel and convince the parents. In some cases, religious leaders in the communities already sensitised about the immunisation campaign were engaged to persuade parents to get their children immunised. From September 2017 to April 2019, Jigawa State conducted 15 rounds of state outreach days – vaccinating over 1.7 million children and improving the immunisation coverage to reach herd immunity levels in every community in the state.

Jigawa State changes immunisation narrative
Since its creation, Jigawa State has never recorded a double-digit immunisation coverage rate, despite several outbreaks of vaccine-preventable diseases. They have changed the narrative! Watch what the Director of Jigawa State Primary Healthcare Development Agency had to say.

The Jakadan Lafiya initiative: A community-centred, homegrown approach
While monthly immunisation campaigns help in the short and medium term to bridge the gap in immunisation coverage rates, longer-term effective and sustainable initiatives that continuously create awareness can help change the beliefs and practices of people, leading to greater acceptance and demand for healthcare services like immunisation. Using community members as advocates to sensitise their people about particular health issues has proven effective in creating acceptance and support. Often known as Volunteer Community Mobilisers (VCMs), they use their knowledge and understanding of the community’s cultures to influence positive attitudinal changes in the community, creating increased demand for a particular service. Borno State is successfully using VCMs in its communities and in Internally Displaced Persons (IDP) camps to promote immunisation in the state. This has largely contributed to the state having the highest immunisation coverage rate in the North East, despite battling with insurgency for years.

In Jigawa State, the JSPHCDA worked with the State Traditional Council, the umbrella body for all community and traditional leaders in the state, to train one mobiliser in each of the 12,000 settlements in the state. The mobilisers were trained to carry out continuous advocacy and sensitisation about immunisation and birth registration in their communities. Referred to as ‘Jakadan Lafiya’, which translates to ‘’Health Ambassador’’, these VCMs were given greater responsibilities than their counterparts in other states.

All VCMs are responsible for managing and monitoring their settlement’s immunisation register. Photo credit: Nigeria Health Watch

Apart from advocacy and sensitisation; the Jakadan Lafiya also keep records of every child born within their settlements through birth registration and track the child’s immunisation schedules, as well as serving as links between the communities and the local health facilities. As soon as a child is born, they notify the nearest health facility so that the necessary vaccines are administered to the child. They then record the child’s name in the settlement’s immunisation register and give the parents an immunisation schedule card. All VCMs are responsible for managing and monitoring their settlement’s immunisation register and oversee arrangements for children to receive their immunisation either at the health facility or at home.

Mallam Hussaini Abdullahi, a VCM under the Jakadan Lafiya initiative started working in September 2017 in Abaya, just outside the state capital Dutse. Since then he has recorded 49 births and helped increase immunisation uptake. Abdullahi believes his role gives him the opportunity to serve his community and takes pride in the fact that childhood diseases especially measles have drastically reduced in his town. “We have not had a single case of measles since we started this programme”, he says, adding that the training he receives from the JSPHCDA every 6 months helps him in his dialogues with members of his community, strengthening his effectiveness.

Mallam Hussaini Abdullahi, a VCM under the Jakadan Lafiya initiative holds a routine immunisation settlement register. Photo credit: Nigeria Health Watch 

One major concern for this initiative is sustainability. Jigawa must ensure that the incredible gains made are sustained through continuous review, capacity building and continued motivation of the health workers and health ambassadors. The health ambassadors’ work could also be broadened into areas such as maternal health and family planning, where the state lags behind. Incentives such as stipends to support the ambassadors’ transport between the communities and health facilities should be implemented. Similarly, consideration should be given towards providing some form of incentive or compensation to community leaders working on the state outreach days, because unlike the health workers and recorders employed formally and paid by the government, the community leaders’ work is mainly voluntary. Providing mobile phones for the health ambassadors could improve information sharing with health workers and others in the system. In addition, addressing some of the other issues of concern such as inadequate health facilities and attitudes of healthcare workers is essential to deepen citizens’ in the state’s healthcare delivery system.

At the 2019 Nigeria Health Watch Forum, on the theme “Prevent Epidemics; Immunise“, participants agreed that the Nigerian government at all levels must invest significantly to ensure that every child receives the necessary vaccinations and thus minimise the threats that infectious diseases pose to the country. While the LQAS survey by the NPHCDA was conducted using different methodology, and so cannot be compared to the MICS and NDHS, the scale of improvement in Jigawa and robustness of the methods employed by the LQAS survey suggests that when/if the MICS is repeated, the improvements recorded are likely to be reflected in its results. The full impact of Jigawa State’s approach of taking immunisation to the doorsteps of people, using community members as advocates and facilitators may well be shown when the next MICS is released. Looking at the results of the LQAS Survey, this may be one approach that other states, especially as new governors come into office at this time should study carefully with a view to replicating similar programmes.

Are there other successful programmes in one state that you think other states should emulate? Do you know about voluntary community mobilisers? What are your thoughts on the roles they play in promoting health in Nigeria? We would like to hear from you. Please leave a comment in the comment section below or via our social media channels

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