Lessons from Kaduna: improving immunisation coverage through local emergency coordination centres

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In the last three decades, the world has gone through a long and tough road in the push to eradicate the crippling wild poliovirus disease. From more than 350,000 cases across 125 countries in 1988, the disease has been reduced to 33 cases in only two countries — Afghanistan and Pakistan, by the end of 2018. Nigeria, once a poliovirus endemic country has not had a case since 2016, the result of various approaches, including improvements and sustenance of immunisation activities. However, arguably some of the biggest threats to the country’s fight against wild poliovirus has been the continued insecurity in North-East Nigeria, preventing the access of disease surveillance and notification officers (DSNO) and polio vaccinators to remote communities. In addition, the sporadic identification and transmission of circulating vaccine-derived poliovirus (cVDPV2), which is excreted by immunised children and found in environmental samples collected by DSNOs.
It is the first Monday of September 2019 and the conference hall of the local government secretariat in Zonkwa, Zango Kataf, Kaduna State, is filled with health workers, mostly women, in their trademark white dresses. They consist of Routine Immunisation (RI) providers from close to 70 health facilities in the LGA, and immunisation focal persons from the LGA’s 11 wards. They are gathered for one purpose; the monthly review meeting, part of the activities carried out by the Local Emergency Routine Immunisation Coordination Centre (LERICC) of the LGA. Their work contributes to the Global Polio Eradication Initiative (GPEI) which catalysed the polio eradication effort in Nigeria, pushing to ensure Nigeria (and the African continent) is polio-free.

The meeting’s goal is to review overall immunisation activities of the preceding month, discuss what worked, identify potential areas for improvement and acknowledge the best performing health facilities in immunisation. Here, health workers from every ward are also able to reconcile immunisation data from their individual facilities with members of the LERICC team.

The monthly immunisation review meeting takes place on first Monday of every month. Routine Immunisation providers, ward immunisation focal persons and members of LERICC review immunisation activities for the preceding month. Photo credit: Nigeria Health Watch

Established across all LGAs in Kaduna state, LERICCs are offshoots of the State Emergency Routine Immunisation Coordination Centre (SERICC), which in turn are the brainchild of the National Emergency Routine Immunisation Coordination Centre (NERICC). NERICC was established in July 2017 by the National Primary Healthcare Development Agency (NPHCDA) to strengthen the coordination of routine immunisation services across the country with the aim of improving the country’s immunisation coverage. The 2016/2017 Multiple Indicator Cluster Survey showed that immunisation coverage for children 12–24 months in Nigeria was as low as 22.9%. SERICC centres were subsequently established at state levels to provide coordination of immunisation activities, share data with NERICC at federal level and provide oversight to LERICCs at LGA levels.
The Zango Kataf LGA LERICC has membership from key health officials of the LGA including the director of health, deputy directors-in-charge of reproductive health, essential drugs, disease control, monitoring and evaluation, community engagements, as well as LGA representatives of WHO and UNICEF. The committee is led by the LGA Routine Immunisation Officer, Mr. Samaila Sambo. They meet once a week to plan and review their activities and assign members of the team that will visit selected wards and health facilities. They provide support and supervision of RI providers, advocacy and outreach activities.

Review of immunisation registers against data recorded and sent by RI providers of every PHC is a critical part of the monthly routine immunisation review meeting carried out by LERICCs across Kaduna state. Photo credit: Nigeria Health Watch

Decentralisation: A key to improved efficiency
To achieve greater efficiency, the Zango Kataf LERICC formed various smaller teams; Logistics, Community Engagement and Monitoring and Evaluation (M&E). The teams allow LERICC to support and track every immunisation activity. The logistics team is responsible for making sure that vaccines are always stocked at health facilities and are properly stored at the right temperatures. They also facilitate the request and delivery of vaccines from the LGA office to the health facilities. The community engagement team works to generate demand for immunisation through advocacy and outreaches. They periodically visit traditional and religious leaders in the LGA to inform them about various immunisation activities and advocate through them the benefits of immunisation to their communities. During the rainy season when many people spend time on the farm with their children, the team works with the traditional leaders to ensure that as many children as possible are available to be vaccinated during outreaches. 
Real time data monitoring to improve immunisation
The work of RI providers is also continuously monitored. Every Monday, each RI provider sends weekly work plans through SMS to a server. The M&E team at the LGA and the SERICC team have access to data stored on the server. The work plan outlines the number of RI sessions the provider intends to carry out at the health facility during the week, as well as any supplementary immunisation activities planned, including community outreaches.

Immunisation register of PHC Maganmiya in Zonzon ward of Zango-Kataf LGA being reviewed by RI providers and members of LERICC during the monthly immunisation review meeting in Zonkwa. Photo credit: Nigeria Health Watch

At the end of every activity, the RI provider sends a report via SMS, highlighting the number of children immunised and vaccines used. RI providers also prepare reports and summaries of activities at the end of every month. These help the team to not only keep track of immunisation activities of every health facility, but also facilitates reconciliation with the providers at the monthly review meeting. Data sent by RI providers and reports are compared and vetted against the immunisation registers of facilities.
From the data sent by RI providers and monthly review meetings, facilities that continuously record low immunisation numbers are supported by a joint team of SERICC and LERICC officials to identify reasons behind the numbers and actions are taken to address them. The joint team also conducts activities tagged Optimised Integrated Routine Immunisation Sessions (OIRIS) which include specific community mobilisation and outreaches and daily immunisation sessions in the facilities for a number of weeks.

Image credit: Nigeria Health Watch

Oversight coordination: The place of the Kaduna SERICC
Just as LERICC teams coordinate the provision of immunisation services at LGA levels, the SERICC team at the state level supervises all 23 LERICCs in the state. Housed inside the Kaduna State Primary Healthcare Development Agency (KDSPHCDA), the SERICC has representatives from all LGAs of the state. Just like LERICCs, it also has various working teams to ensure efficient coordination. While the LERICC teams meet every week, the SERICC team meets every day.
Dr. Clement Bakam, the SERICC Program Manager, said, “On Mondays the service delivery working group makes its presentation, Tuesdays are for community engagement working group, Wednesdays for M&E working group while Thursdays and Fridays are for representatives of LGAs to report on happenings from their domains’’. On the first Monday of every month, at least one member of the SERICC attends the monthly review meeting of an LGA. The SERICC also collaborates with LERICCs in designing micro plans for various immunisation campaigns carried out periodically in the state. “The micro plans help us map and capture all the communities in an LGA so that we have an understanding of the likely number of children to immunise for that campaign. This week our teams will be going to the LGAs to plan for our upcoming immunisation measles and meningitis campaigns’’, Dr. Bakam said.
The work of Kaduna SERICC is vital in polio eradication drive, according to Dr. Bakam.
Kaduna state recorded two cases of weakened polio virus in late 2018, one from the densely populated city of Zaria and the other from Ikara LGA. On identification of the cases, the SERICC team collaborated with the LERICCs of the affected LGAs to organise mass supplementary polio immunisation campaigns in and around the areas the samples were taken, Dr. Bakam said. The campaigns were to improve herd immunity among children, and to prevent the virus from infecting previously unvaccinated children in the two LGAs.

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